Access to Health Coverage for Immigrants Living with HIV

Webinar Transcript January 28, 2015 Access to Health Coverage for Immigrants Living with HIV Hello everyone, and welcome to today's ACE TA Center webinar. My name is Stewart Landers, and I'm the co-principal investigator for the ACE TA Center based at JSI Research and Training Institute. Our goal at the ACE TA Center is to help Ryan White HIV/AIDS program grantees and providers enroll diverse clients, especially people of color, in health insurance coverage. Today our presenters are going to focus on and explain how some immigrants for Marketplace coverage depending on their immigration status and how immigrants can access other federal health care programs. We will also share culturally and linguistically competent strategies to help address clients' fears and concerns about what it means to enroll in health insurance. Before we get started, let me go over a few technical details. You can submit your questions at any time during the call using the chat box. We will stop at a few different points to go over the questions that have come in. Questions that we don't get to on the call will be answered in a separate document. The easiest way to listen to today's call is through your computer. If you can't, can't hear, please make sure your computer sound is turned on. If you still can't hear us, or if you're experience a sound delay, try refreshing your screen, or you can mute your computer audio and call in using your telephone. The number is 1-800-734-4208, on the, it's on the screen as well. Will you read the number again? 1-800-743-4304. Sorry, there was a glitch. Again, if the presenter and the slides are out of sync with each other at any time during the call, you can just mute your computer speakers and use this telephone number instead. Today's learning objectives are as follows: We hope, after this webinar, you will know how to engage and enroll Ryan White HIV/AIDS Program clients who have recently migrated to the United States or who may have family members in this situation in a culturally and linguistically competent manner. We also hope you'll be able to address the fears and concerns of these clients to help them enroll in new, Affordable Care Act, or ACA health insurance options. Today's presenters include Angel Padilla from the National Immigration Law Center and Kate Bicego from Health Care for All. We are so pleased to have both of them with us today, as we've heard from so many of you about the need to learn about and understand more about immigration status and eligibility for ACA coverage options. www.targethiv.org/ace

Angel Padilla, MPA, is a health policy analyst at the National Immigration Law Center. He works closely with other health project staff to develop and implement NILC's federal immigrant health policy agenda. Angel will explain the immigrant eligibility rules for Medicaid and CHIP and then talk about who is eligible for Marketplace coverage under the ACA. He will also walk through some common concerns and then explain the protections that are in place for immigrants and their families. Angel will walk us through a couple of eligibility scenarios to help us apply what we've learned. Kate Bicego is a senior manager at Health Care for All in Boston, Massachusetts, where she led efforts to oversee the expansion of their toll-free health insurance helpline into the largest and most effective consumer health assistance program in Massachusetts, taking 30,000 to 40,000 calls each year. Kate will talk about her program's experience assisting clients with enrollment and will share best practices for supporting immigrant clients, mixed immigrant status families, along with application and enrollment tips from her staff. As you may have noticed, we've scheduled 90 minutes for today's session because there's so much information to cover. We plan to spend about an hour on the actual presentations, and then we'll spend the final half hour taking questions. Mira Levinson, the ACA Center Project Director, will assist with moderating the question session. Within a week of this c-, call, we will also send a written summary of all questions and answers to all the participants. Um, Angel's section has a lot of information in it, but, hang in there, I think it's going to be amazing. Next slide. As a reminder, our webinar will be archived on our Target Center web page at, that you can see on the screen now. All participants in today's call will also receive an email when it is posted, so you can share, the webinar with your colleagues, who may not have been able to attend today. You will also find links at this website for all the tools we're going to present, and if you forget the direct link, you can also find us by going to the Target website home page or through the topic library there. So just to get everyone rolling, we're going to have a quick audience poll, um, question. Very simple, have you ev-, ever been on an ACE TA Center webinar before, and yes, no, or N/A? Okay, giving everyone another few seconds. So r-, roughly speaking, it looks like about 50/50. About half of you have been on one of our calls before and half have not. So welcome to the newbies and very much welcome to all our returning customers. Next. So why the focus on immigrants? First of all, the U.S., immigrant population is an important sub-population for a number of reasons. Actually, 16 percent of the U.S. population of, is, of the U.S. residents are foreign born. Longer residence in the United States is actually associated with increased prevalence of HIV. In other words, most immigrants living with HIV become HIV positive after moving here. Also, immigrants are ACE TA Center webinar transcript Coverage for Immigrants Page 2

more likely than native-born U.S. residents to present for care with and AIDS-defining illness. Several issues often faced by Ryan White HIV/AIDS Program clients in-, include stigma, apprehension about the U.S. health care system, substance use, homelessness, and negotiating the tension between maintaining work and seeking health care. A lot of those issues are compounded by fear and resulting barriers stemming from immigrant status. These factors can create serious b-, barriers to routine care and Affordable Care Act enrollment for immigrants. Also, when the ACA Center did a needs assessment, in our first year, and one of the things we found was that over 90 percent of the agency surveys reported that they were looking for more tailored materials and training that would help them w-, with families with mixed immigration status. As one respondent to part C and part D respondent said, "We would like TA on how to approach enrollment in families where only some of the members are eligible. For example, when some parents are not eligible due to immigration status, often children or other members of the family are eligible. Navigating these issues in culturally competent ways is difficult, both for navigators as well as for families." There are special protections to bear in mind for immigrants with HIV/AIDS in the U.S. First, having HIV/AIDS is no longer a barrier to immigrants attempting to adjust their status. Also, individuals living with HIV/AIDS may have some immigration options available to them if they are available, if they are eligible. Furthermore, HIV status does not impact an immigrant's eligibility for Medicaid and CHIP. Prior to January 4th, 2010, the U.S. HIV travel ban mandated HIV testing for all immigrants who required medical examination for U.S. immigration including, but not all, some entrants desiring long-term residence in the U.S. This change now means that HIV status alone cannot be a reason for excluding, removing, or deporting a person from the United States. The Ryan White community has long been committed to providing care for immigrants and has helped to contribute to build a knowledge base about how to enroll and sustain HIV-positive immigrants in long-term care and coverage. With that, I'll turn it over to Angel. Great. Thank you Stewart. Hi everyone. Before we begin, I just quickly wanted to talk a little bit about the National Immigration Law Center. We are a national legal advocacy organization dedicated to defending and advancing the rights and opportunities of low-income immigrants and their family members, and that's regardless of immigration status. A lot of our work is in access to health care and public benefits. In my presentation, I'll be covering the basic immigrant eligibility rules for Medicaid, CHIP, and the Affordable Care Act. I'll begin with the rules for Medicaid and CHIP, followed by the rules for the ACA. We've also included a couple of cases to look and then additional research... I'm sorry... additional issues of concern for immigrants. ACE TA Center webinar transcript Coverage for Immigrants Page 3

This slide contains an overview of immigrant eligibility for Medicaid and CHIP. These rules were not changed by the health reform law. The current rules originate from the Personal Responsibility and Work Opportunity Act, also known as welfare reform, which passed in 1996. With several exceptions, which I'll discuss shortly, eligibility for these programs still depends on having an immigration status that is defined as a qualified status. Individuals who are not qualified immigrants are considered not qualified and are not eligibility for federal non-emergency Medicaid or CHIP. So what do I mean by 'qualified?' This slide contains the list of qualified immigration statuses who are eligible for Medicaid and CHIP in expansion and non-expansion states. Non-pregnant immigrant adults must have one of these qualified statuses to be eligible for non-emergency Medicaid. The list includes lawful permanent residents, also called green card holders, certain trafficking and domestic violence survivors; and several categories of individuals who obtained their status based on humanitarian reasons, such as refugees, asylees, Cuban and Haitian entrants and s-, and several others. The largest of these groups is green card holders, and is the one that you'll probably see the most of, and, um, and these, the list of qualified immigrant statuses is also posted online on healthcare.gov. I did wanna highlight that there are, there is a 5-year waiting period for Medicaid for most qualified immigrant adults who entered the U.S. on August 22nd, 1996 or later. The waiting period begins when the individual acquires a qualified immigration status, and, in some states, the waiting period can be longer than 5 years. However, there are also statuses, um, qualified statuses that are exempt from the 5-year bar. These are listed on the bottom half of the slide and include refugees, asylees, persons granted withholding of deportation and several others. Some states have elected to offer Medicaid and CHIP to children and pregnant women without the 5-year waiting period. But even though the immigrant eligibility rules are generally very restrictive, most states do receive some Federal funding that become available for immigrants. For example, more than half of the states have taken up what's known as the CHIPRA option, which allows them to provide coverage to lawfully residing pregnant women and children. There are also local efforts to provide coverage to immigrants that vary from state to state and sometimes from county to county. Emergency Medicaid is also available to all individuals regardless of their immigrant status if they are otherwise eligible. But this is only to treat an emergency medical condition. This often simply means stabilizing an individual in a critical, emergency condition, but does include labor and delivery or severe pain. In this next section, we'll look at the immigrant rules for, under the a-, the Affordable Care Act, which fortunately are more inclusive than what we saw for Medicaid and CHIP. We'll go over these in a little more detail, but basically the term 'lawfully present' includes most of the non-u.s. citizens ACE TA Center webinar transcript Coverage for Immigrants Page 4

who have permission to live and work in the United States, including qualified immigrants that we saw under the Medicaid rules. I did want to quickly clarify that lawfully present and lawful permanent residence are not the same thing. A lawful permanent resident is also known as green card, a green card holder and is one of the categories considered lawfully present. Lawfully present is a, a more general term. So this slide, um, lists the immigrant eligibility rules under the ACA. As you can see, they are broader than the m-, than that for Medicaid and CHIP. Remember, for Medicaid and CHIP, a person must be qualified, which is a list on the left and, for some, there is a 5-year waiting period. For the ACA, and individual must be lawfully present, which includes all the qualified immigrants on the left, plus those, um, on the list on the right. Some of the most, most common types of these other categories are individuals with student visas or individuals with temporary protected status, also known as TPS. I did want to also point out that there is an exception to the deferred action category. Although deferred action is generally considered lawfully present for the ACA, persons granted deferred action for childhood arrivals are not. I'll go over this in another slide. Lawfully present for the ACA may also include applicants for certain statuses, including some green card applicants, applicants for asylum, applicants for TPS, and o-, the others listed here. Please note that some of these applicants are only eligible if they have also obtained a work permit. The list of categories of, um, non-citizens is also posted on healthcare.gov. Um, and we also have some of this information on our website, on the NILC's website. Some of you may have questions specifically about the President's recent announcement that certain undocumented immigrants who will be eligible for relief from deportation under the programs known as Deferred Action for Childhood Arrivals, or DACA and Deferred Action for Parents of Americans and LPRs, known as DAPA The short answer is that individuals with DACA or DAPA will not have access to the ACA or to federal Medicaid or CHIP. The regulations for DAPA have not been issued, but we expect, we expect they'll be the same as they were for DACA. Um, the good news is that some say it's, may, um, offer, um, offer coverage to DACA and DAPA recipients using state-only funds. So even though eligibility r-, under the ACA is broader than for Medicaid and CHIP, there are still groups that are left out. Undocumented immigrants and those with DACA and DAPA are ineligible to purchase plans on the individual Marketplace even at full price. However, they are also exempt from the individual mandate that requires individuals to obtain insurance. These individuals can still obtain private coverage outside of the Marketplace or through their employer. I, I did wanna stress that even though this individuals might not be eligible to purchase a plan on the Marketplace for themselves, they may still apply on behalf of eligible family members and can be counted as part of that household. If the d-, if they do apply for eligible family members, they must file a tax ACE TA Center webinar transcript Coverage for Immigrants Page 5

return. If the person is not eligible for a Social Security number, they may file their taxes using and Individual Taxpayer Identification Number, also known as an ITIN. There are also other programs available to individuals left out of the ACA and Medicaid, uh, that does offer a-, that do offer access regardless of immigration status. These include, for example, programs to treat communicable diseases, immunizations, the Ryan White HIV/AIDS Programs, community health centers, and others listed here. The general point that I'm trying to make is that there are many, um, immigrant restrictions for federal health care programs. As you can see in this chart, there are more red X's than there are green checks. Most lawfully present immigrants are eligible for the ACA, but not for Medicaid or CHIP. And, again, some states provide state-only options for those left out of federal programs. In this next section, I'll cover some of the financial assistance available for ACA plans, um, which may also differ depending on a person's status. The two forms of financial assistance under the ACA are premium tax credits and cost sharing reductions. Premium tax credits are a form of financial assistance from the federal government intended to lower the cost of monthly premiums, the monthly bill we, we pay each month to keep our coverage. Cost sharing reductions also come from the federal government and are intended to reduce out-of-pocket costs. In general, lawfully present immigrants who are not eligible for Medicaid, do have access to Marketplace subsidies, including premium tax credits and cost sharing reductions. However, there are a couple special rules for certain immigrants that we need to take into account. So before I begin these next slides, I just wanna say that there's a lot of information here, and so it would be a good idea to come back to these slides, um, and review on your own. Um, so these slides break down the immigrant rules for subsidies on the Marketplace for states that h-, that have expanded Medicaid and those that have not. The states that have expanded Medicaid are represented on the left, and the states that have not expanded Medicaid are on the right. The first thing you'll notice is that lawfully present adults who are not eligible for Medicaid based on their immigration status are eligible for tax credits with income from 0 to 400 percent of the federal poverty line. This is true for both Medicaid expansion states and non-medicaid expansion states. However, in Medicaid expansion states, immigrants who are eligible for Medicaid are only eligible for tax credits if their income is between 138 and 400 percent of the federal poverty line. Those below 138 of the federal, percent of the federal poverty line are not eligible for the Marketplace because they are eligible for Medicaid. And in nonexpansion states, immigrants who are eligible for Medicaid are only eligible for t-, for tax credits if their income is between 100 and 400 percent of the federal poverty line. Those below 100 percent of the federal poverty line are ineligible for both tax credits and Medicaid since ACE TA Center webinar transcript Coverage for Immigrants Page 6

their state is not expanded Medicaid. These individuals fall into what's known as 'the coverage gap.' So, again, there's a lot of information in these slides, um, so I encourage you, uh, to take a look on your own. So as a reminder, uh, any client including lawfully pre-, present immigrants that receive PTCs or CSRs must file federal income taxes. Um, we do have a 'Frequently Asked Questions' document that can help. Uh, the link is both in this slide and has been chatted out, and, um, there you go. Angel. Great. Thank you. Um, so in this next section, we've provided a couple of scenarios to, to test your knowledge. The first family we'll look at consists of Rashid, Alex, and Leila. Rashid and Alex were legally married in the state that recognizes same sex marriage, which means they have the same access to federal health coverage as opposite-sex spouses. So, again, Rashid and Alex are married and live in Oregon. Rashid became a citizen last year. Alex is applying to become a lawful permanent resident, and his visa petition was approved in February. Rashid and Alex have a daughter, Leila, who is enrolled in Medicaid. Their family income is $17,811. Rashid and Alex file taxes jointly and claim Leila as a dependent. Both Rashid and Alex are applying for health coverage. Uh, this slide breaks down the basic eligibility rules for Rashid and Alex and Leila. As you can see, um, Rashid is applying for coverage. He is a citizen and so may be eligible for Medicaid and may be eligible for a, for an ACA plan. Alex, uh, is also applying for coverage, but he is not a citizen. Um, his immigration status is that he is applying to become an, a green card holder, an LPR, um, and has an approved visa petition, so he's not a qualified immigrant and, therefore, ineligible for Medicaid. But he is lawfully present, which makes him eligible for a QHP, um, an ACA plan. And, and Leila has Medicaid so she, uh, does, is not applying for coverage. And this slide breaks it down a little further. Um, in this case, Rashid is eligible for Medicaid because he is a U.S. citizen, and his income is below the Medicaid income limit in Oregon. Alex, on the other hand, is not eligible for Medicaid because he is not a qualified immigrant. He is, however, uh, eligible for subsidies even though his income is under 100 percent of the federal poverty line. This is because, uh, he is not eligible for Medicaid due to his immigration status. Okay. So our poll question is: As a same-sex married couple, can Rashid petition for a green card for his spouse, Alex? Yes or no? Okay, we're gonna close the poll now. And about 80-plus percent indicated that Rashid could sponsor Alex, and that is correct. Uh, yeah, so, um, you know, because they're, um, they're a same-sex couple, but, um, they are also eligible for the same rights as, um, as any other couple. Um, so they are eligible for a immigration visa petitions, um, and, again, for the health care coverage options. ACE TA Center webinar transcript Coverage for Immigrants Page 7

Our next poll question, based on the same scenario is: Alex has applied ha-... I'm sorry... Alex has an approved visa petition and has applied for a green card. Is Alex considered lawfully present for purposes of the ACA? Yes or no? Okay. The votes are coming in. A little over 70 percent, almost 70, about 70 percent say yes, 30 percent say, no. We're gonna close the poll in a few seconds. All right. So just under 70 percent said yes, and Alex... I'm sorry... Angel. (laughs) Yeah, um, the answer's yes. Um, as we went over, uh, lawfully present, also, um, includes individuals who have applied for certain statuses including those who applied for a green card if they also have a, an approved visa petition. So generally what this means is that if a person has a f-, has filed an I-485, they are considered lawfully present for the ACA. Um, if it's, it can get a little complicated, so I would recommend just checking out this document here. There's a link on the, on the, on the screen now, um, that has a breakdown of how that all works. Great. So for example 2, we'll look at a different family. We'll look at Antoine and Eva who are not married, but live together. Antoine and Eva, um... I'm sorry... yes, um, again, they're married, but live together. Eva has Deferred Action for Childhood Arrivals, or DACA, and she earns $29,887 a year. She plans to file federal taxes and will claim Antoine as a dependent. Um, and Antoine is the only one applying for coverage in this scenario. And here's the, an overview of their eligibility. Um, Antoine is applying for coverage, but he's not a U.S. citizen. Um, he is a, his status is that of Temporary Protected Status, um, which all means that he's not a qualified immigrant, which means not eligible for Medicaid, but he is lawfully present, which means he is eligible for a qualified health plan, uh, under the ACA. And Eva, however, is not applying for coverage because she is not eligible. She has, uh, DACA and as I, you know, as I went over in a previous slide, um, individuals with DACA are not eligible for the ACA or Medicaid or CHIP. Just a little bit more information on this scenario. Um, Antoine is, again, lawfully present, but is not eligible for Medicaid because he is not a qualified immigrant. He is, however, eligible for an ACA plan with subsidies. Eva, again, because she is, um, DACA is excluded from Medicaid, from federal Medicaid and the ACA even though she has, um, an authorized work permit and is authorized to be in the U.S. Why is Antoine's income estimated to be at 190 percent of the federal poverty line, even though he's a student and does not work? Is it calculated based on his previous income? Eva's income? His parents' income? Or I am not sure? We'll give everyone a little bit of time for that one. Results are coming in. All right. We're gonna close the poll. And about, just over 65 percent selected Eva's income. Um, and... ACE TA Center webinar transcript Coverage for Immigrants Page 8

So, uh, yeah, so, uh, just quickly, it is Eva's income. Um, income for determining ACA subsidies is based not on the individual's income, but on the household income. So even though Antoine does not work, he lives with his girlfriend, and her income is used to calculate their sub-, his subsidies. And our next question: Eva has DACA and earns just under $30,000 a year. She plans to claim Antoine as a dependent on her taxes. What health coverage options are available to Eva? Marketplace insurance, or the ACA? Federal Medicaid? Emergency Medicaid? Ryan White HIV/AIDS Program? Community health centers? Charity care? Or none of the above? And you can choose multiple... Oh, I'm sorry... You can only choose one item. [inaudible] Okay. So sorry about that. That should be a multi-select, but there is an error in the poll, so just pick one of the ones that you think is correct. Yeah, pick one of the answers you think is right. Okay, we'll give a few more seconds. All right. We're gonna close the poll in 5, 4, 3, 2, 1, 0. Thanks, everybody. Angel? Great. Uh, so um, Eva, again, because she has, um, DACA, she's not eligible for federal Medicaid, um, or for the ACA, which means that, um, you know, she, their, she's not eligible for those programs, but she is eli-, eligible for emergency Medicaid, um, for Ry-, Ryan White, uh, HIV/AIDS Programs, community health centers, and charity care. Um, I did wanna just o-, offer one other clarification just 'cause I know that some people might have questions about this. Um, when is say that DACA and DAPA aren't eligible for, for Medicaid, what I mean is federal Medicaids. I know that some states do go beyond that and, and have, and do offer coverage for, for the, for DACA in the state funded Medicaid. Great. So we also quickly wanted to go, uh, over some of the common concerns for immigrants, uh, that they have when, when they apply for h-, uh, federal health programs. Um, we'll look at these in this, in this next section. The most common concerns we hear about are those related to fears regarding immigration enforcements, but we also hear about public charge, Marketplace barriers, um, and additional concerns for persons living with HIV or AIDs. In terms of immigration enforcement, the good news is that the ACA has strong protections for personal information provided during the application process. Some of these were written specifically with mixed-status families in mind. The U.S. Department of Homeland Security has also clarified that information provided during the application process will not ACE TA Center webinar transcript Coverage for Immigrants Page 9

be used for immigration enforcement purposes. They released this information in both Spanish and English, and, um, the links to those documents is on the bottom. Public charge is another issue that we hear a lot about. Public charge refers to a person who is considered primarily dependent on the government for subsistence, um, cash assistance, um, or long-term care at the government's expense. Medicaid and CHIP... I'm sorry... Medicaid, CHIP, and the Marketplace, uh, subsidies are not considered in screening green card applicants with the exception of long-term insi-, institutional care. Also keep in mind, public charge is not relevant for citizenship applications. And I won't go, uh, too, in too much detail here, uh, but we have heard of a few barriers on the federal Marketplace that disproportionately impact immigrants and that have, have caused a lot of problems for families when they've been applying for coverage. Immigrants often have trouble verifying both their identity and their immigration status, especially those with incomes below 100 percent of the federal poverty line. For, for ID proofing, it's basically that, um, it's based on a person's credit history and, and we know that immigrants generally have less credit history than, than, than citizens. Um, these, these two issues have often stopped consumers, uh, from completing an application on their own, and so we generally recommend, uh, seeking help from a local assister or organization. Okay, so I know we've gone through, um, a ton of slides, so this is, uh, I think my last, uh, section. Um, and we'll be looking at protections for immigrant families. I wanted to stress that discrimination based on race, ethnicity, and national origin including the language spoken, is prohibited by both the Civil Rights Act and the ACA. This applies to all entities receiving federal financial assistance including assisters, clinics, hospitals, etc. Anti-discrimination provisions also apply to processes and procedures that have a chilling effect on eligible immigrants. And I know that we've gone over this in another slide, but I just wanted to stress, again, that, uh, individuals not eligible for the ACA can apply on behalf of eligible family members. Additionally, the Department of Homeland Security has, has clarified that it is safe for non-applicants to apply for their family members. A common question is, uh, that we get is, "When does an individual need to provide a Social Security number?" For Medicaid and CHIP, non-applicants do not have to provide a Social Security number. And so, and by non-applicant, I mean people who are not applying for coverage. For, for the Marketplace, non-applicants should only provide a Social Security number if all the following are true: They have a spouse or tax dependent seeking a premium tax credit. The non-applicant is a tax filer. The non-applicant has a valid Social Security number. The, and they have filed a federal tax return in the 2013 tax year. Um, but, uh, keep in ACE TA Center webinar transcript Coverage for Immigrants Page 10

mind that providing a Social Security number may increase the likelihood that an application is processed accurately. People who are not eligible for a Social Security number may use an Individual Taxpayer Identification Number, also known as an ITIN, to file their taxes, but not for applying for coverage. And a couple final points related to the Small Business Health Options Program, also known as SHOP. N-, so, uh, the SHOP is a, is a health insurance Marketplace designed to help small employers with 50 or fewer full time staff to provide, uh, their employees coverage. There is no immigration status requirement, requirement for individuals to be eligible for insurance through the SHOP. Employers must provide the names and taxpir-, taxpayer identification numbers for workers to the SHOP and must also report to IRS employee enrollment information. However, um, the, there are strict limitations, um, in terms of what the IRS can share with other agencies including the information provided in, for, for this purpose. Um, so that's, um, I know it's a lot of information. I just, um, and I'm sure there are a lotta questions. I'll try to answer some of these that are coming in, but then I'm also available if anyone wants to reach out to me if they have more specific questions. Um, and that's, that's it for me. Thank you. Kate Bicego : Thank you, Angel. Uh, before we here from Kate Bicego. W-, we'd like to hear from you. We're gonna do one more poll. Uh, what is the biggest concern your clients have, your immigrant clients have about enrolling into health coverage programs? Is it immigration enforcement? Concern with being a public charge? ID verification? Inadequate Marketplace coverage? Fear of disclosing HIV status? Or others? And if you wanna chat another to us, please do so, and we will look at the poll results. [inaudible] Check all that apply. Oh, and you can check all that apply on this one, so if you have multiple concerns, feel free to check multiple boxes. Okay. So, um, still have a few more folks chiming in, maybe now that you can check multiple boxes. All right. So we've got about 75 percent, so almost three qu-, over threequarters saying that immigration enforcement is a huge concern. Uh, after that, we're seeing ID verification come in very high, followed by, uh, fear of disclosing HIV status, about a quarter. Uh, and then smaller numbers, uh, for public charge and inadequate Marketplace coverage, about 15 percent for each of those. All right, thanks. We've closed the poll. Thank you everybody. And, with that, um, uh, as a reminder, we are gonna take all questions at the end of today's call, but you can submit your questions at any point by typing them into the chat box on your screen. And, with that, I'm gonna turn it over to Kate Bicego. Hi everyone. Thanks so much, Stewart and Angel. This is Kate Bicego in snowy Boston, Massachusetts. Um, I work for an organization called Health Care for All. Um, we're a statewide organization, and I'm gonna ACE TA Center webinar transcript Coverage for Immigrants Page 11

talk more about Health Care for All, um, but just to get started, I do want to give a, um, brief overview, um, of what I'm gonna cover today. So first, as I said, I'll go over, um, information about the organization that I work for, and I'll talk about our extensive experience assisting immigrants to enroll in both Medicaid as well as, uh, Marketplace coverage and other, uh, public health care coverage programs in Massachusetts. Um, then I'm gonna move into some lessons that we've learned and, you know, highlight as best practices when assisting immigrants who enroll in health care, uh, coverage options. And then last, but not least, I'll, uh, get more into the nitty-gritty about how we, um, use special sort of workarounds for application and enrollment into Medicaid and Marketplace coverage. So just very quickly, um, Health Care for All is a not-for-profit health care advocacy organization. We are based and work only in the state of Massachusetts; although, you may have heard of other, uh, health care advocacy organizations around the country, um, we are an independent organization. Um, we operate a toll-free 1-800 health insurance helpline. You can see our telephone number here. Um, we help a, a lot of people, um, that are immigrants and many that do not speak, um, English. About half of our calls come in a primary language other than English, including Spanish and Portuguese. So we have, um, staff that speak Spanish, Portuguese, and English fluently. We help folks, um, over the phone, to fill out applications for free and lower cost health care coverage through both Medicaid, um, our Marketplace called the Health Connector, as well as other free and lower cost health care coverage options in Massachusetts. Um, outside of that though, we do help to answer any question or trouble-, troubleshoot almost any health care, uh, coverage issue in Massachusetts. So, as I mentioned in my introduction, Health Care for All has had many years' experience assisting immigrants to enroll in subsidized health insurance through our free health insurance helpline. About half of our calls come from households whose primary language is not English. We've served hundreds of thousands of Spanish and Portuguese speaking immigrants in the state of Massachusetts. Um, as many of you know, um, health insurance reform, um, that was a model for the Affordable Care Act was actually passed here in Massachusetts in, in 2006. Um, and since then, our helpline has helped tens of thousands of immigrants enroll into MassHealth, our Medicaid program here in Massachusetts as well as subsidized health insurance coverage through our health insurance Marketplace that was also created in 2006 and is called the Health Connector. Uh, beyond health insurance enrollments, we also help people to understand, uh, what health insurance is and how to use it. Uh, we also help some people to schedule appointments with their health care provider. Additionally, a lot of our work is troubleshooting with consumers in order to identify why a person, and oftentimes their entire family, has fallen through the cracks and remains uninsured and unable to access ACE TA Center webinar transcript Coverage for Immigrants Page 12

health care services. Every year we follow-up with immigrants that we've helped to enroll and let them know they need to renew their health care coverage and help them with their annual renewal forms. We use the experiences of our callers to inform our broader advocacy work at Health Care for All, um, and we meet monthly with high-level officials at Medicaid and the health insurance Marketplace here to share systemic issues that consumers are ex-, um, experiencing and work with them to develop consumer-informed solutions to problems. So I just wanted to share a few of, um, the best practices that we've come up with at Health Care for All when providing application assistance to immigrants. First and foremost, this bul-, first bullet point, uh, talks about application questions and how you should tailor, uh, the questions to the person you're assisting. For example, if a question on the application form says, "Do you have an eligible immigration status?" That's the question we ask here in Massachusetts. It could instead be asked, "Do you have papers?" Ensuring that people fully understand the questions that you are asking and that their response is accurate is also incredibly important. For example, if a question on the application form says, "Are you disabled?" And the person says, "No," even though they are currently out of work doing to complications for a chronic illness, you could clarify the question further by saying something like, "You do not have to be getting disability benefits to be considered disabled." Sometimes you can get better health insurance if you're sick a lot, and you need to check 'yes' to this question in order to get those benefits." We all make mistakes when filling out application forms. Mistakes on the health insurance application can be very damaging if a person is denied benefits due to an error. You can avoid errors by repeating the answers to the person you are helping in order to ensure accuracy. Also, it can be helpful to provide clients with a list of required documents for the application and alternatives if they don't have the needed documents. Last, but not least, it's important to remember that our number one goal in providing application assistance is to get people health care coverage in a way that builds an ongoing and trusting relationship with the people you serve. It's much more likely that the people you serve will return to you for assistance with their renewal form and stay covered as well. I did wanna share a very specific, um, best practice that we use at Health Care for All. We ran into a problem when assisting, um, immigrants over the years that... a lot of folks work in professions and jobs that may not provide traditional payment. Since immigrants do not need to necessarily, since immigrants do... excuse me... need to report their income to Medicaid and the health insurance Marketplace, it's important that they're able to do so in non-traditional ways. So one way that we help immigrants to prove their income is via a "I Earn Cash Affidavit." This is the example of the "I Earn Cash Affidavit" that's on your screen that we use, uh, to send in to Medicaid and the Marketplace to provide proof of income for immigrants that may not have pay stubs or ACE TA Center webinar transcript Coverage for Immigrants Page 13

a tax return. You can feel free to recreate this form and use it in your work. So, basically, if any person says, "I don't have a tax return. I don't file pay stubs," uh, we ask them, "Are you working?" If they say, "Yes," we'll fill out this document and have them sign it. Our Medicaid agency and health insurance Marketplace accept it as proof of income. This letter ensures that immigrants don't, that don't have any other way to prove their income can get and stay covered. Another best practice, um, that we use, um, in order to identify an immigration status is to ask questions, as I spoke about earlier, in a way that people may mo-, be more likely, um, to feel comfortable asking. So it can oftentimes be challenging to identify whether or not the person is a documented or an undocumented immigrant. We've developed this best practice for identifying immigration status for the immigrant we serve. First, we ask the person if they are a U.S. citizen. If they answer, "No," we ask them if they have immigration papers that are current. If they answer, "No," or are hesitant to answer, we say, "This information will not be shared with any, any immigration agency like ICE. We just have to ask this question to see if you could qualify for health care benefits." We also make it clear, as Angel had said, that other family members, uh, in their family may qualify even if they don't qualify for benefits. So just a few more quick, sort of nitty-gritty additional application and enrollment tips, um, that I asked our helpline to come up with in order to share with you today. First and foremost, they encourage to always fill in the immigrant's preferred language so that the Medicaid or health m-, health care Marketplace agency is able to send the person notices and other membership information in a language they can read. Also, in order to make any progress with health care dis-, disparities, Medicaid agencies and the Marketplaces need to know the race and ethnicity data for their members. These fields oftentimes aren't required, but it's really important that we do our best to fill them out in order to make, uh, the immigrants' application pro-, and enrollment process easier. Another best practice that we use is to always complete release forms with the consumers we serve. These forms are called "Permission to Share Information" and "Authorized Representative Designee" forms in Massachusetts, but they're probably called something different in your state. Release forms often give you the authority to contact Medicaid and the Marketplace on a [inaudible] in order to get more information about their insurance status as well as to help troubleshoot. I know that we cannot require, or programs cannot require that these forms are filled out, but you can give folks that you're helping the opportunity or option to fill out these forms so that you can better assist them. Also, when sending in verification documents on behalf of a client always make sure to put their name; Social Security number, if they have one; date of birth; and their Medicaid ID or other health insurance number. This ensures that the Medicaid agency or insurance Marketplace can match the documents to the client's case. Furthermore, if you can't read a ACE TA Center webinar transcript Coverage for Immigrants Page 14

copy of something that you're sending, odds are that neither can the agency. Try to increase the size of the document that you're sending so that it is legible. Also, remember to write the name, Social Security number, date of birth, and Medicaid ID number on every single document you send. This may seem tedious, but it really does ensure that the agency can attach the document to the right case. In order to ensure an appropriate and accurate eligibility decision, people should only provide income information that is current. A person should not provide pay stubs for a job that has ended or pay stubs with overtime income that isn't received regularly. It's also important to make sure that it is clear how often income is received; do they get a pay stub weekly, biweekly, or monthly? And make sure they check off if the income is seasonal. It is also im-, extremely important that you consistently remind people that you insist that they must update any changes in their household to Medicaid and the Marketplace. It's been our experience that people think that Medicaid and the Marketplace will somehow just know or find out when they have a change in their situation. Also, immigrants may get more benefits if their immigration status changes. For example, an immigrant may qualify for Medicaid instead of the Marketplace when they pass their 5-year bar, but they may not be upgraded to Medicaid unless they call the Marketplace or Medicaid to report it. Also, finally, it's really important to encourage clients to keep copies of everything that they submit, including applications, documents, and receipts. And before I wrap up here, I just wanted to provide a few additional pieces. Actually, I think I'm, I'm all set. I think I've gone through, um, everything here, and I am ready to answer your questions. Thank you very much. Thanks so much, Kate, for a terrific presentation. Um, I wanted to, uh, remi-, tell people about one particular ACE TA resource called the "Special Enrollment Period Fact Sheet." I know we're currently in an enrollment period, but that will be ending on February 15th, and what this fact sheet does is talk about changes in people's status that allow them to apply for Marketplace options when we're not in an open enrollment period. And the, as the fact sheet points out, a change in immigration status by becoming a U.S. citizen or a lawfully present individual, um, will re-, will be a change in status that enables people to apply for a, an ACA Marketplace, uh, qualified health plan in, outside of the open enrollment period. So, um, change, a change in immigration status like those described in this resource, uh, will allow someone to apply for coverage outside of the open enrollment period. They have 60 days from the date of that event. And, um, we're just showing this link to r-... the previous slide had a link, uh, to that fact sheet, and we've, uh, chatted that out as well. And this just shows the image of that fact sheet and, uh, particularly where it addresses the issue around immigration status. Um, we have a number of other resources on our webpage that are focused specifically on ACE TA Center webinar transcript Coverage for Immigrants Page 15

immigration. We are chatting that link out to you now. Uh, among those resources are frequently asked questions about mixed-immigration status families and the ACA from the NILC, uh, Angel's organization; an issue brief from NASTAD summarizing the impact of the ACA, uh, on immigrant populations, that's the National Alliance of State and Territorial Aids Directors. Um, so we encourage you, uh to go to those resources. As a, and as a reminder, we have already emailed participants a link to today's slide se-, set. So we know there was a lot of information, but you do have access to the slides if you want to, uh, look at the, some of the details that were presented regarding, uh, immigration status and eligibility. So, thank you. And, with that, we have concluded our presentations, and we are gonna move into our question period, and I'm going to turn it over to our project director, Mira Levinson. Thanks, Stewart, and thanks, again, to Angel and Kate for your very informative presentations and the great ideas and sort of concrete approaches that you've, you provided. Um, I see a ton of great questions coming in. Please keep them coming. Um, I think, uh, we sh-, hopefully, we'll have time to take most of them. And, um, again, just a reminder that if any of you do need to step away from the call now, um, it'll be within the next week or so that we'll be able to send out, um, a summary of responses to all the questions that have come in. Um, but try to stick with us. Um, it looks like most people have been able to stay on all the way though so far. So, um, our first question, um, is a s-, I think a question I'm going to ask Angel to try to take a crack at, and that is, "With regards to lawfully present individuals enrolled in a Marketplace health plan, are any of the presenters aware if the citizenship verification that occurred in mid-2014 will occur again in 2015?" So, um, Angel, if you don't mind just explaining how you're interpreting that question... Sure. Sure.... and then providing a response. Sure, um, so last year, after the first open enrollment period, there were a number of, um, data matching issues, some inconsistencies verifying immigration status, um, and as a result, um, last summer and into the fall, um, the federal Marketplace started asking, uh, consumers for additional documentation. Um, and that, those notices said, you know, "You have to submit documents, and if you don't submit documents and you don't have them verified, then you will lose your coverage." Um, there were, um, you know, some people did lose their coverage. I think the majority of them ended up getting resolved. Um, but I guess the short answer is that if you receive any notice from the Marketplace asking you to su-, to submit additional documents, you need to do that as soon as possible because there is a risk of losing, of losing ACE TA Center webinar transcript Coverage for Immigrants Page 16

coverage. Um, I know that there were a ton of issues with those notices themselves. I mean, there wasn't enough language access. Um, a lot of these immigrants are, don't speak English, English isn't their, their primary language. Um, and yet a lot of these notices were, were only sent in English or Spanish, um, and that excluded, you know, a, a number of o-, other languages, um, that consumers, um, spoke. Um, so, so, again, if, um, the immigration status verification has, it happens when someone applies, if it doesn't, if it doesn't get, uh, properly verified at the moment of the application, um, the, the consumer may have to submit additional documents, and we really encourage them to do that as soon as possible. Kate Bicego : Thank you, Angel. All right. The next question, um, is for Stewart. Um, Stewart, does it matter about the laws regarding marriage in the state? Um, and I believe this was referring to when Angel talked about, um, same-sex marriage, and who is eligible for ACA coverage. Thanks, Mira. Uh, this is an important clarification. So for, um, people who live in a state that does not recognize same-sex marriage, they would still be eligible if they were married in a state that does recognize same-sex marriage. And this is related to the Supreme Court decision of about a year ago that essentially overruled some of the sections of the Defense of Marriage Act, or DOMA. Uh, so the federal benefits under the ACA are still, uh, good for, uh, legally married, same-sex couples regardless of what state they reside in. Thanks, Stewart. Um, all right. The next question is for Kate. Um, and that question is, uh, to do with one of the case studies. The question is, um, "Is income determined based on household size or based on one's modified adjusted gross income or MAGI?" Uh, so, Kate, uh, you wanna try and give that one a shot? Sure, absolutely. And it's a bit more complicated, um, but, generally speaking, because of the Affordable Care Act, eligibility, um, for health insurance coverage through both Medicaid and the Marketplace, is not determined just based on, um, household size, but both a person's household size and their modified adjusted gross income. Great. So, um, if that's, um, person who asked that question has any follow up questions, please feel free to submit those through the chat. Um, and, again, just a reminder that we certainly can still take some more questions. So go ahead and, um, type those in as they come to you. Also, if you think of questions after this call that, uh, you know, you sort of didn't, didn't formalize or formulate while you were on, then you can go ahead and email them to us afterward, and we'll show you our email address at the end of the webinar. Um, so the next one, I'm gonna ask Angel to take, and that question is, "How can we find out which states offer state Medicaid for those impacted by DACA or DAPA? Uh, sure. Um, so this is a little bit of a complicated question just because, um... so there are states that do offer, um, state-funded Medicaid to ACE TA Center webinar transcript Coverage for Immigrants Page 17