Nov 20, 2023


States Failing to Lower Barriers Facing Immigrant Families, Survey Finds

WASHINGTON — A coalition of more than 600 organizations nationwide has asked the federal Center for Medicare and Medicaid Services (CMS) to pause state Medicaid eligibility redetermination processes. The Protecting Immigrant Families coalition (PIF) letter, sent to CMS on Thursday, cites a first-of-its-kind survey of state advocates, finding critical gaps in state policies and practices critical to ensuring accurate Medicaid eligibility determinations for millions of people in immigrant families. This finding comes six months into states’ efforts to “unwind” Medicaid’s pandemic-era continuous coverage requirement.

“States simply are not doing the basic things they must do, if they want to accurately re-assess the Medicaid eligibility of millions in immigrant families,” said PIF director Adriana Cadena. “CMS must act now to avoid widening racial disparities in health care access at a time when families of color are already at risk.”

In March, PIF partners warned that immigrant families faced additional barriers to remaining covered, as states resumed redeterminations. PIF and member advocates urged state policymakers and the federal Centers for Medicare and Medicaid Services (CMS) to mitigate these barriers, through policies and practices like ensuring that state communications consistently include assurances that redetermination will not affect immigration status or applications.

The PIF survey asked advocates to assess their states’ performance in implementing 17 specific measures. Advocates from 28 states responded, and key findings include:

What advocates reported   Why it matters
Almost all (24) states have not included messages addressing public charge or other immigration-status related concerns in renewal-related communications   An Urban Institute report found status-related concerns deter 25% of people in immigrant families from using safety net programs
Many states (12) always or sometimes ask families to resubmit information that is already known to state agencies and unlikely to change, such as citizenship, immigration status, and Social Security number   Immigrant families report concerns that agencies administering Medicaid and other safety net programs will share personally-identifiable information with immigration officials
Most states (16) always or sometimes ask for citizenship and immigration status from parents or other family members who are not applying for or renewing coverage   One in four children have an immigrant parent, and asking for parents’ immigration status can deter parents from applying or renewing coverage for children.
Almost all states do not report disenrollments and other redetermination information by the person’s primary language (25), by ZIP Code (26), or even by race / ethnicity (23)   Without this data, advocates and states themselves do not know if their redetermination policies and practices are widening health coverage disparities

“States knew what they had to do, because advocates told them – they chose not to lower the barriers facing immigrant families,” said Cadena.

Early this year, CMS released a toolkit to support outreach to people covered by Medicaid, focused on helping them prepare for redetermination. Although the toolkit was translated into multiple languages, it did not include messages offering assurance that redetermination will not affect immigration status or applications. CMS also sent a letter to governors in June, expressing concern about the high rate of disenrollments due to administrative processes, and recommending strategies to mitigate administrative disenrollments. That letter did not recommend policies and practices like using state communications to address immigration concerns or reporting disenrollments by immigration status or race.

“States rightly look to CMS for leadership on Medicaid redetermination, but when it comes to the barriers facing immigrant families, CMS dropped the ball,” said Cadena. “The time for CMS to start repairing the damage is now, and the way to start is by telling states to hit the pause button.”

In addition to pausing state unwinding implementation efforts, the PIF letter urges CMS to:

  • Pause the unwinding in states that are inappropriately requesting SSNs and citizenship or immigration status in the Medicaid redetermination process
  • Conduct unannounced assessments of states’ compliance with language access requirements of the Civil Rights Act
  • Monitor wait times and responsiveness of in-language services provided in-person and by phone
  • Ask states to report redetermination data by language, race, and ZIP Code
  • Revise its own toolkit to add messages addressing immigration concerns
  • Ensure that states are leveraging the expertise of community organizations serving immigrant families

Medicaid’s continuous coverage requirement was an important driver of racial health equity. The nonpartisan Commonwealth Fund cited the policy as a key factor driving recent reductions in health coverage disparities for Black and Latinx people. The independent health policy information organization KFF reports that Medicaid unwinding has resulted in more than 8.6 million people losing Medicaid coverage since April. KFF also reports that nearly ¾ (72%) of disenrollments were based not on an actual determination of the person’s eligibility, but on procedural grounds.

Advocates responding to the PIF survey serve the states of Alabama, California, Colorado, Florida, Georgia, Hawaii, Illinois, Kansas, Louisiana, Massachusetts, Michigan, Nebraska, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, and Wisconsin.