HLA submits comments to the Centers for Medicare & Medicaid ...
HLA submits comments to the Centers for Medicare & Medicaid ...
HLA submits comments to the Centers for Medicare & Medicaid ...
Create successful ePaper yourself
Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.
30 Winter Street, Suite 1004<br />
Bos<strong>to</strong>n, MA 02108<br />
T 617-338-5241<br />
F 617-338-5242<br />
W www.healthlawadvocates.org<br />
Board of Direc<strong>to</strong>rs<br />
Mala M. Rafik, President<br />
Brian P. Carey, Treasurer<br />
Lisa Fleming, Clerk<br />
Jeffrey N. Catalano<br />
Michael S. Dukakis<br />
Paul W. Finnegan<br />
Ruth Ellen Fitch<br />
Paula Gold<br />
Joshua Greenberg<br />
Daniel J. Jackson<br />
Wendy E. Parmet<br />
S. Stephen Rosenfeld<br />
Amy Whitcomb Slemmer<br />
Eleanor H. Soeffing<br />
Executive Direc<strong>to</strong>r<br />
Matt Selig<br />
Legal Staff<br />
Litigation Direc<strong>to</strong>r<br />
Lorianne Sainsbury-Wong<br />
Staff At<strong>to</strong>rneys<br />
Leslie Bennett<br />
Jenifer Bosco<br />
Laura Goodman<br />
Samuel Leadholm<br />
Meira Russ<br />
Nancy Ryan<br />
Legal Fellows<br />
Gavi Bogin-Farber<br />
Amy Katzen<br />
Paralegal/Intake Coordina<strong>to</strong>r<br />
Kelsey Meagher<br />
Administrative Staff<br />
Chief Operating Officer<br />
Robert MacPherson<br />
Development Direc<strong>to</strong>r<br />
Scott Bryson<br />
Program and Development<br />
Associate<br />
Grace Rosenthal<br />
Oc<strong>to</strong>ber 29, 2012<br />
VIA ELECTRONIC SUBMISSION at http://www.regulations.gov<br />
<strong>Centers</strong> <strong>for</strong> <strong>Medicare</strong> & <strong>Medicaid</strong> Services<br />
Department of Health and Human Services<br />
Attention: CMS–9995–IFC2<br />
P.O. Box 8016<br />
Baltimore, MD 21244–8016<br />
RE:<br />
CMS–9995–IFC2<br />
Comments on Interim Final Rule Changes <strong>to</strong> Definition of “Lawfully<br />
Present” in <strong>the</strong> Pre-Existing Condition Insurance Plan Program of<br />
<strong>the</strong> Af<strong>for</strong>dable Care Act of 2010<br />
Dear Sir/Madam:<br />
This letter provides <strong>comments</strong> <strong>to</strong> <strong>the</strong> Department of Health and Human Services<br />
(DHHS) <strong>Centers</strong> <strong>for</strong> <strong>Medicare</strong> and <strong>Medicaid</strong> Services (CMS) regarding CMS–<br />
9995–IFC2, relating <strong>to</strong> interim final rule changes <strong>to</strong> <strong>the</strong> definition of “lawfully<br />
present” under <strong>the</strong> Pre-Existing Condition Insurance Plan (PCIP) program of <strong>the</strong><br />
Af<strong>for</strong>dable Care Act of 2010 (ACA). 1<br />
Health Law Advocates (<strong>HLA</strong>) is a non-profit public interest law firm that serves<br />
some of <strong>the</strong> Commonwealth of Massachusetts’ most vulnerable populations.<br />
<strong>HLA</strong> provides pro bono legal representation <strong>to</strong> low-income Massachusetts<br />
residents who have been unjustly denied health care access. We are affiliated<br />
with Health Care For All, <strong>the</strong> premier consumer health policy organization in<br />
Massachusetts.<br />
As a consumer-driven health care access organization, <strong>HLA</strong> recognizes <strong>the</strong><br />
commitment of <strong>the</strong> DHHS with respect <strong>to</strong> its role in implementing Federal health<br />
care re<strong>for</strong>m, and <strong>HLA</strong> is pleased <strong>to</strong> offer <strong>comments</strong> <strong>to</strong> CMS as it applies certain<br />
provisions of <strong>the</strong> ACA that affect disadvantaged populations. It is <strong>the</strong> position<br />
of <strong>HLA</strong> that <strong>the</strong> restriction in <strong>the</strong> definition of “lawfully present” creates a<br />
barrier <strong>to</strong> accessing health care coverage <strong>for</strong> young residents living in <strong>the</strong> United<br />
States and granted deferred action status under <strong>the</strong> Deferred Action <strong>for</strong><br />
Childhood Arrivals (DACA) program.<br />
I. Although deferred action status permits access <strong>to</strong> federally<br />
subsidized health care under <strong>the</strong> ACA, young adults who are DACA<br />
recipients are excluded from <strong>the</strong>se critical benefits.<br />
The objectives of Federal health care re<strong>for</strong>m are <strong>to</strong> provide health care coverage<br />
and <strong>to</strong> reduce <strong>the</strong> number of uninsured residents. 2 Sections 1401 and 2001 of <strong>the</strong>
ACA provide that significant expansions of access <strong>to</strong> federally subsidized<br />
coverage options become effective in 2014, such as graduated Federal subsidies<br />
<strong>for</strong> residents with household incomes between 133 percent and 400 percent of<br />
<strong>the</strong> Federal poverty level <strong>to</strong> enable <strong>the</strong>m <strong>to</strong> purchase health insurance, and<br />
expansions in <strong>Medicaid</strong> <strong>to</strong> include opening eligibility standards <strong>to</strong> low-income<br />
adults who would o<strong>the</strong>rwise not qualify <strong>for</strong> federally subsidized health insurance<br />
due <strong>to</strong> inability <strong>to</strong> meet existing <strong>Medicaid</strong> eligibility requirements.<br />
Despite <strong>the</strong>se ACA expansions, CMS removes DACA young adults from<br />
federally supported insurance coverage by adding paragraph 8 <strong>to</strong> <strong>the</strong> definition<br />
of “lawfully present” under 45 CFR 152.2 (excluding only DACA recipients<br />
from deferred action status).<br />
In 2014, residents with deferred action status – o<strong>the</strong>r than DACA recipients –<br />
will be eligible <strong>for</strong> ACA benefits under <strong>the</strong> insurance exchanges and PCIP. 3<br />
Although deferred action does not confer lawful status, residents who are<br />
granted deferred action are not considered <strong>to</strong> be accruing unlawful presence in<br />
<strong>the</strong> United States during <strong>the</strong> effective dates of <strong>the</strong>ir deferred action status. 4<br />
Deferred action is an exercise of <strong>the</strong> Department of Homeland Security’s (DHS)<br />
prosecu<strong>to</strong>rial discretion <strong>to</strong> defer removal of certain persons, and it ensures “that<br />
governmental resources <strong>for</strong> <strong>the</strong> removal of individuals are focused on high<br />
priority cases.” 5 According <strong>to</strong> CMS in its August 28, 2012 guidance sent <strong>to</strong> state<br />
health officials, <strong>the</strong> justification <strong>for</strong> taking DACA young adults out of <strong>the</strong><br />
insurance pool of eligible residents and denying <strong>the</strong>m access <strong>to</strong> federallysponsored<br />
health care coverage is that “<strong>the</strong> reasons that DHS offered <strong>for</strong><br />
adopting <strong>the</strong> DACA process do not pertain <strong>to</strong> eligibility <strong>for</strong> <strong>Medicaid</strong> or<br />
CHIP[.]” 6<br />
It was unreasonable <strong>for</strong> CMS <strong>to</strong> exclude <strong>the</strong>se young adult DACA recipients.<br />
II.<br />
Excluding DACA recipients from federally supported health care<br />
coverage under <strong>the</strong> ACA will leave most of <strong>the</strong>se young adults<br />
uninsured.<br />
Like o<strong>the</strong>r recipients of a USCIS-approved deferred action status, DACA<br />
recipients who demonstrate an “economic necessity” <strong>to</strong> work in <strong>the</strong> United<br />
States are authorized <strong>to</strong> apply <strong>for</strong> employment authorization effective <strong>for</strong> <strong>the</strong><br />
duration of <strong>the</strong>ir deferred action status. 7 However, even employment<br />
authorization does not eliminate uninsurance among <strong>the</strong>se young adults. DACA<br />
recipients are young and may not be able <strong>to</strong> access employer-sponsored<br />
insurance (ESI) because <strong>the</strong>y do not work <strong>the</strong> requisite number of hours <strong>to</strong> be<br />
eligible <strong>for</strong> ESI enrollment. For those who are offered ESI, it may be<br />
unaf<strong>for</strong>dable.<br />
Without PCIP access <strong>to</strong> federally-sponsored insurance coverage, <strong>the</strong>se young<br />
adults will be left uninsured. DACA recipients are, in general, <strong>the</strong> children of<br />
undocumented immigrant parents, have incurred a lapsed lawful immigration<br />
status as of June 15, 2012, and are persons who are ineligible <strong>for</strong> adjustment of<br />
immigration status under traditional USCIS processes such as family-based<br />
petitions and work certifications. Although health insurance exchanges under<br />
2
<strong>the</strong> ACA will become marketplaces <strong>for</strong> af<strong>for</strong>dable, quality health care coverage<br />
options <strong>for</strong> individuals and small businesses, states may opt <strong>for</strong> flexibility in<br />
implementing exchanges. Even if DACA recipients work <strong>for</strong> employers offering<br />
af<strong>for</strong>dable ESI through federally-supported exchanges, it remains uncertain<br />
whe<strong>the</strong>r <strong>the</strong>se young adults would be eligible <strong>to</strong> enroll due <strong>to</strong> immigration status<br />
and alienage. A higher percentage of working, yet uninsured, DACA recipients<br />
is a <strong>for</strong>eseeable consequence of <strong>the</strong>ir removal from PCIP eligibility, and it can be<br />
presumed that most of <strong>the</strong>se young adults will be left without health insurance. 8<br />
By rendering DACA recipients ineligible <strong>for</strong> <strong>the</strong> PCIP program, CMS prevents<br />
<strong>the</strong>se young adults from accessing needed health coverage by one of <strong>the</strong> primary<br />
means <strong>the</strong>y would o<strong>the</strong>rwise have had available <strong>to</strong> <strong>the</strong>m.<br />
Conversely, if allowed <strong>to</strong> access <strong>the</strong> PCIP program, <strong>the</strong>se young adults would be<br />
economically advantageous contribu<strong>to</strong>rs <strong>to</strong> <strong>the</strong> exchange risk pool because <strong>the</strong>y<br />
are between <strong>the</strong> ages of 15 and 30 years old as of June 15, 2012, 9 and as young<br />
adults <strong>the</strong>y are less costly <strong>to</strong> cover. They would offset <strong>the</strong> medical costs of older<br />
members and help exchanges avoid <strong>the</strong> concerns of adverse risk selection. 10 It is<br />
clear, however, that if excluded from Federal health care access, <strong>the</strong>se young<br />
adults will be compelled <strong>to</strong> obtain services at emergency rooms and urgent care<br />
facilities when <strong>the</strong>y do need care, and this will increase overall health care costs.<br />
III.<br />
DACA recipients are arbitrarily excluded from <strong>the</strong> widely used<br />
definition of “lawful presence,” and <strong>the</strong> requisites of DREAM Act<br />
eligibility are undercut by exclusion from Federal health care<br />
re<strong>for</strong>m exchange provisions.<br />
Statu<strong>to</strong>ry and regula<strong>to</strong>ry definitions of “lawfully residing” and “lawfully<br />
present” under o<strong>the</strong>r public benefit programs demonstrate a Federal policy of<br />
including deferred action recipients in federally-sponsored programs, which may<br />
be adopted by <strong>the</strong> States. 11 In spite of this, CMS has chosen <strong>to</strong> exclude only<br />
DACA recipients from ACA coverage, which will leave most of <strong>the</strong>se young<br />
individuals uninsured.<br />
The Children's Health Insurance Program Reauthorization Act (CHIPRA) is <strong>the</strong><br />
benchmark <strong>for</strong> ACA eligibility with respect <strong>to</strong> noncitizens under its “lawful<br />
presence” standard, as set <strong>for</strong>th in July 1, 2010 CMS guidance. 12 CHIPRA<br />
allows states, such as Massachusetts, <strong>to</strong> cover immigrant children and pregnant<br />
immigrant women through <strong>Medicaid</strong> and CHIP, despite <strong>the</strong> Personal<br />
Responsibility and Work Opportunity Act. 13 CHIPRA provides that “lawfully<br />
present” status is accorded <strong>to</strong> those aliens who secure employment authorization<br />
as well as those granted Temporary Protected Status, asylum applicants, and<br />
residents with approved visa petitions who are awaiting adjustment of status. 14<br />
CHIPRA is indifferent with respect <strong>to</strong> State decisions <strong>to</strong> expand coverage under<br />
Federal/State <strong>Medicaid</strong> and CHIP programs. Accordingly, CMS authorizes<br />
States <strong>to</strong> extend Federal/State <strong>Medicaid</strong> programs and CHIPRA benefits <strong>to</strong><br />
immigrants who are lawfully present on <strong>the</strong> same basis as DACA recipients,<br />
namely deferred action. 15<br />
It is problematic that CMS leaves <strong>the</strong>se DACA children and young adults<br />
uninsured. The implications of this exclusion undercut <strong>the</strong> federal policy of<br />
3
near-universal health insurance and such actions are unjustifiably<br />
counterproductive <strong>to</strong> <strong>the</strong> establishment of a balanced risk pool of covered<br />
beneficiaries. It is equally concerning that DACA eligibility under <strong>the</strong> DREAM<br />
Act requires that applicants demonstrate enrollment in or completion of<br />
education in <strong>the</strong> United States. 16 While <strong>the</strong> DACA educational criterion is<br />
consistent with <strong>the</strong> United States Supreme Court decision in Plyler v. Doe, 457<br />
U.S. 202 (1982) (holding that children without lawful status are entitled <strong>to</strong> attend<br />
public schools), CMS’s expulsion of <strong>the</strong>se children and young adults results in a<br />
perpetuation of public health concerns in <strong>the</strong> public educational setting.<br />
Moreover, it is quite problematic that DACA applicants who do not meet <strong>the</strong><br />
DREAM Act educational criterion but who have been honorably discharged<br />
from <strong>the</strong> United States military may receive deferred action status; 17 however,<br />
as DACA recipients, <strong>the</strong>y may not receive federally supported coverage under<br />
<strong>the</strong> PCIP program.<br />
Ra<strong>the</strong>r than excluding DACA recipients from Federal health care re<strong>for</strong>m<br />
coverage, CMS should redress <strong>the</strong> consequences of expulsion from deferred<br />
action status and denial of eligibility under <strong>the</strong> PCIP program.<br />
IV.<br />
Conclusion<br />
For <strong>the</strong> reasons identified above, <strong>HLA</strong> advocates <strong>for</strong> <strong>the</strong> inclusiveness of <strong>the</strong><br />
term “lawfully present” under <strong>the</strong> ACA. <strong>HLA</strong> opposes <strong>the</strong> removal of children<br />
and young adults who are DACA recipients from federally- supported health<br />
insurance exchanges.<br />
Accordingly, <strong>HLA</strong> recommends that CMS delete subsection 8 of 45 CFR §<br />
152.2 and provide <strong>the</strong>se children and young adults with equal access <strong>to</strong> <strong>the</strong> PCIP<br />
program.<br />
If you should have any questions, please feel free <strong>to</strong> contact <strong>the</strong> undersigned.<br />
Sincerely,<br />
/s/ Lorianne M. Sainsbury-Wong<br />
Lorianne M. Sainsbury-Wong<br />
Litigation Direc<strong>to</strong>r<br />
Health Law Advocates<br />
30 Winter Street, Suite 1004<br />
Bos<strong>to</strong>n, MA 02108<br />
617-275-2987<br />
sainsbury_wong@hla-inc.org<br />
/s/ Gavriela M. Bogin-Farber<br />
Gavriela M. Bogin-Farber<br />
Legal Fellow<br />
Health Law Advocates<br />
30 Winter Street, Suite 1004<br />
Bos<strong>to</strong>n, MA 02108<br />
617-275-2891<br />
gbogin-farber@hla-inc.org<br />
4
1 77 Fed. Reg. 52614 (August 30, 2012).<br />
2 See 42 U.S.C. § 18091(2)(C).<br />
3 See 45 CFR 152.2(4)(v) and 152.14(a) (lawfully present individuals are eligible <strong>to</strong> enroll in a<br />
PCIP, and “lawfully present” includes “aliens currently in deferred action status”).<br />
4 See USCIS, Consideration of Deferred Action <strong>for</strong> Childhood Arrivals Process, Frequently<br />
Asked Questions (September 14, 2012), available at http://tinyurl.com/9t5maht.<br />
5 77 Fed. Reg. 52614 (August 30, 2012).<br />
6 Ctrs. For <strong>Medicare</strong> & <strong>Medicaid</strong> Servs., State Health Official Letter – Individuals with Deferred<br />
Action <strong>for</strong> Childhood Arrivals, August 28, 2012, SHO #12-002, available at<br />
http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SHO-12-002.pdf.<br />
7 See 8 C.F.R. § 274a.12(c)(14); see also USCIS Frequently Asked Questions, supra note 4.<br />
8 Moreover, <strong>the</strong> majority of DACA recipients already have no access <strong>to</strong> ano<strong>the</strong>r corners<strong>to</strong>ne<br />
provision of <strong>the</strong> ACA: dependent coverage. Dependent coverage allows parents <strong>to</strong> keep <strong>the</strong>ir<br />
children on family health insurance plans until <strong>the</strong> children turn 26 years old. DACA young<br />
adults, however, are largely unable <strong>to</strong> access dependent coverage because of <strong>the</strong> unlawful status<br />
of <strong>the</strong>ir parents or parental ineligibility <strong>for</strong> group insurance coverage. These young adults,<br />
<strong>the</strong>re<strong>for</strong>e, demonstrate substantial inability <strong>to</strong> access health care insurance without coverage<br />
under <strong>the</strong> PCIP program.<br />
9 See USCIS, Consideration of Deferred Action <strong>for</strong> Childhood Arrivals Process (September 14,<br />
2012), available at http://tinyurl.com/7ksa6of (requiring that DACA applicants, in addition <strong>to</strong> <strong>the</strong><br />
o<strong>the</strong>r criteria, have been under <strong>the</strong> age of 31 as of June 15, 2012 and have arrived in <strong>the</strong> U.S.<br />
be<strong>for</strong>e turning 16 years old.)<br />
10 See Sharon Silow-Carroll and Diana Rodin et al, Commonwealth Fund, Health Insurance<br />
Exchanges: State Roles in Selecting Health Plans and Avoiding Adverse Selection, States in<br />
Action (February/March 2011), available at<br />
http://www.commonwealthfund.org/Newsletters/States-in-Action/2011/Mar/February-March-<br />
2011/Feature/Feature.aspx (“Adverse selection refers <strong>to</strong> <strong>the</strong> disproportionate enrollment of highrisk,<br />
high-cost individuals, resulting in a rise in costs and premiums. This could result from<br />
lower-risk people [such as young, healthy people] … dropping out of <strong>the</strong> exchange”).<br />
11 See Ctrs. For <strong>Medicare</strong> & <strong>Medicaid</strong> Servs., State Health Official Letter – <strong>Medicaid</strong> and CHIP<br />
Coverage of “Lawfully Residing” Children and Pregnant Women, July 1, 2010, SHO #10-006,<br />
CHIPRA #17, available at http://downloads.cms.gov/cmsgov/archiveddownloads/SMDL/downloads/SHO10006.pdf<br />
(stating that “lawfully present” includes certain<br />
aliens paroled <strong>for</strong> under a year, while disqualifying those “paroled <strong>for</strong> prosecution, <strong>for</strong> deferred<br />
inspection, or pending removal proceedings”).<br />
12 See id.<br />
13 See 42 U.S.C. 1396b(v)(4)(A).<br />
14 See CMS CHIPRA Letter, supra note 11; see also Lorianne Sainsbury-Wong and Nancy Ryan,<br />
Health care coverage <strong>for</strong> lawfully residing aliens: Massachusetts and federal perspectives,<br />
Massachusetts Lawyers Journal (July 2012).<br />
15 See CMS CHIPRA Letter, supra note 11.<br />
16 Specifically, <strong>the</strong> DACA applicant must show that he/she is currently attending school,<br />
graduated or obtained a certificate of completion from a high school, or that he/she o<strong>the</strong>rwise<br />
obtained a general education development certificate. See USCIS, Consideration of DACA<br />
Process, supra note 9.<br />
17 See id.<br />
5