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Perils to Medicaid coverage for Immigrant Families: Summary of PIF’s Medicaid Unwinding Survey

Updated: Apr 23

Since April 2023, millions of people across the country have lost critical health insurance coverage. One study shows that Latinx families are experiencing a larger loss in Medicaid coverage and higher uninsured rate compared to other racial groups This illustrates the need to address the unique challenges for immigrant and limited English proficiency (LEP) individuals.


The dramatic loss in coverage is due to state Medicaid agencies returning to federally mandated requirements to review each household’s eligibility for public health insurance programs. This removal process is referred to as Medicaid “unwinding.” Unfortunately, as we reach the conclusion of unwinding and return to annual reviews of household eligibility, we see that this system of renewing coverage doesn't work. For example, in Tennessee our Medicaid agency, TennCare, reported that 78% of those who lost coverage lost it because of paperwork reasons. One reason is because renewing coverage heavily relies on the agency’s ability to connect and communicate to each household about what is required of them to maintain coverage and then review the household’s eligibility as seamlessly as possible. The challenges of getting through this process is more acute for immigrant community members who face other barriers, such as language access.


Indeed, before unwinding, the U.S. Department of Health and Human Services (HHS) predicted that 35.4% of those disenrolled despite still being eligible would be Latinx families, although in 2022 they were about 29.5% of the non-elderly population on Medicaid. To address these concerns, the Protecting Immigrant Families (PIF) Coalition, brought together national, state and local advocates to focus on the unwinding experience for immigrant community members. As part of this work, PIF surveyed organizations that work with immigrant applicants for Medicaid across the country, including the Tennessee Justice Center (TJC), to learn more about the unwinding experience for immigrant families.

 

Language Access Barriers 

Despite federal language access requirements to assist LEP individuals, implementation varies widely across states. The PIF survey explored whether state agencies conducted outreach about the unwinding in languages other than English and provided in-language assistance through call centers or agency offices. The survey also asked whether states provided in-language information on notices informing recipients on how to receive in-language assistance or provided opportunities to renew coverage in languages other than English. Responses from advocates in 28 states showed that most states have a long way to go. States “are not providing equitable language access in violation of federal law” which “creates obstacles to re-enrollment for people with limited English proficiency” and “imposes a time- and resource-intensive burden on enrollment assisters.”  


Tennessee received a ‘D’ grade along with four other states. In Tennessee, TennCare offers just English and Spanish as options for its call center, its notices, and its online renewal application. Tennessee advocates observed that call wait times were longer for individuals who opted for Spanish or requested an interpreter with the TennCare call center. Additionally, if an interpreter was needed, the call could be dropped – often after a lengthy time on hold. Finally, TennCare does not have any physical offices for members, so getting in-person assistance is not an option for families having difficulty navigating the program due to language access barriers.  

 

Immigration Concern Barriers  

Medicaid is only available to people with certain types of immigration status and Medicaid participation does not impact immigration status or application. However, because of the push to expand the “public charge” rule under the Trump administration, many immigrant families are fearful that participating in safety net programs like Medicaid will impact their immigration concerns. As a result, some decide not to participate. PIF explored whether states were fighting against this “chilling effect” by providing messages that address immigration concerns, avoiding asking for immigration status or Social Security numbers for household members not applying for coverage, and by using historical data, or SAVE data for members.  


Tennessee was graded a D in this category along with five other states among the 27 surveyed, but most states surveyed were graded an F. This is concerning because state governments are key to reducing the chilling effect of immigration fears as adults from immigrant families are most likely to trust government agencies and legal professionals on how public benefits programs will impact their immigration status.  

 

Data Reporting Barriers 

Though CMS does have reporting requirements for states during the unwinding, the minimum information required was whether terminations occurred for paperwork reasons or because the member was found ineligible. States are not required to break down their data based on primary language, race or ethnicity, and zip code, and most states do not report this data. 


Tennessee was graded an F along with most of the other 28 states surveyed. Advocates and state agencies need this data to identify what areas need targeted outreach and if tailoring this outreach to specific demographics is necessary. Additionally, this data will provide insight into inequities in access to the program and may help to address health disparities and combat discrimination.  

 

Recommendations 

Through this survey, PIF and its member organizations, including TJC, identified four recommendations that CMS should follow to ensure that immigrants and their families maintain healthcare coverage and promote health equity: 

  • Comply with tri-agency guidance and prohibit states from asking non-applicants questions about immigration status or SSN 

  • Communicate renewal messages that address public charge and or other immigration-related fears 

  • Follow federal language access laws, conducting secret shopper and other research 

  • Report more specific data by race, language access, county and/or zip code  

The low ratings of Tennessee and other states points to a need to ensure equitable Medicaid access for immigrant families and LEP individuals. PIF and state partners requested that CMS pause Medicaid unwinding until states addressed these concerns. Though CMS did not pause unwinding, these policy recommendations continue to be relevant and should be addressed by Tennessee as TennCare continues to annually review coverage for enrollees.  

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