LOS ANGELES/NEW YORK (Reuters) - Nearly a decade after receiving U.S. citizenship, Guatemalan-born Mayra Lopez thought she had cleared all the hurdles for her parents to join her in the United States.

FILE PHOTO: Hospital beds in the emergency room of a Louisiana hospital. REUTERS/Lee Celano/Files

Then on Oct. 4 U.S. President Donald Trump changed the rules she and others had been complying with: Trump signed a proclamation requiring all prospective immigrants to prove they will have U.S. health insurance within 30 days of their arrival or enough money to pay for “reasonably foreseeable medical costs.”

The new requirement, part of Republican Trump’s hard-line policies on immigration, goes into effect on Nov. 3 and prospective immigrants are scrambling to figure out how to get the necessary coverage, navigating a complex healthcare bureaucracy that has, for the most part, not previously catered to those who are not yet in the country.

The administration gave scant detail about how the new requirements would be implemented beyond a bullet-point list of the types of insurance plans that would be accepted.

A State Department notice on Oct. 29 said consular officers will verbally ask immigrant visa applicants to identify a specific health insurance plan, the date coverage will begin, and “other information related to the insurance plan as the consular officer deems necessary,” but gave the public only two days to comment on that plan instead of the usual several months.

Lopez, 40, who works as a family assistant in California, and many others are finding few options exist for them.

Lopez received a letter for her parents’ appointment to be interviewed on Nov. 25 at the U.S. embassy in Guatemala. Near the top it read: “inability to meet this requirement will result in the denial of the visa application,” according to the letter seen by Reuters.

She immediately called her own insurer, Kaiser Permanente, but she said she was told her parents, both in their 60s with no serious health problems, would not be eligible because they did not have U.S. social security numbers and even if they did, it would cost more than $1,600 a month to cover both of them, according to interviews with Lopez and her attorney.

Lopez then called five other insurers and began to panic when they all told her variations on the same thing, she said.

Tony Barrueta, a Senior Vice President at Kaiser Permanente, said in a statement that a social security number is not required to apply for Kaiser Permanente coverage, but the company may request that information.

Barrueta said the company acknowledges the complexity of the proclamation and other recent actions “and the confusion they may have created for many immigrants and their families.” He said they were continuing to educate their front-line staff on how to address questions.

California’s health insurance marketplace, Covered California, said “consumers must be lawfully present in order to apply for coverage.”

Many prospective immigrants seeking to enter the country legally, including those who do not have lawyers, may not be aware of the new requirements and could end up being denied, immigration advocates said.

When asked about the concerns, a State Department official repeated the guidelines in the proclamation, which are posted on the department’s website.

The White House did not respond to a request for comment.

COVERAGE GAPS

Long term-plans on the state insurance marketplaces are not available to immigrants before they are in the country lawfully, according to the eligibility requirements outlined in the Affordable Care Act (ACA), Democratic President Barack Obama’s signature health care legislation.

The proclamation does not accept subsidized health plans, meaning immigrant applicants would be barred from using income-based subsidies for the purchase of individual coverage, a main tenet of the ACA.

Short-term insurance plans are banned in four states and 20 others limit their duration to less than 364 days, the amount of time required by the proclamation, according to the Commonwealth Fund, a nonprofit research group.

Even where they are available, short-term plans often have large gaps in coverage and can have exclusions for pre-existing conditions, said Pennsylvania Insurance Commissioner Jessica Altman.

Trump has tested the boundaries of established policy, aiming to fulfill his 2016 campaign pledge to curb both legal and illegal immigration, including a yet to be constructed wall along the U.S.-Mexico border. Immigration rights lawyers and civil liberties groups have challenged his policies in court, sometimes with success.

“This order overrides about 100 years of law that has always promoted the ability to live with your immediate family members and targets people in a way that Congress didn’t intend,” said Jesse Bless from the American Immigration Lawyers Association.

“Congress has made rules that has allowed people to come in based on self sufficiency not wealth or health.”

On Wednesday, seven U.S. citizens petitioning for their family members and immigrant advocacy groups filed a lawsuit in Oregon seeking to halt the proclamation.

The proclamation appears squarely focused at limiting family-based migration, which the President has repeatedly derided as “chain migration,” said Xiao Wang, co-founder of the immigration firm Boundless.

The administration issued a rule earlier this year that would limit legal immigration by expanding who could be found to be a “public charge” and barred from residency. The measure has been temporarily halted by federal courts.

FAMILY REUNIFICATION DELAYS

Some immigration lawyers are telling their clients to consider rescheduling their visa interviews until there is more clarity about how the new health insurance rules would be implemented – potentially delaying family reunification.

Some other wealthy countries, such as Germany, require people applying for visas and residency to provide proof of health insurance. But those countries do not have the same healthcare costs and insurance system as the United States.

The Trump proclamation said it aims to stop healthcare providers and taxpayers from bearing “substantial costs in paying for medical expenses incurred by people who lack health insurance or the ability to pay for their healthcare.” It cited data that “lawful immigrants are about three times more likely than United States citizens to lack health insurance.”

Healthcare policy experts say immigrants use the U.S. system less often than Americans. According to an analysis by Leighton Ku, Director of the Center for Health Policy Research at George Washington University, recent immigrants without insurance accounted for less than one-tenth of 1% of U.S. medical expenditures in 2017.

Sometimes having short-term plans that provide only limited coverage can be as costly to the healthcare system as not having insurance at all, Pennsylvania’s Altman said.

The Trump administration has expanded short-term health plans and made them renewable, which experts say undermines the ACA.

Rajeev Shrivastava, the chief executive of VisitorsCoverage, which sells travel insurance policies to U.S. visitors and immigrants, said online search traffic for immigrant plans on his website increased by 150% after the proclamation.

He said the new policy “creates an opportunity” for insurance companies to develop plans for incoming immigrants, though some are waiting for more clarity from the government.

For U.S. citizens married to immigrants who have been living in the country without legal status there are additional considerations. Jorge, 45, has been in the United States for almost 20 years and is married to a U.S. citizen. He has been granted a so-called unlawful presence waiver that would allow him to leave and apply to become a legal resident without facing a multi-year bar.

His visa interview in Colombia is scheduled for later this year. At least 10 insurers have told him he cannot apply unless he can prove he is in the country legally, Jorge said. He also does not qualify for travel insurance, he said, because he is currently in the United States.

“This has been very stressful,” said Jorge, who spoke to Reuters on the condition that his last name not be used.

One option available to him, a short-term health insurance plan that offers limited coverage, is only available for six months in Illinois and the proclamation requires coverage for 364 days. He bought it anyway.