Assuring That Child Health Applications Do Not Deter
Enrollment Among Eligible Children in Noncitizen Families
Prepared for Covering Kids by
Michelle Cochran and Cindy Mann
The high uninsured rate among children from noncitizen families must be addressed if initiatives to lower substantially the number of uninsured children are to be successful. An estimated one in five children is either an immigrant or has at least one immigrant parent, and the percentage of children living in noncitizen families who lack health insurance coverage is growing.
- An analysis by the UCLA Center for Health Policy Research shows that in 1997, 43 percent of noncitizen children were uninsured, up sharply from 36 percent in 1995. 1
- The uninsured rate among citizen children living with noncitizen parents was 27 percent in 1997, compared to 23 percent in 1995.
- Poor noncitizen children are at even greater risk of being uninsured. Nearly half 49 percent of noncitizen children with incomes below the poverty line had no health insurance coverage in 1997. Among poor citizen children with noncitizen parents, 29 percent were uninsured.
- By contrast, in 1997, 19 percent of poor citizen children living with U.S.-born citizen parents were uninsured.
The low rates of coverage among low-income children in noncitizen families is due to many factors, most having nothing to do with childrens eligibility for coverage. Although changes in federal law did result in large numbers of immigrants losing access to public benefits, citizen children living with immigrant parents and most immigrant children continue to be eligible for Medicaid, and now for separate CHIP-funded programs as well.
Many states, as well as health care providers, schools and a wide range of community organizations are engaged in aggressive outreach strategies and public education campaigns to turn these high uninsured numbers around. In this context, it is important to assure that child health applications do not unintentionally create additional barriers to coverage. Efforts to promote enrollment among eligible children in noncitizen families are likely to fall short of their goals if child health applications ask unnecessary questions about citizenship or inappropriately require Social Security numbers from people living in the household who are not applying for benefits for themselves. Such information is not necessary to determine a childs eligibility for health coverage under either Medicaid or a separate CHIP-funded program and is likely to deter families with noncitizen family members from completing the application process.
The Health Care Financing Administration, the federal agency that oversees Medicaid and CHIP, issued guidance to states on September 10, 1998 clarifying the procedures to be followed with respect to Social Security numbers: 2
"We wish to clarify that, under Section 1137 of the (Social Security) Act, a SSN (Social Security Number) must be supplied only by applicants for and recipients of Medicaid benefits. In all other cases, including non-applicant parents of children applying for Medicaid and children applying for a separate State CHIP program (non-Medicaid), States are prohibited from making the provision of a SSN by another family member a condition of the childs eligibility. This also applies to other members of the household whose income might be used in making the childs eligibility determination" (emphasis added).
The guidance further states that while non-applicant family members may be asked for an SSN in order to help verify their income, states cannot require an SSN from non-applicants and cannot deny an application based on failure to provide an SSN for a non-applicant member of the household.3
The guidance also advises states that there is no basis for asking about the immigration status of persons who are not applying for benefits. It states, "The citizenship and immigrant status of non-applicant parents or other (household members) is irrelevant to their childrens eligibility. States may not require that parents disclose this information."
A review of state child health applications shows that the questions about citizenship and Social Security numbers in child health applications often do not comply with the rules laid out in the guidance and proposed regulations. In some cases, there seems to be some effort to comply with these rules, but the application contains conflicting or confusing instructions with respect to the information that is required. Table 1 provides the results of an analysis of each states child health application(s) with respect to questions in the application about Social Security numbers and citizenship status. The methodology used to analyze these applications is described in the section that follows, and the applications reviewed are identified in the appendix to this report.
As states consider revisions to their child health applications to comply with the federal SSN and citizenship rules, it might be helpful to look at how some states have addressed these issues in their child health applications.4 Two state application from California and Illinois are described below.
- California. Californias joint Medi-Cal/Healthy Families application, in section 2, asks for the Social Security number and citizenship of "children under 19 and/or the pregnant woman who want health coverage" and further states in that same section that "Social Security Numbers are not required for Healthy Families or for persons who want emergency or pregnancy related services only." (Medi-Cal is the states Medicaid program and Healthy Families is the California CHIP-funded program.) In section 3, the application asks about other family members living in the home, but this section does not ask about SSNs or citizenship status.
The California application instructions, moreover, provide clear information to applicants about the rules relating to SSNs and citizenship status. In addition, the instructions also assure applicants of confidentiality. The instructions state, "Immigration information we get as part of this application is private and confidential. The State will use this information only for eligibility determination and program administration. (See Privacy Notifications.). Medi-Cal and Healthy Families do not collect information on the immigration status of parents/guardians who are not seeking health coverage for themselves. These programs cannot and will not provide information on the immigration status of such parents to the INS or use immigration information to demand or collect repayment information from recipients for services lawfully received." (Application instructions, page 3.)
- Illinois. Illinois KidCare application (Medicaid and CHIP) asks a number of questions about "all children and pregnant women living with you who want health benefits." This section of the application asks for such individuals SSN (the application states that SSNs are optional for pregnant women) and citizenship status. (See questions 4 and 7.) In a section of the application that follows, information is sought about spouses and children not listed in the earlier section of the application. Question 12 asks for the SSNs of such persons but clearly states that this information is optional.
Table 1 with notes
1. E. Richard Brown, Roberta Wynn and Victoria D. Ojeda, Noncitizen Children's Rising Uninsured Rates Threaten Access to Health Care, UCLA Center for Health Policy Research, June 1999.
2. Letter from Sally Richardson, Director, Center for Medicaid State Operations, Health Care Financing Administration, September 10, 1998 (http://www.hcfa.gov/init/chpelig.htm).
3. With respect to separate CHIP-funded programs, the proposed CHIP regulations issued on November 8, 1999, provide that a state may not "require that any individual provide a social security number, including the social security number of the child or that of a family member whose income or resources might be used in making the child's eligibility determination." Proposed section 457.320(b)(4). Fed. Reg., Vol. 64, No. 215, page 60951.
4. Most state child health applications are posted on the Center on Budget and Policy Priorities' Start Healthy Stay Healthy web site at /archiveSite/shsh/apply.htm.