Older Immigrants and Medicare – Justice in Aging

We gratefully acknowledge Georgia Burke, formerly Justice in Aging’s Director of Medicare Advocacy, for authoring the first edition of this issue brief in 2019. We would also like to thank Nancy Lorenz of Greater Boston Legal Services and Vicky Pulos of Massachusetts Law Reform Institute for their insight and contributions.

INTRODUCTION

Enrolling in the Medicare program and accessing its benefits can be complex and is often confusing for older adults. The process can be even more challenging for older immigrants, some of whom do not have a significant work history in the United States, are not citizens, or have limited English proficiency. More than 8 million U.S. residents age 65 and older are immigrants, and 4 million Medicare beneficiaries have limited English proficiency.^[1]

To assist advocates working with older immigrants who may qualify for Medicare, this issue brief discusses Medicare policies and practices most relevant to older immigrants, including: 

• Eligibility and enrollment, with particular attention to rules affecting non-citizens 
• Help paying for coverage 
• Post-enrollment issues

The issue brief includes numerous hypothetical examples. The names and details are created to illustrate the rules and are not actual case reports.

PROGRAM ELIGIBILITY, ENROLLMENT AND COSTS 

The Social Security Administration (SSA) determines eligibility and handles enrollment for the two core Medicare benefits: Part A, generally referred to as the hospital benefit, and Part B, which covers physicians and most other health services. People with either Part A or Part B coverage can enroll in Part D, the prescription drug benefit. Enrollees with both Part A and Part B coverage have the option to receive their benefits through managed care, called Medicare Advantage (MA). The Centers for Medicare and Medicaid Services (CMS) administers enrollment for both Part D and Medicare Advantage.^[2] Many older immigrants who immigrated later in life have little or no work history in the United States, which affects their Medicare costs, and, in some cases, their eligibility.

Premium costs for Medicare

Part A premiums, which are tied to work history, can be a particular challenge for some immigrants. Nearly all (99%) Medicare enrollees qualify for Part A coverage without paying a premium (“premium-free Part A”) based on their work credits (generally 40 quarters, approximately ten years) or on the work credits of their spouse.^[3] However, those without the required work credits must pay high premiums for Part A coverage, up to $505/mo. in 2024.^[4] Note that work credit requirements are different for people qualifying for Medicare on the basis of disability and that there also are unique rules for people with End Stage Renal Disease (ESRD).^[5]

Regardless of work history, Medicare Part B requires a premium payment, which for 2024 is $174.90/month.^[6] To purchase Part A, an individual must also enroll in Part B. In contrast, it is possible to enroll only in Part B and forgo Part A coverage. Both Part A and Part B have late enrollment penalties that may apply to individuals who do not enroll when first eligible.^[7]

Medicare Part D Prescription Drug Plans (PDPs) also have premiums that vary depending on the plan, as well as late enrollment penalties for delays in enrollment.^[8] Individuals can enroll in the Part D prescription drug benefit if they have either Part A or Part B coverage.^[9] 

Immigration status and enrollment

To enroll in either Part A or Part B, an individual must either be a U.S. citizen or be lawfully present in the United States. Some non-citizens have a length of U.S. residency requirement for Medicare and others do not. In most cases, as discussed in detail below, a non-citizen who does not qualify for premium-free Part A must be a lawful permanent resident (LPR) with five years of continuous residence in the U.S. immediately prior to Medicare enrollment. 

Non-citizens who are not lawfully present (undocumented) are ineligible to enroll in Medicare coverage under any circumstances.^[10] People who are lawfully present and enroll in Medicare but later lose their lawful presence status are not eligible for Medicare payment on any claims. They may still be “enrolled” in Medicare, but Medicare will not process payments for claims submitted by Medicare providers. This policy applies to those in Original Medicare and those in Medicare Advantage.

Citizens have no length of residency requirements 

U.S. citizens face no length of residency requirement to enroll in Medicare, whether or not they have the work credits to qualify for premium-free Part A.^[12] People who do not enroll during the Initial Enrollment Period (IEP) around their 65th birthday can face higher costs and gaps in enrollment, including citizens who are living abroad and return to the U.S. after they reach age 65. In most cases, they do not have a Special Enrollment Period (SEP) when they return so must wait until the General Enrollment Period (GEP), which extends from January 1 to March 31 each year, with coverage starting the first of the month after application.^[13] 

Case Examples: Citizens living abroad

Mr. Santos, born in the Philippines, came to the United States twenty years ago. He worked and contributed to Social Security and Medicare since shortly after he arrived. He has been a U.S. citizen for ten years but has lived in the Philippines for the last four years caring for relatives, who are now deceased. He returned to the United States in the fall last year, shortly after he turned 68. Because he is a U.S. citizen, he was able to begin his Part A Medicare immediately. The fact that he reestablished U.S. residence only months ago was irrelevant to his eligibility for Part A or Part B. Though eligible for Part B, he did not enroll. The fact that he was living overseas and unable to use Medicare benefits did not delay his IEP and there is no SEP for returning citizens. He enrolls in Part B during the GEP with enrollment effective the first of the month after he signs up. Mr. Santos will also owe a late enrollment penalty for his Part B premium because he did not enroll during his IEP. 

Ms. Reyes, who will turn 65 in a few months, came to the U.S. in the same year as Mr. Santos. She also is a citizen and also spent extended periods out of the country to care for family members. She, however, does not have the work history needed for premium-free Part A, but she wants to enroll and pay the premiums. Because Ms. Reyes is a citizen, she can enroll in premium Part A during her IEP and in Part B without any length of residency requirements. The SSA will not consider her time abroad when processing her enrollment. 

Lawfully present non-citizens who qualify for premium-free Part A have no length of residency requirement 

LPRs, individuals in Temporary Protected Status (TPS), and other lawfully present individuals^[14] with work credits that qualify them for premium-free Part A also do not face any length of residency requirement.^[15] Because they qualify for premium-free Part A, these individuals can enroll in both Part A and Part B without any length of residency requirement.^[16]

Although advocates for older adults report that they usually see only LPRs and TPS holders with the required work history, it is possible that other categories of lawfully present individuals, such as Compact of Free Association (COFA) Migrants or asylees, could accrue enough work credits to qualify for premium-free Part A. In many cases, these would be younger individuals who qualify for disability-based Medicare with fewer years of work credits. 

Case Examples: Lawfully present individuals eligible for premium-free Part A 

Ms. Flores, originally from El Salvador, has lived and worked in the United States for 13 years holding Temporary Protected Status. Her work history qualifies her for premium-free Part A. She can enroll in both Part A and Part B without any length of residency requirement. 

Ms. Lopez is an LPR who came to the U.S. three years ago. She married another LPR shortly after arriving. Her husband, a long-term U.S. resident, has enough work credits for premium-free Part A. Ms. Lopez is turning 65. Because she can rely on her husband’s work history, she can start her Part A and Part B coverage right away, even though she has not been a U.S. resident for five years. 

Non-citizens without the work credits to qualify for premium-free Part A face additional status and length of residency requirements 

Many non-citizen immigrants do not qualify for premium-free Part A because they have not worked in the U.S. for a long enough period. To be eligible to enroll in Medicare Part A or B, these individuals must 1) be lawful permanent residents (LPR, i.e., holding a green card) and 2) have five years of continuous residence in the United States immediately prior to Medicare enrollment.^[17] SSA determines whether an individual has met the five-year continuous residency requirements.

When does the five-year period start?

The five-year period of U.S. residency begins the day the individual arrives in the U.S. with the intention of establishing a home. The period can start before the individual has LPR status. The five-year clock can start, for example, with arrival under refugee or asylee status. It cannot start with visitor status since visitors are assumed to be retaining their foreign residence.^[18]

What qualifies as “continuing residence”?

SSA looks at records of entry into the U.S. compiled by the Department of Homeland Security.^[19] Temporary absences do not affect “continuous” residence as long as the individual intends to maintain U.S. residence, but if absences are frequent or of long duration, the agency may inquire to determine whether continued U.S. residency was intended. Examples of evidence of intent could include continuing to pay U.S. income taxes, or maintaining a house or apartment with the individual’s furnishings and belongings. If an absence is over six months, SSA requires a “strong showing” of intent to retain U.S. residence.^[20]  If SSA determines that continuous residence has been broken, the new five-year period begins on the date that the individual has returned to the United States.^[21] 

Case Examples: LPRs without work credits 

Mr. Rao, an LPR, came to the United States at age 62 to live with his son, a U.S. citizen. He has taken on a little part-time work but mostly helps care for his grandchildren. Because he does not have enough work history in the U.S. to qualify for premium-free Part A, Mr. Rao must wait for five years from his date of entry to the U.S. to qualify for Medicare Part A or B. When he meets the five-year residency point, he can enroll in premium Medicare Part A and Part B, or can decide to enroll only in Part B. 

Mr. Lee just turned 65. He has been an LPR since his arrival in the U.S. eight years ago but does not have sufficient work history to qualify for premium-free Part A. Most years, he takes a trip back to Korea to visit family, usually for about six weeks. Mr. Lee applied for Part B Medicare coverage during his IEP. The SSA approved his application because he is an LPR and, despite several short absences, has met the five-year continuous residency requirement. 

What happens to the waiting period if a person marries someone with premium-free Part A?

If an LPR subject to the five-year continuous residency requirement marries someone entitled to premium-free Part A (and who is over age 62), the LPR, after a year of marriage, will also have Part A entitlement based on their spouse’s work history.^[22] The continuous residency requirement will no longer apply.^[23]

Case Example: LPRs with work credits by marriage 

Mr. Williams, a 65-year-old LPR, came to the U.S. from Jamaica last year when he was 64. Because he is subject to the five-year continuous residency period, he cannot enroll in Medicare until he is 69. However, next month he plans to marry Ms. Allen, also an LPR and age 63. She has been in the U.S. over 15 years and, because of her work history, qualifies for premium-free Part A. Once they are married for a year, Mr. Williams will be entitled to Part A based on Ms. Allen’s record. He won’t have to wait for five years to enroll or pay a premium for Part A. 

What about Medicare Part D and Medicare Advantage?

Part D and MA do not have separate citizenship or length of residency requirements. Plans are prohibited from requesting any documentation of citizenship or immigration status. CMS provides the official status to the plan. If CMS records show that a plan member is not lawfully present, the plan is required to disenroll the member.^[24] Individuals with either Part A or Part B can join a Part D plan. To join an MA plan, a beneficiary must have both Medicare Part A and Part B.

AFFORDING COVERAGE

Even when an immigrant qualifies for Medicare coverage, affording that coverage can be a challenge. This is particularly true for immigrants who must pay premiums to enroll in Part A. The steep Part A premium is simply out of reach for many. Premiums for Part B and Part D coverage also add financial burden for low-income immigrants.

State Medicaid programs can assist with Medicare premiums

There are two ways that state Medicaid programs can assist eligible low-income immigrants with Medicare costs. First, every state’s Aged and Disabled (A&D) Medicaid benefit includes payment of the Part B premium for Medicare beneficiaries.^[25] The income and asset limits for A&D Medicaid are low, though they vary by state.

Medicare Savings Programs (MSPs), which state Medicaid agencies administer, also offer premium relief and typically have higher eligibility limits than A&D Medicaid. MSPs do not provide full Medicaid coverage; instead, they are specifically designed to assist with Medicare costs. Federal law sets minimum countable income and asset limits for MSPs, and several states have set more generous limits or eliminated the asset test altogether.^[26]

The MSP with the most robust benefits, the Qualified Medicare Beneficiary (QMB) program, can be particularly helpful to low-income immigrants who must pay a premium for Part A. The QMB program pays both Part A and Part B premiums. In most states, income must be at or below 100% of the federal poverty level (FPL) and countable resources may not exceed (for 2024) $9,430 for an individual and $14,130 for a couple.^[27] QMB also protects enrollees from paying Part A or B Medicare deductibles, co-pays, and co-insurance. Note that many QMBs also qualify for full A&D Medicaid and are referred to as QMB-plus. 

Two other MSP programs, the Specified Low-income Medicare Beneficiary (SLMB) program and the Qualified Individual (QI) program, only pay Part B premiums. The federal minimum income requirements for these programs are 135% and 150% of FPL, respectively. Federal minimum asset limits for both programs are the same as for QMB. 

Most state Medicaid programs serving older adults, including MSPs, have immigration status requirements and waiting periods.^[28] In almost all states, non-citizens must be “qualified” (a designation that is narrower than lawfully present) to be eligible for A&D Medicaid or MSPs. Thus, a Medicare-eligible individual who is not “qualified,” such as an individual with TPS, cannot get help from Medicaid with Medicare costs. In addition, some qualified immigrants, including many LPRs,^[29] are subject to the five-year bar, meaning they must wait five years after attaining a qualified status before they are eligible for Medicaid, including MSPs.^[30]

Case Examples: Medicare Savings Programs 

Ms. Flores, a TPS holder, has premium-free Medicare Part A coverage because of her long work history in the U.S. Her income is below 100% of FPL, but she cannot qualify for QMB assistance with her Part B premiums because TPS is not a “qualified” status. 

Ms. Gonzales, an LPR, has premium-free Part A based on her husband’s work history. Her income and assets qualify her for the SLMB benefit, but she only has three years of continuous residence in the U.S. Due to the 5-year bar, she will have to wait another two years before she can enroll in SLMB to get help with her Part B premiums. 

Enrolling in the QMB program can be challenging 

As discussed above, the QMB benefit can be particularly helpful to low-income immigrants who must pay a premium for Part A. The mechanics and timing of enrolling in the QMB program, however, can be complex for both citizens and non-citizens. Enrollment procedures depend on the state and on whether the individual already is enrolled in Part B. For those who are not enrolled in Part B and/or who are in “group payer states” as discussed below, enrollment may require visits to both the Social Security office to apply for “conditional” Part A enrollment, and to the state Medicaid agency to apply for QMB enrollment. 

In the majority of states (identified as “Part A buy-in states”), individuals can apply for QMB coverage at any time of the year and coverage begins in the month following approval. In 14 states (identified as “group payer states”), however, people without premium-free Part A may only apply at SSA for conditional Part A enrollment during the General Enrollment Period (January 1-March 31) each year,^[35] with QMB and Part A enrollment beginning the first of the month following approval. 

A Justice in Aging fact sheet^[36] and clarifying guidance from SSA detail the specific steps needed to apply in each set of states.^[37] 

Case Example: Enrolling in QMB 

Mrs. Chen is 66 and lives in Arizona, a group payer state. She came to the U.S. seven years ago and has met the status and residency requirements to qualify for Medicare. Since she has no work history, she has not enrolled in Medicare because she cannot pay the premiums, especially the Part A premium. In June, Mrs. Chen meets with an advocate who tells her that, with her income and assets, she qualifies for the QMB program, which will pay both her Part A and Part B premiums. The advocate tells Mrs. Chen, however, that she must wait until January to go to SSA and apply for conditional Part A enrollment and for Part B. With Mrs. Chen’s consent, the advocate also tells her daughter and urges both of them to put the date on their calendars. In December, the advocate contacts both Mrs. Chen and her daughter to remind them to make an appointment with SSA in January and, after applying for conditional enrollment at SSA, to go directly to the state Medicaid office to apply for QMB. The advocate follows up in late January to make sure that Mrs. Chen took the required steps. She did, and finally on February 1, to her great relief, Mrs. Chen gets both Part A and Part B coverage without having to pay premiums. Mrs. Chen, because of her QMB status, is also protected from payment of Medicare related cost sharing, including co-pays, co-insurance, and deductibles. Her QMB enrollment also automatically qualifies her for the Part D Low-income Subsidy (discussed below) to help her with prescription drug co-insurance. 

Marketplace enrollment offers an alternate coverage option 

Immigrants who do not qualify for premium-free Part A or QMB can also consider enrolling in a Qualified Health Plan (QHP) in the Marketplace and applying for financial assistance in the form of premium tax credits and cost-sharing reductions.

Non-citizens who are “lawfully present” are eligible to enroll in QHPs. This includes LPRs as well as individuals on non-immigrant visas, and many temporary status categories such as TPS.^[38] Immigrants who are eligible to enroll in QHPs may also qualify for premium tax credits and cost-sharing reductions to help them afford coverage.^[39] (Note that individuals who have premium-free Part A generally cannot enroll in the Marketplace and are not eligible for premium or cost-sharing assistance.^[40])

There are no length of residency requirements for QHPs or for premium tax credits and cost-sharing reductions. Further, lawfully present individuals, unlike citizens, can receive premium tax credits and cost sharing reductions, even if their income is below 100% of FPL if they are ineligible for Medicaid because of their immigration status.^[41] In contrast to QMB and Medicaid A&D eligibility, eligibility for QHP premium tax credits and cost-sharing reductions is based on Modified Adjusted Gross Income (MAGI) rules, which do not include asset tests.^[42]

Depending on an individual’s income and circumstances, getting coverage through the Marketplace may be less expensive than paying for Part A. Those who choose Marketplace coverage rather than Medicare need to be aware that, if they later decide to switch to Medicare, they can face late enrollment penalties for both Part A and Part B.^[43] They also may face gaps in coverage because they may only be able to enroll in Medicare during the annual General Enrollment Period.

Because Marketplace enrollment is permitted under a range of immigration statuses and does not have a length of residency requirement, QHPs are also an option for older adults who are not currently eligible for Medicare. For example, LPRs who are still in their five-year waiting period and people under age 65 may want to enroll in a QHP. 

Case Examples: Marketplace and Medicare 

Ms. Park is an LPR who is eligible for Medicare but does not qualify for premium-free Part A. Her income is at 200% FPL, which is too high to qualify for the QMB program in her state. Because her income is low enough to qualify her for premium tax credits and cost-sharing reductions in the Marketplace, she decides to enroll in a QHP. Note she will face both Part A and Part B enrollment penalties if she later decides to enroll in Medicare and will only be able to do so during certain times of year. 

Mr. Jones is an LPR who arrived in the U.S. when he was 62. He is now 66 and enrolled in a QHP with premium tax credits and cost-sharing reductions. Next year he will have been in the U.S. for five years. At that time he will become eligible for Medicare and, because of his low income, he will also qualify for his state’s Medicaid program. He will lose his eligibility for Marketplace subsidies so he will switch from the Marketplace to Medicare. His Medicaid coverage will assist with his Medicare costs.

Some people choose to enroll only in Part B 

Enrolling only in Medicare Part B and not in Part A is an available option for people who face steep Part A premiums but don’t qualify for either QMB or Marketplace subsidies. Part B enrollment allows them to also enroll in Part D and, if they qualify, to get the Low-Income Subsidy (LIS) to help pay for Part D costs (see below). This course is far from ideal because it leaves an individual without coverage for hospital costs. However, it is an available option. If these individuals later decide to enroll in Part A, they can face late enrollment penalties and also may be limited to enrolling during the General Enrollment Period. If they enroll in Part B and not in Part D, they could also face Part D late enrollment penalties if they do not have creditable drug coverage through another source. 

Case Example: Declining Part A coverage 

Mr. Singh came to the U.S. eight years ago. He is now 65, an LPR and eligible for Medicare but not for premium-free Part A. From his career in India, he has a pension and a small nest egg, disqualifying him for Medicaid, including the Medicare Savings Programs, or Marketplace subsidies. He decides to conserve resources and only enroll in Part B and not in Part A. By doing so, he will have coverage for doctor visits but risks wiping out his nest egg if he needs hospital care. Though he currently only takes one inexpensive generic drug, he enrolls in a Part D plan so that he will not face late enrollment penalties if he later finds that his drug coverage needs increase. 

Immigrants who are eligible for Part D, i.e., those who are enrolled in either Part A or Part B, also may be eligible for the Part D Low Income Subsidy (LIS or “Extra Help”).^[44] LIS provides help with Part D premiums, deductibles, and co-pays, for prescription drugs, and can waive Part D late enrollment penalties. Because LIS asset and income limits are higher than those for QMB and other Medicare Savings Programs, some individuals with higher incomes may qualify for this benefit. ^[45]

The Social Security Administration determines LIS eligibility based on income and assets. Individuals may apply with SSA in-person, on-line or by phone.^[46] There are no additional immigration status or length of U.S. residency requirements for LIS beyond what is needed for Part A and Part B eligibility. LIS enrollment is automatic for Medicare beneficiaries receiving SSI and for those enrolled in any Medicaid program, including Medicare Savings Programs such as QMB.^[47] 

Case Example: Extra Help v. QMB 

Ms. Flores, a low-income TPS holder with premium-free Part A, successfully applied for the Part D Low Income Subsidy. Although she had been unable to enroll in the QMB program because she was not a “qualified” immigrant, that was not a factor in evaluation her LIS application. Having LIS gives her significant relief from prescription drug costs. 

Summary of Eligibility and Premium Assistance Options— Lawful Permanent Resident (LPR) and Temporary Protected Status (TPS) 

*For those with income below 100% FPL, subsidies are available only if they are ineligible for Medicaid because of their immigration status. 

** Not Applicable because ineligible for Medicare or Medicaid.

POST ENROLLMENT ISSUES 

Medicare does not pay for services outside the U.S. 

Many immigrants, particularly those who are citizens, may spend significant time overseas during their retirement. Medicare does not cover health care provided outside the United States.^[48]

Medicare premium payment liabilities continue even when an enrollee is abroad. 

To maintain enrollment, individuals must continue paying Medicare premiums while abroad. If an enrollee stops paying Part A or Part B premiums, SSA may disenroll them and they will likely have to wait until the next Medicare General Enrollment Period to reenroll, which may cause coverage gaps and late enrollment penalties.^[49] Note that going abroad for a longer period of time may also trigger questions about satisfying Medicaid residency requirements and risk disenrollment from QMB or Medicaid and impact Part D or MA enrollment.

Case Example: Time abroad 

Ms. Adebayo, originally from Nigeria, is a U.S. citizen with premium-free Medicare Part A and Part B coverage. She rushed back to Nigeria after a niece died suddenly to care for her niece’s children. She now realizes that she needs to stay an indefinite time. Though she has the option of stopping her Part B premiums, she decides that she will let SSA continue to deduct the premium from her monthly Social Security benefit. She does not want to face late enrollment penalties when she returns or have a gap in coverage while she waits for the General Enrollment Period to re-enroll. 

Language Access and Medicare

Older immigrants with limited English proficiency (LEP) need language assistance to understand their benefits, address their health care needs, and exercise their rights under Medicare. Federal laws, including the Health Care Rights Law (Section 1557 of the Affordable Care Act) and Title VI of the Civil Rights Act of 1964, provide language access rights to people with Medicare. These laws and their implementing regulations also prohibit discrimination on the basis of primary language or LEP and obligate the Medicare program, insurers, and providers to take reasonable steps to provide meaningful access to each individual with LEP, including free and timely language assistance services. Visit Justice in Aging’s Health Care Rights Law webpage to learn more.^[50]

The 1-800-Medicare help line provides free interpretation services in all languages. Call centers for Medicare Part D plans and Medicare Advantage plans are required to do so as well. SSA provides free interpreter services for Medicare and LIS enrollment.^[51] The SSA website and Medicare and LIS applications are also available in Spanish.^[52]

CMS provides some Medicare resources in other languages. The Medicare consumer website, Medicare.gov, is available in Spanish. The Medicare & You Handbook is also published and available online and to order in print in Spanish, Chinese, Vietnamese and Korean.^[53] CMS’s “Information in Other Languages” page lists all non-English language forms and publications available and is searchable by 27 languages.^[54]

CONCLUSION 

Advocates can assist their older immigrant clients to navigate Medicare enrollment, costs, and language hurdles. Justice in Aging is available to support advocates as they encounter Medicare issues for their immigrant clients. Contact info@justiceinaging.org. 

Endnotes

1. Migration Policy Institute, State Immigration Data Profiles, United States (2022); CMS Office of Minority Health, Understanding Communication and Language Needs of Medicare Beneficiaries, at 8, 10 (Apr 2017). ↑

2. For a description of the parts of Medicare and services covered, see CMS “Medicare & You” (2023). ↑

3. CMS, 2024 Medicare Parts A & B Premiums and Deductibles (Oct. 12, 2023). The regulations regarding Part A entitlement are found at 42 C.F.R. § 406.10. The POMS provisions concerning Part A entitlement are found at subchapter HI 00801. See also CMS, Original Medicare (Part A and B) Eligibility and Enrollment. ↑

4. CMS, 2024 Medicare Parts A & B Premiums and Deductibles. ↑

5. 42 C.F.R. § 406.12 (individuals who qualify for premium-free Part A based on disability determination by the Social Security Administration) and 42 C.F.R. § 406.13 (individuals with End Stage Renal Disease (“ESRD”)). Note that SSA requires fewer work credits for individuals under 65 who qualify for Medicare on the basis of disability, using a formula based on the applicant’s age when becoming disabled. For a chart of credits needed based on age, see SSA, “How You Earn Credits”, p. 3 (2024). ↑

6. CMS, What does Medicare cost?. ↑

7. For a summary of late enrollment penalties see NCOA, Understanding Medicare’s Late Enrollment Penalties (Oct. 2020). ↑

8. CMS, What does Medicare cost?. ↑

9. 42 C.F.R. §§ 423.30. ↑

10. The SSA POMS GN 00303.800 has created some confusion about whether this prohibition applies to undocumented persons with ESRD. The POMS provision notes that there are no residency, citizenship or alien status requirements for Medicare entitlement based on ESRD. Entitlement, however, must be distinguished from actual access to the benefit. Pursuant to the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), no Medicare payments can be made for an undocumented beneficiary. See SSA POMS RS 00204.010(B). Thus, as with other Medicare benefits, ESRD-based Medicare is only available to those non-citizens who are lawfully present. ↑

11. CMS, Disenrollment for Individuals Who Are Not Lawfully Present in the United States (Nov. 2021). ↑

12. 42 C.F.R. § 406.20. ↑

13. See CMS, When does Medicare coverage start? (explains the enrollment periods and coverage start dates). ↑

14. For the definition of lawfully present for purposes of SSA benefits as well as Medicare determinations, see 8 C.F.R. § 1.3 and SSA POMS RS 00204.00. ↑

15. 42 U.S.C § 1395o; 42 C.F.R. § 406.10(a)(1). ↑

16. 42 U.S.C. § 1395o; 42 C.F.R §§406.10 and 407.10(a)(1).  ↑

17. For Part A, these requirements are found at 42 U.S.C. § 1395i-2(a)(3) and 42 C.F.R. § 406.20. The requirements for Part B are found at 42 U.S.C. § 1395o(2) and 42 C.F.R § 407.10(a)(2). ↑

18. SSA POMS GN 00303.800(B)(4). ↑

19. Id. ↑

20. Id. See also SSA POMS GN 00303.740 describing SSA procedures to determine residence. ↑

21. Id. ↑

22. SSA POMS HI 00801.008 – HI Entitlement for Aged Spouse of Age 62 Worker. ↑

23. SSA POMS GN 00303.800(A)(2). ↑

24. CMS, Medicare Advantage and Part D Enrollment and Disenrollment Guidance, at § 20.4 (updated Aug. 2024). ↑

25. CMS, Medicare Managed Care Manual, Ch. 2, at § 50.2.7 (updated Aug. 15, 2023). CMS updated the Medicare Advantage and Part D Enrollment and Disenrollment Guidance for plan year 2025 and this provision is now codified at § 60.2.6. ↑

26. The National Council on Aging (NCOA) has a chart showing each state’s MSP eligibility limits: Medicare Savings Programs Eligibility and Coverage (updated Feb. 27, 2024). ↑

27. Id. ↑

28. See CMS, “Eligibility for Non-Citizens in Medicaid and CHIP” (Nov. 2014). ↑

29. National Health Law Program, Medicaid Coverage for Immigrants (May 17, 2021). ↑

30. Justice in Aging, The Five-Year Bar Prevents Older Immigrants from Accessing Programs that Help Them Meet Basic Needs (Sept. 2021). ↑

31. California Department of Health Care Services, ALL COUNTY WELFARE DIRECTORS 18-09, (May 2018), at p. 5. ↑

32. California Welfare and Institutions Code § 14007.8(a)(2)(A). ↑

33. NY State of Health, New Health Insurance Option for Undocumented Immigrants Age 65 and Over Fact Sheet (Dec. 18, 2023). ↑

34. 42 U.S.C. § 1396p(b)(1)(B)(ii); see Coordination of Benefits and Third Party Liability (COB/TPL) In Medicaid: 2020, at 61, 80. Note that § 1396p(b)(1)(B)(ii) also prohibits estate recovery for payment of Medicare cost-sharing for A&D enrollees as well. ↑

35. These states, called “Group Payer” states, are: AL, AZ, CA, CO, IL, KS, KY, MO, NE, NJ, NM, SC, UT, and VA. California is converting to a Part A Buy-in state in 2025. ↑

36. Justice in Aging, Medicare Part A Conditional Applications (updated Jan. 2023). ↑

37. SSA POMS HI 00801.140. ↑

38. See Healthcare.gov, Immigration status to qualify for the Marketplace. For additional detail, see NILC, “Lawfully Present” Individuals Eligible under the Affordable Care Act (updated Oct. 2022). ↑

39.  Ctr. on Budget & Policy Priorities, “Key Facts: Immigrant Eligibility for Health Insurance Affordability Programs,” (updated June 2024). ↑

40. See IRS, Eligibility for the Premium Tax Credit; HealthCare.gov, Medicare and the Marketplace: Can I choose Marketplace coverage instead of Medicare?. ↑

41. 26 U.S.C. § 36B(c)(B). See also HealthCare.gov, Coverage for lawfully present immigrants. ↑

42. For a primer of MAGI counting rules, see Nat’l Health Law Program, Advocate’s Guide to MAGI (updated 2018). ↑

43. If they don’t enroll in either Part A or Part B, they would not face Part D late enrollment penalties. Late enrollment calculations are only triggered after the individual becomes eligible for Part D. Part D requires either Part A or Part B coverage. See 42 C.F.R. §§ 423.30, 423.38 and 423.46. ↑

44. Medicare.gov: Help with drug costs. ↑

45. For details of eligibility and benefit levels, see NCOA, Part D Low Income Subsidy/Extra Help Eligibility and Coverage Chart (updated 2024). ↑

46. See SSA, Apply for Medicare Part D Extra Help program. The LIS application can be completed in English or Spanish. SSA has sample LIS applications and instructions for other languages: https://www.ssa.gov/site/languages/en/. ↑

47. Medicare.gov: Help with drug costs. ↑

48. There are minor exceptions for people in transit between the continental U.S. and Alaska and for emergency use of a hospital across the border that is closer than the nearest U.S. facility. See Medicare.gov, Travel outside the U.S. ↑

49. See Medicare Rights Medicare Interactive, Medicare coverage when living abroad. ↑

50. Justice in Aging, The Health Care Rights Law. ↑

51. SSA: How to request an Interpreter. SSA also provides some information about Medicare and instructions for the Part D LIS application in other languages: Social Security Information in Other Languages. ↑

52. SSA: Inscríbase en Medicare. ↑

53. Medicare.gov: Medicare & You. ↑

54. Medicare.gov: Publications in Other Languages. ↑