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Page 7 – State Health Official Letter At the same time, neither the text of section 71109 of the WFTC legislation nor its legislative history demonstrates a clear Congressional intent to require that states provide full Medicaid benefits to qualified noncitizens without receiving federal matching funds for that coverage. Under these circumstances and consistent with relevant case law,34 beginning October 1, 2026, CMS will not require states to provide state-only funded health coverage to qualified noncitizens for whom FFP is not available for full Medicaid benefits under 1903(v)(5) of the Act (e.g., asylees, refugees, parolees, or victims of trafficking who are not also FFP-eligible noncitizens), including populations listed at section 1902 of the Act. Moreover, because section 71109 of the WFTC legislation did not clearly and unambiguously alter the fundamental structure of the Medicaid program, whose “cornerstone” is “financial contribution by both the Federal Government and the participating State,”35 we would not consider health coverage that a state opts to continue to provide with 100 percent state-only funds to be Medicaid, notwithstanding the fact that 8 U.S.C. § 1612(b)(2) still describes coverage that will no longer be eligible for federal matching funds beginning October 1, 2026 as “Medicaid,” and notwithstanding the fact that section 1902 of the Act still describes mandatory Medicaid coverage that (when provided to certain populations) will no longer be eligible for federal matching funds beginning October 1, 2026. Therefore, beginning October 1, 2026, a noncitizen must be an FFP- eligible noncitizen or meet one of the statutory exceptions listed in section 1903(v)(5) of the Act to have “satisfactory immigration status” for full Medicaid benefits (including for purposes of section 1137(d) of the Act). See Appendix A for more information on the availability of FFP for coverage by immigration status or category prior to and following the applicability date of the statutory changes made by section 71109 of the WFTC legislation. While PRWORA does not describe any populations who must be eligible for CHIP, the same reasoning identified above for Medicaid applies to CHIP. Specifically, neither the text of section 71109 of the WFTC legislation nor its legislative history demonstrates a clear Congressional intent to require that states provide CHIP benefits to qualified noncitizens without receiving federal matching funds for that coverage, and we do not consider coverage that a state might opt to continue providing with 100 percent state-only funds to be “CHIP.” Impact on Noncitizens Dually Eligible for Medicare and Medicaid The term “dually eligible beneficiaries” generally describes beneficiaries who are eligible for both Medicare and Medicaid. The term includes beneficiaries enrolled in Medicare Part A, Part B, or both, who receive either full Medicaid benefits or assistance with Medicare premiums and often cost- sharing through a Medicare Savings Program (MSP) eligibility group.36 Sections 1903(v)(5) and 1899C of the Act, as added by section 71109 and section 71201 of the WFTC legislation, respectively, both impact noncitizens who are dually eligible for Medicare and Medicaid. Section 1899C of the Act limits Medicare eligibility for noncitizens to the same groups for which section

34 See, e.g., Pennhurst State Sch. & Hosp. v. Halderman, 451 U.S. 1, 17-18 (1981); Harris v. McRae, 448 U.S. 297, 308- 09 (1980); see also Detgen ex rel. Detgen v. Janek, 945 F. Supp. 2d 746, 759 (N.D. Tex. 2013), aff'd, 752 F.3d 627 (5th Cir. 2014). 35 McRae, 448 U.S. at 308. 36 Federal Coordinated Health Care Office Fact Sheet, “Dual Eligibility Categories,” (Jan. 15, 2025), available at: https://www.cms.gov/files/document/dual-eligible-categories-01152026.pdf.