Medicaid Coverage for Former Foster Youth Up to Age 26

Medicaid Coverage for Former Foster Youth Up to Age 26

link to page 2

Updated June 14, 2024
Medicaid Coverage for Former Foster Youth Up to Age 26
Children are removed from families and placed into foster
pathways, state coverage is mandatory, while for others it is
care due to incidents of abuse, neglect, or other family
optional. States and territories (hereinafter, “states”) must
crisis. During FY2022, nearly 570,000 children spent at
submit a state plan to the federal government to describe
least a day in foster care. Out of more than 201,000 young
how they will carry out their Medicaid programs within the
people who exited foster care that year, over 18,000
federal statute’s framework. States that wish to make
emancipated (or aged out). In this context, emancipation
changes beyond what the law permits may seek U.S.
means reaching the state legal age of adulthood or end of
Department of Health and Human Services (HHS), Centers
foster care—typically age 18 or an older age, up to 21, if
for Medicare & Medicaid (CMS) approval to waive certain
the state extends care—without having been reunited with
statutory requirements to conduct research and
family or placed in a new permanent family.
demonstration waivers under SSA Section 1115.
Young people who age out of foster care can have
The Foster Care, Prevention, and Permanency program,
significant health needs. For example, in survey research,
authorized in Title IV-E of the SSA, is a federal-state
13% and 18% of former foster youth at ages 23 or 24,
program that, among other things, jointly finances foster
respectively, reported having a health condition or disability
care for children who a state determines cannot safely
that limited their daily activities, compared to 5% or 6% of
remain in their homes and who meet federal eligibility rules
their same-age peers in the general population, respectively.
(e.g., entered foster care from a low-income household).
Former foster youth also have some elevated mental health
The program also provides some support for services to
needs (e.g., post-traumatic stress disorder) and are more
assist older children in foster care, and those who age out,
likely to experience pregnancies compared to their peers.
in making a successful transition to adulthood. The HHS,
Administration for Children and Families (ACF)
The Patient Protection and Affordable Care Act (ACA, as
administers the Title IV-E program. As of May 2023, HHS
amended; P.L. 111-148) required states, as of January 1,
had approved Title IV-E plan amendments allowing 37
2014, to provide Medicaid coverage to most emancipated
states and 7 tribal nations to extend the maximum age of
youth up to their 26th birthday, provided they continued
federally funded foster care beyond age 18, up to 21.
living in the state in which they had been in foster care. The
Substance Use-Disorder Prevention that Promotes Opioid
While in foster care, nearly all children are eligible for
Recovery and Treatment for Patients and Communities Act
Medicaid under mandatory eligibility pathways. This means
(SUPPORT Act; P.L. 115-271) extended eligibility to
that states must provide coverage because these Medicaid
emancipating youth who turn age 18 on or after January 1,
applicants receive assistance under the Title IV-E foster
2023, regardless of their current state of residence, among
care program, are disabled, low income, or meet other
other changes.
Medicaid eligibility criteria. Under the Title IV-E program,
states must inform foster youth within 90 days prior to
Medicaid eligibility for former foster care children (FFCC,
emancipation about their future options for health care.
or former foster youth) is intended to provide necessary
Title IV-E also directs states to provide these youth with
health coverage in the years immediately after the youth
health information and official documentation that they
age out of foster care. It parallels another ACA requirement
were previously in foster care. Such documentation may be
that private health insurers provide dependent coverage up
necessary to determine eligibility for some former foster
to age 26. A recent, federally overseen longitudinal survey
youth who later apply for Medicaid.
of youth who were in foster care at age 17—thus, at risk of
aging out of care—found that by age 21, 72% reported
Medicaid for Emancipated Youth
having Medicaid and 17% reported having some other
Under federal law as amended by the SUPPORT Act, states
health insurance coverage.
are required to cover otherwise-eligible youth who fulfill
certain criteria under the Medicaid FFCC category. The
The Medicaid and Foster Care Programs criteria vary based on whether a youth reaches age 18
Medicaid, authorized in Title XIX of the Social Security
before January 1, 2023, or on or after that date (Table 1).
Act (SSA), is a federal-state program that jointly finances
In all cases, the FFCC eligibility group continues to be
medical and related services to a diverse low-income
limited to youth who are under age 26 who were enrolled in
population. To be eligible for Medicaid, individuals
Medicaid (under a state plan or Section 1115 waiver) when
generally must meet both categorical (e.g., elderly, children,
they aged out of foster care. Unlike most pathways, there is
or pregnant women) and financial (e.g., income, assets)
no income or resource test for the FFCC group. In addition,
criteria in addition to requirements regarding residency, and
those who meet the eligibility requirements for both the
immigration status or U.S. citizenship (hereinafter,
FFCC group and the ACA Medicaid expansion (i.e.,
“otherwise-eligible”). For some eligibility groups or
https://crsreports.congress.gov

link to page 2
Medicaid Coverage for Former Foster Youth Up to Age 26
nonelderly adults with income up to 133% of the federal
those states’ demonstrations also included “SUPPORT Act
poverty level) must be enrolled in the FFCC group.
eligibility alignment” authority (Figure 1).
Table 1. Medicaid Eligibility Requirements for the
Figure 1. Medicaid Section 1115 Waiver Approvals for
Former Foster Care Children Group, by Birthdate
Otherwise-Eligible “Out-of-State Former Foster
Youth” and “SUPPORT Act Eligibility Alignment,” as
Turn Age 18 before January
Turn Age 18 on or
of May 2024
1, 2023
after January 1, 2023
Under age 26
Under age 26
Not eligible for or enrolled in
Not enrolled in another
another mandatory eligibility
mandatory eligibility group
group
Were in foster care in the state
Were in foster care in any
in which the individual is seeking
state when they turned age
Medicaid eligibility when they
18 (or such older age as
turned age 18 (or such older age that state has elected)
as the state has elected)
Were enrol ed in Medicaid in
Were enrol ed in Medicaid
such state while in such foster
in any state while in such

care
foster care
Source: Congressional Research Service (CRS) analysis of Section
Source: Congressional Research Service (CRS) analysis of Section
1115 waivers, HHS, CMS, accessed May 28, 2024,
1902(a)(10)(A)(i)(IX) of the Social Security Act (SSA).
https://www.medicaid.gov/medicaid/section-1115-demo/
demonstration-and-waiver-list/index.html.
For youth who reached age 18 before January 1, 2023, as
opposed to on or after that date, states are required to cover
Continuity of Medicaid Coverage
individuals who aged out of foster care, and were enrolled
HHS issued state implementation guidance via CMS and
in Medicaid while in such care, only if the youth is in the
ACF on topics including eligibility and enrollment system
same state where they are applying for Medicaid.
changes, outreach to youth, and Section 1115 waiver
Additionally, states are required to determine if an applicant
opportunities. For example, because applicants are only
is eligible for any other mandatory eligibility pathways
required to provide the information necessary to determine
(except the ACA Medicaid expansion, as previously
eligibility for the FFCC group, states should use simplified
discussed) before they are enrolled in the FFCC group.
applications (and employ them only when additional
information is needed). States are also encouraged to accept
By contrast, for youth who reach age 18 on or after January
self-attestation of former foster care and/or Medicaid
1, 2023, the SUPPORT Act requires a state to cover
enrollment status, and update their transitional plan
otherwise-eligible youth who reside in the state, regardless
materials and official documentation for youth aging out.
of whether that youth aged out of foster care in a different
state. Additionally, the act provides that otherwise-eligible
Medicaid Benefits and Cost-Sharing
youth may be enrolled in the FFCC group even if the
FFCC enrollees generally receive services through
individual meets the eligibility requirements of another
traditional Medicaid, which include an array of required or
mandatory eligibility group (except the ACA Medicaid
optional medical assistance items and services listed in
expansion pathway) as long as the individual is not actually
statute. Some states may also furnish Medicaid through
enrolled in such a group.
alternative benefit plan coverage (ABPs), where benefits
are based on an overall coverage benchmark. However, the
As of January 1, 2023, the SUPPORT Act effectively
FFCC group is exempt from mandatory enrollment in
requires states to apply different eligibility rules for the
ABPs. Regardless of the type of Medicaid benefit coverage,
FFCC group, depending on when an individual turned age
youth under age 21 are entitled to Medicaid’s early and
18. These separate rules apply through the SUPPORT Act
periodic screening, diagnostic and treatment (EPSDT)
phase-in period (i.e., through December 31, 2030). States
benefit.
that wish to align the Medicaid eligibility rules for youth
formerly in foster care who turn age 18 before January 1,
While states are prohibited from imposing enrollee cost-
2023, with those for otherwise-eligible youth who turn age
sharing on children who are in foster care and those who
18 on or after January 1, 2023, may seek CMS approval for
leave foster care for adoption or legal guardianship
a “SUPPORT Act eligibility alignment” Section 1115
(provided they are Title IV-E eligible), FFCC enrollees may
demonstration waiver. Alternatively, states may modify a
be subject to allowable premiums and enrollee cost-sharing.
previously approved Section 1115 demonstration to align
FFCC eligibility rules with the SUPPORT Act changes. As
Evelyne P. Baumrucker, Specialist in Health Care
of May 2024, 11 states had “out-of-state former foster care
Financing
youth” Section 1115 demonstration waivers to cover
Patrick A. Landers, Analyst in Social Policy
otherwise-eligible youth formerly in foster care in another
state who turned age 18 before January 1, 2023. Four of
IF11010
https://crsreports.congress.gov

Medicaid Coverage for Former Foster Youth Up to Age 26

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 5 · UPDATED