Updated February 25, 2020
Medicaid Coverage for Former Foster Youth Up to Age 26
Children may enter foster care due to incidents of abuse,
Title IV-E program, states must inform foster youth within
neglect, or some other reason that prevents them from
90 days prior to emancipation about their future options for
remaining with their families. During FY2018, some
health care. Title IV-E also directs states to provide these
687,400 children spent at least a day in foster care. Of the
youth with health information and, as of early 2018, official
250,000 children who exited foster care that year, nearly
documentation that they were previously in care. Such
18,000 emancipated at 18 (or an older age, up to 21, if
documentation may be necessary to determine eligibility for
states extend care). In this context, emancipation means
some former foster youth who later apply for Medicaid.
reaching the state legal age of adulthood and not being
reunified with family or placed in a new permanent family.
Medicaid for Emancipating Youth
The Patient Protection and Affordable Care Act (ACA, as
Young people who age out of foster care can have
amended; P.L. 111-148) required states, as of January 1,
significant health needs. In a sample of former foster youth
2014, to provide Medicaid coverage to youth who have
at age 21 in the Midwest, 11% had a health condition or
emancipated until their 26th birthday. The U.S. Department
disability that limited their daily activity, compared to 5%
of Health and Human Services’ (HHS’) Centers for
of their same-age peers in the general population. The
Medicare & Medicaid (CMS), which administers the
Medicaid pathway for former foster youth is intended to
Medicaid program, issued a proposed rule in January 2013
provide necessary health supports in the years immediately
and a final rule in November 2016 to specify additional
after leaving foster care. It parallels another ACA
parameters about youths’ coverage under the program.
requirement that health insurance companies provide
coverage of children up to age 26 under their parents’
The Medicaid and Foster Care Programs private health care plans.
Medicaid, authorized in Title XIX of the Social Security
Medicaid regulation requires states to determine whether
Act (SSA), is a federal-state program that jointly finances
current beneficiaries, including youth emancipating from
medical and related services to a diverse low-income
foster care, are eligible for other Medicaid pathways to
population. To be eligible for Medicaid, individuals must
avoid gaps in coverage. Upon emancipating from foster
meet both categorical (e.g., elderly, children, or pregnant
care, youth may be eligible for mandatory Medicaid
women) and financial (e.g., income, assets) criteria in
pathways available to adults (e.g., pregnancy or disability
addition to requirements regarding residency, immigration
pathways). If determined eligible, they are to be enrolled
status, and U.S. citizenship. For some eligibility groups or
via these other pathways (with the exception of a pathway
pathways, state coverage is mandatory, while for others it is
for non-elderly low-income adults that was established
optional. States and territories (states) must submit a state
under the ACA). However, if these young people do not
plan to the federal government to describe how they will
qualify for other mandatory pathways, or states do not have
carry out their Medicaid programs within the federal
sufficient information to determine such eligibility, they are
statute’s framework. States that wish to make changes
to be enrolled in the mandatory Medicaid pathway for
beyond what the law permits may seek CMS approval to
former foster youth without interruption in coverage.
waive certain statutory requirements to conduct research
To be eligible for the former foster youth pathway,
and demonstration waivers under Section 1115 of the SSA.
individuals must (1) be under age 26; (2) have been “in
The Foster Care, Prevention, and Permanency program,
foster care under the responsibility of the State” upon
authorized in Title IV-E of the SSA, is a federal-state
reaching age 18 (or any age up to 21 if the state extends
program that, among other things, jointly finances foster
federal foster care to that age); and (3) have been enrolled
care for children who a state determines cannot safely
in Medicaid “while in such foster care.” Unlike most
remain in their homes and who meet federal eligibility rules
eligibility pathways, the former foster youth pathway is
related to being removed from a low-income household and
available to eligible youth regardless of income.
other factors. The program also provides some support for
Based on a 2018 national survey of former foster youth who
services to assist older children in foster care, and those
were age 21 in FY2018, approximately 64% had Medicaid,
who age out, in making a successful transition to adulthood.
18% had some other health insurance, and 19% had neither.
The Administration for Children and Families (ACF) at
HHS administers the Title IV-E program.
Continuity of Medicaid Coverage
While in foster care, nearly all children are eligible for
In the November 2016 final rule, CMS recommended that
Medicaid under mandatory eligibility pathways. This means
states use automated transition of eligible individuals to the
that states must provide coverage because these children
former foster youth pathway if they are not eligible for
receive assistance under the Title IV-E foster care program,
other mandatory eligibility pathways. However, some
are disabled, or meet other eligibility criteria. Under the
former foster youth, such as those who emancipated before
https://crsreports.congress.gov

---

link to page 2
Medicaid Coverage for Former Foster Youth Up to Age 26
January 1, 2014, may need to apply for coverage under this
guidance to states on best practices for removing barriers
pathway. According to CMS, states may allow these youth
and ensuring timely coverage under this pathway, and on
to attest to their eligibility. States that do not accept self-
conducting related outreach and raising awareness among
attestation must use electronic records that show a youth’s
eligible youth. CMS conducted a state training addressing
foster care history and receipt of Medicaid while in care (if
these components on September 9, 2019.
available). If electronic records are not available or are
Figure 1. Medicaid Coverage for Former Foster Youth
limited, states can require that applicants provide
Who Move to Another State Following Emancipation
documentation showing that they had been in foster care.
Further, if a state cannot verify whether a youth remains a
state resident it may require a former foster youth to self-
attest or document his or her state residency.
Optional Coverage for Certain Youth
The Medicaid regulation requires emancipated youth to
have had coverage at the time they left care at age 18 (or
older, up to age 21). However, the rule gives states the
option of providing coverage to youth who emancipated
from foster care and received Medicaid (1) at some point
while in foster care but not at the time they aged out; or (2)
while in the custody of the state child welfare agency, but
were placed in another state and were enrolled in that
state’s Medicaid program

while in foster care or when they
Source: HHS, CMS, Medicaid and CHIP Learning Collaborative
emancipated. According to CMS, this option is made
presentation, September 9, 2019.
available in response to the possible interpretation of the
law that youth are not necessarily required to have had
Medicaid Benefits
Medicaid coverage at the time they emancipated.
In general, the rules for Medicaid benefit coverage for
Youth Who Move to Another State
former foster youth under age 21 are the same as for non-
disabled children. For those over age 21, benefit coverage is
As noted, the ACA specified that individuals were eligible
the same as for non-disabled adults. Former foster youth
for the former foster youth pathway if they were “in foster
generally receive services through what is sometimes called
care under the responsibility of the State” upon reaching
traditional Medicaid—an array of required or optional
age 18 or an older age, up to 21, in states that extend care.
medical assistance items and services listed in statute.
In its January 2013 proposed rule, CMS interpreted the
However, states may also furnish Medicaid through
statute to mean that states were not required to provide
alternative benefit plans (ABPs). Under ABPs, states may
coverage to youth who were enrolled in Medicaid and aged
provide a benefit that is defined by a reference to an overall
out in another state, but could do so. In separate guidance in
coverage benchmark, rather than a list of discrete items and
2013, CMS indicated that it would approve state plan
services. Like traditional Medicaid, ABPs must include
amendments that offered coverage to out-of-state youth,
services under Medicaid’s early and periodic screening,
pending publication of a final rule.
diagnostic and treatment (EPSDT) benefit for youth under
age 21. ABPs can be targeted to certain Medicaid groups,
In its November 2016 final rule, however, CMS reversed its
including former foster youth. However, states may not
earlier interpretation. The rule explained that because the
require such individuals to receive Medicaid via ABPs.
statute provided eligibility to former foster youth who had
emancipated in the state—not a state or any state—it could
Cost Sharing
not be applied by a state to youth who emancipated in a
States may require certain enrollees, including adult former
different state. Accordingly, states could no longer cover
foster youth, to share in the cost of Medicaid services. Cost
these youth via state plan authority; however, they were
sharing requirements for program participation fees (e.g.,
encouraged to seek CMS approval under the Section 1115
premiums) and point-of-service cost sharing (e.g., copays,
waivers. According to CMS, 10 states have received such
coinsurance) may vary by income, and certain services
waiver approval to provide this coverage as of September
(e.g., emergency services, family planning services and
2019. (See Figure 1.) Except for Delaware, these states had
supplies) are exempt. Maximum allowable amounts may
used state plan authority to provide this coverage
differ for individuals with annual income (1) at or below the
previously. Five other states—Georgia, Louisiana,
federal poverty level (FPL) (i.e., $12,760 for an individual
Michigan, Montana, and New York—had prior state plan
in 2020), (2) from 100%-150% of FPL, and (3) above 150%
authority.
of FPL. However, in aggregate, all types of cost sharing
must not exceed 5% of household monthly or quarterly
The Substance Use-Disorder Prevention that Promotes
income, as chosen by the state.
Opioid Recovery and Treatment for Patients and
Communities Act (P.L. 115-271), enacted on October 24,
Adrienne L. Fernandes-Alcantara, Specialist in Social
2018, amended the Medicaid statute on the former foster
Policy
youth pathway. It will permit states, as of January 2023, to
use state plan authority for providing coverage to former
Evelyne P. Baumrucker, Specialist in Health Care
foster youth who move across state lines. The law directs
Financing
HHS, within one year of the law’s enactment, to issue
https://crsreports.congress.gov

---

Medicaid Coverage for Former Foster Youth Up to Age 26

IF11010


Disclaimer
This document was prepared by the Congressional Research Service (CRS). CRS serves as nonpartisan shared staff to
congressional committees and Members of Congress. It operates solely at the behest of and under the direction of Congress.
Information in a CRS Report should not be relied upon for purposes other than public understanding of information that has
been provided by CRS to Members of Congress in connection with CRS’s institutional role. CRS Reports, as a work of the
United States Government, are not subject to copyright protection in the United States. Any CRS Report may be
reproduced and distributed in its entirety without permission from CRS. However, as a CRS Report may include
copyrighted images or material from a third party, you may need to obtain the permission of the copyright holder if you
wish to copy or otherwise use copyrighted material.

https://crsreports.congress.gov | IF11010 · VERSION 3 · UPDATED

---