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Medical staff stand outside the imaging room at Dignity Health West Flamingo Campus, 9892 W. Flamingo Road, on Thursday, Aug. 10, 2017. (Jeff Scheid/The Nevada Independent)

A proposed Trump administration rule that could put immigrants who receive public benefits at risk of losing legal status is having a “chilling effect” on those seeking to purchase health insurance on the state’s exchange, the exchange’s executive director said this week.

Exchange officials say that some immigrants are choosing to either forego purchasing health insurance or are paying hundreds of dollars in unsubsidized premiums this year out of fear that receiving government health insurance discounts could jeopardize their ability to remain in the country legally. The Trump administration announced a draft “public charge” rule in October that would penalize legal immigrants for receiving assistance from taxpayer-funded programs, including Medicaid and the Supplemental Nutrition Assistance Program (SNAP), but not Affordable Care Act subsidies.

The exchange doesn’t have an exact figure on how many immigrants have been dissuaded from purchasing plans or accepting subsidies but has gathered anecdotal reports based on calls received through its call center and reports from partner organizations. But Heather Korbulic, the exchange’s executive director, said most people have felt comfortable enough enrolling once they understand that exchange subsidies are not included in the proposed rule.

“I am relieved that most people are just confused, and once they understand that our subsidies are not included, they are comforted in enrolling,” Korublic said. “But that is requiring some one-on-one in-person assistance.”

Rosa Alejandre, the exchange’s navigator program manager, said the exchange is working to counteract any fear or misunderstandings by stressing that receiving subsidies through the exchange does not disqualify someone from receiving or renewing legal status.

“I think some of the confusion that has happened is that some of the consumers are thinking that the exchange plans are part of the public benefits, and we really want to set the record straight with that,” Alejandre said. “The exchange plans aren’t affected with the public charge rule.”

The exchange, which is two weeks into its 45-day open enrollment period that runs through Dec. 15, is considering adding information to its website in both English and Spanish to emphasize this point and is planning to send out information to health insurance brokers to remind them that exchange subsidies are not included in the proposed rule.

The draft rule, which was published on Oct. 10 by the Department of Homeland Security, proposes to expand the existing definition of who the government considers a “public charge” — in other words, someone who is likely to become dependent on the federal government for assistance — for purposes of determining whether an immigrant should be admitted to the U.S., have his or her stay extended or be approved to become a legal permanent resident through receipt of a green card. (Some immigrants, including refugees and asylees, are exempt from being considered a public charge.)

Immigration officials currently must consider a variety of factors in determining whether someone is likely to become a public charge, including, at a minimum, the individual’s age, health, family status, assets, education, and skills. Among those other factors, immigration officials also look at whether an immigrant is receiving help through any cash benefit programs — including Temporary Assistance for Needy Families (TANF), Supplemental Social Security Income (SSI), or any other federal, state or local cash benefit program — in making their determination.

Under the proposed rule, someone may be automatically considered a public charge if he or she receives one or more public benefits, and the rule expands the definition of such benefits to include not only cash assistance programs but non-emergency Medicaid, the Medicare Part D Low-Income Subsidy Program, the Supplemental Nutrition Assistance Program (SNAP), and several housing programs.

The proposed rule does not include subsidies received to purchase insurance through the health insurance marketplace or benefits received through the Children’s Health Insurance Program (CHIP), though the federal government is soliciting public comments on whether CHIP should be considered a public benefit. The rule also only applies to benefits an immigrant received themselves and not those received by another member of his or her household, including children.

The proposal also expands the categories of immigrants subject to the public charge rule from those seeking to legally enter the U.S. or applying for a green card to also those seeking to extend a current visa or change visa types. The rule is going through a 60-day comment period that will end on Dec. 10.

Alejandre said some people who have called the exchange during open enrollment have asked to be directly referred to an insurance broker to sign up for a plan instead of signing up through the exchange but are vague about why, likely out of fear of coming forward to a state agency. She said the exchange tries to preempt concerns by assuring people over the phone that the proposed rule does not apply to exchange subsidies and that the exchange keeps all information confidential and doesn’t forward it to other agencies, but some people still prefer being referred to a broker or other organization for a face-to-face conversation.

“I understand their fear when it comes to immigration, the moment you talk about immigration it’s like, ‘Nope, nope, let me stop right here and I’ll just do it on my own or forego [insurance] as well,’” Alejandre said. “Even when they have citizen children they think they may be penalized or think they won’t be able to access these benefits.”

Korbulic stressed the importance of the exchange’s partner organizations — which include a number of community organizations including Nevada Health Centers, Three Square and the Asian Community Development Council — in having already built up a certain level of trust with community members to have those conversations if they don’t feel comfortable reaching out to the exchange. The organizations have to go through a rigorous process in order to partner with the exchange, including certification from the Nevada Division of Insurance and training through the exchange and the Centers for Medicare and Medicaid Services.

“That’s exactly why it’s so important for exchanges not just to interact with the broker community but the navigator organizations,” Korbulic said.

If people still don’t feel comfortable coming forward to one of those organizations, they can reach out to U.S. Citizenship and Immigration Services, where they can receive free information at any one of the agency’s offices in Las Vegas, Reno or Salt Lake City, Alejandre said.

Also, an issue that may exist in other states that automatically generate a Medicaid application when someone enrolls in a health insurance plan through the exchange is not a problem in Nevada, Korublic said. She said that the exchange’s pre-screener on its website is anonymous and aimed at directing consumers whether Medicaid or an exchange plan would be appropriate for them based on their income level and is not a formal Medicaid application.

Alejandre noted that immigrants eligible for Medicaid may still choose to enroll in an exchange plan though they won’t qualify for federal subsidies, which are only available for those who make between 138 percent and 400 percent of the federal poverty level. But an analysis of the proposed rule by the State Health and Value Strategies program noted that immigrants won’t start being penalized for benefits received under the new public charge definition until the rule goes into effect, any benefits received before that date would be considered under the prior definition.

As they continue with the last month of open enrollment, exchange officials are emphasizing to those hoping to enroll in a health insurance plan for the upcoming year that the proposed rule hasn’t changed anything yet.

“It’s still a proposed rule,” Alejandre said. “Nothing has changed, and we have to continue moving forward with what is in place right now.”


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