Medicaid Plans Walk Fine Line in Talking About Public Charge

March 2, 2020

Medicaid Plans Walk Fine Line in Talking About Public Charge

Reprinted with AIS Health permission from the March 2, 2020, issue of Health Plan Weekly

New rules that allow immigration officials to consider use of Medicaid coverage and other non-cash benefits in considering whether to approve applications for legal residence are likely to cause a chilling effect on Medicaid enrollment, with the impact spilling over to utilization of other health programs and services, even among family members not directly affected by the rules. Medicaid health plans’ front-line staff members can help with messaging — but the nuances are tricky and communications must be carefully managed, experts say.

The Inadmissibility on Public Charge Grounds final rule was issued by the Department of Homeland Security (DHS) on Aug. 14, 2019. But after several states sued the Trump administration over the rule, preliminary injunctions prevented the regulation from taking effect last year. The Supreme Court on Jan. 27 ruled that the rule could take effect on Feb. 24 in every state but Illinois while litigation works its way through the courts.

The rule changes the “public charge” factors the government is allowed to consider in deciding to bar a noncitizen from entering the U.S. or obtaining legal permanent resident status. Previously, government officials couldn’t consider non-cash government benefits in deciding that someone is likely to rely on government assistance in the future. The 2019 rule changed the definition of a public charge to include health, nutrition and housing programs that were previously excluded and defined a “public charge” as use of government benefits like health care benefits, food stamps or housing for more than 12 months over a three-year period. Officials also can consider factors such as private insurance coverage.



But officials still cannot consider use of Children’s Health Insurance Program (CHIP) coverage or Affordable Care Act exchange subsidies, according to the Kaiser Family Foundation (KFF). In addition, “public charge determinations will only consider use of benefits by the individual and will not take into account benefits used by other family members, including children.” Officials also will not consider public benefits applied for or received prior to Feb. 24, 2020, DHS said.

Despite that, some immigrants have grown fearful that applying for any benefits could jeopardize their immigration status or that of family members, leading them to avoid using health care services at all or giving up exchange subsidies or CHIP coverage.

“This could have a negative impact on Medicaid enrollment — though it’s possible the related impact has already largely been absorbed and the incremental effect of lifting the injunction may not be that meaningful,” said Evercore ISI analysts Michael Newshel and Joseph Amato. They noted that “even though it hadn’t taken effect yet, news of the rule since it was first proposed in October 2018 has already had a ‘chilling effect,’ making many immigrants more reluctant to sign up for Medicaid.”

Asked what the impact of the public charge rule will be on enrollment and margins, Molina Healthcare, Inc. CEO Joseph Zubretsky noted during a Feb. 11 conference call to discuss 2019 earnings that DHS estimates only 140,000 people nationwide are actually affected by the rule. Still, he said, “the chilling effect is something we’re aware of and we certainly considered in our guidance.”

“The general thought is that the greater the fear and confusion caused by the rule, the wider the reach,” said Barclays analyst Steve Valiquette.



KFF estimated in September 2019 that 79% of noncitizens who originally entered the U.S. without legal permanent resident status have at least one factor such as lacking private health insurance or earning an annual income below 125% of the federal poverty level. Disenrollment of Medicaid and CHIP enrollees who are noncitizens or live with a noncitizen could result in 2.0 million to 4.7 million individuals losing health coverage, KFF said.

So what can health plans do?

“Medicaid plans should be clearly messaging to everyone that first of all and most importantly, the enrollment of children and the enrollment of people in the family who [are] citizens does not affect the immigration status of anyone else in the family,” Wendy Parmet, a professor of law and of public policy and urban affairs at Northeastern University, tells AIS Health. “They need to be clarifying who is not impacted. There are a lot of other groups who are not impacted in a technical sense.” She adds that “fear of the rule is harsher than the actual rule….So messaging needs to be done about who is not affected,” such as children.



“Managed care organizations have the ability to communicate with folks both at a global level and on an individual level,” says Jerry Vitti, founder and CEO of Healthcare Financial, Inc. “The issue with the kind of global communications is that every letter or every brochure that is public facing or member facing,…it’s really the state that drives the communications. And the managed care organizations are the vehicle for the communications but are not able to drive them without the partnership of the states. And different states are going to have different receptivity to the messaging.”

He suggests that Medicaid plans “educate their front-line staff.” Call center staff members, case managers, “anyone who is talking to a member can be an influence about public charge.” But, Vitti says, “call centers have a lot of information that they have to share and they’re not immigration experts. So expecting them to be is both not practical and also can be a liability issue.” Despite that, “you can ask a few questions, do a quick screen and provide some information.”

Contact Vitti via Joe Reblando at or Parmet at View the Kaiser study at


by Jill Brown Kettler