Expanded Medicaid Coverage for Youth Aging Out of Foster Care

Vol 33 No 1

Former foster youth are vulnerable to poor overall health upon exiting foster care.2 They are at greater risk of homelessness, substance abuse, disabilities, and mental health issues than the general population.3 In a recent study, 51% of young women who aged out of foster care were pregnant at least once by age 19, even after controlling for race/ethnicity.4 

The disturbing health outcomes for these youth may reverse course now that the Patient Protection and Affordable Care Act (Affordable Care Act or “ACA”) expands Medicaid coverage for youth who age out of foster care. States must make such youth, known as “former foster care children,”5 eligible for Medicaid under the ACA until they turn 26. Youth are eligible provided they:

  • were in foster care when they turned 18 or aged out of foster care as defined by the state in which they aged out,6
  • were receiving Medicaid when they exited care,7 and
  • are not otherwise eligible for, or enrolled in, mandatory coverage.8

Expanded Medicaid will help youth who have aged out of foster care for both preventative and nonroutine medical care through age 26.9 However, categorical Medicaid eligibility for “former foster care children” may create unintended consequences related to permanency, portability, and coverage requirements. 


Expanding the Affordable Care Act

In 1999, under the Chafee Act, Congress permitted states to expand Medicaid coverage to youth aging out of foster care through age 21 (the Chafee Option). About 30 states elected to create a new category of Medicaid coverage to former foster youth.10 The Chafee Option does not require enrollment in Medicaid by age 18 in foster care (in contrast to the ACA), but coverage under the Chafee Option ends at age 21. 

Currently, 20 states that chose not to earmark a Medicaid program through the Chafee Option will now be required to create a former foster care Medicaid category. For a list of states that currently have a Chafee Medicaid category for former foster youth visit: http://aspe.hhs.gov/hsp/13/ChafeeMedicaidReport/rpt2.cfm. 

On July 15, 2013, the Centers for Medicaid & Medicare Services (CMS) determined the parameters for Medicaid eligibility under the ACA for former foster youth11 and further ruled the new ACA coverage supersedes categorical Medicaid eligibility under Chafee.12 Two important features to Medicaid coverage under the ACA are: 

There is no financial means test for Medicaid coverage of former foster care youth, unlike many other eligibility categories.13 

Medicaid eligibility is both proactive and retroactive. Youth who age out of foster care after January 1, 2014, will be eligible for Medicaid coverage until they turn 26. Former foster youth who aged out of care previously and are under age 26 (youth born after 1988), will also be eligible.14 However, identifying youth who qualify may be difficult once they have exited foster care. (See box, below)


Eligibility Requirements

While some youth who age out of foster care may be eligible for Medicaid under other categories of coverage, they will be assigned to Medicaid under their status as a former foster care child unless they qualify under a mandatory Medicaid category.15 Notably, youth who age out of foster care are covered by full Medicaid benefits and EPSDT (Early Periodic Screening Diagnostic Testing) through age 21.16 Coverage for ages 21 through 26 will be determined by state Medicaid plans, but will include preventive services, early intervention services, diagnostic services, and treatment for physical and mental health.17 CMS noted that states will have the option to design and provide voluntary enrollment in an Alternative Benefits Plan (i.e., a health care exchange) targeted to former foster care children that provides more comprehensive coverage.18

 Former Foster Care Children Medicaid coverage is designed to be flexible and can stop and restart based on individual circumstances. Coverage resumes if former foster youth:

  • lose other health insurance coverage due to unemployment,
  • accept a job with no health insurance, or
  • enroll in an education program with inadequate health insurance coverage.19

Former foster care children will also remain eligible for coverage after they leave military service or prison, based on their former foster care status.20 Because former foster youth move often, this built-in flexibility will likely improve stability and health outcomes for those who have exited care.


Potential Challenges


Although every state will be required to provide Medicaid coverage to any youth who ages out of foster care, that does not translate to covering youth who exit care in another state. States will have the option, but will not be required, to cover individuals who were in foster care and had Medicaid coverage in any state, rather than limiting coverage to former foster youth who aged out in that particular state.21 Many child welfare advocates expressed concern regarding this position. However, the final regulation did not address portability and it remains unclear whether the “former foster care children” mandatory expansion will transfer to another state. 22 

This lack of clarity may leave the Department of Health and Human Services (and individual state Medicaid providers) vulnerable to litigation because restricting Medicaid coverage could place an undue burden on a former foster youth’s right to travel or live in another state.23 Potential travel restrictions based on loss of health coverage might hinder opportunities for youth who exit care to attend college, work, or move out of state. 

The “former foster care children” category provides more expansive medical coverage than some basic forms of Medicaid, and not all former foster youth will qualify for different Medicaid packages in other states. Consequently, some former foster youth who elect to live in another state may not have continued Medicaid coverage unless they:

  • meet eligibility criteria for the new state,
  • move where providers accept their home state’s Medicaid, or
  •  move to a state that covers any “former foster care child” regardless of home state.

Therefore, it will be important for independent living caseworkers, lawyers, and advocates to inform youth exiting care of potential changes to their health coverage if they choose to move to another state.

Read the rest of the article, including Permanency Decision Making, Enrollment and Recertification, and resources in Reaching Out to Clients Aging Out of the System by subscribing to CLP.

Eliza M. Hirst, Esq., CWLS, is Deputy Child Advocate, Delaware Office of the Child Advocate.