Health-Care Coverage For Youth In Foster Care—and After

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ISSUE BRIEFMay 2015Health-Care Coverage forYouth in Foster Care—and AfterWHAT’S INSIDEHealth-care needs ofchildren and youthin foster careHealth care is a basic necessity for all childrenand youth. Children and youth who enter fostercare because of abuse or neglect often havesignificant health-care needs. Changes inMedicaid coverage—who is eligible and how?the nation’s health-care laws have increasedOther health-carecoverage (non-Medicaid)some of our most vulnerable children andCoverage benefitsissue brief reviews the eligibility pathways forImproving health-carecoverage for childrenand youth in foster careaccess to and affordability of health care foryouth—those involved with child welfare. Thischildren and youth in foster care to receiveMedicaid or other health-care coverage andlooks at some of the newer benefits nowmandated through the Patient Protection andAffordable Care Act (ACA), especially thosefor older youth in or formerly in foster care.Children’s Bureau/ACYF/ACF/HHS800.394.3366 Email: ntand disclaimer

Health-Care Coverage for Youth in Foster Care—and AfterThis brief provides a general overview; States differ withregard to health-care benefits and how they administermany of the benefits. For specifics in your State, ibility. Inaddition to State examples of what works for Medicaidand non-Medicaid coverage for children and youth infoster care, this brief also provides resources to help youthand young adults understand their health-care optionsand resources for agencies on health-care access forchildren, youth, and families involved with child welfare.Health-Care Needs of Childrenand Youth in Foster CareChildren and youth placed in foster care because ofabuse or neglect often enter care with significant healthchallenges. Health issues may be related to poverty andother at-risk conditions such as parental substance abuseor mental illness. The actual abuse or neglect (includingmedical neglect) can also be a contributing factor to poorhealth, as can the disruption caused by removal from thehome and placement in foster care. A government studythat compared children receiving Medicaid who were infoster care with those not in care found that the childrenin foster care had much higher rates of developmentaldisorders, certain medical disorders (e.g., vision disorders,teeth and jaw disorders), and a number of behavioraldisorders, including attention deficit and adjustmentdisorders (Center for Mental Health Services and Centerfor Substance Abuse Treatment, 2013). This same studyshowed that youth aged 12 through 17 in foster care hadthree times as many behavioral/mental health diagnosesand were more than twice as likely to require inpatientcare of any kind compared to youth not in foster care.The risk factors associated with poor health in childrenin foster care can also contribute to long-term and evenlifetime problems. Studies such as the Adverse ChildhoodExperiences (ACEs) study from the U.S. Centers onDisease Control and Prevention show that, as the numberof ACEs (e.g., abuse, neglect, parental substance abuse,witnessing domestic violence) increases, the risk increasesfor adulthood heart disease, suicide, HIV, and otherconditions that can lead to early death (Anda, 2007).https://www.childwelfare.govACEs are also associated with such factors as relationshipstability and job performance in adulthood. Thus, qualityhealth care for children and youth in foster care addressesmany childhood conditions and also may set the stagefor a healthier, happier, and more successful adulthood.Medicaid Coverage—WhoIs Eligible and How?Medicaid, as authorized by title XIX of the SocialSecurity Act, is a program funded jointly by Federaland State governments to provide health-carecoverage to low-income citizens who meet certainadditional criteria. States determine their owneligibility criteria within broad Federal guidelines.While States are not permitted to use Federal childwelfare funds to pay for Medicaid, they do receivesome reimbursement from Medicaid to help defray thecosts of covering children in foster care (Baumrucker,Fernandes-Alcantara, Stoltzfus, & Fernandez, 2012).The majority of children and youth in fostercare are eligible for Medicaid, and this sectionoutlines how children and youth in foster caremeet those eligibility requirements.Title IV-E and Foster CareThe most common eligibility pathway to Medicaidfor children and youth in foster care is through titleIV-E eligibility. Title IV-E of the Social Security Actprovides funding to support safe and stable out-ofhome care for children who are removed from theirhomes. Title IV-E does not provide Medicaid, butchildren and youth in foster care who receive titleIV-E payments are categorically eligible for Medicaidin every State. This group includes the following:Children and youth who receive title IV-E fostercare maintenance payments. This is the categorythat covers most children and youth in foster care. Iftitle IV-E payments are being received, the childrenor youth are eligible for Medicaid in their State ofresidence. A youth on whose behalf title IV-E fosterThis material may be freely reproduced and distributed. However, when doing so, please credit Child Welfare InformationGateway. This publication is available online at lth-care-foster.2

Health-Care Coverage for Youth in Foster Care—and Aftercare maintenance payments are made is categoricallyeligible for Medicaid in the State of residence, includinga youth up to age 21. A youth aged 18 through 20 iseligible for Medicaid (if IV-E payments are receivedfor such a youth) whether or not the title IV-E agencyin the State of residence has taken the option toprovide extended IV-E assistance (ACF, 2010).Children and youth who receive title IV-Eguardianship assistance program (GAP) payments.Children and youth who receive title IV-E guardianshipassistance payments are eligible for Medicaid in theirState of residence. A youth on whose behalf titleIV-E guardianship assistance payments are madeis categorically eligible for Medicaid in the State ofresidence, including a youth up to age 21. Such a youthis eligible for Medicaid (if IV-E GAP payments arereceived for such a youth) whether or not the title IV-Eagency in the State of residence has taken the optionto provide extended IV-E assistance (ACF, 2010).Children and youth subject to a title IV-E adoptionassistance agreement. Children and youth covered bytitle IV-E adoption assistance agreements are eligiblefor Medicaid. Generally, title IV-E adoption assistanceagreements are available for children or youth who aredeemed to have “special needs” as defined by the titleIV-E agency, and they are children for whom adoptionmight not be feasible without the adoption assistanceagreement. (See Child Welfare Information Gateway’s“Special Needs” Adoption: What Does It Mean? at alneeds/.) Ayouth who is subject to a title IV-E adoption assistanceagreement is categorically eligible for Medicaid in theState of residence, including a youth up to age 21. Sucha youth is eligible for Medicaid (if the IV-E assistanceagreement is in effect for such a youth) whether or not thetitle IV-E agency in the State of residence has taken theoption to provide extended IV-E assistance (ACF, 2010).https://www.childwelfare.govChildren of a minor parent or youth over age 18 infoster care. If a youth in foster care whose costs arecovered by title IV-E foster care maintenance paymentsis or becomes a parent, that youth’s child is categoricallyeligible for Medicaid as a title IV-E child in the State wherethey live. This continues to hold true regardless of whetheror not the title IV-E agency in that State has elected toextend foster care assistance to youth age 18 and older.If the State has placement and care responsibility forboth the parent and the child, title IV-E eligibility must bedetermined individually for each, and title IV-E paymentsdetermine Medicaid eligibility (Children’s Bureau, n.d.).The above information on title IV-E categoricaleligibility for Medicaid is detailed in a ProgramInstruction published in 2010 by the Children’s Bureau,Administration for Children and Families, U.S. Departmentof Health and Human Services, which can be found 1011.pdf.Other Ways Children in Foster CareMay Qualify for MedicaidFor children and youth in foster care who are noteligible under title IV-E, there are other ways thatthey may be eligible to receive Medicaid.Mandatory Medicaid eligibility for children under age19. States are required to provide Medicaid coveragefor children under age 19 whose household income isno more than 133 percent of the Federal poverty line(FPL) or a higher income limit established by the Statefor the child’s age group (under age 1, aged 1 through5, or aged 6 through 18). Often, for a child placed outof home in foster care (especially if the parents do notintend to claim the child as a tax dependent for thecurrent tax year), only the child’s income is considered forMedicaid eligibility. Therefore, most children under age19 in foster care who do not qualify for the Medicaid IV-Eeligibility do qualify for this other mandatory eligibilitygroup. Many States cover children under age 19 to ahigher income limit under the Children’s Health InsuranceProgram (CHIP; see below for more information).This material may be freely reproduced and distributed. However, when doing so, please credit Child Welfare InformationGateway. This publication is available online at lth-care-foster.3

Health-Care Coverage for Youth in Foster Care—and AfterMedicaid eligibility for the adult group. States havethe option to cover the “adult group” added by theACA for nonpregnant individuals aged 19 through 64whose household income is no more than 133 percent ofthe FPL. Currently, 28 States cover this eligibility group.Because youth in foster care aged 19 or older often areconsidered for Medicaid eligibility as a household of oneperson, their income is usually within the limit for thisgroup, if covered by their State of residence (see tml).Youth formerly in foster care and under age 26. TheACA provides a new mandated eligibility pathway forMedicaid, effective in 2014, for the “former foster care”group, which covers older youth no longer in foster careso they may continue to receive Medicaid until their 26thbirthday. This coverage is similar to that of other youngadults with no foster care connection who are able toremain on their parents’ health-care plans until age 26.Youth formerly in foster care are eligible for their State’sfull Medicaid coverage, regardless of their income andregardless of whether the State where they live opted ordeclined to expand Medicaid coverage under the “adultgroup.” This provision applies to individuals under age26 who were both enrolled in Medicaid and in foster careunder the responsibility of the State or Tribe where theycurrently live upon attaining either age 18 or such higherage as the State or Tribe has elected for termination ofFederal foster care assistance under title IV-E. Stateshave the option to cover youth who were in foster careand/or enrolled in Medicaid in another State than wherethey currently live, but they are not required to do so. Todate, 12 States have opted to cover eligible youth fromother States (Houshyar, 2014). For more information,see the Medicaid website at transition to adulthood and independence. Chafeefunds may also cover youth who are adopted or enter aguardianship after their 16th birthday. The Chafee Actauthorizes States to provide Medicaid to certain youthwho age out of foster care. States receive grants tofund Chafee services, and States also have the optionto determine eligibility under Medicaid for this groupof “independent foster care adolescents” up to age 19,20, or 21. Currently, 30 States have elected to cover thisMedicaid group for older youth who were in foster careat age 18 and are not eligible for the mandatory Medicaidgroups such as the former foster care group. Twenty-six ofthese States do not apply an income limit for this group.Youth who age out of foster care in States thatoffer the Chafee option. The Chafee Foster CareIndependence Act of 1999 provides services and supportsto help youth aging out of foster care make a successfulThis material may be freely reproduced and distributed. However, when doing so, please credit Child Welfare InformationGateway. This publication is available online at lth-care-foster.4

Health-Care Coverage for Youth in Foster Care—and Afterhttps://www.childwelfare.govThe ACA’s Coverage for Mandatory Former Foster Care GroupVersus the Chafee Option—What’s the Difference?There is some overlap between the coverage mandated by the ACA for the former foster care group ofolder youth and young adults and the Medicaid coverage that some States provide through the Chafeeoption for older youth who have left foster care. A Medicaid factsheet that includes frequently askedquestions on this topic makes the following points about differences in these Medicaid eligibility groups(Centers for Medicare and Medicaid Services [CMS], 2013; see ter-Care-Children.pdf):Chafee Optional Medicaid Group for Independent Foster Care Adolescents Youth receiving IV-E foster care or, at the State’s option (as elected by all 30 of the States), were in State- orTribal-funded care, are eligible. Youth must have been in foster care at age 18. Young adults with an income above a certain level are not eligible, if the State has an income test for thisgroup (as only 4 out of 30 States do). Young adults are not required to have been in foster care in the same State where they are seeking coverage,unless the State imposes such a requirement (which 2 of the 30 States have). Chafee coverage goes up to age 19, 20, or 21 at State option.ACA Mandatory Medicaid Coverage for Former Foster Care Group Young adults who were receiving IV-E foster care or State- or Tribal-funded foster care and were enrolled inMedicaid at age 18 or when they aged out of care are eligible. There is no income requirement. Young adults are eligible only in the State in which they aged out of foster care, although some States(currently, 12 States) are opting to cover young adults who were in foster care and/or Medicaid in other States. Coverage is provided until the young adult’s 26th birthday.For young adults who meet eligibility requirements under both Chafee and theACA groups, the ACA requirements supersede Chafee option.This material may be freely reproduced and distributed. However, when doing so, please credit Child Welfare InformationGateway. This publication is available online at lth-care-foster.5

https://www.childwelfare.govHealth-Care Coverage for Youth in Foster Care—and AfterOther pathways to Medicaid eligibility. Within a broadrange of Federal guidelines, States may offer other waysfor children and youth in foster care to be eligible forMedicaid if they do not meet the criteria outlined above.These pathways are not specifically targeted for childrenin child welfare, and some are “optional pathways” (incontrast to the federally mandated pathways) availableonly in some States. The other pathways to eligibilityinclude the following (Baumrucker et al., 2012): As noted above, the Federal Government requiresall States to provide Medicaid coverage to childrenin families with incomes at or below 133 percent ofthe FPL or a higher income limit established by theState. Pregnant women are covered with this sameincome requirement. States are also required to coverparents and other caretaker relatives of dependentchildren (through which individuals aged 19 or oldermay be covered) and certain children with severedisabilities who are receiving Supplemental SecurityIncome (SSI) from the Social Security Administration(see .html). In some States, youth who are 19–20 years old mayqualify for Medicaid under the Ribicoff pathway ofoptional reasonable classifications of children under42 CFR 435.222. Each State makes its own decisionabout this eligibility and defines the income andother qualifications. Twenty States cover, under thisprovision, certain children in State- or Tribal-fundedfoster care who do not qualify for the mandatoryMedicaid eligibility groups (especially those aged 19or 20). Ten of those States do not apply an income limitfor this group. A child or youth adopted from foster care and coveredby an adoption assistance agreement funded solelyby the State or Tribe (not IV-E) may be eligible foreither Medicaid or a program with benefits equal toMedicaid if he or she is a child “who the State hasdetermined cannot be placed with an adoptive parentor parents without medical assistance because suchchild has special needs for medical, mental health, orrehabilitative care” (Social Security Act 471(a)(21) at Home/ssact/title04/0471.htm).Every State but one has elected to cover the optionalMedicaid eligibility group for children with State- orTribal-funded adoption assistance agreements ineffect who are under age 18, 19, 20, or 21. All butthree States either do not have an income test for thisMedicaid group or base eligibility on whether the childwas Medicaid-eligible at the time of the adoption.Other Health-Care Coverage(Non-Medicaid)While the great majority of children and youthin foster care are eligible for Medicaid, thosewho are not may be eligible for other subsidizedprograms or other health-care coverage. Childrennot in foster care but whose families are involvedwith child welfare may also be eligible for otherkinds of government-sponsored coverage.The Children’s Health InsuranceProgram (CHIP)Like Medicaid, CHIP is a State-administered programjointly funded by the State and the Federal Government.CHIP provides free or low-cost health-care coverageto children (through age 18) whose families earn toomuch to qualify for Medicaid. In most States, thismeans that children in families with incomes above133 percent FPL and up to 250 percent of the FPL orhigher might qualify for CHIP. The Federal Governmentprovides a website, Insure Kids Now, that describesboth Medicaid and CHIP eligibility and benefits,as well as a map of all the States with links to eachState’s specific Medicaid and CHIP information l).Private and MarketplaceHealth-Care CoverageThe ACA has made private health-care coverage moreattainable by more people and has removed somerestrictions—such as denial of coverage for preexistingconditions and dollar limits on essential benefits—This material may be freely reproduced and distributed. However, when doing so, please credit Child Welfare InformationGateway. This publication is available online at lth-care-foster.6

https://www.childwelfare.govHealth-Care Coverage for Youth in Foster Care—and Afterthat kept citizens from purchasing health insurance.Health insurance purchased through an employer orthrough a marketplace health exchange may be theanswer to coverage for some children and youth inadoption assistance agreements, for some youngadults who have aged out of foster care but do notmeet eligibility requirements for the Chafee optionor for Medicaid, and for some families receiving childwelfare services who are not eligible for Medicaid.Young adults who age out of care withoutMedicaid. Young adults who do not meet the eligibilityrequirements for the Chafee option (or are not livingin a State that provides it) or for other Medicaidgroups can purchase private health-care insurancethrough their employer, if employed, or through themarketplace. Those with lower incomes and largerhouseholds may qualify for plans at a reduced cost. Thewebsite provides a chart that showsqualifying income and household size for Medicaidand for reduced-cost private health plans: sts-chart/.Families receiving child welfare services. Whilethere is no special health-care coverage for familieswith child welfare involvement, the ACA providesnew opportunities for lower-to-middle income andother families who may not have had reliable healthinsurance in the past. Tax credits and subsidies arealso available to help make insurance more affordablefor families. To explore the options for coverage madeavailable by the ACA, visit the Federal Government’shealth-care website at BenefitsChildren need a broad spectrum of health-care coveragethat includes both preventive and treatment services.Screening services are essential for the prevention andearly detection of health issues. Children who enterfoster care may have an even greater need for thebenefits that full health-care coverage can offer. Thissection discusses the general benefits that Medicaid andother health-care insurers offer to children and youth infoster care or those who have aged out of foster care.Medicaid BenefitsState Medicaid programs offer an array of services,including mandatory services such as physician,inpatient hospital, and lab and x-ray services, as wellas optional services such as dental services, physicaltherapy, and clinic services. As such, State Medicaidprograms differ from State to State. The Medicaidwebsite lists both the mandatory and optional servicesat n general, the services for children and youthin foster care include preventive, screening,diagnostic, and treatment services necessary toensure optimal physical and behavioral health.Medicaid’s Early and Periodic Screening, Diagnostic,and Treatment (EPSDT). The EPSDT benefit is amandatory service under the Federal Medicaid programand defined at section 1905(r) of the Social Security Act.EPSDT is the Medicaid program’s comprehensive andpreventive benefit for children and youth under the ageof 21, enrolled in Medicaid. EPSDT includes the following: Screening services, including: Comprehensive health and developmental history(including assessment of both physical and mentalhealth development) A comprehensive unclothed physical Appropriate immunizations Laboratory tests (including blood lead levelassessment) Health education (including anticipatory guidance) Vision services (including diagnosis and treatment fordefects in vision, including eyeglasses) Dental services (which, at a minimum, include reliefof pain and infections, restoration of teeth, andmaintenance of dental health)This material may be freely reproduced and distributed. However, when doing so, please credit Child Welfare InformationGateway. This publication is available online at lth-care-foster.7

Health-Care Coverage for Youth in Foster Care—and After Hearing services (which, at a minimum, includediagnosis and treatment for defects in hearing,including hearing aids) Any other medically necessary health care, diagnosticservices, or treatment coverable under section 1905(a)of the Act to correct or ameliorate defects and physicaland mental illnesses and conditions, whether or notsuch services are otherwise provided in the State’sMedicaid plan.Note: States determine the individual medical necessitycriteria within their State for the services listed above.Detailed descriptions of the EPSDT services listed abovecan be found on the Centers for Medicare and MedicaidServices (CMS) Medicaid website at ening-Diagnostic-andTreatment.html. The goal of EPSDT services is to identifyand treat children and adolescents’ health problemsas early as possible (CMS, 2014). States must establisha schedule for medical, dental, vision, and hearingscreenings and must ensure that enrolled childrenand their families are notified about the availability ofscreenings. Additional information on EPSDT servicesand requirements may be found in the EPSDT Guide forStates, released in June 2014. See rmation/by-topics/benefits/downloads/epsdt coverage guide.pdf.Mental/behavioral health services and traumaservices. The child welfare field has put emphasis on theidentification and treatment of trauma in children andyouth in foster care. As with other mental and behavioralhealth issues, trauma responds best to early diagnosisand individualized treatment. These kinds of services arecovered under the Medicaid EPSDT benefit (see above).These services may include screening, therapy and/or counseling, medication, substance abuse treatment,and, for some children, inpatient services. On March27, 2013, CMS issued additional information through aCMS Informational Bulletin regarding the coverage ofMental Health and Substance Use Disorder Screeningunder the EPSDT benefit (see re.govAdditionally, in July 2013, the Administration for Childrenand Families (ACF), CMS, and the Substance Abuseand Mental Health Services Administration (SAMHSA)sent out a joint letter to State Directors on the topic oftrauma. The letter provides background information ontrauma experienced by children in foster care, discussestreatment and services for trauma, and outlines fundingfor services (see nloads/SMD-13-07-11.pdf).Home- and community-based services. Some healthcare services that might have previously been providedin an institutional setting may now be provided in thehome of a child or youth or in a community-basedsetting. The joint letter from ACF, CMS, and SAMHSA(2013) covers the topic of providing and funding homeand community-based services for the treatment ofbehavioral health issues, including trauma, for childrenin foster care. The letter notes that health-care coveragein the Medicaid State Plan can extend beyond theMedicaid EPSDT services; this extended coverage isgranted in section 1915 of the Social Security Act ( Home/ssact/title19/1915.htm):“[Section 1915(i)] permits States to provide a fullarray of home and community-based servicesto individuals whether or not they qualify for aninstitutional level of care, as long as they havesignificant need. This can include individualswith mental health or substance use disorders[ ] A State can also use section 1915(c) homeand community-based services waiver programsto cover similar services and serve individualswith significant needs who meet institutionallevel of care criteria. Examples of services andsupports beyond those covered under Medicaid’sEPSDT services may include psychosocialrehabilitation, respite care, transition services,and social skill development.” (ACF et al., 2013)This material may be freely reproduced and distributed. However, when doing so, please credit Child Welfare InformationGateway. This publication is available online at lth-care-foster.8

Health-Care Coverage for Youth in Foster Care—and AfterWaiver programs vary by State, but States can combineservices available under a waiver with EPSDT servicesto provide comprehensive or “wraparound approach”care for children and youth with disabilities who mightotherwise require institutionalization (CMS, 2014).Benefits of Home- andCommunity-Based ServicesIn 2013, the CMS joined with SAMHSA todistribute an informational bulletin on coveringthe costs of behavioral health services forchildren and youth with significant mentalhealth conditions who are treated with homeand community-based services, rather thanin residential settings. The bulletin points totwo demonstration programs that illustratethe benefits of early treatment and care that iscommunity-based, coordinated among agencies(wraparound approach), addresses trauma, andinvolves peer services, among other things.The bulletin also describes how Medicaidcoverage can be used to cover the costs ofthese intensive home- and community-basedservices and how these services may result inbetter outcomes for children and families.https://www.childwelfare.govadministered do not always follow best practices (e.g.,Government Accountability Office [GAO], 2011).In response, the Child and Family Services Improvementand Innovation Act of 2011 required States to establishprotocols for the appropriate use and monitoring ofpsychotropic medications with children and youth infoster care (Information Gateway, 2012). To help Statesdevelop these protocols, the Children’s Bureau issuedan Information Memorandum in 2012 to promote “theSafe, Appropriate, and Effective Use of PsychotropicMedication for Children in Foster Care” (see 03.pdf). In addition,the Children’s Bureau published a booklet to help youthin foster care better understand these medications andalternatives to them: Making Healthy Choices: A Guideon Psychotropic Medications for Youth in Foster Care,which is available—in both English and Spanish—on theChild Welfare Information Gateway website at ISSUE BRIEF. May 2015. Health-Care Coverage for Youth in Foster Care— and After. WHAT’S INSIDE. Health-care needs of children and youth in foster care Medicaid coverage— who is eligible and how? Other health-care coverage (non-Medicaid) Coverage benefits Improving health-care coverage .

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