Improving Access to Medicaid Coverage for Former Foster Youth with the SUPPORT Act

One of the most popular provisions of the Affordable Care Act—allowing young adults to stay on their parent’s health plan until age 26—was mirrored by a provision that expanded Medicaid. This provision made former foster youth categorically eligible (regardless of income) for Medicaid until age 26 if: 

1. they were in foster care at age 18 or older;
2. were enrolled in Medicaid at that time;
3. were in foster care in the state they now live in; and 
4. were not eligible for or enrolled in Medicaid under another mandatory category. 

The Centers for Medicare and Medicaid Services (CMS), which administers the Medicaid program, refers to this coverage as the former foster care children group (FFCC).  And while this coverage was, and continues to be, pivotal for young people as they transition from foster care to adulthood, two shortcomings remained in the law that limited access to coverage. 

The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act), which was enacted in 2018 and became effective on January 1, 2023, makes the following “fixes” to address these shortcomings for youth who turned 18 on or after January 1, 2023:

1. States must cover eligible former foster youth regardless of whether they were in foster care in the state they currently reside.
   1. Prior to this change, if a young person moved to another state, that state was not obligated to cover them under the FFCC coverage group. Given the mobility of young adults, this meant many young people lost Medicaid coverage as former foster youth when they moved for school, work, or to be with family. Under the SUPPORT Act, young people who turned 18 on or after January 1, 2023, can move out of state and still be eligible under the FFCC coverage category in the state they move to. 
2. Otherwise eligible young people are eligible for Medicaid under the FFCC category as long as they are not enrolled in another mandatory category.
   1. Prior to this change, the state would need to screen the young person for other mandatory eligibility categories. This entailed collecting information to determine eligibility under these categories, which could create barriers to coverage. Young people who turned 18 on or after January 1, 2023, need not be screened for other mandatory coverage groups. FFCC coverage would only be declined if the young person was already enrolled in another mandatory Medicaid coverage group. 

As noted above, these changes are currently in effect only for young people who turned age 18 on or after January 1, 2023, with the result that some challenges will remain unless states take action through applying for an 1115 Medicaid waiver, which will be discussed below. 

Below are tips for advocates to help you ensure that the new provisions of the law positively impact your clients and engage in systemic advocacy so that states take action to cover more young people and improve practices to help keep more young people covered with Medicaid until at least age 26. 

1.   Include Verification of Post-Discharge Medicaid Coverage in Transition Planning

A transition plan must be developed at least 90 days before a youth 18 or older discharges from foster care and must, among other things, include specific options around health insurance. 42 U.S.C.A. § 675(5)(H). In addition, federal law requires that a young person “is not discharged from care [at age 18 or older] without being provided” their discharge documents, including “health insurance information, including any cards needed to access care[.]”42 U.S.C.A. § 675(5)(I). Attorneys should ensure that the transition plan verifies that the youth is enrolled in Medicaid as a FFCC, in another Medicaid coverage category, or is otherwise covered and raise this issue in the case planning meetings prior to the youth’s discharge. The transition plan should also include information for the young person about coverage renewal and, based on their age, if they can maintain their coverage if they move out of state. Attorneys should raise these issues in court if continued coverage cannot be verified and a discharge should be opposed if coverage cannot be confirmed. Attorneys should check to see if they have stronger and more specific state law provisions about enrollment that can support your advocacy.

2.   Share Information on the New Law with Former Foster Youth from Other States 

If you are working with young adults who turned age 18 on or after January 1, 2023, and who have moved from the state in which they were in foster care, let them know that they will now be covered under the FFCC category and support them in the Medicaid application process if they are not already enrolled. Your support can be critical, especially in the early days of implementation when local Medicaid offices are still learning about these new requirements and changing their processes. They may not realize that youth from out of state are eligible and that they need not be screened for other eligibility categories.

Attorneys who provide social services or civil legal services to young people who are homeless may interact with young people from other states who will benefit from this coverage change.

3.   Help Young Adults Who Don’t Benefit Access Coverage or Care 

Young people who turned age 18 prior to January 1, 2023, and who moved out of state are not directly covered by the SUPPORT Act provisions. Nevertheless, you can still help these young people apply for Medicaid in the event they may be eligible under another category. This is especially the case if you are working in a Medicaid expansion state, which provides options for Medicaid for low-income adults. You can find out if you are in a Medicaid expansion state here. For young people who are not eligible for Medicaid, you can help them identify low cost or free care. To find low cost or free care through federally assisted health care clinics and similar programs, see this list. 

4.   Take Advantage of SUPPORT Act Implementation Efforts

There are many steps that state Medicaid and child welfare agencies can take to increase the odds that young people eligible for Medicaid under the FFCC coverage category are enrolled and stay enrolled. Because many states have not yet taken these steps, there is plenty of room for systemic advocacy. As mentioned in Tip 1, young people who are eligible for the FFCC category should be enrolled prior to aging out of foster care. Systems can be put in place to flag these cases and ensure that steps are taken to move them into the FFCC coverage category when they age out. In the event that does not occur and a young person must apply or reapply between ages 18 and 26, states that provide simplified application processes are the most likely to re-engage young people and improve chances of coverage. For example, states like California have a one page application that is very user friendly and requires only the information that is needed to establish eligibility. 

In addition, advocating for currently permissible procedures like self-attestation of former foster youth status can significantly ease the application process as well as reduce the administrative burdens on the Medicaid and child welfare agencies. Finally, providing automatic renewal for young adults under the FFCC category until age 26 through ex-parte renewals can greatly increase the odds that this group remains insured in their early adulthood without breaks in coverage. Under current law, state agencies must attempt to renew eligibility for all individuals enrolled in Medicaid on an ex-parte basis based on reliable information contained in the beneficiary’s account or other more current information available to the agency, without requiring information from the beneficiary. 42 C.F.R. 435.916 (a)(2) & (b). 

You can find more best practices for enrollment and renewal in Ensuring Continuity of Coverage for Foster Youth Aging Out of Foster Care and Young Adults Eligible for the Former Foster Care Group.

5.   Advocate that your State Apply for an 1115 Medicaid Waiver

CMS’s Guidance on the SUPPORT Act provisions provide states the option to apply for an 1115 Waiver so the state can cover former foster youth who turned 18 prior to January 1, 2023. This action is highly recommended to maximize the impact of the new provisions. This will also reduce the administrative burdens for local state Medicaid programs so that they do not have to distinguish between young people who reached 18 before or after January 1, 2023, and can simply focus on the key elements of eligibility (in foster care at age 18, enrolled in Medicaid at that time, and currently not enrolled in another mandatory coverage category).

Note that we are still waiting for responses from CMS on several questions, including questions related to waiving the requirement to screen for eligibility under other mandatory eligibility groups for youth who turned age 18 prior to January 1, 2023. We will provide more information as well tips and tools for your advocacy in the coming months. This will include tools related to advocating that your state apply for an 1115 Waiver. In the meantime, please feel free to reach out to Jenny Pokempner with any questions.