Frequently Asked Questions

We noted in a previous FAQ released on May 22, 2012 (available at: http://www.medicaid.gov/sites/default/files/state-resource-center/FAQ-medicaid-and-chip-affordable-care-act-implementation/downloads/Eligibility-Policy-FAQs.pdf), states are not required to track the pregnancy status of women enrolled in the adult group, and are not required to move them to the eligibility group for pregnant women if the state becomes aware of their pregnancy outside of the regular redetermination process. Women who become pregnant must be given the option of moving to the pregnancy-related coverage category, and states must inform women of the differences in coverage between the adult group and pregnancy-related coverage (including any differences in benefits, premiums and cost sharing) so that pregnant women can make an informed choice about reporting the pregnancy and changing their eligibility status between regular renewals. We clarify that, at a regularly scheduled renewal, states must determine whether a current beneficiary enrolled in the adult group meets all eligibility criteria to remain eligible in the adult group. If at that time the state is aware that a woman is pregnant (either because of ex parte information confirmed during the renewal process by the state or through the return of a pre-populated renewal form from the woman), she no longer would meet the requirements for eligibility under the new adult group and, if otherwise eligible for coverage based on pregnancy, must instead be enrolled in the pregnant women's group. The state may give a pregnant woman the option to remain enrolled in the same alternate benefit package she is enrolled in through the new adult group, to minimize any disruption to her coverage or access to providers. Note that if the state covers any additional benefits for pregnant women under 42 CFR 440.250(p) not provided to other individuals eligible under the state plan, such benefits also must be provided to pregnant women enrolled in such alternative benefit package. Between regular renewals, if a woman enrolled in the adult group who becomes pregnant does not elect to switch groups and remains in the adult group, her status for FMAP purposes (as newly eligible or not) is unchanged until her next regularly scheduled redetermination. If, consistent with the policy described above, her enrollment is transferred to the pregnant women's group either prior to or at the point of her regular renewal, regular FMAP would apply because she would no longer be in the adult group.

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Section 1903(v)(2) of the Social Security Act limits the availability of federal Medicaid matching funds for states' expenditures for medical assistance for certain individuals to expenditures for services furnished to treat an emergency medical condition. If such individuals meet the eligibility criteria for the Medicaid new adult group in the state to be considered "newly eligible" under the state's FMAP methodology for the new adult group, state expenditures consistent with section 1903(v) are matched at the newly eligible FMAP described in section 1905(y). This treatment for purposes of federal reimbursement is consistent with current law and regulation.

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Section 2004 of the Affordable Care Act added a new mandatory group for former foster care children at section 1902(a)(10)(A)(i)(IX) of the Social Security Act (the Act). Proposed 42 CFR 435.150 of the January 22, 2013 proposed rule, available at http://www.gpo.gov/fdsys/pkg/FR2013-01-22/pdf/2013-00659.pdf, would codify the provisions of section 1902(a)(10)(A)(i)(IX). Under the statute, states must cover individuals under age 26 who were both enrolled in Medicaid and in foster care under the responsibility of the state or tribe upon attaining either age 18 or such higher age as the state or tribe has elected for termination of federal foster care assistance under title IV-E. We are interpreting the statute also to permit states, at their option, to cover individuals who were in foster care and receiving Medicaid in another state upon turning 18 or "aging out" of foster care in the other state, but are not required to do so. There is no income test for eligibility under this group.

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States cannot cover individuals who left foster care before aging out under the former foster care children group. Section 1902(a)(10)(i)(IX) of the Act only provides Medicaid eligibility for individuals who were in foster care when they turned 18 or such higher age when the state's foster care assistance ends. Individuals who left foster care before age 18, or who were not in foster care and Medicaid either upon turning 18 or upon "aging out" of foster care at the higher age elected by the state, are not eligible for coverage under this group. However, these individuals may be eligible under a different eligibility group.

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Yes, we will approve state plan amendments to cover individuals who were in foster care and receiving Medicaid when they turned age 18 or "aged out" of foster care in another state. This option is provided in the state plan amendment (SPA) page (S33) for this group. Because this provision has not yet been finalized, if section 435.150 is later finalized in such a way that conflicts with the state's approved state plan amendment, a subsequent amendment to the state plan may be necessary (see 42 CFR section 430.12(c)(1)(i)). The state would be able to receive federal financial participation for expenditures under an approved SPA if the policy later changed, until the state (within a reasonable period of time) had submitted a new SPA and modified its policies and procedures to comply with such change in federal policy.

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Yes. Effective as of January 1, 2014, coverage is available to individuals under age 26 who meet the eligibility requirements described above. For example, an applicant who is 23 years old in January 2014 and who was in foster care and receiving Medicaid at the time he or she turned 18 (back in 2009) will be eligible for coverage under the former foster care group.

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Yes.

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Title IV-E foster care stops either when the individual attains age 21 or attains age 20, 19, or 18, as specified in the state's IV-E state plan.

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According to federal regulations at 45 CFR 1355.20, "Foster care means 24-hour substitute care for children placed away from their parents or guardians and for whom the [state or tribal] agency has placement and care responsibility. This includes but is not limited to, placements in foster family homes, foster homes or relatives, group homes, emergency shelters, residential facilities, child care institutions, and preadoptive homes. A child is in foster care in accordance with this definition regardless of whether the foster care facility is licensed and payments are made by the State, Tribal or local agency for the care of the child, whether adoption subsidy payments are being made prior to the finalization of an adoption, or whether there is Federal matching of any payments that are made."

Receipt of foster care maintenance payments is not required for a child to be considered "in foster care" under this definition/ Thus, children placed with a relative or in another non-licensed out-of-home placement, with respect to whom foster care maintenance payments are not being provided, may be considered to be "in foster care" according to this definition if they are also under the placement and care of the state or tribal agency.

This definition of "foster care" is contained in regulations implementing titles IV-B and IV-E of the Social Security Act. However, because the federal regulations implementing titles IV-B and IV-E require state and tribal title IV-E agencies to agree to certain program requirements for all children in foster care, this definition applies to all foster care provided in a state or tribe, even that which is provided without federal participation.

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No. Federal guardianship assistance payments provided under section 473(d) of title IV-E of the Act are not considered federal foster care maintenance payments. Because the title IV-E agency no longer has placement and care responsibility for youth receiving such payments, these youth are not considered to be in foster care and therefore would not be eligible for coverage under the former foster care group.

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