S. 2149 — 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 ACA exchanges for undocumented individuals, (3) eliminate state authority to restrict Medicaid eligibility for lawful permanent residents, and (4) eliminate other barriers to accessing Medicaid, CHIP, and other medical assistance.

This section requires states to provide Medicaid to individuals lawfully residing 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 specified prior aid), notwithstanding PRWORA restrictions in §§401(a), 402(b), 403, and 421 that previously limited such noncitizen eligibility. (As background, PRWORA generally deems certain lawfully present noncitizens ineligible for Medicaid for five years or subjects them to sponsor income deeming, with states previously having the option—but not the federal matching requirement—to cover additional groups.) It further eliminates sponsor liability under affidavits of support for such Medicaid costs and updates related terminology to include individuals "lawfully present." This section applies the same Medicaid eligibility requirement to CHIP. The amendments take effect for services furnished 90 days after enactment (or the first day of the first calendar quarter after the first regular legislative session thereafter, if state legislation is required).

This section deems individuals granted federally authorized presence in the United States (including deferred action) to be lawfully present for purposes of eligibility under (1) health insurance Exchanges established under the Patient Protection and Affordable Care Act (ACA), (2) premium tax credits under IRC §36B (i.e., refundable credits covering the excess of second-lowest-cost silver plan premiums over a percentage of household income, currently 0%-8.5% on a sliding scale), (3) ACA cost-sharing reductions, and (4) Medicaid and CHIP (including under SSA §1903(v)). The provision takes effect on the date of enactment and requires the Secretary of Health and Human Services to establish a special enrollment period under ACA §1311(c)(6)(C)—beginning no later than 90 days after enactment for individuals already granted such presence—allowing affected individuals to enroll in Exchange plans and qualify for premium tax credits or cost-sharing reductions prior to the next annual open enrollment period.

This section eliminates immigration status restrictions on eligibility for Affordable Care Act (ACA) premium tax credits, cost-sharing reductions, Basic Health Programs, and related verification and definition provisions, effective for applicable taxable years, plan years, and years beginning after December 31, 2025. Specifically, it (1) amends the premium tax credit special rule under IRC §36B(c)(1)(B) to explicitly cover noncitizens ineligible for Medicaid due to immigration status and strikes subsection (e) limiting credits to lawfully present individuals; (2) strikes the cost-sharing reduction restriction under ACA §1402(e); (3) removes the "lawfully present" requirement for Basic Health Program eligibility under ACA §1331(e)(1)(B); (4) strikes the federal payment restriction under ACA §1412(d); (5) eliminates the individual mandate exemption for certain noncitizens under IRC §5000A(d)(3); and (6) makes conforming amendments to ACA verification and qualified individual definitions under §§1411(a) and 1312(f), including striking the limitation to citizens and lawful residents. (Thus, noncitizens ineligible for Medicaid due to immigration status—previously excluded from these ACA subsidies—may access them through 2025 plan years and later.)

This section establishes a state option under Medicaid (Title XIX of the Social Security Act) 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 (i.e., added as new subclause (XXIV) to section 1902(a)(10)(A)(ii)); makes a conforming amendment to include such individuals in the definition of medical assistance under section 1905(a); and authorizes a parallel state option under the Children's Health Insurance Program (CHIP, Title XXI) to cover individuals without lawful presence who would qualify as targeted low-income children or pregnant women if citizens (i.e., new section 2112A). (Medicaid provides health coverage to low-income individuals, families, pregnant women, children, seniors, and people with disabilities; CHIP covers uninsured children in families with incomes above Medicaid limits.) The section further excepts eligibility elected under these options from the general federal prohibition on providing benefits to noncitizens without lawful presence.

This section preserves eligibility for premium tax credits under IRC §36B(c)(1)(B) for lawfully present noncitizens ineligible for full-scope Medicaid benefits (i.e., coverage of all services under a state plan equivalent to that for individuals described in SSA §1902(a)(10)(A)(i)), based on Medicaid provisions for such noncitizens as in effect prior to enactment of this Act.

This section expands Medicare Part A and Part B eligibility by replacing the prior restriction—limited to aliens lawfully admitted for permanent residence who resided continuously in the U.S. for the five years immediately preceding the application or enrollment—with eligibility for any individual who is lawfully present in the United States, including those with an approved or pending application for deferred action or other federally authorized presence (as defined in section 8(c) of the Health Equity and Access under the Law for Immigrant Families Act of 2025). (1) The change applies to Part A hospital insurance enrollment criteria under SSA §1818(a)(3); (2) it applies to Part B supplementary medical insurance enrollment criteria under SSA §1836(a)(2); and (3) "lawfully present" includes, at a minimum, all immigration categories treated as lawfully present for Medicaid (title XIX) purposes as amended by section 3. (As background, Medicare Part A funds inpatient hospital stays and related services through the Federal Hospital Insurance Trust Fund, while Part B covers physician services and outpatient care.)