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9
August25, 2021
Noncitizen Eligibility for Medicaid and CHIP
Medicaid and the State Children's Health Insurance
Program(CHIP) provide a health care safety net for low-
income populations. The availability of these programs for
noncitizens (i.e., aliens in immigration law) depends on the
noncitizen's immigration status and certain other factors.
The Migration Policy Institute estimates 2.4 million low-
income noncitizens were enrolled in Medicaid, CHIP, or
another public health insurance programin 2019. This In
Focus provides an overview of Medicaid/CHIP eligibility
rules for non-U.S. citizens.
Medicaid and CHIP Background
Medicaid, authorized in Title XIX of the Social Security
Act (SSA), is a joint federal-state programthat finances the
delivery of primary and acute medical s ervices-as well as
long-terms ervices and s upports-to a diverse, low-income
population, including children, pregnant women, adults,
individuals with disabilities, and people aged 65 and older.
CHIP, authorized in SSA Title XXI, provides health
insurance coverage to low-income, uninsured children in
families with incomes above applicable Medicaid income
standards, as well as to certain pregnant women.
Participation in both programs is voluntary for states,
though all states, the District of Columbia, and the U.S.
territories (i.e., American Samoa, the Commonwealth of the
Northern Mariana Islands [CNMI], Guam, Puerto Rico, and
the U.S. Virgin Islands) choose to participate.
States must follow broad federalrules to receive federal
matching funds,but they have flexibility to design their
own versions of Medicaid and CHIP within the federal
statute's basic framework. The U.S. territories operate their
Medicaid and CHIP programs under rules that differ from
those applicable to the50 states andDC (e.g., capped
Medicaid funding, eligibility flexibilities). Both programs
include several statutory waiver and demonstration
authorities that allow states to operate their programs
outside of certain federalrules. This flexibility results in
variability across state Medicaid and CHIP programs in
factors such as eligibility and coveredbenefits.
Medicaid and CHIP Eligibility
There are a number of eligibility pathways through which
individuals may qualify for Medicaid. (An eligibility
pathway is the specific federal statutory reference[s] that
extends Medicaid coverage to certain groups of
individuals.) Often an applicant's eligibility pathway
dictates the Medicaid state plan services to which a given
programenrollee is entitled. In general, individuals must
meet both categorical (e.g., children, pregnant women) and
fmancial(i.e., income and sometimes assets limits) criteria.
Some eligibility pathways are mandatory, meaning that all
states with a Medicaid programmust cover them; others aie
optional. Subject to federalminimum standards, states have
discretion in determining certain eligibility criteria for both
mandatory and optional eligibility groups, which results in
substantialvariability across states. Under CHIP, states
have broad dis cretion in setting their income eligibility
standards, and eligibility varies by state.
Medicaid and CHIP applicants must also meet federal and
state requirements regarding
* State Residency: SSA §§ 1902(a)(16), 1902(a),
1902(b)(2) and 2102(b)(1)(A) [42 U.S.C.
§§ 1396a(a)(16), 1396a(a), 1396a(b)(2) and
1397bb(b)(1)(A)];
* Documentation of U.S. Citizenship: SSA
§ § 1137(d)(2), 1902(a)(46), 1902(ee), 1903(x) and
2105(c)(9)(A) [42 U.S.C. § § 1320b-7(d)(2),
1396a(a)(46), 1396a(ee), 1396b(x) and
1397ee(c)(9)(A)]; and
* Immigration Status: SSA §§1902(b)(3) and
2105(a)(3)(F) [42 U.S.C. § § 1396a(b)(3) and
1397ee(a)(3)(F)]; and Personal Responsibility and Work
Opportunity Reconciliation Act of 1996 (PRWORA;
P.L. 104-193), as amended § §401, 402, 403, 421 and
431 [8 U.S.C. §§1611, 1612, 1613, 1631, 1641].
While most Medicaid and CHIP eligibility rules reside
within SSA Titles XIX and XXI, noncitizen eligibility for
these programs is largely governedby provisions within (1)
SSA Title XI and (2) PRWORA, as amended. The
intersection of these laws establish the rules for noncitizen
eligibility under Medicaid and CHIP, as summarized below.
Medicaid and CHIP Noncitizen Eligibility
Rules
Noncitizens' eligibility for Medicaid and CHIP largely
depends on (1) an applicant's immigration status; (2)
whether they arrived in the United States (or were enrolled
in Medicaid) before August 22, 1996 (the date PRWORA
was enacted); and (3) how long they have lived and worked
in the United States. In addition, alien applicants must meet
the programs' other eligibility requirements (e.g., financial,
categorical, state residency).
Qualified and Nonqualified Aliens
With respect to an applicant's immigration status,
generally, noncitizen eligibility for most federalpublic
benefits -including Medicaid and CHIP-is governed by
the termqualifiedalien (8 U.S.C. § 1641), which was
created in PRWORA, as amended. Qualified aliens include
lawful permanent residents (LPRs), refugees, aliens paroled
into the United States for at least one year, aliens granted
asylumor related relief, certain abused spouses and
children, and Cuban-Haitian entrants. (For more
information on these statuses, see CRS Report R46697,
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