The 111 th Congress has made health reform a priority. As health reform is debated, one possible issue that may surface is the rights and requirements of noncitizens (aliens) under health reform. Because some of the proposals to address health reform in the United States would create a mechanism to provide health insurance to the overwhelming majority of individuals in the nation, this report explores the health insurance coverage of noncitizens in the United States, as well as noncitizen usage of selected safety-net providers and the impact of unauthorized aliens on the health care system. The report begins with an overview of noncitizen eligibility for health insurance in the United States. Next, it provides an analysis of health insurance coverage for noncitizens in the United States and an examination of the impact of noncitizens on the number of uninsured persons in the United States over time. The report continues with discussions of noncitizen usage of emergency Medicaid and emergency departments, and of noncitizens' eligibility to receive care through federal health centers. The report concludes with an overview of the literature on the cost to the health care system of unauthorized aliens. One of the issues with analyses of the noncitizen population is that researchers are often not studying the same population or using the same terminology. For example, some research examines immigrants, some the Hispanic population, others immigrant- headed households, and some the unauthorized (illegal) alien population. Also, some studies use the same term to refer to different groups. For example, the term immigrant is often used to refer to all noncitizens (especially when using Current Population Survey [CPS] or other Census data), but it can also be used to refer to foreign born persons permanently in the United States (e.g., legal permanent residents, naturalized U.S. citizens). Table 1 presents the definitions of some of the groups for whom health policy studies have been done. For this report, however, the studies discussed are limited to those that examine some portion of the noncitizen population. Noncitizens are not barred from having health insurance or from paying for health care on their own. Indeed, due to the quality of health care in the United States, some noncitizens come to the United States to receive health care from world-renowned doctors and hospitals. In the group (employer) health insurance market, there is no legal burden for the insurer to confirm that a worker is legally entitled to work in the United States. Furthermore, U.S. law mandates that Medicare-participating hospitals provide emergency medical services for all patients who seek care, regardless of their ability to pay; this includes services to all noncitizens, regardless of their immigration status. Nonetheless, the 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) established comprehensive new restrictions on the eligibility of noncitizens for federal, state, and local public benefits—with significant exceptions for those with a substantial U.S. work history or military connection—setting specific eligibility requirements and exceptions for many health care services. In general, PRWORA states that an alien who is not a qualified alien is not eligible for any f ederal public benefit with specified exceptions for certain short-term, emergency related benefits (see below). In addition, with specified exceptions, any alien who is not a qualified alien, a nonimmigrant, or an alien paroled into the United States under INA section 212(d)(5) for less than one year is not eligible for a state or local public benefit. In other words, almost all legally present noncitizens are eligible for state and local public benefits, but in general, only those aliens who are or are expected to become immigrants (legal permanent residents) are eligible for federal public benefits. In addition, PWORA placed additional restrictions on receiving federal means-tested public benefits. The health related means-tested public benefits are Medicaid and the State Children's Health Insurance Program (CHIP), and are discussed below. The law defines "public benefit" as: …any retirement, welfare, health, disability, public or assisted housing, postsecondary education, food assistance, unemployment benefit, or any other similar benefit for which payments or assistance are provided to an individual, household, or family eligibility unit by an agency of the United States or by appropriated funds of the United States. [8 U.S.C. 1611(c) and 8 U.S.C. 1621(c)] The exemptions to these restrictions consist of the following: (A) Medical assistance under title XIX of the Social Security Act [Medicaid]…for care and services that are necessary for the treatment of an emergency medical condition…of the alien involved and are not related to an organ transplant procedure, if the alien involved otherwise meets the eligibility requirements for medical assistance under the State plan approved under such title. (B) Short-term, non-cash, in-kind emergency disaster relief. (C) Public health…for immunizations with respect to immunizable diseases and for testing and treatment of symptoms of communicable diseases whether or not such symptoms are caused by a communicable disease. (D) Programs, services, or assistance (such as soup kitchens, crisis counseling and intervention, and short-term shelter) specified by the Attorney General, in the Attorney General's sole and unreviewable discretion after consultation with appropriate Federal agencies and departments, which (i) deliver in-kind services at the community level, including through public or private nonprofit agencies; (ii) do not condition the provision of assistance, the amount of assistance provided, or the cost of assistance provided on the individual recipient's income or resources; and (iii) are necessary for the protection of life or safety. [8 U.S.C. 1611(b)] A notice published by the Attorney General includes in the exemptions from the alienage restrictions for public benefits ambulance services; medical and public health services (including treatment and prevention of diseases and injuries) and mental health, disability, or substance abuse assistance necessary to protect life or safety; activities designed to protect the life and safety of workers, children and youths, or community residents; and any other programs, services, or assistance necessary for the protection of life or safety. In summary, noncitizens have specific eligibility requirements under law for public benefits, including means-tested public benefits such as Medicaid and CHIP, which can, however, pay for emergency medical services of certain noncitizens who are otherwise eligible. In addition, due to the exemptions and the fact that under regulation federally funded health centers are not defined as federal public benefits, there does not appear to be specified eligibility requirements or prohibitions related to noncitizens' use of Federally Qualified Health Centers, including community health centers and migrant health centers. The Medicaid program is authorized by Title XIX of the Social Security Act, as amended. It is a federal/state matching program of medical assistance for low-income persons who are aged, blind, disabled or members of families with dependent children. In general, CHIP allows states to cover targeted low-income children with no health insurance in families with income above Medicaid eligibility levels. States may also extend CHIP coverage to pregnant women when certain conditions are met. As discussed above, PRWORA defined Medicaid as a means-tested public benefit, triggering additional eligibility requirements for "qualified aliens." Currently, noncitizens' eligibility for federal Medicaid and CHIP benefits depends largely on their immigration status and whether they arrived (or were on a program's rolls) before August 22, 1996, the enactment date of PRWORA. Notably, the aliens must also meet the financial and categorical eligibility requirements for Medicaid or be targeted low-income uninsured children or eligible pregnant women for CHIP. Most legal permanent residents (LPRs) entering after August 22, 1996, are barred from Medicaid and CHIP for five years, after which they are eligible for CHIP and eligible for Medicaid at the state's option. States may also choose to use state and federal Medicaid and CHIP funds to cover pregnant women and children who are LPRs within the first five years of arrival. In addition, states have the option to use state funds to provide medical coverage for other LPRs within five years of their arrival in the United States. Refugees and asylees are eligible for Medicaid and CHIP for seven years after arrival. After the seven years, they may be eligible for Medicaid and CHIP at the state's option. LPRs with a substantial (10-year) U.S. work history or a military connection are eligible for Medicaid and CHIP without regard to the five-year bar. LPRs receiving Supplemental Security Income (SSI) on or after August 22, 1996, are eligible for Medicaid because Medicaid coverage is required for all SSI recipients. Finally, in the case of LPRs sponsored for admission after 1997, the income and resources of their sponsor are "deemed" available to them when judging their eligibility. Nonetheless, all aliens regardless of immigration status who otherwise meet the eligibility requirements for Medicaid are eligible for emergency Medicaid. Thus, unauthorized aliens are ineligible for Medicaid but may qualify for emergency Medicaid. In addition, states may use their own money to cover noncitizens who are ineligible for Medicaid or CHIP. Generally, as noted above, noncitizens face additional eligibility restrictions for Medicaid. In general, unauthorized aliens are ineligible for Medicaid, with the exception of emergency Medicaid. Emergency Medicaid may pay for the care of unauthorized aliens, nonimmigrants, and LPRs within the first five years of arrival (or longer if the state does not exercise the option to provide coverage for LPRs after the five years) for emergency conditions if they meet the other eligibility requirements of the Medicaid program.