H.R. 4104 — Health Equity and Access under the Law for Immigrant Families Act of 2025

This section declares the purposes of the Act to (1) ensure eligibility for all federally funded health care programs for individuals lawfully present in the United States, (2) advance health insurance coverage through exchanges established under the Patient Protection and Affordable Care Act for undocumented individuals, (3) eliminate state authority to restrict Medicaid eligibility for lawful permanent residents, and (4) eliminate other barriers to accessing Medicaid, the Children's Health Insurance Program (CHIP), and other medical assistance.

This section requires states to provide Medicaid to lawfully residing or present individuals in the United States (including battered individuals under PRWORA §431(c) and those with approved or pending deferred action or other federally authorized presence) who otherwise meet eligibility requirements under the state plan (other than receipt of aid under title IV, SSI benefits under title XVI, or state supplementary payments), notwithstanding PRWORA restrictions in §§401(a), 402(b), 403, and 421 that generally limit such coverage (e.g., via a five-year waiting period for qualified aliens). (1) It eliminates sponsor liability under affidavits of support for the costs of such assistance, which previously could be treated as an unreimbursed cost; and (2) it makes technical conforming changes to reference the mandatory nature of the requirement and to include "lawfully present" individuals. This section also applies these Medicaid eligibility rules to CHIP by cross-reference. The amendments take effect for services furnished 90 days after enactment, except in states requiring legislation, where compliance is delayed until the first day of the first calendar quarter after the first regular legislative session following enactment (with two-year sessions treated as separate years).

This section deems individuals granted Federally authorized presence (i.e., including deferred action) in the United States as lawfully present for eligibility purposes under four health coverage programs: (1) health insurance Exchanges established under section 1411 of the Patient Protection and Affordable Care Act (ACA); (2) premium tax credits under IRC §36B (i.e., refundable credits to help eligible individuals and families afford premiums for qualified health plans purchased through an Exchange); (3) reduced cost-sharing under ACA section 1402; and (4) Medicaid and CHIP under Social Security Act titles XIX and XXI (including under section 1903(v)). The change takes effect on the date of enactment, and the HHS Secretary must provide a special enrollment period in ACA Exchanges—beginning no later than 90 days after enactment for individuals with such status as of enactment—for those newly qualifying for cost-sharing reductions or premium tax credits.

This section eliminates immigration status restrictions on eligibility for multiple Affordable Care Act (ACA) programs, effective for applicable years beginning after December 31, 2025, by (1) amending the premium tax credit under IRC §36B(c)(1)(B) to explicitly cover noncitizens ineligible for Medicaid due to immigration status and striking subsection (e); (2) striking the immigration restriction in ACA §1402(e) for cost-sharing reductions; (3) striking the "lawfully present" requirement in ACA §1331(e)(1)(B) for the Basic Health Program; (4) striking ACA §1412(d) restricting federal payments based on immigration status; (5) striking the immigration-related exemption in IRC §5000A(d)(3) from the individual shared responsibility requirement; and (6) making conforming amendments to ACA §§1411(a) and 1312(f), including striking the limitation of "qualified individuals" to citizens and lawful residents. (As background, these ACA programs provide premium tax credits and cost-sharing reductions to lower-income individuals purchasing coverage through Exchanges, federal payments to issuers and states, and an optional Basic Health Program for states to offer standard coverage to low-income individuals.)

This section establishes a state option under Medicaid to provide full-scope medical assistance to individuals without lawful presence who would be eligible under the state plan (or waiver) if they were U.S. citizens, with a conforming amendment to the definition of medical assistance to include such individuals. It establishes a parallel state option under the Children's Health Insurance Program (CHIP) to cover individuals without lawful presence who would qualify as targeted low-income children or pregnant women if they were U.S. citizens. It further amends the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 to exempt such state-elected coverage from the federal prohibition on noncitizen eligibility under Medicaid and CHIP.

This section provides that nothing in this Act prevents lawfully present noncitizens ineligible for full benefits under the Medicaid program (title XIX of the Social Security Act)—typically limited to emergency services—from claiming the premium tax credit under IRC §36B(c)(1)(B), as in effect prior to enactment of this Act. It defines full benefits as medical assistance equivalent in amount, duration, and scope to coverage under a state Medicaid plan for individuals described in SSA §1902(a)(10)(A)(i) (42 U.S.C. §1396a(a)(10)(A)(i)). (Thus, such noncitizens retain access to subsidized exchange coverage despite any Act changes restricting Medicaid.)

This section revises Medicare Part A (Hospital Insurance) eligibility under section 1818(a)(3) and Part B (Supplementary Medical Insurance) eligibility under section 1836(a)(2) to include individuals lawfully present in the United States—including those with approved or pending deferred action or other federally authorized presence—as defined in subsection (c) (from prior restrictions to certain lawfully admitted permanent resident aliens residing continuously in the U.S. for at least five years or other qualified aliens). Subsection (c) defines "lawfully present" to include, at a minimum, all immigration categories treated as lawfully present for Medicaid (title XIX) purposes as amended by section 3.