Providing Medicaid Coverage for Former Foster Youth: Issues In Implementing the Affordable Care Act

PURPOSE Nearly 30,000 youth aged out of foster care in FY2009 (DHHS 2010), a number that has been growing steadily over the past decade. These youth face significant challenges as they transition to living on their own especially with respect to education, employment, housing, and health (Courtney et al. 2005; Goerge et al. 2002; Pecora et al. 2005). In response to increased concerns about former foster youth's transition to adulthood, the Chafee Foster Care Independence Act of 1999 expanded the availability of services and financial support for these youth. Significantly, the Federal act gave states the option to extend Medicaid to youth who age out of foster care until they turn 21 (the Chafee Option). That option will be superseded in 2014 by the Patient Protection and Affordable Care Act (ACA, i.e. health care reform), which mandates Medicaid coverage until age 26 for any youths in foster care on their 18th birthday. The Chafee Option has been taken by 30 states which have implemented the Medicaid expansion in different ways, and this paper is the first to document and analyze state policy variation with respect to eligibility, enrollment, and recertification procedures.

METHODS We use public documents and interviews with state officials to gather information on states' eligibility requirements, enrollment procedures, and recertification procedures. The information gathered from our interviews are summarized and put into the context of the decisions states will have to make to implement the foster care provision of the ACA. By examining how states implemented the Chafee Option and the implications of different implementation choices, the paper provides insights on the different decisions states might make as they implement the ACA, the implications of those decisions, and the tradeoffs to be considered.

FINDINGS Eligibility requirements for continued coverage are fairly consistent from state-to-state; only a handful of states maintain an income restriction, generally at levels that don't affect young former foster youth. Procedures for enrollment vary from completely automatic enrollment with no youth involvement to the youth enrolling themselves at the Medicaid office. Recertification varies from states that do not require recertification before age 21 to those that require submitting a full set of documentation including income verification.

IMPLICATIONS States have many options for how to implement extended Medicaid for youth who age out of foster care. These include the degree to which the process is automated and the degree to which youth are required to be involved. Making the enrollment process automatic for youth likely leads to increased continuity of coverage, but may not teach the life skill of engaging with the health care system. In the absence of youth involvement in the process, it is not clear that youth necessarily understand how to access health care. They may not fare any better than other poor youth in obtaining needed health care despite their categorical eligibility for Medicaid coverage.