State Letter 13-10

Expansion of Medicaid Eligibility under the Affordable Care Act and Compliance with ORR Regulations at 45 CFR 400.101

Publication Date: December 6, 2013


FROM: Eskinder Negash
             Office of Refugee Resettlement

SUBJECT: Expansion of Medicaid Eligibility under the Affordable Care Act and Compliance with ORR Regulations at 45 CFR 400.101

The Affordable Care Act (ACA) includes several provisions to fill the current gaps in health care coverage, including the expansion of Medicaid eligibility to millions of Americans previously ineligible.

The purpose of this State Letter is to provide guidance to States in the context of Medicaid expansion on compliance with the regulations at 45 CFR 400.100, which limits eligibility for Refugee Medical Assistance (RMA) to refugees who are ineligible for Medicaid.  In those states where Medicaid is being expanded, States shall make every effort to re-determine eligibility of refugees receiving RMA and when determined eligible, transition refugees from RMA to Medicaid. This will ensure equal and timely access to Medicaid for both refugees who arrive prior to the implementation of Medicaid expansion and refugees who arrive after expansion.

Medicaid Expansion

The ACA provides States with additional federal support to extend Medicaid coverage to individuals between the ages of 19 and 64 with incomes up to 133 percent of the Federal Poverty Level. In States with expanded Medicaid, many newly-arrived single adults or married couples without dependent children may now be eligible for Medicaid for the first time. Additionally, many refugees currently enrolled in RMA may now be eligible for Medicaid.

Children are currently and will remain eligible for either Medicaid or the Children’s Health Insurance Program (CHIP) at higher income levels based on the eligibility standards already in effect in their State.

For most States that choose to expand Medicaid, this eligibility expansion will go into effect on January 1, 2014. However, States can choose to expand coverage before this date, and some States may implement expansion after January 1, 2014.

Transitioning from RMA

The regulations at 45 CFR 400.100 provide that eligibility for RMA is limited to refugees who are ineligible for Medicaid or CHIP. As States implement expanded Medicaid eligibility, refugees previously ineligible could qualify for Medicaid and would, therefore, no longer be eligible for RMA under the regulations.

Every effort shall be made by States to re-determine eligibility as Medicaid expands and when appropriate, transition the client from RMA to Medicaid. This is in accordance with the regulations at §400.100 and in the best interest of refugees as it provides stable health insurance to meet refugees’ health care needs. ORR is not obligated to reimburse States not in compliance with the regulations at 45 CFR 400.100.

States shall make every effort to transition clients to Medicaid to ensure that all clients, including refugees already receiving RMA and new arrivals, have equal access to Medicaid. This applies even if the refugee is close to the 8-month limit of eligibility for coverage under RMA.

States that are not expanding Medicaid at this time will be subject to the terms of this ORR State Letter at such time that Medicaid expands in the state.

In order to minimize disruption and ensure that refugees do not lose health insurance coverage, caseworkers at local affiliates should assist clients with Medicaid enrollment.

If you have questions about any of the information in this State Letter, please contact Dr. Curi Kim at 202-401-5585, or by e-mail at

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