The Social Security Act addresses some of the health care needs of children in foster care—through provisions in titles pertaining to child welfare (Titles IV-B and IV-E) and those in the title pertaining to the Medicaid program (Title XIX). Effective January 1, 2014, the Patient Protection and Affordable Care Act (ACA, P.L. As many as one-half to three-fourths show behavioral or social competency problems that may warrant mental health services. In addition, states must develop a strategy that addresses the health care needs of each child in foster care including, among other things, health care screenings and oversight of prescription medicines. States must also ensure that young people aging out of foster care are provided a copy of their health records, and information about health insurance options and designating other individuals to make health care decisions on their behalf in the event that they are unable to do so. Unlike most Medicaid eligibility pathways, eligibility for former foster youth who aged out of care must be provided without regard to the youths' income and assets. The Supreme Court's ruling effectively allows states to choose whether or not to provide Medicaid coverage to this new eligibility group. The ACA made additional changes outside of Medicaid to assist childless adults and children and their families (e.g., children in foster care who are vulnerable to losing Medicaid upon returning home) in obtaining and maintaining Medicaid eligibility, and in obtaining private health insurance. Other research has found that young adults who aged out of foster care at age 18 or soon thereafter were more likely than their peers generally to report having a health condition that limits their daily activities and to participate in psychological and substance abuse counseling. Finally, under the Chafee Foster Care Independence Program (Section 477, Title IV-E of the Social Security Act) state child welfare agencies receive funds to provide independent living services—such as mentoring, tutoring, substance abuse prevention, and preventive health services—to youth who are expected to age out of foster care (without placement in a new permanent family), those who have recently aged out, and those who left foster care for adoption or kinship guardianship at age 16 or older. Child Welfare Policies Addressing the Health Care Needs of Children in Foster Care and Those Aging Out of Foster Care

As a condition of receiving federal funds dedicated to child welfare purposes, states must meet federal requirements related to planning for and administering services to children and families, and they must provide certain protections for children in foster care. Child welfare policy does not permit states to use federal child welfare program funds (under Title IV-B or Title IV-E) to pay medical expenses of children in care or those who leave foster care due to their age. Health Care Records

Federal law requires that the state child welfare agency have a written plan for each child in foster care, including certain health-related records. Additionally states are not permitted to require mandatory enrollment of these children in Medicaid ABPs. Under fee-for-service, state Medicaid agencies pay providers directly for each covered service received by the Medicaid beneficiary. Overall Medicaid Service Spending for "Foster Care" Children

For FY2010, the most recent year for which data were available for this analysis from all states, state Medicaid agencies reported spending $5.754 billion on services for children in foster care. Notably, four pathways are specifically available for this population—a mandatory pathway for children if they qualify for the Title IV-E program (whether in foster care or after leaving foster care for adoption or legal guardianship); an optional pathway for certain children who are adopted (primarily from foster care) and who receive adoption assistance funded wholly by the state; as of January 1, 2014, a mandatory pathway for young adults up to the age of 26 who "aged out" of foster care at age 18 (or 19, 20, or 21 years of age if the state extends federal foster care to that older age); and an optional pathway for "independent foster care adolescents" up to the age of 21 who were in foster care at age 18. ACA Income Counting Rule, Protections for Children, and Exemptions

The ACA established the Modified Adjusted Gross Income (MAGI) income counting rule, which draws on federal income tax rules to establish uniform standards for what income to include or disregard in determining Medicaid eligibility for most non-elderly and non-disabled people. In transitioning to the new income counting rule, states were required to establish income eligibility thresholds no less than the effective income eligibility levels that were applicable in the state on the date of enactment of the ACA (i.e., March 23, 2010). These eligibility pathways are subject to MAGI income counting rules. Finally, children in care, including those who are age 18, may also be eligible under the Supplemental Security Income (SSI) eligibility pathway for certain individuals (any age) with severe disabilities. Optional Pathways

A child in foster care who is not eligible for a mandatory pathway may be covered under several optional Medicaid eligibility groups. Some states reported having explicit definitions of what it means to be in care on a youth's 18 th birthday. Families of Children Entering Foster Care

The ACA may also provide greater opportunities for a child welfare agency to provide mental health or other Medicaid-supported services to the parents of children entering foster care.
Approximately 641,000 children spend some time in foster care each year. Most enter care because they have experienced neglect or abuse by their parents. Between 35% and 60% of children entering foster care have at least one chronic or acute physical health condition that needs treatment. As many as one-half to three-fourths show behavioral or social competency problems that may warrant mental health services. A national survey of children adopted from foster care found that 54% had special health care needs. Research on youth who aged out of foster care shows these young adults are more likely than their peers to report having a health condition that limits their daily activities and to participate in psychological and substance abuse counseling.
The Social Security Act addresses some of the health care needs of children in, or formerly in, foster care through provisions in the titles pertaining to child welfare (Titles IV-B and IV-E) and to the Medicaid program (Title XIX). Under child welfare law, state child welfare agencies are required to have a written plan for each child in foster care that includes, among other items, the child's regularly reviewed and updated health-related records. In addition, state child welfare agencies, in cooperation with state Medicaid agencies, must develop a strategy that addresses the health care needs of each child in foster care. Upon aging out of foster care, youth must receive from the state child welfare agency a copy of their health record and information about health insurance options and designating other individuals to make health care decisions on their behalf if they are unable to do so on their own.
States are not permitted to use federal child welfare program funds to pay medical expenses of children in care or those who left foster care due to their age or placement in a new permanent family. However, states can (and do) receive federal support through Medicaid to pay a part of the medical expenses, including well-child visits, dental care, and other services for many of these children and youth. In FY2010, the most recent year for which these data were available from all states, Medicaid agencies reported spending $5.754 billion to provide services to foster care children. Most of this Medicaid services spending was provided on a fee-for-services basis (82%) with the remainder provided through managed care arrangements.
Most children in foster care are eligible for Medicaid under mandatory eligibility pathways, meaning that states must provide coverage because these children receive assistance under the Title IV-E program, or, because they meet other eligibility criteria such as low income, or receipt of Supplemental Security Income (SSI). Children in foster care who are not eligible under mandatory pathways generally qualify for Medicaid because the state has implemented one or more optional eligibility categories allowing coverage. Further, children who leave foster care for legal guardianship and nearly all children with state-defined "special needs" who leave foster care for adoption retain mandatory eligibility for Medicaid provided they receive Title IV-E assistance. Additionally, special needs adoptees who receive state-funded support may also be eligible under an optional Medicaid eligibility pathway specifically for them.
Separately, as of January 1, 2014, states are required to continue Medicaid coverage to youth who age out of foster care on their 18th (or later) birthday. This Medicaid coverage was added to the law by the Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended), must be available until the youth reaches age 26, and unlike most Medicaid pathways must be provided without regard to the youth's income and assets. This new pathway for youth who age out of care without return to their parents or placement with a new permanent family parallels another ACA requirement that directs health insurance companies to continue coverage of children up to age 26 who are enrolled in their parents' private health care plans. Additionally, under a separate eligibility pathway states continue to have the option of providing Medicaid to youth aging out of foster care (up to the age of 21). Under this optional pathway, and unlike the newer mandatory pathway, a youth does not need to have received Medicaid while in foster care to be eligible for the coverage.
Effective January 1, 2014, the ACA established the Modified Adjusted Gross Income (MAGI) income counting rule. MAGI draws on federal income tax rules (with certain revisions defined in Medicaid law and regulation) to establish uniform standards for what income to include or disregard in determining Medicaid eligibility for most non-elderly and non-disabled people. In transitioning to the new MAGI income counting rule, states were required to establish income eligibility thresholds no less than the effective income eligibility levels that were applicable in the state on the date of enactment of the ACA (i.e., March 23, 2010). In addition to this transition policy, several additional protections ensure that children in, or formerly in, foster care retain eligibility under the new counting rules.
The ACA made additional changes to assist adults in obtaining private health insurance, and young adults leaving foster care may benefit from these changes. The ACA may also include new opportunities for providing health insurance to child welfare-involved children and their families, such as those children in foster care who are vulnerable to losing Medicaid upon returning home.