THE TORCH: CONTENTS By Alejandra Caballero Pinedo, Andy Flores, and Kathleen Hoang

August 15, 2023

The FirstGEN Fellows Program connects first generation college students with legal organizations, including the National Immigration Law Center, Asian Americans Advancing Justice, and the Lawyers’ Committee for Civil Rights Under Law. Throughout ten weeks in a paid summer internship, we gained firsthand experience in social justice careers, while developing our own personal professional capacity through weekly seminars, discussions, and mentorship. Continue reading to find out more about this year’s fellows and their summer!

Alejandra Caballero Pinedo, rising senior at Trinity University:

As a FirstGEN fellow working with the National Immigration Law Center, I have greatly benefited from being immersed in a space where I constantly learn about the interactive dynamic of litigation, policy, and advocacy. At NILC, I supported the policy and advocacy department by adding to the organization’s institutional knowledge through research, crafting a factsheet for bipartisan congressional review on a bill relating to telehealth language access, taking notes on congressional hearings, and assisting in the review of the DACA campaign strategy. Through it all, one of the greatest gifts I have gained from this program is the renewed faith I have found within myself to accomplish the unexpected.

The support from my supervisors and the staff members at NILC has been transformative. I have learned to whole-heartedly believe in the trust that has been placed in me. Additionally, my contributions have been welcomed and celebrated which has led me to feel uplifted as a first-generation college student, fellow, and colleague. Conversations in DACA team meetings and FirstGEN fellows weekly meetings have been instrumental to my intellectual growth and in developing myself in a professional sphere. Not only was this summer internship empowering and uplifting, but my knowledge base on career paths significantly expanded. I was able to discover different potential career paths in the social justice, policy, advocacy, and legal fields.

Nearing the end of this fellowship, I am beyond proud of my intellectual, personal, and professional growth. Additionally, I embrace the crucial role that NILC and the FirstGEN Fellows program have played in planting these seeds of growth within me.

Andy Flores, recent graduate from University of Mississippi:

As a FirstGEN fellow with the Lawyers’ Committee for Civil Rights Under Law this summer, I developed a rich and intimate understanding of how racial justice advocacy works behind-the-scenes. In my first few weeks, my team entrusted me with facilitating local rallies, shaping our national advocacy strategy, and generating key materials for our Educational Opportunities Project. I was also consistently invited to share my perspective on weighty issues, such as the team’s affirmative action litigation before the Supreme Court. As the weeks progressed, Wednesday meetings with the FirstGEN Fellowship cohort were a grounding opportunity to share in community alongside interns who understood the first-gen experience. It was replenishing. Both personally and professionally, I felt empowered to show up as my full self and make substantive contributions.

This summer also demystified the legal field for me and clarified what my career could look like as a future first-gen lawyer. Too often, it can be difficult to connect with attorneys, understand their day-to-day role, and benefit from their wisdom. As a FirstGEN Fellow, I was consistently surrounded by brilliant and welcoming professionals who were dedicated to public service. I had one-on-one meetings with someone new every week, and every time, I learned something new about myself. I now feel more prepared than ever to apply to law school and pursue a career as a civil rights litigator.

Kathleen Hoang, rising junior at Columbia University:

As a FirstGEN fellow with Asian Americans Advancing Justice | AAJC, I have not only delved into projects related to radicalized state histories and data disaggregation, but I’ve also had the privilege of meeting amazingly talented staff members who shared their rich educational and career trajectories with me. Through conversations and mentorship, I gained invaluable insights into the professional social justice world and learned how to navigate challenges with resilience and grace. Their encouragement and willingness to invest time in my growth meant the world to me.

I walk away from AAJC inspired, knowing that as long as I have the intention to leave the world a little bit better, my path will unfold before me. The terrifying, infinite possibilities of my career stand before me and yet I feel more ready and excited than ever before to take what I learned at AAJC into my work with human rights.

We are so grateful for this fellowship, all the invaluable skills we gained professionally, and the self-confidence we built through generous mentorship from staff. We encourage everyone to apply to next year’s program and join the FirstGEN Fellowship.

THE TORCH: CONTENTS By Laiba Waqas & Ben D’Avanzo 

August 9, 2023

In March 2023, after a three-year pause, states resumed terminating the eligibility of Medicaid recipients. These terminations signaled the restart of eligibility redeterminations, which had been halted during the COVID-19 pandemic. Enrollees who face the termination of their eligibility are already up against significant administrative barriers, but people with limited English proficiency (LEP) are more likely to lose Medicaid coverage during this unwinding process even if they remain eligible for Medicaid due to language barriers and ineffective communication. States have an opportunity to remove these barriers and avoid worsening access to in-language explanations and applications so that everyone, regardless of how much money they have, where they were born, or what language they speak, can access the health care they need to thrive.

Under federal civil rights laws, including Title VI of the Civil Rights Act of 1964 and Section 1557 of the Affordable Care Act states have obligations to ensure that individuals have meaningful access to their federally funded programs, including Medicaid. A recent letter from Department of Health and Human Services Office of Civil Rights (HHS OCR), emphasized that states must abide by language access requirements during the unwinding to prevent individuals with LEP from losing coverage. The Centers for Medicare and Medicaid Services has reminded states that regulations require state Medicaid programs to provide in-language oral interpretation and written translations to people with LEP Given that 89 percent of people with LEP are people of color, failure to provide these protections will exacerbate racial health disparities. To identify trends of how states provide information for obtaining language assistance through call centers and on state Medicaid home pages, we analyzed how people with LEP may try to initiate their Medicaid redetermination. Our analysis of call centers and Medicaid websites across all 50 states uncovered some concerning trends. 

Medicaid Call Centers

We looked at whether state Medicaid call centers provide immediate access to in-language assistance upon connection, and, if so, in which languages. For example, to ensure a call line is accessible, a phone menu should start by asking for the caller’s language preference and may ask them to press a number to indicate a specific language. However, nine states: Arizona, Hawaii, Michigan, Mississippi, Montana, North Carolina, Pennsylvania, Rhode Island, and Virginia failed to offer immediate language options and instead began with long English prompts, making their systems potentially unusable by someone with LEP.

Nineteen states’ phone menus provided prompts for people who speak only English and Spanish, not even offering an “other” option. For the 38 percent in the U.S. with LEP who don’t speak those languages, this obstacle makes it unclear how they are supposed to obtain assistance with their Medicaid renewals.

Only 13 states, plus the District of Columbia, had specific language options on their phone menu beyond English, Spanish and a general “other language” option. However, in some states, these language options were stated in English rather than using the identifying word in the language itself. (“Spanish” instead of “Español”)

State Medicaid Websites

Because people with LEP may first go to their state’s Medicaid website for information on renewals, we looked to see if there was any information on how to access in-language information from those homepages.

Alabama, Alaksa and Idaho all failed to provide any information on how to access language services on their Medicaid home pages or application page. Most other states had an option to translate the website, including the renewal application, into Spanish; however, in 18 states, other languages were only accessible through Google Translate, which is often riddled with grammar and syntax errors that reduce the accuracy of information.

Thirteen states, and DC, had translated resources and informational flyers regarding Medicaid application and free translation services on their website; these translations were available in anywhere from two to fifteen languages. Most states had drop-down menus, identified only in English, from which language services could be accessed if available. Notably, only nine states and DC had taglines or footers that either linked to a translated version of the entire website or opened additional resources and information in that language. While some states may have additional information in-language on portions of their website, they were not clearly accessible from the home page.

Many states have failed to abide by the best practices that HHS OCR has communicated, putting themselves at risk of failing to comply with civil rights and Medicaid enrollment requirements. States must ensure people with LEP can access language assistance to mitigate Medicaid coverage gaps and losses.

Recommended Best Practices for States

From the findings above, many states have a long way to go to ensure that people with LEP can access the tools and information they need to renew Medicaid. Our analysis uncovered some important steps that states can take to improve language access:

Call centers should:

• Provide unique phone numbers for speakers of different languages, bypassing the challenges of complex phone trees, as California does in 12 languages.
• Immediately ask callers for their language preferences, using the in-language terminology for the offered languages, as Oregon does for 6 languages.
• Remove lengthy English prompts prior to asking a customer’s language, as consumers must navigate in Arizona, Hawaii, and Montana.

Websites should:

• Provide language access options that use professional translation services. The proposed revisions to Section 1557 regulations note that unreviewed machine translations do not count as meaningful access.
• Place language translation options in a conspicuous location on the website rather than buried within an English drop-down menu. For example, Washington state offers Spanish at the top of the page and taglines in 15 languages at the bottom of the website.

States should:

• Utilize the language preference data that all Medicaid applications collect to identify and regularly publish demographic trends during the unwinding, as Washington and Oregon do. Without data, we cannot truly know how big the coverage loss disparities will be for people with LEP.

States must provide meaningful language access to ensure that no one else loses their health care because of ineffective and inaccessible communications. CMS and OCR should provide oversight and consider pausing renewals in states that do not. No one should be denied access to health care coverage because of the language they speak.

Laiba Waqas is a NILC Summer 2023 Legal Intern.

THE TORCH: CONTENTS By Gabrielle Lessard

May 5, 2023

The senseless exclusion of immigrants with Deferred Action for Childhood Arrivals (DACA) from Affordable Care Act (ACA) coverage is finally ending. The Centers for Medicare and Medicaid Services (CMS) has published a proposed rule that would modify the definition of “lawfully present” used to determine eligibility for ACA health plans and certain other health care programs.

The proposed regulations would make DACA recipients eligible:

• To purchase plans, and receive income-based subsidies, on healthcare exchanges like Healthcare.gov,
• To participate in Medicaid or CHIP coverage for children and/or people who are pregnant in many states, and
• To enroll in Basic Health Programs in certain states (currently New York and Minnesota).

Colin Anderson Productions

Currently, people who have deferred action under categories other than DACA are considered lawfully present for purposes of the three programs listed above. In publishing the proposed regulations CMS has recognized that it is not required to treat DACA recipients differently than other recipients of deferred action, and that doing so is contrary to the purposes of DACA and the ACA.

The proposed regulations also incorporate important clarifications and technical corrections. The proposal clarifies that people who received special immigrant juvenile status (SIJS) are eligible for the three programs listed above. It also eliminates a 180-day waiting period for children under age 14 applying for certain kinds of humanitarian relief, including asylum.

The proposed regulations incorporate a November 1, 2023 effective date, which coincides with the beginning of the ACA open enrollment period. There is no real justification for making DACA recipients continue to wait for access to affordable coverage. As people newly eligible for ACA coverage, DACA recipients would be eligible for a ‘special enrollment period’ that enabled them to enroll outside of open enrollment.

CMS is accepting public comments on the proposed regulation through June 23, 2023. Check back on NILC’s website for additional news and resources about the regulation as it moves forward.

Gabrielle Lessard is a Senior Policy Attorney at NILC.

THE TORCH: CONTENTS By Ben D’Avanzo

February 7, 2023

Millions of people who receive health care through Medicaid will have their eligibility reviewed for the first time in over three years. Medicaid eligibility review, or ”redetermination” normally takes place at least once a year but was suspended due to policies related to the COVID-19 pandemic.

The redetermination process will disproportionately put immigrants and their families at risk of losing health coverage unnecessarily, because they face unique barriers to maintaining coverage. These barriers include the additional application steps required to verify their immigration status, challenges with identity verification, and household composition issues such as living in multi-generational families. Policymakers must go beyond current practices to ensure that immigrants retain health coverage through Medicaid or make a successful transition to the Affordable Care Act marketplaces. Here’s how:

Simplify Enrollment as Much as Possible – Determining Medicaid eligibility is complicated for both applicants and eligibility workers. This complexity is compounded for immigrants, who are required to demonstrate satisfactory immigration status and often encounter challenges in verifying their identities. Many immigrants, such as those working in seasonal or unstable jobs, also have difficulty verifying their income. States are required to redetermine applications without the recipients’ involvement, when possible, known as “ex parte” redetermination. States should seek out additional sources of information they can use in making ex parte redeterminations, such as information held by other state benefits agencies. States should accept applicants’ self-declaration of income that they can verify independently, such as income, and allow for reasonable variances.

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Ensure Medicaid Eligibility Workers are Trained on Immigrant Eligibility – The rules that govern immigrants’ eligibility for Medicaid are complicated, with variations by immigration status, time spent in the U.S., age, pregnancy and beyond. There have also been recent changes, for example, people living in the U.S. under the Compact of Free Association became eligible since Medicaid redeterminations were last conducted, as well as some Afghan and Ukrainian parolees. Medicaid agencies should ensure their staff receive regular training on immigrant eligibility to ensure no one is improperly denied coverage.

Conduct Outreach and Enrollment in Multiple Languages – Current Medicaid practices consistently fail people with limited English proficiency (LEP), despite the prevalence of LEP individuals in Medicaid households being more than double those of non-Medicaid households. For example, many states provide applications in English only, and very few translate their applications into languages beyond Spanish. State Medicaid agencies, which are responsible for ensuring meaningful access to their programs for people with LEP under Title VI of the Civil Rights Act of 1964 and Section 1557 of the Affordable Care Act, should, to the extent possible, communicate with applicants in their preferred language at all points in the process.

Without in-language applications, outreach and notices, LEP households may fail to realize they need to update their information with their Medicaid agency before losing coverage. The Centers for Medicare & Medicaid Services (CMS) suggests that states review their language access plans and review the availability of interpreters, among other steps, and currently offers toolkits in Spanish, Chinese, Hindi, Korean, Tagalog, and Vietnamese. California offers its applications in 12 languages. While Virginia only offers applications in Spanish, the state has programmed its systems to translate notices into several other languages. Given that many people with LEP prefer oral interactions, states may also want to follow the example of Oregon, which offers specific phone lines for different languages. State Medicaid agencies should use the opportunity of the unwinding to take the next available step towards greater language access in their application process.

Utilize All Forms of Communication – The Consolidated Appropriations Act, 2023 requires states to attempt to reach beneficiaries at risk of disenrollment with more than one method of communication. States should consider going beyond this requirement by attempting to contact people using all available forms of communication. For immigrants, particularly migrant workers or humanitarian immigrants who may move from where they were originally resettled to be closer to family, geographic movement is common. As a result, mailing addresses and phone numbers may have become outdated since their last redetermination over three years ago.

Nonetheless, postal mail remains an important form of communication and the way in which beneficiaries expect to receive notices from state agencies. States should act affirmatively to obtain change of address information through postal databases to supplement beneficiary updates.

Utilize and Fund Trusted Community Institutions – In addition to the challenges described above, agency communication with immigrant households is often hampered by their distrust of government. Concerns about interacting with government agencies or the consequences of receiving benefits may cause recipients to discard or ignore government communications. Agencies should proactively convene community-based organizations, schools, health clinics, non-English language media, and influencers on social media apps, like WhatsApp and WeChat, that are commonly used by immigrants. For example, California has created a Coverage Ambassadors campaign. Agencies should also recognize that community-based organizations are often under-resourced and should provide financial support for their participation in the redetermination process.

Assure Immigrants About Their Protections and Privacy – Some immigrants may be concerned about sharing the personal information needed to redetermine their eligibility, particularly if they have family or household members who are concerned about immigration enforcement. The time gap since redeterminations last occurred may have led to eroded trust. Families may act with suspicion or uncertainty when presented with the need to respond to a government notice. Medicaid agencies and other entities engaged in outreach can adopt trusting community approaches and welcoming policies to help educate applicants about how their data will and will not be used. They should also proactively address immigration status–related concerns like public charge.

Overall, states will have up to a little over a year to conduct these redeterminations. Without careful planning, including proactive, intentional steps like those outlined above and in more detail through the Protecting Immigrant Families network toolkit, more immigrant families will lose health coverage. Instead of defaulting to usual practices, policymakers should view this restart of renewals as an opportunity to make improvements to their Medicaid outreach and enrollment practices to promote health equity. Otherwise, parents may arrive at their children’s pediatrician’s appointments only to find, through no fault of their own, they are now uninsured.

Ben D’Avanzo is a Senior Health Policy Analyst at NILC.