	Introduction

The degree to which foreign nationals (noncitizens/aliens) should be accorded access to certain benefits as a result of their presence in the United States, as well as the responsibilities of such persons given their legal status (e.g., immigrants, nonimmigrants, unauthorized aliens), often figures into policy discussions in Congress. These issues become particularly salient when Congress considers legislation to establish new immigration statuses or to create or modify benefit and entitlement programs. The 111 th Congress enacted the Patient Protection and Affordable Care Act ( P.L. 111-148 ), which has been amended by the Health Care and Education Reconciliation Act of 2010 ( P.L. 111-152 ) and several other bills. (ACA refers to P.L. 111-148 as amended by P.L. 111-152 and the other legislation.) The ACA created new responsibilities (e.g., the requirement that most people in the United States obtain health insurance) and new benefits (e.g., tax credits to help certain people purchase health insurance), and it addressed the eligibility and responsibility of foreign nationals for these provisions. One issue that has arisen during debates to amend provisions in the ACA and during discussions of immigration reform is the eligibility of foreign nationals for some of the ACA's key provisions. This report then analyzes the eligibility of foreign nationals for key provisions in the ACA that have restrictions based on immigration status: the requirement to maintain health insurance, the ability to purchase insurance through an exchange, and eligibility for the premium tax credit and cost-sharing subsidies. Treatment of Noncitizens Under the Patient Protection and Affordable Care Act (ACA)

The following section discusses alien eligibility for the following provisions under the ACA: the health insurance mandate, the exchanges (the Marketplace), and premium tax credits and cost-sharing subsidies. The term "lawfully present" in the INA is only defined in regards to noncitizen eligibility for Social Security. (The exchanges are also called health insurance marketplaces.) The law allows all lawfully present noncitizens to purchase insurance through an exchange, but specifies that a person is only considered lawfully present if the person is, and is reasonably expected to be for the entire period of enrollment, a U.S. citizen or national or an alien who is lawfully present in the United States. Although the shortest period of enrollment has been established by regulation as 12 months, the Department of Health and Human Services (HHS) has indicated that an exchange will determine an individual's eligibility for the period of time for which the individual's lawful presence has been verified. Aliens who are not lawfully present are barred from obtaining insurance through an exchange. In order to claim the credit or subsidy, an individual's household income generally must be at least 100% but no more than 400% of the applicable federal poverty level (FPL). This is because the credit and subsidy are only available for months during which a person purchases health insurance through the exchanges and aliens who are not lawfully present are prohibited from buying insurance through an exchange. Under the ACA, lawfully present noncitizens (including some LPRs within five years of entry) who are ineligible for Medicaid due to their alien status are eligible to participate in an exchange and receive premium credits and cost-sharing subsidies. Verification of Alien Status Under the ACA

To enforce the alien eligibility requirements under the act, Section 1411 of the ACA requires the Secretary of Health and Human Services (HHS) to establish a program to determine whether an individual who is to be covered through an exchange plan or who is claiming a premium tax credit or reduced cost-sharing is a citizen or national of the United States or an alien lawfully present in the United States.
The degree to which foreign nationals (noncitizens/aliens) should be accorded access to certain benefits as a result of their presence in the United States, as well as the responsibilities of such persons given their legal status (e.g., immigrants, nonimmigrants, unauthorized aliens), often figures into policy discussions in Congress. These issues become particularly salient when Congress considers legislation to establish new immigration statuses or to create or modify benefit or entitlement programs.
The 111th Congress enacted the Patient Protection and Affordable Care Act (P.L. 111-148), which has been amended by the Health Care and Education Reconciliation Act of 2010 (P.L. 111-152) and several other bills. (ACA refers to P.L. 111-148 as amended by P.L. 111-152 and the other legislation.) The ACA created new responsibilities (e.g., the requirement that most people in the United States obtain health insurance) and new benefits (e.g., tax credits to help certain people purchase health insurance), and it addressed the eligibility and responsibility of foreign nationals for these provisions. One issue that has arisen during some debates to amend provisions in the ACA and during discussions of immigration reform is the eligibility of foreign nationals for some of the ACA's key provisions.
At the center of noncitizen eligibility for provisions under the ACA is the term "lawfully present." Aliens who are "lawfully present in the United States" are generally subject to the health insurance mandate and are eligible, if otherwise qualified, to participate in the exchanges (the health insurance marketplace) and for the premium tax credit and cost-sharing subsidies available to certain individuals who purchase insurance through an exchange. For purposes of the ACA, "lawfully present" has been defined in regulation and includes lawful permanent residents (LPRs), asylees, refugees, foreign nationals admitted under any nonimmigrant visa who are in status, and certain other classifications under the Immigration and Nationality Act (INA).
To purchase insurance through an exchange, a noncitizen must be expected to be lawfully present for the entire period of coverage. Although the minimum period of coverage was established by regulation as 12 months, the exchanges will decide on an enrollment period based on the length of time the alien is authorized to be in the country. The ACA bars foreign nationals who are not lawfully present from purchasing insurance through a health insurance exchange.
In addition, certain individuals who purchase insurance through an exchange may be eligible for the premium tax credit and cost-sharing subsidies to help defray the cost of the insurance. To be eligible, an applicant must meet income requirements based on family size and the federal poverty level, and must also file a tax return in order to claim the credit. Noncitizens who are not lawfully present are ineligible for the premium credit and cost-sharing subsidies because they are barred from purchasing insurance through an exchange.
To enforce the noncitizen eligibility requirements under the ACA, the act required the Secretary of Health and Human Services to establish a program to determine whether an individual who is to be covered in the individual market by a qualified health plan offered through an exchange or who is claiming a premium tax credit or cost-sharing subsidy is a citizen or national of the United States or an alien lawfully present in the United States. This system first checks the Social Security Administration (SSA) records. If SSA can confirm that the person is a citizen, then the check stops at that point. If the person is a "noncitizen" in SSA records, the system checks against Department of Homeland Security (DHS) records to confirm lawful presence. The Departments of Health and Human Services and Homeland Security have stated that no information collected as part of enrollment in an exchange plan will be used for any civil immigration enforcement actions.