For the last two decades, roughly one million people per year have been granted lawful permanent residence in the United States. 1 In addition, there were about 10.5 million undocumented immigrants in the U.S. in 2021, although that number has fallen from a high of more than 12 million in 2007. 2 (Note that lawful permanent residency is not the same thing as citizenship, although both grant a person the right to be in the United States. Undocumented immigrants are not U.S. citizens and do not have any valid immigration documents, such as a visa, that would allow them to be in the U.S. lawfully.)
New immigrants – including those who gain citizenship or lawful permanent residency – can obtain health insurance from a variety of sources, including employer-sponsored plans, the individual/family market, and health plans that are marketed specifically for immigrants.
However, recent immigrants are often confused in terms of what health insurance options are available to them. Persistent myths about the ACA have made it hard to discern what’s true and what’s not in terms of how the ACA applies to immigrants who haven’t obtained U.S. citizenship
So let’s take a look at the health insurance options for immigrants, and how they’ve changed – or haven’t changed – under the ACA and various state-based approaches.
Yes, as long as they’re lawfully present in the U.S.
And starting with the open enrollment period that begins in November 2024, DACA recipients will be able to use the Marketplace for the first time. 3 DACA recipients are not lawfully present (although they are considered lawfully present for some purposes during their deferred action period), so they have not historically been allowed to enroll in Marketplace coverage. The Biden administration finalized a rule change in 2024 that allows DACA recipients to use the Marketplace starting November 1, 2024 (for coverage effective in 2025) and qualify for income-based subsidies on the same terms as any other enrollee.
As discussed below, some states are starting to establish their own programs that provide health coverage to eligible applicants regardless of immigration status.
Open enrollment for individual-market health insurance coverage runs from November 1 to January 15 in most states, although some states have different deadlines. During this window, any non-incarcerated, lawfully present U.S. resident (except DACA recipients, and that will change in November 2024 as described above) can enroll in a health plan through the exchange in their state. (Depending on the state, this can be a state-run platform or the federally run HealthCare.gov.) It’s also an option to enroll outside the exchange during that window, although financial assistance is not available outside the exchange.
When you become a new U.S. citizen or gain lawfully present status, you’re entitled to a special enrollment period in your state’s exchange (Marketplace). You’ll have 60 days from the date you became a citizen or a lawfully present individual to enroll in a plan through the exchange, with subsidies if you’re eligible for them.
There are a variety of other special enrollment periods that apply to people experiencing various qualifying life events. These special enrollment periods are available regardless of whether a person is a lawfully present immigrant or a native-born U.S. citizen.
You do not have to be a U.S. citizen to benefit from the ACA. If you’re in the U.S. legally – regardless of how long you’ve been here – you’re eligible for subsidies in the exchange if your income is in the subsidy-eligible range and you don’t have access to an affordable employer-sponsored plan that provides minimum value. (As discussed below, some states are establishing programs that use state funds to subsidize health coverage for undocumented immigrants).
Premium subsidies are normally only available to exchange enrollees if their income is at least 100% of the federal poverty level (FPL), but subsidies also extend below the poverty level for recent immigrants, as described below.
Lawfully present immigrant status applies to a wide range of people, including those with “non-immigrant” status such as work visas and student visas (as mentioned above, DACA recipients will be allowed to enroll in Marketplace plans starting in November 2024). So even if you’re only in the U.S. temporarily – for a year of studying abroad, for example – you can purchase coverage in the health insurance exchange for the state you’re living in while in the U.S. Depending on your income, you might be eligible for a premium subsidy to offset some of the cost of the coverage.
Yes. The ACA called for the expansion of Medicaid eligibility to all adults with income up to 138% of the poverty level, and no exchange subsidies for enrollees with income below the poverty level, since they’re supposed to receive Medicaid coverage instead. But Medicaid isn’t available in most states to recent immigrants until they’ve been lawfully present in the U.S. for five years. (Note that the majority of the states do provide income-based Medicaid to lawfully-present children and/or pregnant people who have been in the U.S. less than five years.) 4 To address this issue, Congress included a provision in the ACA to allow recent immigrants to get subsidies in the exchange regardless of how low their income is.
Low-income, lawfully present immigrants – who would be eligible for Medicaid based on income but are barred from Medicaid because of their immigration status – are eligible to enroll in plans through the exchange with full subsidies during the five years when Medicaid is not available to them. (For reference, this issue is detailed in ACA Section 1401(c)(1)(B), and it appears on page 113 of the text of the ACA.) Their premiums for the second-lowest-cost Silver plan are entirely covered by the premium subsidy through at least the end of 2025. (The elimination of premiums at this income level is due to the American Rescue Plan and its enhancement of the ACA’s premium subsidies. These provisions were extended through 2025 by the Inflation Reduction Act.)
Lawmakers included subsidies for low-income immigrants who weren’t eligible for Medicaid to avoid a coverage gap for this population. Ironically, there are currently about 1.5 million people in nine states who are in a coverage gap that exists because those states have refused to expand Medicaid. (Ten states have refused to expand Medicaid, but only nine of them have a coverage gap; Wisconsin provides Medicaid to adults with income up to the poverty level, so there is no coverage gap in Wisconsin.) 5
The ACA provides that there would be no coverage gap for recent immigrants by requiring all states to expand Medicaid eligibility. In 2012 however the Supreme Court declared the Medicaid expansion mandate unconstitutional. In practice this makes Medicaid expansion optional for the states and some states have blocked expansion, leading to a coverage gap for hundreds of thousands of U.S. citizens.
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Yes. Most individuals become eligible for Medicare when they turn 65, and no longer need individual-market coverage. However, recent immigrants are not eligible to buy into the Medicare program until they’ve been lawfully present in the U.S. for five years.
As a result of the ACA, policies in the individual market are available on a guaranteed-issue basis, regardless of age. And if the plan is purchased in the exchange, subsidies are available based on income, just as they are for younger enrollees. (It’s unlawful to sell an individual-market plan to anyone who has Medicare, but recent immigrants cannot enroll in Medicare.) 6
The ACA also limits premiums for enrollees age 64 or older to three times the premiums charged for an enrollee who is 21. 7 (A few states limit that further, 8 and two states – New York and Vermont – do not allow premiums to vary at all based on age. 9 ) So there are essentially caps on the premiums that apply to elderly recent immigrants who are using the individual market in place of Medicare, even if their income is too high to qualify for subsidies.
No, unless a state has established a program for this purpose. Although the ACA provides benefits to U.S. citizens and lawfully present immigrants alike, it does not provide any benefits for undocumented immigrants.
The ACA specifically prevents non-lawfully present immigrants from enrolling in coverage through the exchanges. 10 And they are also not eligible for Medicaid under federal guidelines. So the two major cornerstones of coverage expansion under the ACA are not available to undocumented immigrants.
Some states – described in more detail below – have implemented programs to cover undocumented immigrants – particularly low-income children and/or people who are pregnant.
It’s important to understand that if you’re lawfully present, you can enroll in a plan through the exchange even if some members of your family are not lawfully present. Family members who aren’t applying for coverage are not asked for details about their immigration status. And HealthCare.gov clarifies that the immigration details you provide to the exchange during your enrollment and verification process are not shared with any immigration authorities.
Several states use their own funds to provide Medicaid coverage to undocumented immigrants with low incomes.
But what about allowing undocumented immigrants to purchase coverage through a state-run exchange, either at full price or with state-funded subsidies? That idea has been gaining traction in recent years.
It was first considered by California in 2016 (via legislation and a 1332 waiver submission to the federal government). But in January 2017, just two days before Donald Trump’s inauguration, California withdrew its waiver proposal, citing concerns that the Trump administration might use information from Covered California to deport undocumented immigrants.
New York lawmakers considered legislation in 2019 that would have allowed undocumented immigrants to purchase full-price coverage in NY’s state-based exchange, but it did not progress in the legislature. As noted in the text of the legislation, New York would have needed to obtain federal permission to implement this law if the state had enacted it.
But other states are now making this idea a reality:
Maryland enacted legislation in 2024 that directs the state to seek federal permission to allow undocumented immigrants to use the state-run exchange starting in 2026, with state-funded subsidies available to eligible enrollees. 16
California lawmakers are considering legislation in 2024 that would allow undocumented immigrants (who aren’t already eligible for Medicaid) “to enroll in health insurance coverage in a manner as substantially similar to other Californians as feasible,” while being consistent with federal rules. This is likely referring to the sort of separate platform that Colorado created, as the legislation does not call for the state to seek federal permission to allow undocumented immigrants to use the Covered California platform. The bill passed in the California Assembly in May 2023, and was being considered in the Senate more than a year later, in August 2024. 17
In terms of the insurance status of undocumented immigrants, the numbers tend to be rough estimates, since exact data regarding undocumented immigrants can be difficult to pin down. But according to Pew Research data, there were 10.5 million undocumented immigrants in the U.S. as of 2021. 18
According to a recent Kaiser Family Foundation analysis, undocumented immigrants are significantly more likely to be uninsured than U.S. citizens: as of 2023, about 50% of undocumented immigrants are uninsured, versus about 8% of citizens.
So about half of the undocumented immigrant population has some form of health insurance coverage. Kaiser Family Foundation’s Larry Levitt noted via Twitter that “some are buying non-group, but I’d agree that it’s primarily employer coverage.” Undocumented immigrants also have the option to enroll in student health plans and individual (i.e., non-group) plans purchased off-exchange (on-exchange, enrollees are required to provide proof of legal immigration status).
Uninsured undocumented immigrants do have access to some healthcare services, regardless of their ability to pay. The Emergency Medical Treatment & Labor Act (EMTALA), a federal law, requires Medicare-participating hospitals to provide screening and stabilization services for anyone who enters their emergency rooms, without regard for insurance or residency status.
Since emergency rooms are usually the most expensive setting for healthcare, local officials in many areas have opted for less expensive alternatives. Of the 25 U.S. counties with the largest number of undocumented immigrants, the Wall Street Journal reports that 20 have programs in place to fund primary and surgical care for low-income uninsured county residents, typically regardless of their immigration status.
Yes. As part of the enrollment process, the exchanges are required to verify lawfully present status. Applicants who are asked to provide documentation to verify citizenship or immigration status have 95 days in which to do so. If they don’t, their coverage and/or financial assistance can be terminated. 19
The details of how HealthCare.gov resolves immigration status data matching issues are explained here. There are enrollment assisters in your community who can help you with this process if necessary. But if you’re not lawfully present, you cannot enroll through the exchange in most states, even if you’re willing to pay full price for your coverage. You can, however, apply for an ACA-compliant plan outside the exchange, as there’s no federal restriction on that.
Immigrants who are unable to afford ACA-compliant coverage might find that a short-term health insurance plan will fit their needs and it’s better than being uninsured, although it is not a replacement for major medical health insurance. Short-term plans are not sold through the health insurance exchanges, so the exchange requirement that enrollees provide proof of legal residency does not apply to short-term plans. However, proof of residency may still be required by an insurer that offers short-term plans.
Short-term plans provide coverage that’s less comprehensive than ACA-compliant plans, and for the most part, they do not provide any coverage for pre-existing conditions. The premiums for short-term plans are lower than the unsubsidized premiums for ACA-compliant plans because short-term plans do not provide comprehensive coverage like ACA-compliant plans and do not cover things like the ACA’s 10 Essential Health Benefits or pre-existing conditions. But most lawfully present immigrants will qualify for premium subsidies in the exchange, especially through the end of 2025 as a result of the American Rescue Plan’s subsidy enhancements (which have been extended through 2025 under the Inflation Reduction Act).
Recent immigrants who are eligible for premium subsidies in the exchange will likely be best served by enrolling in an ACA-compliant plan through the exchange – the coverage will be comprehensive, with no limits on annual or lifetime benefits and no exclusions for pre-existing conditions.
With any insurance plan, it’s important to read the fine print and understand the ins and outs of the coverage. That’s particularly important with short-term plans, as they’re not subject to the same sort of insurance regulations that apply to other types of coverage. Some states have extensive rules for short-term plans, so availability varies considerably from one state to another (you can click on a state on this map to see how the state regulates short-term plans).
Travel insurance plans are another option, particularly for people who will be in the U.S. temporarily and who don’t qualify for premium subsidies in the exchange. Just like short-term plans, travel insurance policies are not compliant with the ACA, so they generally won’t cover pre-existing conditions, tend to have gaps in their coverage (since they don’t have to cover all of the essential health benefits), and will come with limits on how much they’ll pay for an enrollee’s medical care. But if the other alternative is to go uninsured, a travel insurance plan is better than no coverage at all.
In August 2019, the Trump administration finalized rule changes for the government’s existing “public charge” policy, after proposing changes nearly a year earlier. And in October 2019, President Trump issued a proclamation to suspend new immigrant visas for people who were unable to prove that they’d be able to purchase (non-taxpayer funded) health insurance within 30 days of entering the US “unless the alien possesses the financial resources to pay for reasonably foreseeable medical costs.”
Even before they were initially blocked by the courts, Trump’s public charge rule and immigrant health insurance requirement did not change anything about eligibility for premium subsidies in the exchange – subsidies continued to be available to legally present residents who met the guidelines for subsidy eligibility. But these new rules were designed to make it harder for people to enter the United States in the first place, and potentially deterred otherwise eligible people from applying for financial assistance with their health coverage, including assistance via Medicaid or CHIP for their US-born children.
Here’s the backstory on these rules:
The public charge rule was initially delayed for a few months amid legal challenges, but it was implemented in February 2020. It was vacated by a federal judge in November 2020, but that order was soon stayed by the Seventh Circuit Court of Appeals, allowing the Trump administration’s version of the public charge rule to continue to be implemented while litigation on the case continued. Soon thereafter, the Ninth Circuit Court of Appeals blocked the rule from being used by immigration officials in 18 states and DC, but it could still be used in the majority of the states until the Biden administration revoked it in April 2021.
Advocates noted that the rule, which was proposed in 2018, began to lead to coverage losses immediately, even though it didn’t take effect until 2020. The rule resulted in numerous immigrants forgoing the benefits for which they and their children were eligible, out of fear of being labeled a public charge. Georgetown University’s Health Policy Institute, Center for Children and Families noted in 2020 that the public charge rule change was one of the factors linked to the sharp increase in the uninsured rate among children in the U.S.
The longstanding public charge rule states that if the government determines that an immigrant is “likely to become a public charge,” that can be a factor in denying the person legal permanent resident (LPR) status and/or entry into the U.S.
For two decades, the rules excluded Medicaid (except when used to fund long-term care in an institution) from the services that are considered when determining if a person is likely to become a public charge. But under the 2019 rule change, Medicaid, along with Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), and several low-income housing programs were added to the list of services that would push a person into the “public charge” category. The National Immigration Law Center noted that the public charge assessment did not apply to lawful permanent residents renewing their green cards.
Critically, CHIP and ACA premium subsidies were not included among the new additions to the public charge determination, although the final rule in 2019 did incorporate a “heavily weighted positive factor” that essentially gave the person credit for having private health insurance without using the ACA’s premium subsidies. (In other words, a person’s likelihood of being labeled a public charge would decrease if they had health insurance without premium subsidies, but enrolling in a subsidized plan through the exchange would not count as a negative factor in determining whether the person was likely to become a public charge.)
Very few new immigrants are eligible for Medicaid, due to the five-year waiting period that applies in most cases (As noted above, there is an exception to the five-year waiting period in many states for children and people who are pregnant.) But immigrants who have been in the U.S. for more than five years can enroll in Medicaid, and more recent immigrants can enroll their U.S.-born children in Medicaid; these are permissible uses of the Medicaid system. But even before the 2019 rule was scheduled to take effect, advocates noted that it was making immigrants fearful about applying for subsidies, CHIP, or health coverage in general – for themselves as well as for their family members who were U.S. citizens and thus entitled to the same benefits as any other citizen.
The public charge rule was slated to take effect on October 15, 2019, but federal judges blocked it on October 11, temporarily delaying implementation. In January 2020, the Supreme Court ruled (in a 5-4 vote) that the public charge rule could take effect while an appeal was pending, and it took effect in February 2020. The Supreme Court declined to temporarily pause the rule amid the COVID pandemic. But U.S. District Judge Gary Feinerman, in Chicago, vacated the rule in its entirety, nationwide, as of November 2020. Just two days later, however, the Seventh Circuit Court of Appeals stayed Judge Feinerman’s order, allowing the Trump administration’s version of the public charge rule to continue to be implemented while litigation on this case continues.
On December 2, however, the Ninth Circuit Court of Appeals blocked the rule from being applied in 18 states and DC. So as of December 2020, the public charge rule could be used by immigration officials in some states but not in others. But the public charge rule was revoked nationwide in April 2021.
If the health insurance proclamation for new immigrants had been allowed to take effect, people applying to enter the United States on an immigrant visa after November 3, 2019 would have had to prove that they had or would imminently obtain health insurance, or that they had the financial means to pay for “reasonably foreseeable medical costs” – which was certainly a very grey area and very much open to interpretation.
The rule would not have allowed new immigrants to plan to enroll in a subsidized health insurance plan in the exchange. Premium subsidies would have continued to be available to legally present immigrants, but new immigrants entering the U.S. on an immigrant visa would have had to show that their plan for obtaining health insurance did not involve premium subsidies in the exchange. And applicants cannot enroll in an ACA-compliant plan unless they’re already living in the US, so people trying to move to the U.S. would not have been able to enroll until after they arrived.
There were also concerns about the logistics of getting a plan in place if a person wanted to sign up for a full-price ACA-compliant plan: Gaining lawfully present immigration status is a qualifying event that allows a person to enroll in a plan through the exchange (but not outside the exchange), but the special enrollment period is not available in advance; it starts when the person gains their immigration status.
At that point, the person has 60 days to enroll. Before 2022, enrollments had to be completed by the 15th of the month to have the coverage take effect the first of the following month. If they signed up after the 15th of the month, coverage wouldn’t start until the first of the second following month, which might be more than 30 days after the person arrives in the country (as of 2022, HealthCare.gov and most of the state-run exchanges allow coverage to take effect the first of the month following enrollment, regardless of which calendar day the person enrolls 20 and that will be the case in all states by 2025). 21 In short, the requirements of the proclamation didn’t necessarily match up with the logistics of how enrollment worked in the ACA-compliant market at that point.
Under the terms of the proclamation, short-term health insurance plans would have been considered an acceptable – albeit temporary – alternative for new immigrants. But short-term plans often have a requirement that non-US-citizens have resided in the U.S. for a certain amount of time before enrolling, which would make them unavailable for people living outside the U.S. who are applying for an immigrant visa. A travel/expat policy (which has a limited duration, just like short-term coverage) would be available in these scenarios, however, and can be readily obtained by healthy people who are going to be living or traveling outside of their country of citizenship.
The health insurance rules for immigrants were initially blocked by the courts, just like the public charge rule changes. In November 2019, the day before the proclamation regarding health coverage for immigrants was to take effect, a 28-day restraining order was issued by District Judge Michael H. Simon. Judge Simon subsequently issued a preliminary injunction, blocking the rule from taking effect. And an appeals court panel upheld the ruling in May 2020. But in December 2020, a three-judge panel from the U.S. Court of Appeals for the Ninth Circuit vacated the preliminary injunction, issuing a 2-1 ruling in favor of allowing the Trump administration’s immigrant health insurance requirements to be implemented.
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org.
