Coverage for Immigrants

.Purpose

Policy

Background

Release Date:

4/11/16

Definitions

Requirements

Verification Docs

MEDI-CAL

Coverage for Immigrants Under Health Care Reform

Purpose

( ) To release a new policy

( ) To release a new form

( ) To convert existing policy to new writing style only – No concept changes

(X) Revision of existing policy and/or form(s).

What changed?

1. Policy and procedures for processing current Refugee Medi-Cal Assistance (RMA) cases.

2. Policy and procedures for the Trafficking and Crime Victims Assistance Program (TCVAP).

3. Scope of eligibility for Temporary Protective Status.

NOTE: Changes are shown highlighted in gray throughout the document.

Policy

U.S. Citizens/Legal Permanent Residents

As of January 2014, U.S. citizens and Legal Permanent Residents (LPR):

a) Are required to have Minimum Essential Coverage (MEC), or pay a tax penalty.

b) May enroll in a health plan from the Covered California health benefit exchange.

c) May be eligible for Advance Premium Tax Credits (APTC) and Cost Sharing Reduction (CSR) subsidies.

Permanently Residing Under Color of Law (PRUCOL)

PRUCOL is a public benefits category created by the federal courts but is not recognized as an immigration status by the U.S. Citizenship and Immigration Services (USCIS). PRUCOL means that the USCIS is aware of an immigrant’s unlawful presence, but is not actively pursuing his or her deportation.

a) Although PRUCOL immigrants are not U.S. citizens or LPRs, they are considered to have the same rights as LPRs for Medi-Cal eligibility purposes.

b) PRUCOL has 16 status categories in Section B, Question 5, of the Statement of Citizenship, Alienage, and Immigration Status (MC 13) form (see Attachment I)

c) PRUCOL immigrants are eligible for full-scope Medi-Cal.

d) Medi-Cal benefits for immigrants under PRUCOL have not changed with the implementation of Health Care Reform (HCR).

Deferred Action for Childhood Arrivals (DACA)

On June 15, 2012, the Secretary of Homeland Security announced that certain individuals who came to the U.S. under the age of 16 and meet specified criteria, may request consideration of DACA status for a period of two years, subject to renewals.

a) DACA immigrants are considered to be “lawfully present”.

b) DACA is considered PRUCOL under the deferred action status (Section B, Question 5, Category 12 on the MC 13).

c) Self-attestation of DACA status is acceptable but must be verified through the Systematic Alien Verification for Entitlements (SAVE) process.

d) Full-scope Medi-Cal benefits must be granted to the applicant/beneficiary while DACA immigration status is being verified, if otherwise eligible.

e) The MC 13 form is only required if verification of DACA immigration status is unsuccessful.

f) The California Healthcare Enrollment, Eligibility and Retention System (CalHEERS) is currently not programmed to recognize DACA eligibility; therefore, a manual update of benefits is required in the Medi-Cal Eligibility Data System (MEDS) for Modified Adjusted Gross Income (MAGI) eligible DACA beneficiaries.

g) Verification of DACA status includes:

o Employment Authorization Document (EAD) with status code “C-33”.

o Form I-797 Notice of Action (NOA).

o Documents other than those noted above may require a secondary SAVE verification process (G-845). (see Attachment II)

Note: Medi-Cal Program will soon be releasing instructions for the implementation of Senate Bill (SB) 75 regarding full-scope benefits for all minors. Parts of this policy may be impacted by SB 75 requirements.

If…	Then…
The County is unable to determine the claimed immigration status via SAVE	An MC 13 form should be used along with the manual secondary SAVE verification process (G-845).
The manual G-845 verification of claimed DACA status fails	The applicant must be given a 90-day opportunity period to provide documentation.
The applicant fails to provide verification via EAD or I-797 for DACA status within the provided 90-day period	Medi-Cal benefits must be reduced to restricted-scope. Note: Due to implementation of SB 75, children under age 19 may continue to receive State-funded full-scope benefits.
An applicant provides documentation other than an EAD or I-797	This newly provided information must be verified through the SAVE process.
The SAVE process for other documentation does not verify Satisfactory Immigration Status (SIS)	Medi-Cal benefits must be reduced to restricted-scope. Note: Due to implementation of SB 75, children under age 19 may continue to receive State-funded full-scope benefits.

The Deferred Action for Childhood Arrivals (DACA) Desk Guide is attached for reference (see Attachment III).

Note: DACA immigrants are prohibited from purchasing insurance coverage through the Covered California health benefit exchange.

Undocumented Immigrants

a) Not required to have MEC.

b) Not allowed to purchase private health insurance through Covered California, even if paying full cost.

c) Not eligible for APTC or CSR.

d) Who meet all other program requirements for Medi-Cal will be eligible to receive restricted-scope benefits.

e) Due to implementation of Senate Bill (SB) 75, children under age 19 will be entitled to State-funded full-scope benefits.

Eligible Population	Level of Benefits
Undocumented Immigrant Childless Adult	Included in the MAGI Medi-Cal Expansion for restricted benefits.
Undocumented Immigrant Parents, and Pregnant Women	Eligible for restricted-scope benefits via the coverage groups that exist under HCR.
Undocumented Immigrant in Need of Long-Term Care (LTC)	Aged, blind and disabled are eligible under State-funded Non-MAGI LTC Program with aid code 55 (restricted). Ages 19 to 64 are eligible under all restricted MAGI aid codes.

Note: Undocumented immigrants may seek non-emergency health services at community health centers and safety-net County hospitals.

Refugee Medical Assistance Program (RMA)

The RMA Program is a time-limited federal medical assistance program designed to provide no-cost health coverage to refugees during their first eight (8) months in the United States. RMA is funded by the Federal Office of Refugee Resettlement. RMA provides coverage to individuals with countable incomes up to 200% of the Federal Poverty Level (FPL) who do not have categorical eligibility to Medi-Cal.

a) Individuals receiving RMA benefits with incomes up to 138% of the FPL must be evaluated for MAGI Medi-Cal.

b) Individuals with incomes from 139% to 200% of the FPL shall be evaluated for the RMA program.

o RMA eligible cases (aid code 02) must not be processed through CalHEERS in order to correctly evaluate the eligibility and corresponding aid codes.

c) Individuals with incomes above 200% of the FPL shall be evaluated for APTC/CSR and Non-MAGI Medi-Cal with Share-of-Cost (SOC).

d) Participants not eligible for Medi-Cal (MAGI or Non-MAGI) benefits will continue to receive no-cost health coverage for 8 months under the RMA program, if otherwise eligible.

Participants eligible for Medi-Cal (MAGI and Non-MAGI), APTC or CSR, and RMA benefits must be aided under the most beneficial program. Staff must use the table below as a guide to assist with this determination.

If Eligible for…	Select
MAGI Medi-Cal and RMA	MAGI Medi-Cal
APTC/CSR and RMA	RMA
Non-MAGI Medi-Cal with no SOC and RMA	Non-MAGI Medi-Cal
Non-MAGI Medi-Cal with SOC and RMA	RMA

Current RMA Cases

At any time an RMA case is reviewed, staff must evaluate for other Medi-Cal programs. When reviewing an RMA case upon receiving the State listing of RMA cases nearing the end of their eight months of eligibility, staff must evaluate for eligibility under other Medi-Cal programs.

1. As MAGI Medi-Cal is more beneficial than RMA, current RMA cases must be evaluated for MAGI Medi-Cal eligibility prior to the expiration of the eight-month time limit.

2. MAGI eligibility shall be based on information already provided within the last eight months or by using the existing ex-parte review procedures.

3. If eligibility for MAGI cannot be determined through the ex-parte review or the Federal Data Hub (HUB), then a request for additional information must be sent to the participant using the MC355 form (Medi-Cal Request for Information).

4. MAGI eligibility evaluation shall not be delayed due to the lack of a completed Request for Tax Household Information (RFTHI) form; individuals shall be treated as non-tax filers.

5. Once an RMA case is determined to be eligible for MAGI Medi-Cal and is processed in LEADER/LRS, the system will automatically reset the annual renewal date 12 months from the date of review.

6. Staff must ensure the correct NOA is sent to the beneficiary.

7. If found not eligible for MAGI Medi-Cal due to income, RMA eligibility shall continue for the remainder of the eight-month RMA period

Trafficking and Crime Victims Assistance Program (TCVAP)

TCVAP was established as of January 2007 in compliance with Senate Bill 1569. TCVAP allows full scope eligibility for undocumented individuals who are victims of trafficking, domestic violence and other serious crimes, if otherwise eligible. With the implementation of ACA, individuals eligible for TCVAP benefits, under RMA rules, may also qualify for benefits under Medi-Cal rules.

Coverage and Eligibility Requirements

There are two groups that are covered:

Group A	Individuals who do not have Satisfactory Immigration Status (SIS), but are otherwise eligible for full-scope Medi-Cal benefits.
Group B	Individuals who do not have SIS, but otherwise meet the RMA income limits and eligibility requirements.

Note: Date of entry is required for the RMA program.

Persons Eligible for TCVAP

There are two groups eligible for TCVAP.

1. Trafficking Victims

2. Survivors of Domestic Violence and Serious Crimes:

Trafficking Victims:

a) TCVAP considers the main individual/victim and derivative relatives (see Definitions) who have filed for, are preparing to file for, or have yet to file for T Non-Immigrant Status, also known as T Visa at application, or

b) Are taking steps to meet the benefit eligibility conditions under the U.S. Department of Health and Human Services, Office of Refugee Resettlement (ORR) Certification process. ORR will certify that an individual is a victim of human trafficking when the individual:

c) Has filed an application with USCIS for a T Visa and the application has not been denied; or,

d) USCIS has granted the individual “continued presence” status in order to effectively prosecute traffickers.

Note: Child victims of trafficking do not require ORR certification to be eligible for benefits. ORR issues child trafficking victims an interim eligibility letter or an assistance letter in lieu of an ORR certification.

Survivors of Domestic Violence and Other Serious Crimes:

TCVAP considers the main individual/victim and derivative relatives who have filed for or have been granted U Non-Immigrant status, also known as a U Visa, survivors of domestic violence and other serious crimes.

Period of Eligibility – Group A and Group B

Group A - TCVAP Based on Medi-Cal Rules Involving T Visa Applicants

If…	Then…
Applicant reports TCVAP status	Eligible for full-scope benefits for one year.
TCVAP applicant has filed for T Visa within one year	Eligibility for full-scope benefits is extended until T Visa is granted or denied, or is ORR certified.
Beneficiary’s T Visa is granted or is ORR certified	Eligible for federally-funded full-scope Medi-Cal, if otherwise eligible.
Beneficiary’s T Visa is denied	TCVAP benefits must end and the case must be evaluated for all other Medi-Cal programs.

Group A – TCVAP Based on Medi-Cal Rules Involving U Visa Applicants

If…	Then…
Applicant reports TCVAP status	Eligible for restricted-scope benefits until the applicant has filed for a U Visa.
TCVAP applicant has filed for U Visa	Eligible for full-scope benefits until the beneficiary’s U Visa is administratively denied.
Beneficiary’s U Visa is granted	Full-scope benefits must continue for the life of the Visa or until immigration status is changed, whichever is sooner, if all other eligibility requirements are met.
Beneficiary’s U Visa is administratively denied	TCVAP benefits must end and the case must be evaluated for all other Medi-Cal programs.

Group B - TCVAP Based on RMA Rules Involving T Visa Applicants

If…	Then…
Applicant reports TCVAP status	Eligible for full-scope benefits for eight months, until the applicant has filed for a T Visa.
TCVAP applicant has filed for T Visa within eight months	Eligibility for full-scope benefits is extended until T Visa is granted or denied, or is ORR certified.
Beneficiary’s T Visa is granted or is ORR certified	Eligible for federally-funded full-scope Medi-Cal or RMA benefits without break in aid, if otherwise eligible. Note: RMA benefits are limited to eight months from the date of ORR certification.
Beneficiary’s T Visa is denied	TCVAP benefits must end and the case must be evaluated for all other Medi-Cal programs.

Group B - TCVAP Based on RMA Rules Involving U Visa Applicants

If…	Then…
Applicant reports TCVAP status	Eligible for restricted-scope benefits, until the applicant has filed for a U Visa.
TCVAP applicant has filed for U Visa	Eligible for full-scope benefits until the beneficiary’s U Visa is administratively denied.
Beneficiary’s U Visa is granted	Full-scope benefits must continue for the life of the Visa or until immigration status is changed, whichever is sooner.
Beneficiary’s U Visa is administratively denied	TCVAP benefits must end and the case must be evaluated for all other Medi-Cal programs.

TCVAP Documentation Requirements to Establish Victim Status

The following documentation is required to establish an individual’s status as a victim:

1) The individual’s sworn statement or declaration under penalty of perjury; or

2) A sworn statement from an authorized representative if the individual is unable to complete a sworn statement; and

3) At least one additional form of evidence as outlined below:

a) Police, government agency, or court records/files;

b) News articles;

c) Documentation from a social services, trafficking or domestic violence program, or a legal, clinical, medical, or other professional from whom the applicant has sought assistance in dealing with the crime;

d) A statement from any other individual with knowledge of the claim;

e) Physical evidence (not contained in the list of items described under 1 or 3 above, e.g., wheelchair, bruises, or casts);

f) A copy of a completed Visa application; or

g) Written notice from the federal agency noting the receipt of the Visa application.

NOTE: If the individual is unable to provide an additional form of evidence from the list above, then a second Sworn Declaration Under Penalty of Perjury shall be sufficient if the county or State law enforcement agency investigating the crime has determined that the individual is credible.(see Attachment IV)

Social Security Numbers (SSNs) and Other Verifications

a) SSN is not required to be eligible for TCVAP benefits;

b) Case must not be denied if the individual cannot provide an SSN;

c) Some victims of trafficking with ORR certification may have SSNs and EADs (these individuals will have citizen/alien indicator code “O” on MEDS);

d) An SSN will be required if the individual has an SSN assigned;

e) There may be other documentation barriers such as unavailable birth certificate or identification card (ID). In these instances, individuals may use other forms of verification, for example: foreign ID, non-photo ID, etc.; and

f) If no documents exist, then a sworn declaration of identity must be accepted.

Individuals with Temporary Status

Immigrants with Temporary Visas

Immigrants with temporary Visas who do not intend to permanently stay in the U.S. are not typically eligible for Medi-Cal benefits, unless they can establish that they intend to permanently reside and meet all other eligibility requirements.

Lawfully present individuals with temporary visas include:

1) Foreign visas,

2) Student visas, and

3) Employment authorization visas.

Individuals with temporary visas that are found eligible for Medi-Cal and meet all other eligibility requirements, will receive the same restricted-scope benefits as undocumented individuals. Due to implementation of SB 75, children under age 19 will receive full-scope benefits.

Immigrants with Temporary Protected Status (TPS)

The Secretary of Homeland Security may designate individuals from specified countries with TPS who are already in the United States. Due to ongoing armed conflicts, environmental disasters, or other extraordinary conditions, these individuals are unable to safely return to their home country.

Immigrants with TPS may obtain an EAD, however this is not verification of full- scope eligibility.

Individuals with TPS may be eligible to full-scope benefits based on declaration of PRUCOL (please refer to the attached PRUCOL Desk Guide) (See Attachment V). Additionally, due to implementation of SB 75, minors under age 19 will receive State-funded full-scope benefits.

Mixed Immigration Households

1) Undocumented parents of citizen or LPR children are eligible:

a) To purchase health care insurance from Covered California on behalf of their children, but not for themselves.

b) For premium tax credits and subsidies on behalf of their children, but not for themselves (if they file taxes).

Citizen or LPR children of undocumented parents are eligible for full-scope Medi-Cal, if otherwise eligible

Background

Medi-Cal Eligibility

Five-Year Bar Requirement - Federal Regulations

Current federal regulations establish that LPRs are not eligible for federally-funded Medi-Cal benefits during the first five years after they have secured qualified immigrant status. This is known as the five-year bar. The five-year bar rule applies to HCR.

The following immigrants are exempt from the five-year bar:

· Refugees,

· Asylees,

· Veterans and military families,

· Pregnant women and children, and

· Other humanitarian immigrants.

Five-Year Bar Requirement - State Regulations

California currently provides State-only funded full-scope Medi-Cal benefits to qualified immigrants under the five-year bar who do not qualify for federally-funded Medi-Cal.

Upon HCR implementation, California will continue to provide State-only funded Medi-Cal benefits to LPRs who have not met the five-year bar requirement.

Qualified Immigrants

Medi-Cal uses the term Qualified Immigrants to define those immigrants eligible for full-scope Medi-Cal under the following categories:

· Pregnant women,

· Children, and

· Parents, seniors, and persons with disabilities.

Under HCR, Medi-Cal expansion covers eligible qualified immigrants who are childless adults with incomes up to 138% of the FPL. As with all applicants, Medi-Cal expansion eliminates the linkage, deprivation, and asset requirements. It requires that qualified immigrants only meet the income and State residency requirements.

Definitions

Term	Description	Level of Benefit
Legally Present Immigrants	Immigrants that have been granted permission to remain in the U.S., such as LPRs, refugees, and asylees.	Full-Scope
Lawfully Present	Individuals with foreign visas (e.g. temporary work visas or student visas).	Restricted-Scope
Undocumented Immigrants	Immigrants who entered the U.S. with permission and subsequently lost their lawful status, and those who have entered without permission.	Restricted-Scope. Per SB 75, minors under age 19 will receive full-scope
Qualified Immigrants	Term used by Medi-Cal to define immigrants who are eligible for full-scope Medi-Cal benefits. Qualified immigrants include: LPRs, PRUCOL, DACA, asylees, refugees, Cuban and Haitian Entrants Program (CHEP), battered spouses and children as defined in the Violence Against Women Act (VAWA), victims of trafficking, individuals granted conditional entry, individuals granted withholding of deportation/removal, and individuals paroled into the U.S. for at least one year, and Unaccompanied Refugee Minors (URM).	Full-Scope
Permanently Residing Under Color of Law (PRUCOL)	PRUCOL is not recognized as an immigration status by the USCIS. This category was created by the courts, and is a public benefits eligibility category. For a person to be residing “under color of law”, the USCIS must know of the person’s presence in the U.S., and provide the person with written assurance that enforcement of deportation is not planned.	Full-Scope (based on declaration of PRUCOL status)
Deferred Action for Childhood Arrivals (DACA)	DACA (also referred to as the Dream Act) is a type of administrative relief from deportation where a non-U.S. citizen is permitted to temporarily remain in the U.S.	Full-Scope (based on declaration of PRUCOL Status)

TCVAP-Related Definitions

Term	Definition
Sex Trafficking	The recruitment, harboring, transporting, delivering, or obtaining of an individual for the purpose of sex acts that are performed in exchange for money.
Trafficking Victims	1) Sex trafficking in which a sex act is performed for sale by force, fraud, or intimidation, or the person performing such acts is not 18 years old; or 2) The recruitment, sheltering, transporting, delivering, or obtaining of an individual for work or services, through the use of force, fraud, or persuasion for the purpose of involuntary slavery.
Derivative Relatives	Are certain eligible family members. Please note that ORR does not issue separate certification letters to these relatives of trafficking individuals. Their eligibility for benefits begins with the main individual/victim receiving their ORR certification.
Victims of Domestic Violence and Other Serious Crimes	1) Have suffered extensive physical, or mental abuse as a result of having been a victim of criminal activity, involving one or more of the following activity in violation of federal, State or local criminal law: rape; torture; trafficking; domestic violence; incest; sexual assault; prostitution; sexual exploitation; stalking; female genital mutilation; slave trade; kidnapping; involuntary servitude; held hostage; abduction; false imprisonment; unlawful criminal restraint; blackmail; extortion; manslaughter; murder; witness tampering; perjury; obstruction of justice; fraud in foreign labor contracting; or attempt, conspiracy or solicitation to commit any of the above-mentioned crimes; and 2) Has information regarding criminal activity described above or in the case of an alien child under the age of 16, is the parent, guardian, or next friend of the alien; and 3) Have been helpful, are being helpful, or are likely to be helpful to federal, State, or local authorities investigating or prosecuting criminal activities described above; and 4) Have been victims of a criminal activity that violated the laws of the U.S.
Next friend of the alien	A person who acts for the benefit of an individual under the age of 16 or incapacitated or incompetent, who has suffered extensive physical or mental abuse as a result of being a victim. This person is not a party to the legal proceeding and is not appointed as a guardian.

Requirements

MC 13 Form – Statement of Citizenship, Alienage, and Immigration Status

The MC 13 form is not required of applicants/beneficiaries who meet condition 1 and 3 or condition 2 and 3 below:

1. Attest to being a U.S. citizen/national or to having satisfactory immigration status on the Medi-Cal application including but not limited to the single streamlined application, SAWS 2 PLUS, and CF 285 forms; or

2. Are secondary adults on a case who did not sign the application and the primary applicant attests the individual is a U.S. citizen/national; and

3. Whose citizenship/immigration status is verified via electronic means including the HUB or SAVE process, California birth match, or the Social Security Administration citizenship verification process.

In compliance with current policy, full-scope benefits shall be granted without delay to otherwise eligible applicants/beneficiaries attesting to have satisfactory immigration status. Self-attestation of citizenship is acceptable via any application pathway.

Although the MC 13 is no longer required for self-attestation of citizenship status, it is still required for those individuals who do not meet the above identified conditions, and for those who are claiming any PRUCOL status and their immigration status cannot be electronically verified.

Note: Staff must not advise the participant on what immigration status to declare on the MC 13 form. The individual must declare their present status without any assistance from staff.

Systematic Alien Verification for Entitlement (SAVE)

The SAVE process is automatically initiated when the alien number is updated in LEADER. The SAVE process in LRS is initiated when the alien number is entered in the Individual Demographics page and the Citizenship Detail page is completed. In addition, citizenship and immigration information reported by the applicant will be sent through CalHEERS and verified against the HUB.

1. If a discrepancy is reported by the SAVE process, staff will need to request secondary verification of the reported immigration status. When secondary verification is required, staff is to use the same process as used today by sending a G-845 form (see Attachment II) to the USCIS and following-up accordingly once a response is received.

2. If otherwise eligible, benefits are not to be delayed pending a response related to the secondary verification request from the USCIS. If the client declares to have a satisfactory immigration status, full-scope Medi-Cal benefits are to be issued while pending a response from USCIS for the G-845.

Reasonable Opportunity Period (ROP)

If the applicant’s immigration status cannot be initially verified via the HUB or the SAVE process, then staff must submit a manual secondary G-845 request by using the information provided on the application. If the manual G-845 process is not successful, then the applicant/beneficiary must be allowed a 90-day ROP to provide satisfactory immigration status verification. In accordance with current policy, applicants shall be granted full-scope benefits, if otherwise eligible, during ROP. If citizenship/immigration status cannot be verified within the 90-day ROP, then staff must appropriately reduce benefits to restricted-scope. Staff must keep and image a copy of the manual SAVE results and other documents in the Electronic Document Management System (EDMS).

Verification Documents

Category

Acceptable Documents

Citizenship/Immigration

Status

Self-Attestation of citizenship/immigration status will be accepted. This information will be verified through the HUB, SAVE, or G-845. If the response is not compatible, the beneficiary must provide proof of citizenship/immigration status, such as birth certificate, U.S. Passport, LPR card (I-551), etc.

DACA Documentation

DACA	1. Employment Authorization Document (EAD) with status code “C-33”. 2. Form I-797 Notice of Action. 3. Other immigration documents will require SAVE process.

T and U Visa Documentations

Trafficking Victims

(T Visa)

1) T Visa (Form I-914) application copy.

2) USCIS confirmation receipt or letter verifying an application has been filed.

3) Statements from law enforcement officials, advocates, or individuals in official capacity who have or are assisting with T Visa application process.

4) If no documentation is available, individual’s statement that she/he intends to apply for, has filed, or is taking steps to become ORR certified is acceptable.

Domestic Violence and Other Serious Crimes Victims
(U Visa)

1) U Visa stamp in passport.

2) Form I-797 approving U Visa.

3) EAD with code “A19” or “A20” for approved U Visa.

4) EAD with code “C9” along with first page of Form
I-485 application for LPR.

5) USCIS confirmation receipt or letter (Form I-918) verifying U Visa has been filed.

6) A completed copy of Form I-918, if that is the only evidence; however, the individual must provide, within reasonable time, USCIS submission verification.

7) Form I-797C Extension of U Visa.

8) Form I-797 receipt for Form I-485 application for LPR based on U Visa.

9) Form I-797 receipt for EAD application based on
U Visa.

Note: After three years in U Visa status, the individual is eligible to apply for a change in their immigration status to LPR.