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Granite State Rumblings: Medicaid Expansion Helps Former Foster Kids Receive Healthcare Till Age 26

As a former foster parent I was thrilled that when the Affordable Care Act was signed into law in March 2010 it contained a provision to expand Medicaid coverage to former foster children up to age 26. Here’s what the law states:

Patient Protection and Affordable Care Act (ACA) Section 2004:
Medicaid Coverage for Former Foster Care Children

Beginning in 2014, states must provide Medicaid coverage for individuals under age 26 who were in foster care at age 18 and receiving Medicaid. Consistent with this rule, youth are eligible for Medicaid if they:

  • Are under age 26;
  • Are not eligible for and enrolled in mandatory Medicaid coverage; and
  • Were in foster care under the state’s or tribe’s responsibility and also enrolled in Medicaid under the state’s Medicaid state plan or 1115 demonstration (or at state option were in foster care and Medicaid in any state rather than “the” state where the individual is now residing and applying for Medicaid) at age 18 or older if the state’s federal foster care assistance under title IV-E continued beyond that age.

First Focus released a new SPARC brief last week Former Foster Youth: An Update on the State Option and State Efforts to Ensure Coverage for All Young People Irrespective of Where They Aged Out of Care. This policy brief provides an overview of the new mandatory Medicaid coverage for former foster youth under the ACA, highlighting relevant Centers for Medicare and Medicaid Services (CMS) regulatory activity to date and additional concerns regarding the “state option,” summarizes state progress in taking up this option to provide coverage for former foster youth, irrespective of where they aged out of care, and makes recommendations for what more should be done to ensure access to coverage for every young person aging out of care.

Here are a few excerpts from that brief.

Why Health Coverage Matters

The expansion of Medicaid to cover youth previously in foster care to age 26 is a significant victory for this population because it provides access to critical health coverage for an especially vulnerable group of young adults. Children who have been abused or neglected often experience a range of physical and mental health needs, physical disabilities and developmental delays, far greater than other high-risk populations. For example, foster children are more likely than other children who receive health coverage through Medicaid to experience emotional and psychological disorders and have more chronic medical problems. Research suggests that nearly 60 percent of children in foster care experience a chronic medical condition, and one-quarter suffer from three or more chronic health conditions. Roughly 35 percent have significant oral health problems. In addition, nearly 70 percent of children in foster care exhibit moderate to severe mental health problems, and 40 to 60 percent are diagnosed with at least one psychiatric disorder.

Not surprisingly, youth aging out of foster care continue to experience poor health outcomes into adulthood, including high rates of drug and alcohol use, unplanned pregnancies and poor mental health outcomes. More than half of former foster youth report being uninsured, and more than one-fifth report unmet needs for medical care. Findings from the Midwest Study highlight that one-third of youth aging out reported two or more emergency room visits in past year, 22 percent were hospitalized at least once, 43 percent were uninsured, fewer than half had dental insurance, three-quarters of young women had been pregnant, and 19 percent received mental or behavioral health care in the past year.

Given that former foster youth have well-documented and often significant health care needs, these young people should be eligible for Medicaid coverage in any state, and once enrolled, should be able to retain their coverage irrespective of changes in residency.

Regulatory Guidance to Date on the ACA Provision for Former Foster Youth

In early 2013, CMS issued a number of documents to clarify how states should implement the new provision. On January 22, 2013, CMS issued a proposed rule in the Federal Register, which clarified CMS’s interpretation that a youth is only eligible for Medicaid coverage in the same state in which he or she was in foster care at age 18 and enrolled in Medicaid. While CMS gave states the option to cover youth under this group who were in foster care and Medicaid in any state at the relevant point in time, it did not require that they do so.

On July 15, 2013 CMS published the final rule, clarifying several outstanding issues, including that the new eligibility category of former foster youth are eligible for full Medicaid benefits including Early, Periodic, Screening, Diagnosis, and Treatment (EPSDT) up to age 21. On December 31, 2013, CMS issued a FAQ that clarified that it would approve state plan amendments8 to cover youth who were in foster care and receiving Medicaid when they turned 18 or aged out of foster care in another state – meaning that states could receive federal reimbursement for out-of-state foster youth if they choose to enroll them in Medicaid.

More recently, on August 24, 2014, CMS posted a State Highlights feature on Medicaid.gov focusing on the provision to enable former foster youth to keep their Medicaid coverage, and highlighting efforts in Idaho and Georgia to reach out to and enroll young people who have aged out of care.  It is noteworthy that CMS chose to highlight this provision and demonstrates that it is tracking implementation progress in states.

To date, only 12 states have taken up the option to extend coverage to youth who aged out in another state:

  • California
  • Georgia
  • Kentucky
  • Louisiana
  • Massachusetts
  • Michigan
  • Montana
  • New York
  • Pennsylvania
  • South Dakota
  • Wisconsin
  • Virginia (pending state plan amendment)

Unfortunately, with a majority of states opting to not cover youth aging out in other states, many young people will be left without essential medical coverage.

The expansion of Medicaid to cover youth previously in foster care to age 26 is a significant victory for this population. One of the most popular parts of health reform is coverage for kids up to age 26 on their parents’ insurance plan. This new mandatory coverage for former foster youth has the potential to provide equal treatment in cases where the state steps in to care for children removed from the home as a result of abuse or neglect. It is critical that we remove any barriers to coverage for young people aging out of care, and that includes removing the eligibility restriction tied to residency.

While we hope that both Congress and CMS will consider taking steps to resolve this concern, it is also critical that state advocates, policymakers and other stakeholders continue to work to push states to take up the option to cover all former foster youth residing in their state.

GROWING UP GRANITE

Last week the Census Bureau released the Supplemental Poverty Measure for 2013.  The SPM extends the official poverty measure by taking account of many of the government programs designed to assist low-income families and individuals that are not included in the current official poverty measure.

Our friends at the NH Fiscal Policy Institute delve into the Census Bureau release in their new Common Cents blogpost and find that the New Hampshire poverty rate increases with the Supplemental Measure:

Ask any scientist or researcher and they’ll tell you: measurement matters. While one might commonly think of a biologist or an astronomer calibrating instruments to arrive at more accurate observations, that truth extends to the social sciences as well, where better, more robust measures can yield new insights into economic conditions.

For instance, a more comprehensive measure of poverty – known as the Supplemental Poverty Measure (SPM) – demonstrates that New Hampshire’s poverty rate is much higher than typically thought. New SPM data released last week by the US Census Bureau indicate that New Hampshire’s poverty rate for the 2011-2013 period was 10.5 percent, 2.2 percentage points higher than the rate under the traditional, official poverty measure for that time frame. It also suggests that approximately 138,000 Granite Staters lived in poverty during that period, an increase of roughly 29,000 people or nearly 27 percent over the number living in poverty under the traditional measure.

Economists and other experts have long understood that that official measure of poverty suffers from significant shortcomings. It both fails to account properly for all of the costs people face and neglects the fact that certain parts of the country can be far pricier than others. The SPM attempts to address these fundamental flaws and to assess more precisely the resources available within families to meet basic needs, counting not just income, but the cash value of benefits like nutrition assistance or housing subsidies.

These adjustments have a distinct impact in New Hampshire, which was one of just 13 states where the poverty rate was higher under the SPM than under the official measure. In contrast, some 26 states enjoyed lower poverty rates under the SPM, while, in the remaining 11, there was no statistically meaningful difference between the two measures. The reasons for the differences among the states are uncertain, given the data available from the Census Bureau, but the agency’s analysis of national level data reveal that out-of-pocket medical expenditures as well as work expenses can drive up poverty rates under the SPM. It may also be telling that many of the 13 states with heightened rates are concentrated in the Northeast, which tends to have a higher overall cost of living.

The latest Supplemental Poverty Measure data, when combined with traditionally measured poverty rates that are still higher than pre-recession levels in New Hampshire, suggests that much remains to be done to ensure greater economic security for all Granite Staters.

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About MaryLou Beaver

New Hampshire Campaign Director Every Child Matters Education Fund
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