HEALTH CARE FOR IMMIGRANTS

Introduction

Health care coverage for immigrants in Pennsylvania is a complex matter. This page will focus on providing three areas of information.

I. Immigrant eligibility for Medical Assistance (Medicaid) – the most important publicly-funded health program in Pennsylvania. This includes a discussion of the Emergency Medical Assistance program, which every immigrant, advocate, and provider must understand.

II. Other health programs which “non-qualified” immigrants are eligible for in Pennsylvania.

III. Special issues in helping immigrants get health care coverage and overcoming barriers to care. Topics include: language problems, dealing with Social Securty Numbers, when proof of immigration status is required, and more.

 

PART I. Medical Assistance for Immigrants & Emergency Medical Assistance

Medicaid is a federal program to provide health coverage to low income individuals and families. Medicaid is administered by states using state funds for which states receive federal matching funds. Pennsylvania's Medicaid program is called "Medical Assistance" or “MA”. The state agency which administrers Medicaid is the Department of Public Welfare (DPW), at their "welfare" offices also known as County Assistance Offices. (Note that Medicaid is completely different than Medicare. Medicare is a federal program proving health coverage for individuals over the age of 65 or who have been receiving Social Security Disability Income for over 2 years. Medicare is available only to U.S. and Legal Permanent Residents who have been in the United States for at least 5 years. For more information, see the Official Medicare Website ).

Generally speaking, to be eligible for any kind of Medical Assistance an individual must meet four requirements:

(1) BE A PA STATE RESIDENT (Note: This has nothing to do with legal permanent residency. It simply requires the individual to have a Pennsylvania address where they reside with intent to remain.)

(2) FIT INTO A “CATEGORY” OF MEDICAL ASSISANCE.

(3) MEET INCOME AND RESOURCE REQUIREMENTS FOR THE CATEGORY

(4) HAVE A “QUALIFIED” IMMIGRATION STATUS

For further information on the first three requirements, see our PHLP MA eligibility guide for general information on Medical Assistance eligibility. The rest of this section will focus on the fourth requirement, Qualified Immigrant Status.

 

"Qualified" Immigrant Status

Citizens, legal permanent residents (LPR), and some other "qualified" immigrant categories are eligible for full Medical Assistance. (Immigrants who are not eligible for full Medical Assistance are eligible for Emergency Medical Assistance -- see below.) It is important to remember that children born in the United States are full citizens and are entitled to full Medical Assistance if eligible, regardless of the immigration status of their parents. In addition, it is important to remember that Puerto Rican citizens are also entitled to full Medical Assistance if eligible.

Because there are many qualified immigration statuses that are eligible for full Medical Assistance, it is vital to always verify if an immigrant who is not a citizen or LPR falls into one of the qualified immigrant categories eligible for full Medical Assistance. Here is the list of Immigrants eligible for Full Medical Assistance (as listed in sections A and B). Remember, even if an immigrant does fall into one of the qualified groups, he or she must still meet the other three MA requirements listed above. These immigrants should apply for Medical Assistance as described on our page on how to apply, bearing in mind they will be required to provide some evidence of their immigration status.

Non-qualified immigrants and Emergency Medical Assistance

Immigrants who do not fit into any of the qualified immigrant categories, such as immigrants on a student visa or undocumented immigrants, are only eligible for Emergency Medical Assistance, also called “EMA”. EMA is essentially a temporary enrollment in the MA program to treat a specific problem. It is of the utmost importance that immigrants and advocates understand that the term "Emergency Medical Assistance" is a misnomer. EMA does NOT require an "Emergency" in the Emergency Room sense of the word. It does require that the immigrant has an Emergency Medical Condition. This defition focuses on whether the person has a serious condition, not whether they need to go to an ER. For example, a small tumor which is potentially fatal may not warrant a trip to an Emergency Room, but should certainly be considered a possibility for EMA. If you or an immigrant you are advocating for have a serious medical condition, you should apply for EMA!!!

To apply for Emergency Medical Assistance, an immigrant applies for Medical Assistance using the standard forms ( PA-600P for an adult, PA-600CH for an adult with children or a child alone, or a PA-600CH-S for anyone who speaks Spanish), but must submit an additional letter from a doctor verifying the EMC. The doctor's letter is absolutely required, and must meet very particular specifications. These are the requirements of the doctor's letter. See our sample letter for requesting help from a doctor. For an example of what an actual Emergency Medical Condition letter should look like, see our sample EMA letter or try using this sample EMA letter template.

It is also important to note that a few of the normal MA application requirements do NOT apply to applications for EMA, such as signature of a citizenship declaration, verification of immigration status, and providing a Social Security number.

Applications for Emergency Medical Assistance may require extra or active advocacy by/on behalf of the immigrant seeking care. If advocates or immigrants in Philadelphia need help submitting or following up on an Emergency Medical Assistance application, they should contact the local MA Liaison for Emergency Medical Assistance applications. Advocates or immigrants should call the Pennsylvania Health Law Project at (800)274-3258 if they need additional information or assistance.

Chronic Care Cases

As a general rule, Emergency Medical Assistance only covers short-term acute conditions. However, in 2004, the Department of Public Welfare issued an Operation Memorandum clarifying that chronic care, such as dialysis, may be approved in certain cases. Immigrants or advocates preparing these cases should follow all of the Emergency Medical Assistance process explained above, and do two additional things. First, include a copy of the 2004 Operation Memorandum with the Emergency Medical Assistance application. Second, in the Emergency Medical Assistance doctor's letter, explain (a) the extreme seriousness of the consequences of nontreatment (for example, "without this treatment, this patient is likely to die within days"), and, (b) the expensive medical emergencies that nontreatment will cause (for example, "without this treatment, the patient will likely have a more expensive hospitalization and require extremely expensive emergencies surgeries").

Further discussion about issues and barriers immigrants face in applying for MA can be found below in Part III.

 

PART II. Other Healthcare Options for Non-qualified Immigrants

Non-qualified immigrants are immigrants who are not in an immigration status which is eligible for important health care programs such as MA and CHIP. Unfortunately, there are not a wealth of other resources available to ensuring the health of non-qualified immigrants. But there are some programs and resources that may be available, regardless of immigration status. They include:

- Philadelphia Health Care Centers. The city health clinics in Philadelphia should provide basic primary care for city residents regardless of their immigration status. These city health centers, and specifically the doctors who treat patients, may be important tools in establishing the medical documentation needed for an Emergency Medical Assistance application (i.e. the Emergency Medical Condition doctor letter). The connection to Emergency Medical Assistance is important because in many cases the city health center will only be able to provide basic primary care, and not the specialist examinations or advanced testing that are required after basic primary diagnoses are made. In addition, language services must be made available to immigrants who do not speak English. Here is a listing of the Philadelphia Health Care Centers. Note the following important protections for immigrants using the City Health Care Centers:

The Philadelphia City Solicitor has officially clarified that all immigrants are eligible for Philadelphia City Servics such as the District Health Centers, and that immigration status is confidential information that city employees can not share.

The Philadelphia City Department of Public Health has officially clarified that all immigrants can get care at health care centers, that social security numbers are not required, that the health care centers must be extremely flexible about residence/identification accepted, and that no patient should be turned away without seeing a clinician if they don't have proof of identification or residence. This is confirmed in a letter to Health Care Center patients which patients should receive before being turned away.

- Philadelphia Prenatal care. In Philadelphia, prenatal care services are available for all women, including immigrants. The Philadelphia Divison of Maternal, Child, and Family Health (MCFH) is the division of the City Health Department which is in charge of providing these services, which were formerly known as the Maternity Services Programs. (Archived information: Maternity Services Program, clarification letter). There are over 40 prenatal care providers through MCFH. Contact MCFH for further information or provider sites. Advocates and immigrants will find that although there is universal coverage for prenatal care in Philadelphia, funding limitations sometimes make it hard to get everyone care. Please contact Leonardo Cuello at LCUELLO@PHLP.ORG if you have suggested resources (programs, clinics, etc.) on pre-natal care for immigrants outside of Philadelphia County.

- Federally Qualified Health Centers statewide. Federally Qualified Health Centers (FQHC) provide health care services regardless of immigration status. Often, they employ a sliding fee scale to make it affordable or free for lower income consumers. The County Assistance Office keeps a list of FQHCs. Or see the full Community Health Center listings. Another tool for finding health centers is the Department of Health's search tool .

- Nurse-managed Health Centers. Nurse-managed health centers are an excellent option for immigrant health coverage. Nurse-managed health care centers are staffed by nurses who provide excellent care for patients at the centers on a sliding fee scale or in some cases for free. There are no restrictions for treatment based on immigration status or not having a Social Security Number. It is extremely important to note that, in the event an immigrant need specialist care beyond the scope of the nurse-managed health care center, the nurse practitioner's can complete MA forms and EMA letters on behalf of patients, thus helpgin them secure MA coverage for the needed specialty care. Please see the following NNCC listing of the Pennsylvania nurse-managed health care centers to find a nearby cener or learn more about nurse-managed health care centers.

- HealthyWoman cites. Healthy Woman/"50+" sites offer reduced-cost treatment on a sliding fee scale for numerous women's health services, including mammograms, PAP tests, and other services. The service is available to all women 50 year old or older, and some services are available to some women age 40 or older. All of these basic HealthyWoman services (with one important exception below) are currently available regardless of immigration status. Here is a statewide map of HealthyWoman sites.

(Note: The HealthyWoman cites are also the entry point into the Breast and Cervical Cancer Prevention and Treatment (BCCPT) program, which is a Medical Assistance program. Women any age are eligible for BCCPT screening at a HealthyWoman site, but BCCPT program treatment is subject to the normal Medical Assistance immigration status requirements and specific income requirements. Immigrant women who are not in a Medical Assistance "qualified" immigrant status will be able to access HealthyWoman Medical Assistance BCCPT services only through the Emergency Medical Assistance process, as described above in Part I. So, in summary, BCCPT services paid for by MA require the EMA process for a woman in a "non-qualified" immigrant status, but all other HealthyWoman services are available to immigrant women without limitations. See our Health Care for Women page for details about the BCCPT program.)

- WIC. The Women, Infants, and Children program is available to provide food and nutrition information to pregnant and breast-feeding women, as well as to children up to the age of 4, without regard to immigration status. For information on the WIC Center closest to you, call 1(800)WIC-WINS. In Philadelphia, the WIC program has the same protections for immigrants as the Philadelphia Health Care Centers -- see the Philadelphia City Solicitor document.

- PACE/PACENet. PACE is a fantastic low-cost prescription drug program for Pennsylvanians 65 and older who meet the PACE income requirements, regardless of immigration status. For individuals over the PACE income limit, there is another tier of coverage called PACENet, with an even higher income limit. For more information about PACE, see the PACE program website .

- Prescription assistance programs. NeedyMeds.com, RxAssist.org, and other prescription program sites have information available about free or reduced rate prescription programs run by drug companies. Some of these programs may be open to individuals regardless of immigration status. Immigrants with prescription drug needs who can't get them through programs such as MA or PACE/PACENet should see if they can get their prescription drugs covered through sites such as NeedyMeds.com or RxAssist.org. Immigrants can also directly contact the drug companies who produce the drugs they use to find out about what reduced-cost programs their drug company has.

- COBRA/HIPAA laws. COBRA and HIPAA each have provisions designed to protect workers who are displaced from a job through which they get health insurance coverage, and these laws operate regardless of immigration status. These laws may be very important to immigrants as the state tries to encourage lower-wage and smaller employers to take up health care for employees.

COBRA requires an employer to allow a former employee to purchase into the group insurance plan for a period of 18 months (in most cases) after losing employment. The employee must start COBRA coverage within 63 days of losing their job coverage. Although the group plan often expensive, it is often high quality, and it provides coverage during the transition period after the job. It is vital to understand that if coverage lapses for more than 63 days at any point, new insurance companies will be allowed to apply a pre-existing conditions exclusion against the potential recipient. For information on COBRA, immigrants should talk to their employers.

HIPAA is a federal law which requires the state to offer at least two health plans that do not have pre-existing exclusion clauses to an individual who lost an employment/government/church insurance plan that they had for at least 18 months prior. These plans can only be accessed after any available COBRA coverage runs out. For more information, see an excellent summary about HIPAA from the Georgetown University Health Policy Institute. Again, it is vital to not have a 63 lapse in coverage at any point, or else there is no coverage for pre-existing conditions. To enroll in a HIPAA plan, contact your local Blue Cross/Blue Shield plan.

- Special Care. Special Care is a private reduced-cost insurance available to low-income individuals and families. It is currently the policy of the Special Care HMO contractors to allow enrollment regardless of immigration status. Special Care is not a free program, has pre-existing condition exclusions, and does not offer coverage as comprehensive as programs like Medical Assistance and CHIP. Nonetheless it may be a good option for an immigrant or immigrant family that is in a "non-qualified" immigration status (and therefore ineligible for MA or CHIP) and would like to purchase a basic health insurance. More information about Special Care is available at the Caring Foundation website. (Please note: "Qualified" immigrant children should never be enrolled in Special Care; if they are eligible for Special Care they are certainly also eligible for CHIP, which provides much better coverage for free (or at a much lower premium).

- Charity Care. Most Pennsylvania hospitals provide free uncompensated care to some patients, based on complex state and federal funding requirements as well as optional charitable missions. Typically, access to this funding is not automatic. Instead, the hospital typically has an application process, whereby someone with outstanding medical bills requests to have those bills paid for by the charity care funds. In many cases, this charity care funding is available regardless of immigrant status. If an immigrant is unable to have bills paid through Emergency Medical Assistance (see Part I. above), they should attempt to apply for Charity Care at the hospital. They should contact hospital social workers and staff and ask about how to apply for hospital charity care programs.

-County MH/MR services. Every county in Pennsylvania is required to provide Mental Health and Mental Retardation services for county residents. These services may include everything from basic wellness visits, to home supports, to crisis intervention care. Because the system is organized at the county level, and due to the wide range of funding sources (local, state, and federal funds), it is difficult to generalize about what servics are available without regard to immigration status. It is important to remember that County MH/MR programs may offer numerous important services which are available to all immigrants, and should always be consulted for problems that involved mental or behavioral health or mental retardation. More information is available on the Department of Public Welfare website about county MH/MR services.

- Other options . For other options for free health care for immigrants, see our information on free dental care and free eye care.

 

PART III. Special issues in helping immigrants get health care coverage and overcoming barriers to care.

Even if an immigrant is eligible for a public health program, there are a whole host of barriers and challenges which may prevent the immigrant from applying and becoming eligible.

•  Mixed Status Families

A mixed status family is one where some members of the family have different immigration statuses from other members of the family. For example, a family where the parents are undocumented immigrants, but their child is a citizen, is a mixed status family. Remember, any child born in the U.S. is a U.S. citizen with all of the full rights of citizenship, regardless of the immigration status of his or her parents. Any person who is eligible for a publicly funded program such as MA is eligible regardless of the status of his or her family or household members, and should apply immediately. See the NILC publication on Immigrants & Public Benefits for a nice description of this issue.

•  Fear of Applying For Programs

Many immigrants do not apply for health programs they are eligible for, or do not apply for their children, out of fear that they will have problems with government or immigration authorities. The reality is that although there is never a 100% guarantee, applying for public health programs is extremely low risk for immigrants. There are numerous reasons why it is extremely low risk and immigrants should not be afraid to apply. First of all, as mentioned above, only the immigration status of the intended beneficiary is relevant to an application for a program such as Medicaid or CHIP. It does not matter if other household members are, for example, undocumented immigrants. See the NILC publication mentioned above.

In addition, it is also not the policy of health care programs to "report immigrants". PHLP is aware of no policy in any PA public health program encouraging or requiring the sharing of personal immigration status information with immigration or governmental authorities. In fact, some programs explicitly prohibit the sharing of private immigrant information. For example, the City of Philadelphia considers immigration status to be confidential information and specifically prohibits city employees from disclosing this information about immigrants using city services such as the City Health Care Centers. See page 3 of the City Solicitor's letter.

Some immigrants are also concerned about how the use of public health programs will affect their pending or future immigration applications. But the reality is that use of public health programs does not affect residence or citizenship applications, with the very limited exception of health programs for Long Term Care (such as institutionalization or nursing homes). For an excellent description of this issue, see the NILC Guide on "Public Charge".

•  Language Problems

Language access is a major access issue for immigrants who are “Limited English Proficient” (“LEP”). The law on this issue is clear: Any entity receiving Federal funding (and most public programs receive Federal funding) must be in compliance with policy guidances designed to enforce Title VI of the 1964 Civil Rights Act which prohibits discrimination on basis of national origin, including language. Immigrants should be provided translation and interpretation services when using public health care programs, including Medical Assistance, CHIP, Philadelphia Health Care Centers, and virtually all others. In addition, most hospitals are required to provide language assistance also.

At the very least, immigrants at health program offices (such as welfare offices) and hospitals should be provided an interpreter through a language-line, which is an interpreter that is used by the telephone. An immigrant should be provided a card to select their language, and then an interpreter is called who can interpret the conversation or documents. Here is a sample language-line card.

•  Verification Problems

Verifications are documentation requirements that health programs have to confirm information that is required when you apply. Although verification often causes problems, in many cases verifications are not really necessary, or there are simple solutions.

 The most common problems involve:

•  Social Security numbers (SSN). Although most programs request a Social Security number, it is not always required. EMA does not require SSNs. Neither do the Philadelphia Health Care Centers or other city programs, as confirmed in a first and second city document. MA does require SSNs (except children under age 1), but the welfare office must assist eligible immigrants in applying for SSNs, and once an immigrant has applied for an SSN they can not be denied or delayed benefits if they are otherwise eligible. This rule comes from Federal agency guidance. Remember also, as mentioned above, that the SSNs of household members who are not beneficiaries of the application should not be required.

•  Immigration Status. Proof of immigration status is also not required in all programs. EMA does not require proof of immigration status (see also MAEH 322.1 and 322.33). Philadelphia Health Care Centers and other city services also do not require proof of immigration status (see also Policy notice). Although MA does require "qualified" immigrant applicants to verify their immigration status, immigrants who are having trouble proving their immigration status due to lacking "documentation" can refer the CAO to the SAVE program "verification" process. Note in the rules that an application can not be delayed while a "verification" is conducted. In some situations the CAO may allow benefits based on the "verification" where and immigrant lacks "documentation". In situations of dire medical need where immigration status is contested by the CAO, an immigrant/advocate may consider running the application through Emergency Medical Assistance, which has no immigrant status documentation/verification requirements.

•  City, County, State residence. Geographic residence is a requirement for many state programs. It is important to understand this has nothing to do with immigration “Permanent Residence” status; this is just a question of what your address is. For example, to use a Philadelphia Health Center you must have a Philadelphia address. In cases where an immigrant has difficulty establishing an address for MA or EMA, refer to the rules on homelessness and/or consider having an organization write a letter confirming the address. For Philadelphia Health Centers, it is also acceptable to have an organization write a confirmation letter.

•  Proof of income. Eligibility for MA programs depends on income, which must be proven through documentation. This can be especially tricky for immigrants, who may be paid in cash or “under the table”. If an immigrant is paid by check, copies of the paystubs suffice. Otherwise, the immigrant will usually need a letter from the employer confirming the employment and wage. An advocate may need to be involved to explain to a nervous employer the very limited purpose for sharing this information. In the most difficult cases, advocates should try and find reliable sources ("collateral contacts") who can confirm the employment and wages. This type of soluation requires active advocacy with reliable sources and the CAO office until a solution is worked out. It is important to note that as long as the immigrant is cooperating with the CAO to get verification, the CAO must help the immigrant get the verification, and his or her case can not be denied. For these rules, and for more options for income verification, see MAEH 350.11.

 

FOR MORE INFORMATION ABOUT HEALTH CARE FOR IMMIGRANTS, CONTACT THE PA HEALTH LAW PROJECT HELPLINE AT 1-800-274-3258.