National Academy for State Health Policy © 20071 State Options for Covering Young Adults State...

National Academy for State Health Policy © 2007 1

State Options for Covering Young Adults

State Coverage Initiatives Workshop for State Officials

August 3, 2007

Sonya Schwartz

Program Manager

National Academy for State Health Policy

[email protected]

202-903-0101

mailto:[email protected]


Young Adults (19-23) Often Lack Insurance

• 13.7 million young adults lacked coverage in 2004 (an increase of 2.5 million young adults since 2000)

• 40% from families below 100% FPL• 69% from families below 200% FPL

– Fastest growing age group among the uninsured from 2000-2004

– Account for 30 percent of the non-elderly uninsured (but only 17 percent of the population)

Source: Sara R. Collins, et al, Right of Passage? Why Young Adults Become Uninsured and How New Policies Can Help, The Commonwealth Fund, May 2006.


Lacking Health Insurance Threatens Young Adults Access to Care, 2005

Source: Commonwealth Fund Biennial Helath Insurance Survey (2005).

Percent of adults ages 19-29 reporting the following problems in the past year because of cost:

17 12 1118

3132 31 2842

54

38 37 3545

57

0

40

80

Did not fill aprescription

Did not see aspecialist

when needed

Skipped amedical test,treatment, or

follow-up

Had medicalproblem, did

not see doctoror clinic

Any of the fouraccess

problems

Insured all year Insured now, time uninsured in past year Uninsured now


Aging Out of Medicaid & SCHIP

• Young adults often uninsured and have low-incomes

• Young adults age out of most states’ Medicaid and SCHIP programs on 19th Birthday

• Medicaid mandatory categories do not generally fit the young adult population– Unless pregnant, a parent, or disabled


Aging out of Medicaid & SCHIP

Percent Uninsured

Children Age 18 and Under

Young Adults Ages 19-29

Total 12% 31%

< 100% FPL 20% 54%

100%- 199% FPL

17% 42%

> 200% FPL 7% 18%

Percent Uninsured, Children and Young Adults by Poverty Level, 2004

Source: Sara R. Collins, et al, Right of Passage? Why Young Adults Become Uninsured and How New Policies Can Help, The Commonwealth Fund, May 2006.


Public Coverage Options to Improve Access to Coverage

We will talk briefly about:• Medicaid Optional Eligibility Pathways for 19 and

20 year olds• 1115 Waivers• Additional Options Under the Deficit Reduction

Act• Public Program Buy-Ins• State-Funded Coverage


Brief Reminder of Medicaid/SCHIP Rules

• Medicaid– States must cover certain children.

• Pregnant women and infants under age 6 up to 133% FPL• Children 6-18 up to 100% FPL• Title IV-E funded foster care children to 18th birthday

– States may cover some young adults (see next slide).

• SCHIP– SCHIP only covers children up to age 19


Medicaid Optional Pathways

• Several Medicaid options to cover some 19 and 20 year olds:– “Ribicoff”– Subsidized adoption– Chafee/FCIA: Foster care leavers – Medically Needy


Ribicoff Eligibility

• Children who meet a state’s July 1996 AFDC income and resource requirements

• 15 states (as of 2006) use this option to cover 19 and 20-year-olds*– AFDC standards have not changed: now 30% or less

of FPL– States can disregard income under 1902(r)(2) to

“modernize” income requirements• 0-49% FPL in 4 states• 50-99% FPL in 5 states.• 100% FPL or higher in 6 states

* Source: Fox HB, Limb SJ, and McManus MA. The Public Health Insurance Cliff for Older Adolescents. Washington, DC: Incenter Strategies, April, 2007


Ribicoff Eligibility (ctd)

• States can opt to cover this entire population, or “reasonable classifications”– “Reasonable classifications” include:

• Foster children (IV-E and/or non-IV-E)• Children in nursing home, ICF/MR, and/or inpatient

psychiatric hospital settings

• States may opt to cover kids up to 20th or 21st birthday– Most states cover to 21


States with Ribicoff Option for Young Adults

NH MA

ME

NJ

CTRI

DE

VT

NY

DC

MD

NC

PA

VAWV

FL

GA

SC

KY

IN OH

MI

TN

MSAL

MO

IL

IA

MN

WI

LA

AROK

TX

KS

NE

ND

SD

HI

MT

WY

UT

CO

AK

AZ

NM

IDOR

WA

NV

CA

State covers youth <21 (16)

No Ribicoff program

Source: Fox HB, Limb SJ, and McManus MA. The Public Health Insurance Cliff for Older Adolescents. Washington, DC: Incenter Strategies, April, 2007.


Subsidized Adoption

• Title IV-E funded adoptions of children with special health needs, or special situations (multiple siblings, etc.)

• These children have Medicaid coverage, and it may be extended to 21st birthday


Medically Needy

• Option to allow certain groups with high medical expenses to “spend down” into Medicaid– “Spend-down” requirement must be met every

1 to 6 months• 16 states have MN programs that cover 19-

20 year olds as of 2006*– Must cover children under 18 and pregnant

women– May cover other groups, including children

ages 19 - 20



Medically Needy• The Medically Needy Income Limit is

133% of 1996 AFDC payment or 54% of FPL in 2006– But, states can use income disregards under

1902(r)(2) to “modernize” income limits– State income levels range from 22% FPL to

102% FPL for these programs

• States can restrict MN benefits; most don’t– EPSDT is covered in 15 of 16 states that

cover 19-20 year olds in MN programs*



States with Medically Needy Option for Young Adults

NH MA

ME

NJ

CTRI

DE

VT

NY

DC

MD

NC

PA

VAWV

FL

GA

SC

KY

IN OH

MI

TN

MSAL

MO

IL

IA

MN

WI

LA

AROK

TX

KS

NE

ND

SD

HI

MT

WY

UT

CO

AK

AZ

NM

IDOR

WA

NV

CA

State covers age 19 through 20 (16)

State does not cover age 19 through 20

Source: Fox HB, Limb SJ, and McManus MA. The Public Health Insurance Cliff for Older Adolescents. Washington, DC: Incenter Strategies, April, 2007


Chafee Option/Foster Care Independence Act

• Optional Medicaid coverage for children in foster care on their 18th birthday, up to 21st birthday– May restrict to “reasonable classifications”

(e.g., IV-E funded kids)– May set income eligibility (e.g. 200% FPL)

• With rosier state budgets, more states are implementing this option


States Pursuing FCIA Option

NH MA

ME

NJ

CTRI

DE

VT

NY

DC

MD

NC

PA

VAWV

FL

GA

SC

KY

IN OH

MI

TN

MSAL

MO

IL

IA

MN

WI

LA

AROK

TX

KS

NE

ND

SD

HI

MT

WY

UT

CO

AK

AZ

NM

IDOR

WA

NV

CA

Implemented option (16)

Investigating Option (5)

No Program (30)

Source: American Public Human Services Association. Medicaid Access for youth aging out of Foster Care. APSHA 2007


1115 Waiver Basics

• States have broad authority to waive statutory and regulatory provisions of Medicaid and SCHIP– Some waivers large and comprehensive (e.g.

mandatory managed care) – Some waivers focused (e.g. family planning)– 2001 HIFA Initiative focused on expanding

coverage within existing resources– Budget Neutrality Requirement


1115 Waivers Vary in Many Ways

Age

Cost-Sharing

Tied to Employment

Benefits

Funding Source

Income

Size


States Covering Childless Adults with 1115 Waivers

NH MA

ME

NJ

CTRI

DE

VT

NY

DC

MD

NC

PA

VAWV

FL

GA

SC

KY

IN OH

MI

TN

MSAL

MO

IL

IA

MN

WI

LA

AROK

TX

KS

NE

ND

SD

HI

MT

WY

UT

CO

AK

AZ

NM

IDOR

WA

NV

CA

1115 Waivers for childless adults (22)

No Program (28)Source: NASHP Scan


States Covering Family Planning with 1115 Waiver

NH MA

ME

NJ

CTRI

DE

VT

NY

DC

MD

NC

PA

VAWV

FL

GA

SC

KY

IN OH

MI

TN

MSAL

MO

IL

IA

MN

WI

LA

AROK

TX

KS

NE

ND

SD

HI

MT

WY

UT

CO

AK

AZ

NM

IDOR

WA

NV

CA

States providing services based on income (17)

States providing services to women losing Medicaid postpartum (6)

States providing family planning benefits for women losing Medicaid for any reason (2)

No Program (26)Source: www.guttmacher.org/statecenter/spibs/spib_SMFPE.pdf


Additional Options Under DRA?

• No new option to cover childless adults – DRA prohibits covering childless adults with SCHIP funds

• New option to provide “alternative benefits plans” in Medicaid and to charge modest premiums and cost-sharing– Fifteen states could file Medicaid State Plan Amendment to

provide “alternative benefits plans” to 19 and 20 year-olds at higher income levels (Ribicoff states)

– If individual is eligible under an eligibility category that had been “established under the state plan on or before the date of enactment of DRA (February 8, 2006)”

– State could also disregard income and asset limits under 1902(r)(2) to reach above the original AFDC levels


Public Program Buy-Ins

• Seven states allow buy-in to SCHIP for higher-income families – Some allow children up to 21 to buy into their SCHIP

program at full cost

• Existing programs are small– Most have only a few hundred participants– NY and FL have thousands of participants

• Premiums for children range from $100-200 per child per month


State-Funded Coverage

• A handful of states provide state-funded coverage for low-income adults without children– Some use Medicaid funding and other state

funding (e.g. Vermont)– Some use state funding only (e.g. Washington

Basic Health)


Helpful Resources

• Harriette B. Fox, et al, The Public Health Insurance Cliff for Older Adolescents (Washington: Incenter Strategies: April 2007).

• Sara Collins, et al, Rite of Passage? Why Young Adults Become Uninsured and How New Policies Can Help (New York: Commonwealth Fund, May 2006)

• Medicaid Access for Youth Aging Out of Foster Care, (Washington: APHSA, 2007)

• Improving Access to Medicaid for Transitional Youth (Washington: NASHP, forthcoming).

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