How immigrants can obtain health coverage

Can immigrants select from any available health plans during ACA open enrollment?

Yes, as long as they’re lawfully present in the U.S.

And starting with the open enrollment period that begins in November 2024, DACA recipients will be able to use the Marketplace for the first time.³ DACA recipients are not lawfully present (although they are considered lawfully present for some purposes during their deferred action period), so they have not historically been allowed to enroll in Marketplace coverage. The Biden administration finalized a rule change in 2024 that allows DACA recipients to use the Marketplace starting November 1, 2024 (for coverage effective in 2025) and qualify for income-based subsidies on the same terms as any other enrollee.

As discussed below, some states are starting to establish their own programs that provide health coverage to eligible applicants regardless of immigration status.

Open enrollment for individual-market health insurance coverage runs from November 1 to January 15 in most states, although some states have different deadlines. During this window, any non-incarcerated, lawfully present U.S. resident (except DACA recipients, and that will change in November 2024 as described above) can enroll in a health plan through the exchange in their state. (Depending on the state, this can be a state-run platform or the federally run HealthCare.gov.)  It’s also an option to enroll outside the exchange during that window, although financial assistance is not available outside the exchange.

Are immigrants eligible for health insurance premium subsidies?

You do not have to be a U.S. citizen to benefit from the ACA. If you’re in the U.S. legally – regardless of how long you’ve been here – you’re eligible for subsidies in the exchange if your income is in the subsidy-eligible range and you don’t have access to an affordable employer-sponsored plan that provides minimum value. (As discussed below, some states are establishing programs that use state funds to subsidize health coverage for undocumented immigrants).

Premium subsidies are normally only available to exchange enrollees if their income is at least 100% of the federal poverty level (FPL), but subsidies also extend below the poverty level for recent immigrants, as described below.

Lawfully present immigrant status applies to a wide range of people, including those with “non-immigrant” status such as work visas and student visas (as mentioned above, DACA recipients will be allowed to enroll in Marketplace plans starting in November 2024). So even if you’re only in the U.S. temporarily – for a year of studying abroad, for example – you can purchase coverage in the health insurance exchange for the state you’re living in while in the U.S. Depending on your income, you might be eligible for a premium subsidy to offset some of the cost of the coverage.

Are recent immigrants eligible for ACA subsidies?

Yes. The ACA called for the expansion of Medicaid eligibility to all adults with income up to 138% of the poverty level, and no exchange subsidies for enrollees with income below the poverty level, since they’re supposed to receive Medicaid coverage instead. But Medicaid isn’t available in most states to recent immigrants until they’ve been lawfully present in the U.S. for five years. (Note that the majority of the states do provide income-based Medicaid to lawfully-present children and/or pregnant people who have been in the U.S. less than five years.)⁴ To address this issue, Congress included a provision in the ACA to allow recent immigrants to get subsidies in the exchange regardless of how low their income is.

Low-income, lawfully present immigrants – who would be eligible for Medicaid based on income but are barred from Medicaid because of their immigration status – are eligible to enroll in plans through the exchange with full subsidies during the five years when Medicaid is not available to them. (For reference, this issue is detailed in ACA Section 1401(c)(1)(B), and it appears on page 113 of the text of the ACA.) Their premiums for the second-lowest-cost Silver plan are entirely covered by the premium subsidy through at least the end of 2025. (The elimination of premiums at this income level is due to the American Rescue Plan and its enhancement of the ACA’s premium subsidies. These provisions were extended through 2025 by the Inflation Reduction Act.)

Can recent immigrants 65 and older buy exchange health plans?

Yes. Most individuals become eligible for Medicare when they turn 65, and no longer need individual-market coverage. However, recent immigrants are not eligible to buy into the Medicare program until they’ve been lawfully present in the U.S. for five years.

As a result of the ACA, policies in the individual market are available on a guaranteed-issue basis, regardless of age. And if the plan is purchased in the exchange, subsidies are available based on income, just as they are for younger enrollees. (It’s unlawful to sell an individual-market plan to anyone who has Medicare, but recent immigrants cannot enroll in Medicare.)⁶

The ACA also limits premiums for enrollees age 64 or older to three times the premiums charged for an enrollee who is 21.⁷ (A few states limit that further,⁸ and two states – New York and Vermont – do not allow premiums to vary at all based on age.⁹) So there are essentially caps on the premiums that apply to elderly recent immigrants who are using the individual market in place of Medicare, even if their income is too high to qualify for subsidies.

Are undocumented immigrants eligible for ACA coverage?

No, unless a state has established a program for this purpose. Although the ACA provides benefits to U.S. citizens and lawfully present immigrants alike, it does not provide any benefits for undocumented immigrants.

The ACA specifically prevents non-lawfully present immigrants from enrolling in coverage through the exchanges.¹⁰ And they are also not eligible for Medicaid under federal guidelines. So the two major cornerstones of coverage expansion under the ACA are not available to undocumented immigrants.

Some states – described in more detail below – have implemented programs to cover undocumented immigrants – particularly low-income children and/or people who are pregnant.

It’s important to understand that if you’re lawfully present, you can enroll in a plan through the exchange even if some members of your family are not lawfully present. Family members who aren’t applying for coverage are not asked for details about their immigration status. And HealthCare.gov clarifies that the immigration details you provide to the exchange during your enrollment and verification process are not shared with any immigration authorities.

How are states making efforts to provide health coverage to undocumented immigrants?

Several states use their own funds to provide Medicaid coverage to undocumented immigrants with low incomes.

For example:

• Oregon’s Cover All Kids program provides coverage to kids in households with income up to 305% of the poverty level, regardless of immigration status.
• California has had a similar program for children since 2016. And as of January 1, 2024, all adults in California whose income makes them eligible for Medi-Cal (Medicaid) can enroll regardless of immigration status.¹¹
• New York covers kids and people who are pregnant in its Medicaid program regardless of income, and covers emergency care for other undocumented immigrants in certain circumstances. New York’s Basic Health Program (the Essential Plan) expansion that took effect in April 2024 allows DACA recipients to enroll in the Essential Plan, allowing about 12,000 DACA recipients to switch from Medicaid to the Essential Plan.¹²
• Connecticut’s HUSKY (Medicaid/CHIP) program covers income-eligible undocumented kids up to age 12, and this will extend to age 15 starting in July 2024.¹³
• Vermont created the Immigrant Health Insurance Plan, starting in 2022, that provides health coverage to children under age 19 and pregnant women who are not eligible for Medicaid due to their immigration status.
• Starting in 2025, Colorado will provide Medicaid coverage to undocumented pregnant people and children who would otherwise be eligible based on income.
• Hawaii is considering legislation in 2024 (carried over from 2023) that would allow the state to “purchase health care services” for uninsured immigrants who aren’t eligible for Medicaid, CHIP, or coverage through the exchange, and whose incomes is up to 150% of the poverty level.¹⁴

But what about allowing undocumented immigrants to purchase coverage through a state-run exchange, either at full price or with state-funded subsidies? That idea has been gaining traction in recent years.

It was first considered by California in 2016 (via legislation and a 1332 waiver submission to the federal government). But in January 2017, just two days before Donald Trump’s inauguration, California withdrew its waiver proposal, citing concerns that the Trump administration might use information from Covered California to deport undocumented immigrants.

New York lawmakers considered legislation in 2019 that would have allowed undocumented immigrants to purchase full-price coverage in NY’s state-based exchange, but it did not progress in the legislature. As noted in the text of the legislation, New York would have needed to obtain federal permission to implement this law if the state had enacted it.

But other states are now making this idea a reality:

• Colorado debuted a program in the fall of 2022 that allows undocumented immigrants to enroll in qualified health plans via a separate platform (instead of using the state-run exchange), so federal permission was not required. Colorado provided subsidies to the first 10,000 people who enrolled through that platform, and reached that number within the first several weeks the program was available. For 2024, Colorado increased the number of subsidy-eligible spots to 11,000 and filled all of them within the first two days of open enrollment.¹⁵
• Washington state received federal approval to allow undocumented immigrants to enroll in coverage through the state-run exchange starting in the fall of 2023 (for 2024 coverage). State-funded subsidies are available for undocumented enrollees, but no federal subsidies.

Maryland enacted legislation in 2024 that directs the state to seek federal permission to allow undocumented immigrants to use the state-run exchange starting in 2026, with state-funded subsidies available to eligible enrollees.¹⁶

California lawmakers are considering legislation in 2024 that would allow undocumented immigrants (who aren’t already eligible for Medicaid) “to enroll in health insurance coverage in a manner as substantially similar to other Californians as feasible,” while being consistent with federal rules. This is likely referring to the sort of separate platform that Colorado created, as the legislation does not call for the state to seek federal permission to allow undocumented immigrants to use the Covered California platform. The bill passed in the California Assembly in May 2023, and was being considered in the Senate more than a year later, in August 2024.¹⁷

How many undocumented immigrants are uninsured?

In terms of the insurance status of undocumented immigrants, the numbers tend to be rough estimates, since exact data regarding undocumented immigrants can be difficult to pin down. But according to Pew Research data, there were 10.5 million undocumented immigrants in the U.S. as of 2021.¹⁸

According to a recent Kaiser Family Foundation analysis, undocumented immigrants are significantly more likely to be uninsured than U.S. citizens: as of 2023, about 50% of undocumented immigrants are uninsured, versus about 8% of citizens.

So about half of the undocumented immigrant population has some form of health insurance coverage. Kaiser Family Foundation’s Larry Levitt noted via Twitter that “some are buying non-group, but I’d agree that it’s primarily employer coverage.” Undocumented immigrants also have the option to enroll in student health plans and individual (i.e., non-group) plans purchased off-exchange (on-exchange, enrollees are required to provide proof of legal immigration status).

Uninsured undocumented immigrants do have access to some healthcare services, regardless of their ability to pay. The Emergency Medical Treatment & Labor Act (EMTALA), a federal law, requires Medicare-participating hospitals to provide screening and stabilization services for anyone who enters their emergency rooms, without regard for insurance or residency status.

Since emergency rooms are usually the most expensive setting for healthcare, local officials in many areas have opted for less expensive alternatives. Of the 25 U.S. counties with the largest number of undocumented immigrants, the Wall Street Journal reports that 20 have programs in place to fund primary and surgical care for low-income uninsured county residents, typically regardless of their immigration status.

Do ACA exchanges check the status of immigrants who want to buy coverage?

Yes. As part of the enrollment process, the exchanges are required to verify lawfully present status. Applicants who are asked to provide documentation to verify citizenship or immigration status have 95 days in which to do so. If they don’t, their coverage and/or financial assistance can be terminated.¹⁹

The details of how HealthCare.gov resolves immigration status data matching issues are explained here. There are enrollment assisters in your community who can help you with this process if necessary. But if you’re not lawfully present, you cannot enroll through the exchange in most states, even if you’re willing to pay full price for your coverage. You can, however, apply for an ACA-compliant plan outside the exchange, as there’s no federal restriction on that.

Should immigrants consider short-term health insurance?

Immigrants who are unable to afford ACA-compliant coverage might find that a short-term health insurance plan will fit their needs and it’s better than being uninsured, although it is not a replacement for major medical health insurance. Short-term plans are not sold through the health insurance exchanges, so the exchange requirement that enrollees provide proof of legal residency does not apply to short-term plans. However, proof of residency may still be required by an insurer that offers short-term plans.

Short-term plans provide coverage that’s less comprehensive than ACA-compliant plans, and for the most part, they do not provide any coverage for pre-existing conditions. The premiums for short-term plans are lower than the unsubsidized premiums for ACA-compliant plans because short-term plans do not provide comprehensive coverage like ACA-compliant plans and do not cover things like the ACA’s 10 Essential Health Benefits or pre-existing conditions. But most lawfully present immigrants will qualify for premium subsidies in the exchange, especially through the end of 2025 as a result of the American Rescue Plan’s subsidy enhancements (which have been extended through 2025 under the Inflation Reduction Act).

Recent immigrants who are eligible for premium subsidies in the exchange will likely be best served by enrolling in an ACA-compliant plan through the exchange – the coverage will be comprehensive, with no limits on annual or lifetime benefits and no exclusions for pre-existing conditions.

With any insurance plan, it’s important to read the fine print and understand the ins and outs of the coverage. That’s particularly important with short-term plans, as they’re not subject to the same sort of insurance regulations that apply to other types of coverage.  Some states have extensive rules for short-term plans, so availability varies considerably from one state to another (you can click on a state on this map to see how the state regulates short-term plans).

Travel insurance plans are another option, particularly for people who will be in the U.S. temporarily and who don’t qualify for premium subsidies in the exchange. Just like short-term plans, travel insurance policies are not compliant with the ACA, so they generally won’t cover pre-existing conditions, tend to have gaps in their coverage (since they don’t have to cover all of the essential health benefits), and will come with limits on how much they’ll pay for an enrollee’s medical care. But if the other alternative is to go uninsured, a travel insurance plan is better than no coverage at all.