Historically, immigrants who are “lawfully present” in the United States but not citizens have had access to certain benefits, including financial help to purchase health coverage. This explainer clarifies what health coverage is available to immigrants in the United States and how this will change because of the 2025 reconciliation law known as H.R. 1 and recent rule changes from the U.S. Department of Health and Human Services (HHS).
How does the federal government define legal or lawfully present immigrants, and how does that affect their access to health coverage?
For the purpose of accessing certain health programs, the federal definition of “qualified noncitizens” includes the following categories of immigrants:
- lawful permanent residents (green card holders)
- persons fleeing persecution, including asylum seekers and refugees, and other immigrants granted temporary protected status for humanitarian reasons
- Cuban/Haitian entrants
- survivors of domestic violence
- survivors of trafficking, or individuals with a pending application for a victim of trafficking visa
- members of federally recognized Indian tribes, or American Indians born in Canada
- citizens of the Marshall Islands, Micronesia, or Palau who are living in one of the U.S. states or territories (referred to as Compact of Free Association, or COFA, migrants).
(For more detailed explanations of these categories and others not listed here, see this resource from the National Immigration Law Center.)
A rule finalized during the Biden administration expanded the definition of lawfully present immigrants with respect to certain health programs to include individuals with Deferred Action for Childhood Arrivals (DACA) status, known as “Dreamers.” As qualified noncitizens, Dreamers and other immigrants can buy coverage in the Affordable Care Act (ACA) marketplaces with financial assistance, or they can enroll in Basic Health Program coverage.
To enroll in Medicaid or the Children’s Health Insurance Program (CHIP), many immigrants must wait five years once obtaining qualified noncitizen status. States may waive the five-year waiting period for children and pregnant people. As of January 2025, 38 states waive the waiting period for lawfully present immigrant children, and 32 states waive it for lawfully present pregnant immigrants.
Immigrants who are lawfully present can buy in to Medicare once they turn 65 and have lived in the U.S. legally for at least five years. And those age 65 and older who have paid payroll taxes for 10 years can qualify for Medicare without paying a Part A premium.
Are undocumented immigrants eligible for federally funded health programs?
No, undocumented immigrants are not eligible for Medicaid or Medicare and cannot receive financial help to purchase coverage through the ACA marketplaces.
States may choose to cover unborn children under CHIP through the From Conception to End of Pregnancy (FCEP) option. This option provides prenatal and pregnancy-related care for certain low-income children, regardless of the parent’s immigration status. At birth, coverage for the pregnant person ends, and the child often remains covered either through Medicaid or CHIP. Twenty-four states and the District of Columbia have taken up the FCEP option, and 12 states plus D.C. use state-only funding or CHIP initiatives to provide 12-month postpartum coverage for the parent.
Some states use state-only funding to provide health coverage for immigrants, regardless of legal status, who meet income eligibility: 14 states and D.C. use state-only funds to cover immigrant children, and seven states and D.C. use state-only funds to cover immigrant adults. This coverage may be limited to certain ages or capped based on available funds.
How does H.R. 1 change Medicaid coverage for immigrants?
Beginning in October 2026, H.R. 1 changes the definition of “eligible alien,” restricting eligibility for Medicaid to lawful permanent residents, certain Cuban and Haitian immigrants, COFA migrants lawfully residing in the U.S., and lawfully residing immigrant children and pregnant adults in states that waive the five-year waiting period. This will end eligibility for many groups of lawfully present immigrants, including asylees, refugees, and survivors of domestic violence and trafficking.
Under the Emergency Medical Treatment and Labor Act (EMTALA), emergency departments are required to provide stabilizing care for patients with an urgent medical condition, regardless of citizenship status. Emergency Medicaid reimburses hospitals for the costs of care provided to low-income immigrants who, except for their immigration status, would qualify for Medicaid. Starting in October 2026, H.R. 1 limits the federal matching payment (FMAP) for Emergency Medicaid for individuals who, except for their immigration status, would qualify for expanded Medicaid. This reduces the federal match from 90 percent to as low as 50 percent, the minimum regular FMAP for states.
How do H.R. 1 and the recent marketplace final rule change coverage for immigrants in the marketplace?
The ACA allowed lawfully present immigrants in the five-year waiting period for Medicaid to receive financial help in the form of premium tax credits to buy marketplace plans. Beginning in January 2026, H.R. 1 prohibits lawfully present immigrants with income below the federal poverty level who do not qualify for Medicaid due to immigration status from receiving this financial assistance.
The final HHS marketplace rule, which took effect in August 2025, reversed the Biden administration’s definition of lawfully present immigrant: it now excludes DACA recipients from financial assistance for ACA marketplace coverage and Basic Health Program coverage. Broader restrictions will take effect in January 2027, when H.R. 1 changes the definition of “eligible alien.” Starting then, only lawful permanent residents, certain Cuban and Haitian immigrants, and COFA migrants lawfully residing in the U.S. will be eligible for financial help in purchasing a marketplace plan.
This revised definition also extends to people in employer plans. That means employers are not required under the ACA employer mandate to offer minimum essential coverage to lawfully present immigrants not covered by the new definition.
How does H.R. 1 change Medicare coverage for immigrants?
H.R. 1 immediately changes the definition of eligible alien, restricting eligibility for Medicare to lawful permanent residents, certain Cuban and Haitian immigrants, and COFA migrants lawfully residing in the U.S. That means some lawfully present immigrants will no longer be able to enroll in Medicare, including individuals with status as refugees, asylees, and temporary protected status designees. Individuals with disqualifying statuses who are currently enrolled in Medicare will be disenrolled on January 4, 2027.
What are the impacts of excluding some lawfully present immigrants from Medicaid, the ACA marketplace, and Medicare?
Rise in the uninsured. More than 1 million people will become uninsured due to immigration-related provisions in H.R. 1. The Congressional Budget Office (CBO) estimates the new definition of eligible alien will cause 100,000 people in Medicaid and 100,000 people in Medicare to lose their health coverage. Approximately 10,000 DACA recipients in marketplace plans and 1,000 enrolled in Basic Health Plans also will become uninsured.
Yet restrictions on immigrant eligibility for marketplace financial help will cause most coverage losses: CBO estimates 900,000 people will lose marketplace coverage by 2034 due to restricted eligibility for premium tax credits. An additional 300,000 lawfully present immigrants who are in the five-year waiting period for Medicaid will lose health coverage.
Higher premiums. Marketplace plan premiums for 2026 were already expected to spike owing to recent marketplace policy changes, the Trump administration’s tariffs, rising health care costs, and uncertainty that Congress will extend the enhanced premium tax credits expiring in December 2025. The loss of lawfully present immigrants, who tend to be younger and healthier, in ACA marketplace plans will leave the insurance risk pools smaller and sicker, likely causing premium costs to increase for everyone.
Greater strain on the safety net. Most of the lawfully present immigrants who will no longer be eligible for Medicaid, Medicare, or affordable marketplace plans will become uninsured. Those with chronic conditions may rely on charity care and community health centers (CHCs), which offer care on a sliding scale for those without insurance. Along with other policy changes, this could put additional financial strain on CHCs and reduce the availability of services for everyone who relies on CHCs for care.
Many uninsured people skip preventive care and delay routine care until they end up in the emergency room needing urgent care. This increases wait times for all emergency room users and the amount of uncompensated care provided by hospitals. Combined with other H.R. 1 provisions, the rise in uninsured patients could put additional financial strain on hospitals, especially rural hospitals that already operate on narrow margins. This could lead to hospital closures which would reduce access to care for everyone in the affected community, and to cost-shifting, with commercially insured patients paying more for hospital care.
Implementation of H.R. 1 and the marketplace regulations will limit affordable coverage options for lawfully present immigrants, resulting in higher uninsured rates and higher costs for many Americans. And with providers losing revenue and unable to keep their doors open, many Americans could also experience reduced access to care.
