Q: We would like our 80-year-old grandmother to come to the USA and live with us so we can take care of her. How do we get health insurance for her?
A: Prior to 2014, there were few options available for someone in your grandmother’s position. Individual health insurance generally wasn’t available to people over age 64, and Medicare and Medicaid have five-year waiting periods for legal immigrants. (Some states have relaxed guidelines when it comes to Medicaid. See below.)
Seniors were able to purchase travel insurance, but it generally doesn’t cover pre-existing conditions, and new coverage must be purchased periodically when the existing one expires, since they’re sold to cover a limited time frame.
But thanks to the ACA, seniors who aren’t eligible for Medicare – including immigrants – can purchase guaranteed-issue private health insurance in the exchanges, and can receive premium tax credits to offset the cost if their income is under 400 percent of the poverty level.
Medicare for immigrants
An obvious question is whether your grandmother would be covered since she’s over 65. If your grandmother was a U.S. citizen – and if she had been paying payroll taxes for 10 years – she could expect coverage from Medicare, as most Americans do at age 65. (Folks who have paid into the system don’t have to pay a premium for Part A.)
But your grandmother obviously hasn’t been paying into the system. What’s more, Medicare regulations stipulate that she needs to have been lawfully admitted for permanent residence and have resided continually in the country for five years before she’s eligible to enroll.
Then, upon becoming eligible after five years, she’d still have pay for the Part A and Part B premium since she wouldn’t have the Social Security work credits. Part A and Part B premiums added up to $511.90 per month in 2015.
Medicaid for immigrants
A 1996 welfare reform law stipulates that immigrants must have five years of legal U.S. residency to become eligible for federal benefits such as Medicaid. The good news is that some states decided to not adhere strictly to that rule, and they provide coverage through state dollars for those who meet specified income standards.
According to HHS data (see figure 4), as of 2011, 15 states allowed the use of state funds to provide Medicaid benefits for qualified immigrants who would otherwise be ineligible because of their immigration status – including the fact that they had resided in the United States for less than five years (note that New Jersey is included in HHS’ list of states that provide state-funded Medicaid coverage to recent immigrants, but New Jersey has changed that rule and no longer does so). So if your grandmother has a limited income, don’t rule out Medicaid as an option until you check with your state Medicaid office.
Immigrants and individual health insurance
This is the area that has changed the most for recent immigrants who are 65 or older. Prior to 2104, obtaining individual health insurance for your grandmother on the private market would have been difficult, since very few major insurers were interested in selling coverage to people over 65 because of their high health risks.
But the Affordable Care Act has changed that. Health history is no longer used to determine eligibility or premiums in the individual market, and private carriers now offer coverage to people who are 65 or older, as long as they are not enrolled in Medicare. (It’s against the law to sell individual coverage to someone who is enrolled in Medicare.)
The ACA also stipulates that older enrollees cannot be charged more than three times the premiums that younger enrollees pay. Since most individual market enrollees are 64 or younger, this rule typically means that a 64-year-old will pay no more than three times as much as a 21-year-old for the same coverage. But if an 80-year-old enrolls in that plan, her premium will be the same as a 64-year-old.
So for the first five years that your grandmother lives in the United States (during the waiting period for Medicare), she’ll be able to purchase individual health insurance through the exchange in the state where she lives. If her income is under 400 percent of the poverty level but above the Medicaid threshold in that state (100 percent of poverty if the state has not expanded Medicaid, or 138 percent of poverty level if the state has expanded Medicaid), she’ll be eligible for subsidies to lower the cost of the premiums.
And if her income makes her eligible for Medicaid but her state doesn’t allow Medicaid coverage for immigrants who haven’t been in the U.S. for five years, she’ll be able to purchase an individual plan through the exchange with a subsidy. (In 2015, this means that the second-lowest-cost Silver plan would cost her 2.01 percent of her income).
In addition to standard individual health insurance, immigrants will find no shortage of links to special “inbound-immigrant” policies by doing a simple Web search such as “immigrant health insurance” or “health insurance options for immigrants.”
These policies provide health insurance for recent immigrants for a limited period of time – usually five years or less. The policies may focus on emergency benefits and may have a maximum benefit of $50,000 or $100,000 or daily limits on expenses such as hospital stays.
Buyers should definitely be on the lookout for exclusions, including not only pre-existing conditions, but a long list of exams and treatments one might otherwise expect under individual coverage.
And it’s important to be aware that travel insurance, limited benefit plans, and short-term insurance are not considered minimum essential coverage under the ACA. This means that legally-present U.S. residents who rely on such plans as their only source of coverage could be subject to the ACA’s shared responsibility (individual mandate) penalty.
In most cases, it’s probably better to purchase comprehensive health insurance through the exchange, especially since such coverage is now available regardless of medical history, covers pre-existing conditions, and can be obtained with subsidies if the enrollee’s income is under 400 percent of the poverty level.
Even if you have health insurance coverage through your employer, you can’t add your grandmother as a dependent. However, some families that own and operate a small business actually hire their older family members as employees so they can offer them health benefits.
This option might make sense if you have your own business, but rest assured that coverage for your grandmother is now available in the individual market, making it easier than ever for elderly recent immigrants to obtain health insurance when they arrive in the U.S.