The Moment When Three Things End at Once

There is a specific kind of financial shock that immigrant families know well: the moment when a single administrative event — a TPS termination date, a visa expiration, an automated layoff email — ends your work authorization, your income, and your health coverage simultaneously.

Most of the guidance that exists for these situations is either written for US citizens or fails to account for the immigration dimension. “Just sign up for COBRA” is accurate advice, but incomplete when COBRA costs $800 a month and your 60-day grace period on an H-1B visa is running out at the same time. “Check Medicaid eligibility” means nothing if you do not know that TPS holders are being phased out of federal Medicaid eligibility under the One Big Beautiful Bill Act.

This guide untangles each scenario: TPS termination, work visa status changes, and employer-sponsored coverage lost through layoff. It covers what your current coverage situation is likely to be, how long you have to act, what programs remain open to you in 2026, and the safety-net options that exist regardless of status.

The 60-day window is real. Understanding what is inside it is what this article is for.

The 2026 Policy Landscape: What Has Changed

Before reviewing specific scenarios, it is essential to understand the federal policy changes that took effect or are taking effect in 2026 — because the advice that was accurate 12 months ago may no longer apply.

The One Big Beautiful Bill Act (OBBBA)

Signed into law on July 4, 2025, the OBBBA is the most significant restructuring of immigrant health coverage eligibility in decades. The changes roll out on a staggered timeline:

Already in effect (2025–2026):

  • DACA recipients lost ACA Marketplace eligibility entirely as of August 25, 2025.
  • Lawfully present immigrants with income below the federal poverty level can no longer access premium tax credits for ACA coverage — they must earn at least 100% of the federal poverty level to qualify.

Effective October 1, 2026:

  • Federal Medicaid eligibility is restricted to US citizens, lawful permanent residents (green card holders), certain Cuban-Haitian entrants, and COFA citizens (from the Marshall Islands, Palau, and Micronesia). TPS holders, asylees, refugees, and humanitarian parolees lose federal Medicaid eligibility at this date.

Effective for 2027 ACA plans (open enrollment fall 2026):

  • TPS holders, asylees, and refugees lose eligibility for ACA premium tax credit subsidies. Marketplace plans remain technically available to purchase at full unsubsidized cost, but subsidized access ends.

What has not changed:

  • Emergency Medicaid (for acute, life-threatening conditions) remains available regardless of immigration status, though federal reimbursement rates to states change in October 2026.
  • EMTALA still requires Medicare-participating hospitals to screen and stabilize anyone presenting to an emergency room, regardless of insurance or immigration status.
  • Children’s coverage protections remain stronger than adult protections in most states.
  • Federally Qualified Health Centers remain open to all patients regardless of immigration status or ability to pay.

Understanding this timeline is the foundation for everything else in this article.

Scenario 1: Your TPS Has Ended or Is Ending

What Happens to Your Health Coverage

TPS termination does not directly cancel your health insurance — but it typically triggers the job loss that does. Most TPS holders work on the Employment Authorization Document (EAD) that TPS provides. When TPS ends, the EAD expires, employers are legally required to end your employment, and employer-sponsored health coverage ends with it.

The sequence matters because your health insurance clock starts when you lose coverage, not when TPS officially terminates. That distinction gives you a window to act.

Your Immediate Options

COBRA (if you had employer-sponsored coverage): If you were covered under an employer’s group health plan, you are entitled to COBRA continuation regardless of your immigration status. COBRA allows you to keep exactly the same coverage you had — same network, same doctors, same plan — for up to 18 months. The cost is the full premium that you and your employer were previously paying combined, plus up to a 2% administrative fee. This is often expensive: $400 to $800 per month for an individual, more for a family.

You have 60 days from the date you lose coverage to elect COBRA. Do not let this window close. Once it does, there is no way to retroactively elect coverage, and you cannot create a new Special Enrollment Period by letting COBRA lapse through non-payment.

ACA Marketplace — 2026 coverage: If you still have valid TPS or are in a legal status that qualifies as “lawfully present,” you can enroll in a Marketplace plan through a Special Enrollment Period triggered by loss of coverage. For 2026 plans currently in force, subsidies are not affected mid-year. For new enrollment in 2026 coverage, you must earn at least 100% of the federal poverty level to qualify for premium tax credits.

ACA Marketplace — 2027 coverage (open enrollment fall 2026): If your TPS has ended and you have no other lawful status, you may not be eligible to enroll in a Marketplace plan at all — Marketplace access requires lawfully present status. If you do have another qualifying status, you can still enroll but will no longer qualify for subsidies starting with 2027 plans.

State-funded coverage: Several states use their own funds to provide health coverage to residents who do not qualify for federal programs. As of 2026, about seven states plus DC provide some form of state-funded coverage to income-eligible adults regardless of immigration status: California, Colorado, Illinois, Minnesota, New York, Oregon, and Washington. These programs have specific income limits, enrollment caps, and eligibility rules that vary by state. Contact your state’s Medicaid or health exchange agency directly to understand what is currently available.

Note on California: California’s Medi-Cal had previously covered adults regardless of immigration status, but the state froze enrollment for adults aged 19 and older who are TPS holders and asylum seekers in 2026 due to budget constraints related to federal funding cuts. Existing enrollees may be affected differently from new applicants. Contact Covered California or your county Medi-Cal office for your current situation.

Children’s Coverage: More Protected Than Yours

If you have US-citizen children, their Medicaid and CHIP eligibility is not affected by your TPS status at all. Their eligibility is based on their own citizenship and family income.

If your children are not US citizens but are lawfully residing in the US, they remain protected from the five-year Medicaid waiting period in states that have adopted the Immigrant Children’s Health Improvement Act (ICHIA) option — which most states have.

As of 2026, 14 states plus DC cover children regardless of immigration status using state funds: California, Colorado, Connecticut, Illinois, Maine, Minnesota, New Jersey, New York, Oregon, Rhode Island, Utah, Vermont, Washington, and Washington DC. If you are in one of these states, your children’s coverage may be unaffected even if your own is not.

Scenario 2: You Lost Your Job on an H-1B, L-1, or Other Work Visa

The Double Clock: 60 Days for Status, 60 Days for Insurance

A layoff on an employer-sponsored work visa creates two simultaneous 60-day clocks that operate independently but must both be managed urgently.

The immigration clock: H-1B holders have a 60-day grace period from the date of termination to find a new sponsoring employer, change status, or depart the US. This clock is set by USCIS policy. It does not automatically extend.

The health insurance clock: Separately, loss of employer-sponsored group health coverage is a qualifying event that triggers a 60-day Special Enrollment Period for COBRA and for the ACA Marketplace. This clock starts when coverage ends — which may be the day of termination or the last day of the month, depending on your employer’s policy.

These two clocks run in parallel. Managing both simultaneously is the defining challenge of a layoff on an employer-sponsored visa.

COBRA: Your Fastest Bridge

COBRA is your most immediate option because it requires no new underwriting, no new enrollment decision, and provides no gap in coverage — it is retroactive to the day after your employer coverage ended. You can even elect COBRA after a medical event has already occurred, as long as you are within the 60-day election window.

To elect COBRA: your former employer must send you a COBRA election notice within 14 days of reporting the qualifying event to the plan. You then have 60 days from receiving that notice (or losing coverage, whichever is later) to elect coverage. After electing, you have 45 days to make your first payment — and that payment covers you back to the day coverage ended.

The main constraint is cost. For an H-1B worker with family coverage, COBRA premiums can reach $1,500 to $2,500 per month. If your severance includes temporary employer continuation of health benefits, use that window; it does not count against your COBRA election period.

ACA Marketplace: An Alternative Worth Comparing

Losing job-based coverage is a qualifying event for a Special Enrollment Period on the ACA Marketplace. You have 60 days from the date of coverage loss to enroll. Coverage starts the first day of the month after you select a plan.

For H-1B visa holders, Marketplace eligibility depends on having lawful presence in the US — which an H-1B visa provides for its duration. During the 60-day grace period, your H-1B is still technically valid (you are in a period of authorized stay), so you may still qualify for Marketplace enrollment.

Compare COBRA and Marketplace options before deciding. Marketplace plans may be significantly less expensive, especially if you have income interruption that reduces your projected annual income for the remainder of the year. Use the income estimate that reflects your current situation, not your former salary — this affects subsidy eligibility.

What About Medicaid?

H-1B holders are generally not eligible for federal Medicaid, which is restricted to citizens, green card holders (after a five-year wait), and a few other specific categories. This does not change under the OBBBA for H-1B holders, who were already excluded.

Scenario 3: Visa Expiration Without Renewal

The Lapse Risk

A visa overstay or lapse — even an unintentional one — removes lawful presence status, which removes Marketplace eligibility. If you are enrolled in a Marketplace plan and your status lapses, the exchange will eventually conduct an eligibility verification and may terminate your coverage.

The more immediate concern: if you had employer-sponsored coverage and your visa expired while you were employed (which may happen with processing delays), your employer is required to terminate your employment once they are aware of the lapse. That termination triggers the same sequence as a layoff — 60 days for COBRA, 60 days for Marketplace enrollment — but with the added complication that your Marketplace eligibility may be compromised by the lapse itself.

The practical priority: If your visa is expiring and renewal is delayed, speak to an immigration attorney immediately. Many delays can be managed with timely filing, and maintaining lawfully present status — even on a pending application — is critical for health insurance eligibility.

Pending Applications and Lawful Presence

If you have a pending renewal or adjustment of status application, you may still qualify as lawfully present for Marketplace purposes, depending on the application type. Check current USCIS guidance and confirm with your immigration attorney, as this area of policy has changed significantly in recent years.

The Safety Net: Coverage That Exists Regardless of Status

Federally Qualified Health Centers (FQHCs)

FQHCs are the most important resource in this article that most immigrants do not fully understand. There are approximately 1,400 FQHCs operating more than 15,000 service sites across the United States. They are funded by the federal government through the Health Resources and Services Administration (HRSA) and are required by law to serve every patient who walks in the door — regardless of immigration status, insurance status, or ability to pay.

Every FQHC operates a sliding fee discount schedule based on household income:

  • At or below 100% of the federal poverty level: Care is essentially free. The center may collect a small nominal charge, but the visit cost is minimal.
  • Between 100% and 200% of the federal poverty level: Sliding scale discounts with at least three discount levels.
  • Above 200% of the federal poverty level: Full charges apply, though these are typically lower than standard private practice rates.

FQHCs offer primary care, preventive services, dental care, behavioral health, and pharmacy services at most locations. You do not need to disclose your immigration status to receive care. You will need to provide proof of income so the center can place you on the correct fee tier — pay stubs, a tax return, or a signed self-declaration are all accepted.

Find the nearest FQHC by entering your zip code at the HRSA health center locator: findahealthcenter.hrsa.gov.

Emergency Medicaid

Anyone in the United States — regardless of immigration status — may qualify for Emergency Medicaid to cover acute, life-threatening medical conditions including emergency labor and delivery. Emergency Medicaid does not cover non-emergency care and does not require enrollment in advance. To apply, contact your state Medicaid office or the hospital’s financial assistance department when you present for emergency care.

Starting October 1, 2026, the federal reimbursement structure for Emergency Medicaid changes under the OBBBA — states will receive a lower federal match for emergency services provided to undocumented immigrants — but the program itself is not eliminated.

EMTALA: The Emergency Room Floor

The Emergency Medical Treatment and Active Labor Act (EMTALA) requires every Medicare-participating hospital to screen and stabilize anyone who presents to an emergency room, regardless of insurance or immigration status. This is a legal floor, not a comprehensive solution — it covers stabilization, not ongoing care. But it is unconditional and cannot be denied on the basis of status, insurance, or ability to pay at the point of presentation.

Hospital Financial Assistance Programs

Many hospitals — particularly non-profit and public institutions — operate their own financial assistance programs that apply to patients regardless of insurance or immigration status. These programs go by different names: charity care, financial hardship assistance, or sliding fee schedules. If you receive a hospital bill you cannot pay, ask the billing department about financial assistance programs before making any payment or accepting a payment plan.

Your Decision Timeline: The First 60 Days After a Status Change

DayPriority Action
Day 1Confirm the exact date your health coverage ends (check with HR or your plan)
Days 1–5Request your COBRA election notice from your former employer if not received
Days 1–14Identify your nearest FQHC for immediate care needs during the gap
Days 1–30Compare COBRA vs. ACA Marketplace costs for your household
Days 1–30Check your state’s current immigrant health coverage programs
Days 1–30Verify your children’s coverage status separately — it may be more protected than yours
Days 30–60Elect COBRA or enroll in a Marketplace plan before the 60-day window closes
Before Day 60Confirm enrollment and verify your first payment is processed

Critical: Missing the 60-day window for both COBRA and Marketplace enrollment leaves you without a path to coverage until the next Open Enrollment period (November 1 through December 15 for 2027 coverage on the federal marketplace). Do not let this deadline pass.

The Public Charge Rule: A Fear That Costs People Coverage

One of the most damaging phenomena in immigrant health access is the public charge chilling effect: families disenrolling from benefits they are legally entitled to — or avoiding care they would qualify for — out of fear that accessing health coverage will hurt their future immigration applications.

The public charge rule applies in the context of green card and certain visa applications. As of 2026, the rule focuses primarily on cash assistance and long-term institutional care. Emergency Medicaid has never been considered a public charge factor under any version of the rule. FQHC care is not a public charge factor. CHIP coverage for children is not a public charge factor. And using EMTALA emergency room services has no immigration consequence.

If you or someone in your household is pursuing a green card or other immigration benefit, consult an immigration attorney before disenrolling from benefits out of fear. The actual legal risk is almost always far smaller than rumored — and forgoing medically necessary care to avoid an imaginary consequence is one of the most preventable harms in immigrant health.

What Remains Stable: A Summary by Coverage Type

Coverage TypeWho It Covers After OBBBAWhat Changes in 2026–2027
Employer-sponsored insuranceAnyone employed by a covered employerNo change — availability tied to employment, not status
COBRAAnyone who had employer group coverageNo change — eligibility based on coverage loss, not status
ACA Marketplace (unsubsidized)Lawfully present immigrantsNo change in eligibility; DACA excluded as of Aug 2025
ACA Premium Tax CreditsGreen card holders, Cuban/Haitian entrants, COFA citizensTPS holders, asylees, refugees lose subsidies for 2027 plans
Federal MedicaidGreen card holders (after 5-yr wait), certain othersTPS holders, asylees, refugees lose eligibility Oct 1, 2026
Emergency MedicaidAnyone, regardless of statusFederal reimbursement rate to states changes Oct 2026
CHIP (children)Lawfully residing children; state option for all childrenNo federal change; state programs vary
FQHCsAnyone, regardless of status or ability to payNo change
State-funded coverageVaries by stateSome states scaling back due to budget pressure; verify locally

Finding Help: Key Resources

If you are navigating a status change and need assistance understanding your health coverage options, these organizations provide free guidance to immigrant communities:

Sources

  • American Medical Association (AMA): OBBBA healthcare changes overview — ama-assn.org
  • National Immigration Law Center (NILC): State medical assistance programs for immigrants — nilc.org
  • SC Appleseed Legal Justice Center: OBBBA healthcare changes for immigrants — scjustice.org
  • HIAS: OBBBA impact explainer — hias.org
  • American Immigration Council: Immigrant access to SNAP and Medicaid — americanimmigrationcouncil.org
  • healthinsurance.org: Immigrant ACA coverage after OBBBA — healthinsurance.org
  • U.S. Department of Labor: COBRA continuation coverage — dol.gov
  • Healthcare.gov: Special Enrollment Periods after job loss — healthcare.gov
  • Health Resources and Services Administration (HRSA): FQHC locator — findahealthcenter.hrsa.gov
  • NPR: Immigrant seniors lose Medicare coverage despite paying into it — npr.org
  • Manifest Law: TPS complete guide and 2026 termination timeline — manifestlaw.com