Obtaining citizenship or lawful permanent resident status will trigger a special enrollment period

Becoming a U.S. citizen, U.S. national, or lawfully present individual is a qualifying life event that triggers a 60-day special enrollment period in the exchanges.

Depending on the state and the date the application is submitted, coverage can be effective the first of the month following enrollment, or the first of the second following month. (In some state-run Marketplaces, a special enrollment period application submitted on June 16 will result in coverage effective August 1 instead of July 1). But starting in 2025, Marketplaces in all states will make coverage effective the first of the month following a person’s application date, regardless of the date the application was submitted.¹

Unlike the other qualifying life events qualifying life events, this one only applies if you’re enrolling through the exchange (either the federally run HealthCare.gov or a state-run exchange).² Off-exchange, carriers can allow this special enrollment period or not – it’s at their discretion.

Read more about how immigrants can obtain health coverage in the United States..

Becoming a U.S. citizen is a qualifying life event

Becoming a U.S. citizen involves successfully completing the naturalization process. Once you gain citizenship, you’ve got 60 days to enroll in a health insurance plan through the exchange, and regular effective date guidelines apply. (As noted above, coverage in most states will take effect the first of the month after you enroll, and this will be the case in every state by 2025).

Note that a special enrollment period does not apply if you already had a lawfully present immigration status prior to becoming a citizen. Any change in immigration status only triggers a special enrollment period if the person did not previously have a lawfully present immigration status.²

If you’re a U.S. national living in a U.S. state, you may be eligible for a SEP

All U.S. citizens are U.S. nationals, but the reverse is not necessarily true. People born in American Samoa – including Swains Island – are U.S. nationals, but are not U.S. citizens unless they move to a U.S. state for at least three months and then go through the naturalization process.

People born in the Northern Mariana Islands are granted U.S. citizenship, but can elect instead to be non-citizen U.S. nationals. People born in the other U.S. territories – Guam, Puerto Rico, and the U.S. Virgin Islands – are U.S. citizens.

Most of the ACA’s provisions do not apply in the U.S. territories. (This is a reversal of the position that the Department of Health and Human Services (HHS) took in 2013, when they said that the ACA would apply in the territories.) Still, plans sold in the territories cannot have annual or lifetime benefit maximums, and must cover preventive care with no cost-sharing.

None of the territories have established their own exchanges, and HealthCare.gov does not offer plans in the territories. The annual open enrollment period does not apply in the territories, since the ACA’s requirement that health plans be guaranteed-issue is not applicable in the territories.

So it’s important to note that someone who becomes a U.S. national is eligible for a special enrollment period (SEP), but they have to move to a U.S. state in order to take advantage of it, since that’s where ACA-compliant plans are offered.

Medicare and Medicaid are available to eligible residents in U.S. territories, and the Centers for Medicare & Medicaid Services (CMS) website has resource pages for people in the territories, with contact information for the available programs.

Your SEP starts when you become a U.S. citizen, national, or lawfully present individual

There is a wide range of immigration statuses that qualify as “lawfully present.”³ Lawfully present U.S. residents can enroll in health plans through the exchange (HealthCare.gov or a state-run platform, depending on where they live), and have a special enrollment period that runs for 60 days from the date that they gain lawfully present resident status in the U.S.

Note that until 2024, DACA – Deferred Action for Childhood Arrivals – is not an eligible immigration status for the purpose of obtaining health insurance, so a person with DACA status cannot use the health insurance exchange to obtain coverage. This is true in both state-run exchanges and HealthCare.gov. ⁴ But this will change starting in November 2024. At that point, DACA recipients will be able to use the health insurance exchange in every state to enroll in coverage and qualify for income-based subsidies.⁵

Before November 2024, DACA recipients in most states cannot obtain subsidized health insurance. But Washington state obtained federal permission to allow undocumented immigrants to use its Marketplace as of 2024, and Colorado has created a separate platform where people can enroll in coverage if they aren’t eligible to use the Marketplace due to immigration status. (In both Washington and Colorado, state-funded subsidies are available for these enrollees.)⁶ And the Basic Health Programs in New York⁷ and Minnesota,⁸ – both of which are accessed via the state-run Marketplace – allow DACA recipients to enroll.)

New immigrants with income below the federal poverty level are eligible for premium subsidies

The SEP triggered by gaining citizenship or lawfully present resident status applies regardless of income, and regardless of whether the person is eligible for premium subsidies in the Marketplace federal exchange. But eligibility for premium subsidies for new immigrants (those who have been in the U.S. less than five years) differs from the rules for other Marketplace enrollees:

Under Section 36B(c)(1)(B) of the ACA, lawfully present residents with income below 100% of the federal poverty level (FPL) are eligible for premium subsidies in the Marketplace if they are not eligible for Medicaid as a result of their immigration status. (Lawfully present residents generally have a five-year waiting period before they can be eligible for Medicaid, although some states use state funds to provide Medicaid coverage to lawfully present residents who have not met the five-year waiting period requirement).

For background, federal premium subsidies in the exchanges (both state-run exchanges and HealthCare.gov) are otherwise only available if the applicant is not eligible for Medicaid and has an income above 100% of the federal poverty level. If Congress had not added the provision allowing subsidies for lawfully present residents with income below 100% of the federal poverty level, these individuals would likely otherwise have not been able to find affordable health insurance.⁹(They’re not yet eligible for Medicaid, and have income too low for subsidies.)

In 2012, the Supreme Court ruled that states could not be obligated to implement the ACA’s Medicaid expansion, and as a result, there are 10 states where Medicaid has not been expanded. In nine of those states (all but Wisconsin), there are nearly 1.5 million people in the coverage gap, with no realistic access to health insurance.¹⁰

Their incomes are below the federal poverty level, so they’re not eligible for subsidies. And their states have not expanded Medicaid, so they’re not eligible for Medicaid either.

Ironically, it was this exact sort of situation that Congress was trying to prevent – in the case of lawfully present residents who hadn’t been in the U.S. long enough to qualify for Medicaid – when they included Section 36B(c)(1)(B) in the ACA. But they had no idea that the Supreme Court would issue a ruling a few years later that would ultimately throw millions of U.S. citizens into the same sort of health insurance gap..

Immigrants age 65 and older are eligible for a SEP when they become lawfully present individuals

Prior to 2014, individual market plans generally did not accept applicants who were 65 and older, even if they were ineligible for Medicare. (There were some exceptions, and some states had high-risk pools that would cover these applicants. The Texas high-risk pool was one example.)¹¹ Immigrants are not allowed to purchase Medicare until they’ve been in the U.S. for five years.¹²

Before the ACA took effect, these older immigrants were in a tough spot for health insurance, since they also weren’t able to purchase individual market coverage. The ACA changed that. People 65 and older who aren’t eligible for Medicare are allowed to purchase individual market coverage, with premium subsidies and cost-sharing reductions available if their income makes them eligible, and their unsubsidized premiums cannot be more than three times the premiums charged for a 21-year old.¹³ So a person who becomes a lawfully present U.S. resident has access to the special enrollment period even if he or she is 65 or older.

And premium subsidies are available (depending on the person’s income) in the exchange/marketplace as long as the person is not eligible for premium-free Medicare Part A. This will generally be the case for older immigrants, since they typically don’t have the ten years of work history in the U.S. necessary to qualify for premium-free Medicare Part A. These individuals can continue to receive premium subsidies indefinitely (again, depending on income), since they would have to pay a premium for Medicare Part A once they’ve been in the U.S. for five years and can enroll in Medicare. But note that if they ever did want to transition to Medicare, a late enrollment penalty would apply if they continued to use the exchange/marketplace coverage after the five-year waiting period for Medicare eligibility.

---

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org.

Footnotes

1. “Patient Protection and Affordable Care Act, HHS Notice of Benefit and Payment Parameters for 2025; Updating Section 1332 Waiver Public Notice Procedures; Medicaid; Consumer Operated and Oriented Plan (CO-OP) Program; and Basic Health Program” U.S. Department of the Treasury; U.S. Department of Health and Human Services. April 2, 2024 ⤶
2. “Special Enrollment Periods Available to Consumers” Centers for Medicare & Medicaid Services. June 23, 2017 ⤶ ⤶
3. “Coverage for lawfully present immigrants” HealthCare.gov. Accessed April 26, 2024 ⤶
4. “Exclusion of Youth Granted “Deferred Action for Childhood Arrivals” from Affordable Health Care” National Immigration Law Center. Updated December 2022 ⤶
5. “Biden-Harris Administration Finalizes Policies to Increase Access to Health Coverage for DACA Recipients” Centers for Medicare & Medicaid Services. May 3, 2024 ⤶
6. “On the Path Toward Health for All” National Immigration Law Center. Published December 2023 ⤶
7. “New York State Department of Health and NY State of Health Announce the Essential Plan Expansion Increasing Access to Affordable Health Insurance Begins Today” New York State Department of Health. April 1, 2024 ⤶
8. “MinnesotaCare Eligibility for DACA Grantees” Minnesota Department of Human Services. Accessed April 26, 2024 ⤶
9. “Definition: applicable taxpayer from 26 USC § 36B(c)(1)” Cornell.edu. Accessed May 3, 2024 ⤶
10. “How Many Uninsured Are in the Coverage Gap and How Many Could be Eligible if All States Adopted the Medicaid Expansion?” KFF. February 26, 2024 ⤶
11. “Texas Health Insurance Risk Pool” Accessed April 26, 2024 ⤶
12. “Original Medicare (Part A and B) Eligibility and Enrollment” Centers for Medicare & Medicaid Services. Accessed April 26, 2024 ⤶
13. “Guidance Regarding Age Curves and State Reporting” (Appendix 1). Centers for Medicare & Medicaid Services. December 16, 2016 ⤶