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Can recent immigrants to the United States get health coverage if they’re over 65?

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. (A few states have relaxed guidelines when it comes to Medicaid. See below.)

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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 doesn’t exceed 400 percent of the poverty level and they don’t qualify for certain other government- or employer-sponsored coverage.

The option to purchase coverage in the exchange with a premium subsidy continues even after the person has been in the U.S. for five years and becomes eligible to purchase Medicare coverage (see questions A.6 and A.8 on this guidance from CMS). People who are eligible for premium-free Medicare Part A (because they have worked in the U.S. for at least 10 years) are NOT eligible to receive premium subsidies in the exchange. But that restriction doesn’t apply to people who would have to pay for Medicare Part A.

How long do immigrants have to wait before they're eligible for Medicare?

If you’re a U.S. citizen or have been a lawfully present U.S. resident for more than five years, you could expect coverage from Medicare, as most Americans do at age 65. People who have paid into the system via payroll taxes – their own or a spouse’s – don’t have to pay a premium for Part A. This encompasses the vast majority of Americans, although there’s also an option for people to purchase Medicare Part A (with premiums of up to $437/month in 2019) if the enrollee doesn’t have enough work history to qualify for premium-free Medicare Part A.

But people who have not been in the U.S. for five years are not eligible to enroll in Medicare. Obviously, your grandmother hasn’t been paying Medicare payroll taxes in the U.S., which means she won’t be eligible for premium-free Medicare Part A. But federal 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 – even with premiums.

Once she’s been lawfully present in the U.S. for five years, she’ll be eligible to enroll in Medicare if she wants to, but with premiums for Part A (and Part B, which all enrollees pay, regardless of their work history). Assuming she doesn’t establish a work history in the US and ends up having to pay Medicare Part A premiums forever, she may be eligible for premium assistance from the state Medicaid program (see page 5). But she would also have the option to maintain her individual market coverage through the exchange. She would still be allowed to receive premium subsidies, as clarified in the chart on Question A.8 in the CMS guidance.

But the details in Question A.9 are important here too: If she opts to keep her individual market coverage even after she has the opportunity to buy into Medicare (ie, once she’s been in the US for five years), she would then be subject to the late enrollment penalties if she ever decides to enroll in Medicare at a later date. And she would also be limited to enrolling only during the general enrollment period (the first quarter of each year), with coverage effective in July.

So for example, if she were to gain a substantial income later in life and no longer qualify for premium subsidies in the exchange, the plan she has in the individual market might end up being more expensive than Medicare. But she would have to wait until the annual general enrollment period to switch, and she would have to pay the late enrollment penalty for Medicare Part A and Part B, based on the amount of time since she was first eligible to enroll (ie, when she had been in the US for five years) to the time that she actually enrolled.

Are immigrants eligible for Medicaid?

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 rules were relaxed somewhat in 2009, under the Children’s Health Insurance Program Reauthorization Act (CHIPRA), to allow states the option to provide federally-funded Medicaid and CHIP benefits to pregnant women and children, even if they have not resided in the U.S. for five years, and well over half the states have opted to do so. But some states have opted to also use state funds to provide coverage to additional recent immigrant populations.

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). But as of 2016, an Urban Institute report indicated that only six states and DC were funding public health benefits for immigrants who had not yet been in the U.S. for five years.

If your grandmother has a limited income, don’t rule out Medicaid as an option until you check with your state Medicaid office. But be aware that it’s unlikely that she’ll be eligible for Medicaid benefits, as few states provide Medicaid coverage for elderly recent immigrants.

Can immigrants buy individual health insurance?

This is the area that has changed the most for recent immigrants who are 65 or older. Prior to 2014, obtaining individual health insurance for your grandmother on the private market would have been difficult or impossible, 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 or eligible for premium-free Medicare Part A, but recent immigrants are not eligible for Medicare at all.)

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 doesn’t exceed 400 percent of the poverty level, she’ll be eligible for subsidies to lower the cost of the premiums, and if her income is doesn’t exceed 250 percent of the poverty level, she’ll also be eligible for cost-sharing reductions if she buys a silver plan.

For American citizens and immigrants who have been in the U.S. for at least five years, there’s also a lower income threshold in order to be eligible for premium subsidies and cost-sharing reductions in the exchange. The idea is that people below that threshold are eligible for Medicaid instead (although that hasn’t been the case in 16 states where Medicaid expansion has been rejected, leaving a coverage gap). But that lower income threshold doesn’t apply to recent immigrants, as they aren’t generally eligible for Medicaid coverage. So even with income below the poverty level, a recent immigrant who is lawfully present in the U.S. can obtain a plan in the exchange with premium subsidies. As of 2018, a recent immigrant with income below the poverty level would have to pay 2.01 percent of her income (after subsidies) for the second-lowest-cost silver plan in the exchange.

Once your grandmother has been lawfully residing in the U.S. for five years, she’ll be eligible to purchase Medicare. But she’ll also have the option to continue to buy coverage in the exchange instead, and she’ll be able to continue to receive a premium subsidy (and cost-sharing reduction, if applicable) through the exchange if she’s eligible based on her income.

Read more about health coverage for immigrants.

Immigrants, premium subsidies, and the new public charge rule

In 2019, the Trump administration finalized new rules for determining whether an immigrant is likely to become a “public charge.” (Longstanding rules allow immigration authorities to deny a person entry to the U.S. and/or lawful permanent resident status if there is reason to believe that the person will become a “public charge,” which means they’re expected to be relying on various public benefits instead of being financially self-sufficient.)

The new rule updates the list of public benefits that will be considered when determining whether a person might become a public charge. Medicaid is on the list, but premium subsidies in the exchange are not. So an immigrant who uses premium subsidies won’t necessarily be considered a public charge. However, having private insurance without subsidies is a “heavily weighted positive factor” that will count in a person’s favor when officials are reviewing a person’s application for entry to the U.S. or adjustment of legal permanent residency status.

Is there health insurance specifically for immigrants?

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. Although there is no longer an individual mandate penalty for not having minimum essential coverage, there are still prior coverage rules for several types of special enrollment periods, with a requirement that a person must have had minimum essential coverage in place prior to the qualifying event in order to have a special enrollment period triggered by the qualifying event (you can learn more about the specifics in our guide to special enrollment periods)

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 doesn’t exceed 400 percent of the poverty level.

Employer-sponsored coverage

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 much easier than it used to be for elderly recent immigrants to obtain health insurance when they arrive in the U.S.


Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

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Dee Pollock
1 year ago

My wife recently received her green card and wants health care insurance. Perfect health, no pre existing conditions. I am Chairman of The Board of Rural Critical Hospital located in Wickenburg AZ so understand health care.
Louise Norris was highly recommended…could I chat/ with her

Admin
1 year ago
Reply to  Dee Pollock

We’ll reply by email at the address you provided.

Qasim Ali
1 year ago

Wonderful article, clearly explains the public charge definition in the light of new rule. However, it would be nice if a rough dollar amount range could be put against let’s say for a person who wants to buy private insurance without subsidies for an elderly parent > 65 years old. This would give an idea of what cost we are looking at for “heavily weighted positive factor” in the immigration process

11 months ago
Reply to  Qasim Ali

Qasim,
Are you wondering about the full-price cost of a health insurance policy? If so, that will vary considerably from one place to another. The good news is that the cost of a plan for a 95-year-old won’t be more than the cost of a plan for a 64-year-old, since the ACA’s age banding rules require an insurer to charge someone who is 64+ no more than three times the amount they charge someone who is 21.
But the prices vary from one insurer to another and from one area to another. For example, the cheapest full-price plan available for an elderly person in Cheyenne, Wyoming is currently $1,275 per month. But in Salt Lake City, Utah, an elderly person can get a full-price plan for $546/month.

Sergey
11 months ago

I read this article and wondered how successfully the author placed all essential information about health insurance for immigrants in one post.
I highly recommend this article to everyone who are interested in this subject. Do not go to other sites, just read all above carefully.
Great thanks to author, now my not systemized knowledge of the subject converted into organized system.

Venkat
8 months ago

Hi My mother is living with me at New York and she will get green card in 4 months. She will be 73 years old in Dec 2020. I am looking for good health insurance covering pre-existing condition too.

8 months ago
Reply to  Venkat

She’ll be able to enroll in an individual market plan through New York State of Health: https://nystateofhealth.ny.gov/ That’s the state-run health insurance exchange in New York. Coverage is available for lawfully present immigrants regardless of age, and premium subsidies would be available to her if she’s eligible based on income. And if her income is too low for premium subsidies, she’d be able to enroll in The Essential Plan (a NY-specific plan for people with low-modest incomes; it does not have a five-year waiting period for coverage the way Medicaid and Medicare have).
Here’s more information that might be useful for you in terms of how individual market coverage works for immigrants: https://www.healthinsurance.org/obamacare/how-immigrants-are-getting-health-coverage/

Varadan
1 month ago
Reply to  Venkat

Hi Venkat,
Which insurance did you get for your mother. I have a similar situation also. Would you please be able to share?

Thank you,

Varadan

Nikki Flores
8 months ago

Hi. I’m planning on petitioning my father who is currently in the Philippines, so he can stay with me here in California. He is 83 years old, with pre-existing condition. He doesn’t have any income, and doesn’t own any asset worth over $1,000. Once my petition gets approved, would he be able to apply for medi-cal once he gets here in California? If not, is there any low-cost health coverage available for him?

Elizabeth Gonzalez
7 months ago

Hello. My mother is 74, she received her permanent residence since 2011. She has been traveling back and foth because of my sister who has been denied the visa and who depends on my mom. The idea has olwas been for my mom to stay here in California but she hasn’t been able to stay more than three months. Now she is ill and I want to bring her here for treatment. She never workde here and she doesn’t have health insurance. What Insurance can I get for her to be able to take her to good hospitals. She doesn’t have any income but my husband and I could pay for her premium if necesary. Because of the pre-existance and the age, private insurances won’t take her and because she hasn’t work here, she doesn’t apply for medicare. Could you please help me find a solution for her? I would need to bring her in less than two months and I don’t want to take her just anywhere because she doesn’t have insurance, I need to do things right.

7 months ago

I’m sorry your mother is ill, and I hope you’re able to help her get the treatment she needs. If she hasn’t resided continuously in the US for the last five years, she would not be able to enroll in Medicare. Her pre-existing conditions would not keep her from enrolling in a private ACA-compliant plan in the individual market (ie, through Covered California), but she would need a qualifying event in order to enroll outside of open enrollment. Here’s a guide to the various qualifying events: https://www.healthinsurance.org/special-enrollment-guide/why-you-need-this-book/ If she’s been living overseas and is returning to the US, she would qualify for a special enrollment period triggered by a permanent move: https://www.healthinsurance.org/special-enrollment-guide/how-your-big-move-can-trigger-an-sep/
She could also enroll in a plan through Covered California during open enrollment, which begins November 1. But coverage selected during open enrollment doesn’t take effect until January 1. So if she’s moving back to the US in the near future, the permanent move special enrollment period is probably a better option, as it will allow her coverage to take effect sooner.

Srkpriv
17 days ago

Your mother will be eligible for CA Medi-CAL (medicaid) in California

Jerry Mullins
7 months ago

Could you please tell me the cost of health insurance for 87 year old in Florida I would like to bring my sister back to the USA from England she had a green card but it has ran out thank you.

Admin
6 months ago
Reply to  Jerry Mullins

Jerry, this article has more information about individual health insurance for immigrants. You can use the quote form at the top of the page to get an idea of the plans available and plan costs. https://www.healthinsurance.org/obamacare/how-immigrants-are-getting-health-coverage/

You can also call the phone number at the top of the page to talk about your coverage needs with a professional licensed in Florida.

Pete
6 months ago

Hello,

My wife currently doesn’t work but we are sponsoring both of her parents to immigrate to the US. We file a joint tax return and I make over $100k. Her father will be over 65 when they get here. Would her parents be able to get subsidized health insurance from the market or do I make too much and would have to pay the full premium? We currently reside in Nevada. Thank you!

Editor
6 months ago
Reply to  Pete

We recommend that you speak with a financial advisor for specifics about your situation. But in general, when determining their eligibility for premium subsidies in the marketplace, your income would only be considered if you’re planning to claim them as tax dependents on your own tax return. Assuming that’s not the case, they would apply for premium subsidies based on their own income, and would then file their own tax return to reconcile the subsidy amounts that are paid on their behalf.

Miriam
5 months ago
Reply to  Louise Norris

Hello!
I would like to follow up on this as I am in a similar situation, planning (along with my husband) to sponsor my mom for a green card. I am reading in other sources that for legal immigrants who have signed a legally binding affidavit of support on or after December 19, 1997, the income and resources of the sponsor are counted as available to the immigrant when determining the immigrant’s eligibility for ACA health plan. It appears this is regardless whether the immigrant is listed as a dependent on the sponsor’s tax return. Most immigrants cannot apply for green card without their US citizen direct relative sponsorship, so does that mean that would make them ineligible for health coverage through ACA because of level of income of their sponsors? Or only limits the eligibility for subsidies?
The other question is, how does one obtain a health plan in the USA via ACA if they do not have a SSN issued to them yet, as they are just applying for permanent residency (not a green card holder yet).
Thank you!

foo bar
5 months ago
Reply to  Miriam

Miriam –
I am reading in other sources that for legal immigrants who have signed a legally binding affidavit of support on or after December 19, 1997, the income and resources of the sponsor are counted as available to the immigrant when determining the immigrant’s eligibility for ACA health plan

where are you seeing this? Do you have any sources? I’m in the same boat that’s why I’m asking.

Naila
6 months ago

Hello Louise,
Thank you for the informative article. My parents are 75 and 62. They just got their green card and I know they are not eligible for the state or federally funded programs.
I would appreciate if I can speak to you, and get guidance on what insurance I can get them. We’re in NY. My sibling who sponsored them is in TX.
Hope to hear from you soon.

Editor
6 months ago
Reply to  Naila

Hello Naila,
They should be able to enroll in a plan through NY State of Health, so I’d advise you to start there: https://nystateofhealth.ny.gov/ You can contact them directly, or reach out to a Navigator in New York: https://info.nystateofhealth.ny.gov/navigatorsitelocations

Suzanne Hendery
6 months ago

Dear Louise, thank you for offering your excellent advice! I am seeking direction on bringing my 88 year old dad, who is a dual citizen- US and Canadian, with a pre-existing condition, who has lived in Canada for 45 years, to my home of Reno, Nevada to be a permanent resident. Early in his career, he lived in the US for 5+ years and paid payroll taxes. Your advice please. I would not list my dad as a dependent on my taxes, and he would not be eligible for Medicaid. Thank you!

Editor
6 months ago

Thanks, Suzanne! Since your dad would not be eligible to enroll in Medicare or Medicaid, he can enroll in a plan through Nevada Health Link instead (he would need 5 years of continuous presence in the US immediately prior to enrolling in Medicare; his 5+ years of prior work history would only be counted in terms of whether he’d need to then pay premiums for Medicare Part A, and it would have to be at least 7.5 years of work history in order to make a dent in the Medicare premiums).
Because he’s not eligible for premium-free Medicare (or any Medicare at all for the first five years after he moves to the US) and would also be ineligible for Medicaid for five years, he’d qualify for premium subsidies through Nevada Health Link if his income is between 0% and 400% of the poverty level. This would be based on the income that he files on his own tax return; your income would not be counted since he wouldn’t be listed on your tax return.
I’d advise reaching out to Nevada Health Link or to one of their certified enrollment assisters or brokers. Here’s the contact info: https://www.nevadahealthlink.com/get-help/

Ray Snook
5 months ago

My wife and I were greencard holders for 15 years, but left the U.S in 2017 to look after elderly parents in the UK. Our daughter is a US citizen and can sponsor us for greencards if we want to return to live in the US as retirees.
Would our 15 years of residency count for us to apply for Medicaid immediately or would we have to wait another 5 years upon returning?

Martha
5 months ago

Thanks for writing this article. If I were to bring my parents here, would their retirement savings count as income when determining whether they qualify for health care subsidies, or just the interest they make on those savings? They wouldn’t be working, so they wouldn’t have any additional income, they’d just be living off of their savings.

Editor
3 months ago
Reply to  Martha

Subsidy eligibility is based on an ACA-specific definition of MAGI: https://www.healthinsurance.org/glossary/modified-adjusted-gross-income-magi/ For most people, it’s the same as AGI from their tax return, but there are a few things that have to be added in, if they have them.
So for example, if a person is taking withdrawals from a traditional (non-Roth) retirement account that was saved pre-tax in the US, the money withdrawn would all be taxable and would thus be counted as income. But if the withdrawals aren’t considered taxable income, they’re not going to affect AGI or ACA-specific MAGI.

Yonayumi
4 months ago

I am looking for medical health insurance options for my parents – both 74, not working, greencard holders and resident for 1.5yrs in WA. A health plan navigator told my parents would need to submit a joint $0 income (separate to our household) to avail cheap and affordable health plan. My husband and I were both working and the company shoulders our health insurance. If we consider household income, health plans for my parents would not be affordable and costs $1700 each per month. Is the navigator right, is this legal?

Editor
3 months ago
Reply to  Yonayumi

You’d only consider your income and your husband’s income if you claim your parents as dependents on your tax return. Otherwise, assuming they file their own tax return, it’s just based on their own income. If they have no income at all, they’ll qualify for a premium tax credit, as explained here: https://www.healthinsurance.org/obamacare/how-immigrants-are-getting-health-coverage/ (recent immigrants are not eligible for Medicare or Medicaid, which is why premium subsidies are available even to those with no income, as long as they’re lawfully present in the U.S.)

Kate Subu
3 months ago

Hello, My parents are 74 and 78 respectively. They are Canadian citizens living in India. I’m planning on sponsoring them for Green card so they can spend time in US. I know they will not be eligible for Medicaid. As far as the ACA is concerned, do they qualify for plans in NJ. How much does it cost? They will have minimum income so would qualify for subsidy i imagine. Please let me know the details. Thanks.

Editor
3 months ago
Reply to  Kate Subu

Yes, they would be able to buy coverage through the health insurance exchange/marketplace in New Jersey. Here’s the exchange website, where you can see pricing (based on their income) and plan availability: https://www.nj.gov/getcoverednj/
And here’s more about the New Jersey exchange: https://www.healthinsurance.org/new-jersey-state-health-insurance-exchange/

John ] Edward
3 months ago

Hi Louise,

Awesome article! I have a quick question, my parents are GC holders living with me in US but receive pensions in India (7000 USD annual). They are eligible for ACA health plans but what is there gross income? Is it my Income since i claim them as dependents or their annual pension income from foreign accounts? If i used their income as gross income to buy the health plan (which will be heavily subsidized) then can i continue include them in my taxes as defendants or they should file separately?

Editor
3 months ago
Reply to  John ] Edward

The question of whether or not to claim your parents as your tax dependents would need to be addressed with a tax advisor, as it has a lot of ramifications either way.

But in terms of premium subsidies, it’s fairly straightforward: If you claim them as tax dependents, then the entire household income (yours and theirs) would be counted, as would all the members of the household (you, them, as well as any other people who show up on your tax return). So for example, if there are a total of five people on the tax return, you’d be looking at the federal poverty level numbers for a household of five, and comparing that with the total household income.m This article might be helpful in understanding how this works: https://www.healthinsurance.org/faqs/we-claim-our-son-but-not-our-daughter-on-our-taxes-how-are-premium-subsidies-calculated-for-families-like-ours/

On the other hand, if your parents file their own tax return, their subsidy eligibility would be based on their own total income versus the poverty level numbers for a household of two.

Cynthia
1 month ago

Are there a required numbers of hours an immigrant has to work over 5 years to be eligible for Medicare?

Karen kim
1 month ago

Hi, my mom is 70 years old and she will obtain green card this year. I recently found out that she won’t be eligible for any government health benefits for next 5years, so i am trying to buy a private health insurance since mom would need medical attention and daily medications. I have no idea what the cost will be like, or it’s even possible for her to get the insurance with pre-existing health conditions. Can you please advise me?

Varadan
1 month ago

I am from India. My parents are 83 and 78 and wish to come here to stay with us on green card (not filed petition yet, but will do soon). My mother has preexisting conditions. I would like to know what reasonable options for healthcare coverage are available for my parents in the first five years? Appreciate any information. Thanks!

Srkpriv
17 days ago

In California, permanent residents (Green Cards) who are senior citizens are covered by California Medi-CAL (Medicaid). I am sure other states may have similar facilities… Of course, through ACA you can buy medical insurance through ACA exchanges (which are subsidized for Senior Citizens in states where there is no medicaid or limited medicaid).

Last edited 17 days ago by Srkpriv
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