BOOM: 100,000 uninsured DACA recipients expected to gain healthcare coverage as Biden Admin finalizes rule change!

Just over a year ago, the Associated Press reported that the Biden Administration planned on opening up eligibility for ACA exchange, Basic Health Program, Medicaid & CHIP coverage to hundreds of thousands of Americans who have Deferred Action of Childhood Arrivals status:

President Joe Biden is set to announce that his administration is expanding eligibility for Medicaid and the Affordable Care Act’s health insurance exchanges to hundreds of thousands of immigrants brought to the U.S. illegally as children, according to two U.S. officials briefed on the matter.

The action will allow participants in the Obama-era Deferred Action for Childhood Arrivals program, or DACA, to access government-funded health insurance programs. The officials spoke on the condition of anonymity to discuss the matter before the formal announcement on Thursday.

As I noted at the time:

There's roughly 580,000 immigrants who have DACA status as of today. While all of them would presumably become eligible for ACA enrollment (and, therefore, federal ACA subsidies) via the change in their residency status, that doesn't mean 580K new ACA exchange enrollees. According to the Kaiser Family Foundation, around 39% of them are currently uninsured, or roughly ~230,000, give or take. The rest have other types of healthcare coverage just like most other Americans do.

Even among those ~230K, not all of them will necessarily qualify for financial subsidies as some may have too high an income, although I suspect that number will be minimal among this population. And of course some of them will become eligible for Medicaid instead. On the other hand, some of the other ~350K DACA recipients who are currently categorized as "insured" may have terrible coverage via short-term or other types of "junk" plans and thus may become eligible for ACA/Medicaid coverage as well.

Shortly after this story ran, the Centers for Medicare & Medicaid Services (CMS) made it official, with a targeted effective date of November 1st, 2023.

As I noted on November 5th...

Well, November 1st, 2023 has come and gone...and unless I missed a press release, the proposed rule still hasn't been finalized, and DACA recipients still aren't considered to be "lawfully present" for purposes of enrollment in ACA exchange plans, BHP plans, Medicaid or CHIP. If anyone can confirm or correct me on this I'd be happy to post an update.

Cut to two days ago:

Update..The DACA rule has now cleared.

— Amy Lotven (@amylotven) May 1, 2024

When you visit the OMB's Office of Information & Regulatory Affairs link, sure enough:

Title: Clarifying Eligibility for a Qualified Health Plan Through an Exchange, Advance Payments of the Premium Tax Credit, Cost-sharing Reductions, A Basic Health Program and Medicaid and CHIP (CMS-9894) 

This final rule makes several clarifications and updates to the definitions currently used to determine whether a consumer is eligible to enroll in a Qualified Health Plan (QHP) through an Exchange; a Basic Health Program (BHP), in States that elect to operate a BHP; and for some State Medicaid and Children’s Health Insurance Programs (CHIP). This rule modifies the definition of lawfully present to include Deferred Action for Childhood Arrivals (DACA) recipients, and makes additional technical modifications to the definition.

Boom, there it is. I was planning on posting a write-up about it this morning, but the New York Times beat me to the punch:

Thousands of undocumented immigrants will be able to obtain health care through the Affordable Care Act under a new federal rule, U.S. officials said this week.

The new eligibility comes for those in the Deferred Action for Childhood Arrivals program, which since 2012 has protected undocumented immigrants who came to the United States as young people from deportation. The program also provides recipients with work permits. More than 500,000 immigrants have DACA protections but have been ineligible for benefits such as federal health insurance programs.

A rule set to be published Friday by the Health and Human Services Department would change that, granting such immigrants access to health coverage and subsidies under the Affordable Care Act when the regulation takes effect in November.

U.S. officials estimate that about 100,000 uninsured people could obtain health insurance as a result.

UPDATE: Here's the official press release from CMS:

Today, the U.S. Department of Health and Human Services, through the Centers for Medicare & Medicaid Services (CMS), is publishing a final rule to modify the definition of “lawfully present” applicable to eligibility for enrollment in a Qualified Health Plan (QHP) through the Health Insurance Marketplace and a Basic Health Program (BHP). With this modification, DACA recipients will no longer be excluded from that definition, thereby making it possible, effective November 1, 2024, for DACA recipients who meet all other eligibility requirements to enroll in:  

(1) a QHP through the Marketplace with financial assistance like Advance payments of the premium tax credit (APTC) and cost-sharing reductions (CSRs) or 

(2) a BHP.   

These changes support the Affordable Care Act (ACA)’s goals of increasing access to health insurance and improving the health and well-being of people by providing access to affordable, quality health coverage for many uninsured DACA recipients. CMS estimates that this rule could lead to 100,000 previously uninsured DACA recipients newly enrolling in health coverage through a Marketplace plan or a BHP. 

Under this rule, DACA recipients will be treated the same as other individuals granted deferred action for purposes of eligibility for coverage through a Marketplace plan or a BHP. ​In addition, CMS made some technical modifications to the definition of “lawfully present” used to determine eligibility for these programs to create administrative efficiencies, streamline verification processes, and promote clarity and transparency. The rule’s technical changes to the definition of “lawfully present” will benefit consumers by enabling CMS and states to administer their programs more efficiently for eligible noncitizens and to ensure complete, accurate, and consistent eligibility determinations and verification processes for health coverage for these populations.  

However, there is one important point noted in the press release which I didn't see mentioned above:

CMS is not finalizing a definition of “lawfully present” for Medicaid and the Children’s Health Insurance Program (CHIP) under section 214 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA 214 option) at this time. The CHIPRA 214 option allows states to provide Medicaid and CHIP coverage to children and pregnant individuals who are lawfully residing in the United States, including those within their first five years of having certain legal status. The current definition of “lawfully present” used in determining eligibility for Medicaid and CHIP under the CHIPRA 214 option, based on State Health Official (SHO) letters, SHO #10-006 and SHO #12-002, continues to apply.

Huh. OK, so exchange QHPs and BHPs are in, but Medicaid/CHIP is out?

We expect that individuals who would have been eligible for Medicaid or CHIP under these proposals, including DACA recipients, will be eligible for Health Insurance Marketplace coverage with financial assistance or BHP coverage if they meet other eligibility requirements. The ACA allows noncitizens who are ineligible for Medicaid due to their immigration status to access financial assistance, such as Premium Tax Credits (PTC)[1] and Cost Sharing Reductions (CSRs)[2] through a Marketplace plan even if their income is below 100% of the federal poverty level (FPL).   

...except that...

The final rule also updates the definition of “qualified noncitizen” for Medicaid and CHIP, which clarifies the categories of noncitizens that states must cover in these programs. In finalizing the definition, the rule implements existing statutory requirements and is intended to promote clarity and transparency that will support states’ implementation of eligibility policies, training, and accurate eligibility determinations for noncitizens.

Huh. OK, I guess there's some extremely in-the-weeds details about Medicai/CHIP eligibility here, with some being tweaked & others not. So be it.

After a review of comments from the public regarding the rule’s effective date, CMS has finalized November 1, 2024, as the effective date for all provisions in the rule in order to align with the individual market Open Enrollment Period in most states and allow time for required operational updates. Starting November 1, 2024, DACA recipients will be considered lawfully present for Marketplace and BHP coverage and, if they meet all other eligibility requirements, will be eligible to enroll in a QHP through the Marketplace with financial assistance such as APTC and CSRs or a BHP. 

Newly eligible individuals, including DACA recipients, will qualify for a special enrollment period to enroll in a QHP through the Marketplace during the 60 days following November 1, 2024. Consumers who apply for coverage through a SEP during November 2024 can have their Marketplace coverage begin as early as December 1, 2024, if they meet all other eligibility requirements. Consumers who apply for coverage through a SEP during December 2024 can have their Marketplace coverage begin as early as January 1, 2025, if they meet all other eligibility requirements. Finally, consumers who apply for coverage in January 2025 through the individual market Open Enrollment Period can have their coverage begin February 1, 2025, or March 1, 2025, depending on when they apply and their state’s rules. For DACA recipients who are eligible for a BHP, coverage could begin as early as November 1, 2024.

This last paragraph may sound confusing, but what it means is that DACA recipients are actually eligible for their coverage to start as early as December 1st instead of having to wait until January 1st, depending on when they enroll.