Sometimes, it’s the simplest provision of a law that works the best – like the Affordable Care Act (ACA) provision that allows young adults to stay on their parents’ health plan until 26. But youth leaving the foster care system as they transition to adulthood don’t have families to fall back on, so the ACA allows these young adults to retain Medicaid coverage until age 26. With no income or asset test, it should be a pretty straightforward process to determine eligibility for these youth, right?

Well, maybe not. There are several reasons why this simple provision of the ACA may not be so simple. 

1)   The proposed regulations leave it to the discretion of states as to whether they will cover youth who aged out of the foster care system in another state. The ACA requires that an individual be in foster care under the responsibility of ‘‘the” state and be enrolled in Medicaid under ‘‘the” state plan’ or an 1115 demonstration. In the proposed rule, CMS interprets “the” state as opposed to “a” state as meaning that the individual was in foster care and enrolled in Medicaid in the same state in which coverage under this eligibility group is sought. The Congressional record suggests that this was not what Congress intended. 

2)   While there is there is no income or resource test for this group, the ACA creates a hierarchy of coverage that could impede enrollment. The ACA states that, if former foster youth are eligible for other Medicaid mandatory categories, they must be enrolled in that group. But there are very few circumstances under which a former foster youth would fare better enrolled under a different group and it would certainly be a more straightforward process if they could simply be determined eligible as a former foster youth. Of course, states can still streamline the process: if a youth is over the age for coverage as a child (which most will be) and is not a parent, then Medicaid need not track down additional information (i.e. income verification or tax filing status) that could lead to enrollment delays. Needless to say, state implementation bears watching to make sure that youth are not denied coverage for a lack of information needed only for other Medicaid categories.

3)   While states may accept self-attestation of former foster youth status, they have the option to verify eligibility. As required for all Medicaid recipients, states must verify the Social Security number and citizenship or qualified immigrant status, all of which can be done electronically through the federal data hub in real time. But states are lacking the data systems to electronically verify that an individual was in foster care. While establishing these data linkages will be important going forward, it is not clear what states will do to verify former foster youth status in the interim. This could be a sticking point and deter states from offering coverage to youth who were in foster care in a different state.

4)   Finding youth that have already left the foster care system but are under the age of 26 may be challenging. In the future as youth transition out of foster care, state child welfare agencies should take steps to connect them with ongoing coverage. For those who have already left foster care but are under the age of 26, finding these youth may be trickier. It will be important to identify and share promising strategies and effective practices that are emerging in states that are making this aspect of the ACA a priority.

CMS did put out some helpful guidance in this FAQ. But notably, federal regulations on this provision, which were proposed in January 2013, have yet to be adopted. The lack of final rules, and competing demands in ACA implementation, makes the current status of covering former foster youth at the state level somewhat murky.

But the need is quite clear. Youth are placed in foster care often as the result of neglect or maltreatment. They have high rates of acute and chronic medical, mental health and developmental problems, making it vitally important that they be provided with high-quality, coordinated health care. Health care coverage is a direct link to the services they need as they transition to adulthood and independence.

California is making that link work, thanks to savvy and effective efforts by advocates as detailed in this fact sheet from our friends at NHeLP. I particularly like the one-page application the state created to enroll former foster youth. These young adults have faced too many hardships in their young lives. The least we can do is create an express lane to coverage for them as the “Golden State” has done.