1. National Academy for State Health Policy © 20071 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 sschwartz@nashp.org 202-903-0101

2. National Academy for State Health Policy © 20072 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.

3. National Academy for State Health Policy © 20073 Lacking Health Insurance Threatens Young Adults Access to Care, 2005 Source: Commonwealth Fund Biennial Helath Insurance Survey (2005). Insured all year Insured now, time uninsured in past year Uninsured now

4. National Academy for State Health Policy © 20074 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

5. National Academy for State Health Policy © 20075 Aging out of Medicaid & SCHIP Percent Uninsured Children Age 18 and Under Young Adults Ages 19-29 Total12%31% < 100% FPL20%54% 100%- 199% FPL 17%42% > 200% FPL7%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.

6. National Academy for State Health Policy © 20076 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

7. National Academy for State Health Policy © 20077 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 18 th birthday –States may cover some young adults (see next slide). SCHIP –SCHIP only covers children up to age 19

8. National Academy for State Health Policy © 20078 Medicaid Optional Pathways Several Medicaid options to cover some 19 and 20 year olds: –“Ribicoff” –Subsidized adoption –Chafee/FCIA: Foster care leavers –Medically Needy

9. National Academy for State Health Policy © 20079 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

10. National Academy for State Health Policy © 200710 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 20 th or 21 st birthday –Most states cover to 21

11. National Academy for State Health Policy © 200711 States with Ribicoff Option for Young Adults

12. National Academy for State Health Policy © 200712 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 21 st birthday

13. National Academy for State Health Policy © 200713 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 * Source: Fox HB, Limb SJ, and McManus MA. The Public Health Insurance Cliff for Older Adolescents. Washington, DC: Incenter Strategies, April, 2007

14. National Academy for State Health Policy © 200714 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* * Source: Fox HB, Limb SJ, and McManus MA. The Public Health Insurance Cliff for Older Adolescents. Washington, DC: Incenter Strategies, April, 2007

15. National Academy for State Health Policy © 200715 States with Medically Needy Option for Young Adults

16. National Academy for State Health Policy © 200716 Chafee Option/Foster Care Independence Act Optional Medicaid coverage for children in foster care on their 18th birthday, up to 21 st 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

17. National Academy for State Health Policy © 200717 States Pursuing FCIA Option

18. National Academy for State Health Policy © 200718 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

19. National Academy for State Health Policy © 200719 1115 Waivers Vary in Many Ways Age Cost-Sharing Tied to Employment Benefits Funding Source Income Size

20. National Academy for State Health Policy © 200720 States Covering Childless Adults with 1115 Waivers

21. National Academy for State Health Policy © 200721 States Covering Family Planning with 1115 Waiver

22. National Academy for State Health Policy © 200722 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

23. National Academy for State Health Policy © 200723 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

24. National Academy for State Health Policy © 200724 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)

25. National Academy for State Health Policy © 200725 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).