Q: We would like our 80-year-old grandmother to come to the United States and live with us so we can take care of her. How do we get health insurance for her?
A: You’re in luck, thanks to the Affordable Care Act (ACA). And the American Rescue Plan and Inflation Reduction Act have made coverage even more affordable than it used to be. You also don’t need to worry about immigrant health insurance requirements or changes to the “public charge” rule, as both have been revoked by the Biden administration.
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, described 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.
Can recent immigrants to the United States get health coverage if they’re over 65?
Thanks to the ACA, seniors who aren’t eligible for Medicare – including lawfully-present immigrants – can purchase guaranteed-issue private health insurance in the exchange (Marketplace), and can receive income-based premium tax credits to offset some or all of the premium cost if they don’t qualify for certain other government- or employer-sponsored coverage.
There is normally an income cap equal to 400% of the poverty level, above which a household would not be eligible for premium subsidies. But the American Rescue Plan and Inflation Reduction Act have eliminated that income threshold through 2025, allowing higher-income households to qualify for subsidies if the benchmark plan would otherwise cost more than 8.5% of the household’s income.
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 a monthly premium for Medicare Part A.
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). But it should be noted that the rules to qualify for subsidies will change slightly once the person has been in the U.S. for five years:
- For the first five years, they can qualify for Marketplace subsidies even if their income is below the poverty level. This is due to ACA Section 1401(c)(1)(B), which clarifies that if a person’s household income is under the poverty level (which would normally disqualify them from subsidy eligibility) and they aren’t eligible for Medicaid due to their immigration status (in most states, that means they’ve been in the U.S. for under five years), they are treated as having an income equal to the poverty level and are thus eligible for subsidies.
- After they’ve been lawfully present in the U.S. for at least five years, they have the same access to Medicaid as American citizens, which means they can qualify for Medicaid based on income or income + assets, depending on their eligibility category (eligibility for people who are 65 or older is based on income and assets). But since they are no longer barred from Medicaid due to their immigration status, ACA Section 1401(c)(1)(B) does not apply anymore. That means they need to have an income equal to at least the prior year’s federal poverty level to continue to qualify for premium subsidies in the Marketplace. And if they are eligible for Medicaid, they are not eligible for premium subsidies in the Marketplace (qualifying for Medicaid after age 65 is more challenging, as the asset limits tend to be quite low).
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 can enroll in Medicare if you’re at least 65 years old or qualify for coverage due to a long-term disability. People who have paid into the Medicare system for at least 10 years 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 $505/month in 2024) 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 (there’s an exception for immigrants who have been married for at least a year to someone who is over the age of 62 and entitled to premium-free Medicare Part A due to their work history in the U.S.).
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, which runs from January through March each year.
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.
How does Medicare work for U.S. citizens living abroad or returning from abroad?
If you’re a U.S. citizen, you qualify for Medicare when you turn 65. You can enroll in Medicare even if you’re living abroad, but you won’t be able to use the coverage outside of the United States and its territories. You can only enroll in a Part D plan or Medicare Advantage plan if you’re living in the plan’s service area. And you can only enroll in a Medigap plan if you’re living in the state where the plan is offered.
If you don’t enroll in Medicare Part B when you’re first eligible, or if you drop it when you move abroad, you may have to pay a late enrollment penalty if and when you re-enroll in Part B. And you’ll be limited to using the General Enrollment Period, which runs from January through March each year. To avoid these issues, some people choose to continue to pay for Medicare Part B while living abroad, even though they can only use the coverage during trips to the U.S.
Read more from CMS about Medicare for U.S. citizens living abroad, including details about access to Medicare Advantage, Medicare Part D, and Medigap. (Note that the General Enrollment Period details in that guide are outdated. If you enroll during the GEP, coverage now starts the following month. You no longer have to wait until July for the coverage to take effect.)
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 in the private market would have been difficult or impossible, since very few major insurers were interested in selling coverage to people over 65.
But the Affordable Care Act 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, 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 is lawfully present 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. Depending on her income, she may be eligible for subsidies to lower the cost of the premiums, and if her income doesn’t exceed 250% 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, premium subsidies are only available if the household’s income is at least 100% of the poverty level. The idea is that people below that threshold are eligible for Medicaid instead (although that hasn’t been the case in 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/Marketplace with premium subsidies. Through at least 2025, a recent immigrant with income below the poverty level would have to pay nothing at all (after subsidies) for the second-lowest-cost silver plan in the exchange (prior to the American Rescue Plan, they would have had to pay about 2% of their income for that plan, but the ARP and Inflation Reduction Act have temporarily enhanced the premium subsidies, to make coverage more affordable).
There has also been some progress at the state level (for example, California) in allowing older adults to enroll in Medicaid regardless of their immigration status.
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, and assuming she isn’t eligible for Medicaid.
Can recent immigrants buy health coverage while they're waiting for a green card?
In order to use the marketplace/exchange, they will need to have a lawfully present status in the U.S. That includes people who already have a green card, but it also includes other groups, such as asylees and refugees – some of whom may go on to later receive a green card. However, if your parents do not yet have a lawfully present status, they won’t be able to purchase coverage through the Marketplace.
But they have the option to enroll in coverage outside the Marketplace/exchange directly from a health insurance carrier. (These plans are ACA-compliant and cover pre-existing conditions, and like Marketplace plans, they are only available during open enrollment or a special enrollment period.) They can also purchase travel insurance or short-term health insurance. (Travel coverage and short-term coverage are available year-round, but generally do not cover pre-existing conditions, and do not have to comply with ACA rules. And short-term plans effective in September 2024 or later are limited to total durations of no more than four months, including renewals.)
Read more about health coverage for immigrants.
And as of 2024, a dozen states used state funds to provide Medicaid to low-income children regardless of immigration status (meaning the coverage could be provided to undocumented immigrant children) and two of those states also extend the coverage to people who are pregnant, regardless of immigration status.
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 (California is a notable exception).
Employer-sponsored coverage
Even if you have health insurance coverage through your employer, you generally can’t add your grandmother as a dependent. But the rules for this will vary from one employer to another, so you’ll want to check with your HR department to find out whether your health plan will allow it. (As of 2023, California law allows people to add parents or stepparents as dependents on their individual/family health coverage, but this does not apply to employer-sponsored coverage.)
However, some families that own and operate small businesses 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.
Footnotes
Tags: immigrants, Medicaid
