Moving to the United States comes with both opportunities and challenges, especially when it comes to healthcare access and insurance coverage. An example is the 5 year waiting period for Medicaid. Under this restriction, a lawful permanent resident (or green card holder) faces restrictions on obtaining Medicaid that a citizen does not. There is a required waiting period before most immigrants become eligible for full Medicaid benefits.
We have previously discussed the benefits of Medicaid for new immigrants, what are the eligibility requirements, and how to apply. In this guide, we will focus on explaining everything you need to know about this waiting period, including what the restriction is about, who it applies to, and options for new immigrants to get health care coverage while waiting.
What is the 5 Year Waiting Period for Medicaid?
What is Medicaid and Medicaid coverage?
Medicaid is a healthcare program funded jointly by state and federal governments that provides insurance to adults and children with limited income and resources. Medicaid covers medical cost incurred from doctor visits, hospital care, prescriptions, and more.
What is 5 year waiting period and how does that relate to new immigrants?
The Personal Responsibility and Work Opportunity Reconciliation Act established a 5 year waiting period before most qualified immigrants can enroll in Medicaid. This means they are often unable to get Medicaid coverage for the first 5 years after entering the U.S., even if they meet all other eligibility requirements.
The 5 year waiting period for Medicaid first took effect on August 22, 1996. After 25 years, this restriction remains in place for qualifying immigrants who arrive after this date. The main reasons for this five-year restriction are to control federal spending on Medicaid, to encourage new immigrants to be more self-reliant during their transition and integration into American society, and to prioritize citizens for health coverage and benefits.
What are the Medicaid eligibility criteria?
While the 5 year waiting period applies specifically to immigrants, Medicaid eligibility is also determined by other general criteria aside from immigration status. To be eligible for Medicaid, applicants must meet requirements related to residency, income limits, asset limits, and citizenship/immigration status.
States generally use income thresholds equivalent to 138% of the Federal Poverty Level to determine financial eligibility. Applicants must also be residents of the state in which they are applying, U.S. citizens or qualified immigrants, and fall into coverage categories such as children, pregnant women, elderly, or disabled.
Detailed eligibility guidelines and required documents that applicants must provide vary by state. Meeting these basic thresholds along with immigration status requirements is key to successfully obtaining Medicaid benefits.
Who Does the Five Year Waiting Period Apply To?
The 5 year waiting period for Medicaid applies to many types of lawfully present immigrants, including:
- Lawful permanent residents (green card holders)
- Refugees
- Victims of human trafficking
- Citizens of Micronesia, Marshall Islands, and Palau
- Immigrants paroled into the U.S. for a least a year
- Conditional entrants
These immigrants have legal status but must wait 5 years before applying for non-emergency full-scope Medicaid. There are certain exempt groups not subject to the five year waiting period, such as:
- Veterans and active duty military members
- Pregnant women and children under 21 years old
- Immigrants who receive a medical recommendation for coverage
- Certain humanitarian immigrants
- Immigrants who are blind or disabled
Check your eligibility status carefully to see if you qualify for an exemption or must complete the five year waiting period. The start date for calculating the 5 years is your date of entry with qualifying status.
Getting Health Coverage During the Waiting Period
Despite the restrictions, there are options immigrants can look into for health insurance before becoming Medicaid-eligible:
Employer Health Plans
Getting coverage through a job is often more affordable than individual plans, as many employers pay a large portion of premiums. Employees typically only pay a share of premium costs to be deducted from their paychecks. Employer plans usually offer comprehensive benefits like doctor visits, prescriptions, hospitalization, etc. Just be aware that coverage will end if you leave the job.
Individual Private Insurance
Immigrants can buy health insurance plans directly from private providers outside the healthcare marketplace during open enrollment periods or after qualifying life events. Compare plans carefully to find one that fits your budget and covers your medical needs. Having a broker can help navigate plan options. Those under 30 may find catastrophic plans with lower premiums but very high deductibles.
Children's Health Insurance Program (CHIP)
The Children’s Health Insurance Program covers children up to age 19 whose families exceed Medicaid income limits but cannot afford private insurance. CHIP coverage includes check-ups, dental, vision, prescriptions, emergency medical condition and more with little to no cost sharing. Each state runs its own program with varying eligibility rules. You can also apply any time, unlike marketplace plans.
Community Health Centers
These clinics funded by the federal government offer primary care on an income-based sliding scale for the uninsured, regardless of immigration status. Services include check-ups, treatment for illness/injury, immunizations, dental care, mental healthcare, and substance abuse counseling. Staff can also help with insurance enrollment.
Emergency Medicaid
Regardless of status, Medicaid will pay for emergency treatment at a hospital for serious injuries or illnesses that require immediate care. This only includes conditions like heart attacks, severe pain, accidents, or onset of labor – not non-emergency care.
Short Term Insurance
Basic temporary insurance plans can help fill gaps in coverage but won’t cover pre-existing conditions. These bare-bones plans usually have capped benefits and high out-of-pocket costs. Read limitations carefully before purchasing short term insurance.
Charity Care Programs
Hospitals or non-profits may offer free or very low cost medical and dental services for uninsured patients who complete their application process and qualify based on income. Programs vary greatly so check with your local hospitals.
Meeting the 5-Year Requirement
Once you’ve lived in the U.S. as a qualified immigrant for 5 full years, you can apply for Medicaid by submitting the proper documentation and forms. Make sure to keep records showing:
- Date you obtained qualified immigration status
- Any changes in this status over the past 5 years
- State and county of residence for the past 5 years
- Income going back 5 years
Medicaid eligibility requirements is still based on meeting certain income thresholds even after completing the waiting period. These income limits will depend on factors like household size and state.
When applying, be prepared to provide proof of identity, immigration status, state residency, and income. If you have a disability or require care in a medical facility, additional documentation may be needed. Having an advocate to help navigate the process can be useful.
If approved, coverage may be backdated up to 3 months from your application date. So it’s important to apply immediately once hitting 5 years in status and meeting other criteria.
Gaining Access to Affordable Healthcare
The five year waiting period for Medicaid creates barriers for many immigrants in accessing essential health services. But subsidized private insurance, CHIP for kids, community clinics, and hospital programs can help fill gaps until becoming eligible.
Making it through the 5 year waiting period will open up valuable options. Just be sure to plan ahead and save documentation to help avoid roadblocks when it comes to time to finally apply for Medicaid. With perseverance and the right help, immigrants can get covered and get healthy.
