January 14, 1998  
Dear State Health Official:  
The Department of Health and Human Services is writing to provide States 
with information regarding the existing authority under the new Title XXI of 
the Social Security Act to meet the health care needs of immigrant children. 
As you know, the Children's Health Insurance Program (CHIP) represents a 
historic opportunity to meet the health care needs of uninsured, low-income 
children. The Department wants to ensure that immigrant children benefit 
from this new program to the maximum extent possible under the law. 
Current Population Survey data from 1995 showed that 51.7 percent of poor, 
foreign born persons were uninsured, compared to 26.4 percent for native 
born Americans. This letter explains how health care for immigrant children 
and children born in the U.S. to immigrant parents may be improved through 
CHIP.  
We have determined that Title XXI health insurance coverage meets the 
definition of a Federal, means-tested public benefit. Therefore, its health 
insurance coverage cannot be made available to certain immigrant children. 
States may not segregate their CHIP expenditures to convert a portion of 
the program into a fully State funded, means-tested program in order to 
circumvent the restrictions established by the Personal Responsibility and 
Work Opportunity Reconciliation Act of 1996 (PRWORA), which banned 
certain immigrants from receiving Federal means-tested public benefits for 
their first 5 years in the country.  
Nevertheless, you should be aware that several groups of legal immigrant 
children are eligible for the full range of benefits provided under CHIP. In 
addition to providing insurance coverage to eligible immigrant children, 
States may use a limited amount of CHIP funds for expenditures other than 
health insurance assistance to conduct targeted outreach and health services 
initiatives in communities that include substantial numbers of immigrant 
children. Further guidance on these issues is provided below:   Eligible "Immigrant" Children  
PRWORA did not change longstanding law providing that any child born in 
the United States is a citizen. Census data from 1996 found that there are 9.9 
million children born in the U.S. to an immigrant parent. These children are 
U.S. citizens and are subject to the same criteria and procedures to determine 
eligibility for public programs as any other U.S. citizen.  
Additionally, there are certain other categories of immigrant children 
who may be eligible for both Medicaid and CHIP due to exemptions 
from the restrictions in PRWORA. They include:  
All legal immigrant children who were in the U.S. before August 22, 
 
1996,  
Refugees, asylees, and certain Cuban, Haitian and Amerasian 
 
immigrants,  
Unmarried, dependent children of veterans and active duty service 
 
members of the Armed Forces, and  
Legal immigrants arriving on or after August 22, 1996, and in 
 
continuous residence for 5 years. (Earliest eligibility for this group is August 
22, 2001. Also, their sponsor's income and resources will be taken into 
account in determining their eligibility for those who have signed legally 
binding affidavits of support.)  
 
Moreover, although Medicaid is classified as a "designated Federal 
program" under PRWORA, meaning States may deny benefits to qualified 
aliens other than those listed above, States may not deny benefits to 
otherwise qualified and eligible aliens under Title XXI. Accordingly, after 
the expiration of the 5 year period beginning with the date of the alien's 
entry to the United States, qualified alien children will be eligible for 
coverage under a Title XXI CHIP program if they meet the other eligibility 
requirements for that program.  
 
Outreach   In order to facilitate the enrollment of eligible children, States may choose to 
target outreach activities toward low-income communities with high 
concentrations of immigrants. Given the significant numbers of low-income 
children residing in immigrant communities who are uninsured and qualify 
for Federal public benefits, targeting outreach to such communities is part of 
an effective outreach strategy. Funding is authorized in Title XXI for 
outreach to families of children likely to be eligible for benefits under Title 
XXI or under other public or private health coverage programs, to inform 
these families of the availability of the State program, and to assist them in 
enrolling their children when appropriate. Uninsured, low-income children 
found to be ineligible for CHIP or Medicaid coverage should be referred to 
other sources of health benefits coverage such as private, charitable 
insurance programs and safety net providers in their area, to the extent 
available.  
 
Health services initiatives  
Additionally, at the State's option, low-income, immigrant communities, 
including the temporary communities of migrant and seasonal farm 
workers, can be targeted for health services initiatives. Title XXI, 
authorizes CHIP funds to be used for "expenditures for health services 
initiatives... for improving the health of children (including targeted low 
income children and other low income children)."  
The legislation further indicates that these initiatives may benefit the health 
of all low income children, including but not limited to children eligible to 
receive services under Title XXI. Therefore, health services initiatives such 
as health education activities, school health programs and direct services 
(such as newborn hearing screening and lead testing programs), could be 
targeted to low-income immigrant communities. Both qualified and non-
qualified immigrants may benefit from health services initiatives if  
such initiatives promote child health in a targeted county, community, or 
school. (It is important to note that except in States granted waivers, 
expenditures for health services initiatives, together with outreach,  
administrative costs, and other child health assistance, are subject to a 10 
percent limit as set forth in section 2105(c)(2)(A).)  
  We hope that this information will help your State achieve the goal of 
providing access to comprehensive health care for all vulnerable children. 
Thank you for your continued efforts toward achieving this goal. If you 
have any further questions, please contact Marty Svolos at (410) 786-
4582.  
 
Sincerely,  
 
Sally K. Richardson  
Director  
Center for Medicaid and State Operations  
Health Care Financing Administration  
 
Claude Earl Fox, M.D., M.P.H.  
Acting Administrator  
Health Resources and Service Administration  
 
cc: Governor's Offices All HCFA Regional 
Offices All PHS Regional Offices  
Ms. Lee Partridge - 
Director Health Policy 
Unit American Public 
Welfare Association  
Ms. Jennifer Baxendell - Senior Policy Analyst Human Resources Group - 
National Governor's Association  
Ms. Joy Wilson - 
Director, Health 
Committee National 
Conference of State 
Legislatures