DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, Maryland 21244-1850 
 
                  SHO# 22-003 
RE: Coverage of Youth Formerly 
in Foster Care in Medicaid 
(Section 1002(a) of the SUPPORT 
Act) 
 
December 16, 2022 
 
Dear State Health Official:  
 
The purpose of this letter is to provide guidance to states1 on important changes to the mandatory 
Medicaid eligibility group serving youth formerly in foster care (the former foster care children 
group, or FFCC group).  These changes, which were made by the Substance Use-Disorder 
Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities 
(SUPPORT) Act, Pub. L. No. 115-271, expand eligibility to individuals who were in foster care 
from other states and simplify eligibility determinations and enrollment processes for this 
population.  
 
Currently, under section 1902(a)(10)(A)(i)(IX) of the Social Security Act (the Act), youth 
formerly in foster care in a state other than their current state of residence are not eligible for the 
FFCC group.  Section 1002(a) of the SUPPORT Act modifies the Act to establish that 
individuals are eligible in the FFCC group if they were receiving Medicaid while in foster care 
under the responsibility of any state (and meet all other eligibility criteria).  Section 1002(a) of 
the SUPPORT Act also provides that individuals who meet the eligibility requirements for the 
FFCC group may be enrolled in that group even if they meet the eligibility requirements for 
another mandatory eligibility group, so long as the individual is not actually enrolled in such 
 
1 For the purposes of this letter, states refers to the 50 states, the District of Columbia, and the United States 
territories of American Samoa, Commonwealth of the Northern Mariana Islands, Guam, Puerto Rico, and the U.S. 
Virgin Islands.  
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing 
requirements under the law.   Page 2  State Health Official 
 
group.  These required changes are effective for individuals who reach age 18 on or after January 
1, 2023.  States that wish to enroll all individuals who received foster care in another state, 
including those who turned 18 before January 1, 2023, may seek authority through a section 
1115 demonstration.  This option is discussed in greater detail later in this letter under 
Considerations for Implementation on pages 6 and 7. 
 
Section 1002(b) of the SUPPORT Act instructs CMS to issue guidance to states on: (1) best 
practices for removing barriers and ensuring streamlined, timely access to Medicaid coverage for 
youth formerly in foster care up to age 26; (2) outreach and awareness efforts among such youth 
regarding Medicaid coverage options; and (3) examples of states that have successfully extended 
Medicaid coverage to youth formerly in foster care.  In September 2019, CMS released this 
guidance through a Medicaid and Childrens Health Insurance Program (CHIP) Coverage 
Learning Collaborative webinar and slide deck posted on Medicaid.gov, entitled Ensuring 
Continuity of Coverage for Foster Youth Aging Out of Foster Care and Young Adults Eligible in 
the Former Foster Care Group.  The guidance and strategies outlined in the 2019 deck can 
support states to facilitate enrollment and continuity of coverage for youth formerly in foster care 
as states implement changes made by the SUPPORT Act.  The appendix to this letter includes a 
link to the 2019 deck.  
 
The guidance in this letter provides new information for states and stakeholders regarding the 
effective date and implementation of these new requirements outlined in section 1002(a) of the 
SUPPORT Act.   
 
Background  
 
Every year, more than 20,000 young people transition to independent adulthood from, or age 
out of, foster care in the United States.2  Access to health coverage and physical and behavioral 
 
2 See National Youth in Transition Database, November 2019. Highlights from the NYTD Survey: Outcomes 
reported by young people at ages 17, 19, and 21 (Cohort 2). Available at: 
https://www.acf.hhs.gov/sites/default/files/documents/cb/nytd_data_brief_7.pdf; and U.S. Department of Health and 
Human Services, Administration for Children and Families, Administration on Children, Youth and Families, 
Children's Bureau, October 4, 2021. The AFCARS Report. Available at: 
https://www.acf.hhs.gov/sites/default/files/documents/cb/afcarsreport28.pdf, page 3. 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing 
requirements under the law.   Page 3  State Health Official 
 
healthcare services is essential for these young adults to live healthy and successful lives.  
Children in foster care and youth aging out of foster care are much more likely to have multiple 
adverse childhood experiences (including witnessing violence, having an unsafe home 
environment, or experiencing abuse or neglect) than the overall population, increasing their risk 
of negative health outcomes in adulthood.3  Youth transitioning from foster care often have a 
history of complex trauma and are at high risk for behavioral and cognitive problems, as well as 
other comorbidities stemming from this trauma.4  
 
Children with disabilities and Black, Hispanic, and American Indian/Alaska Native children are 
disproportionately represented in foster care and among those older youth aging out of foster 
care.5  Foster care placements, risks and challenges are also equally prevalent in rural and urban 
areas, with placements in rural areas sometimes at higher rates.6  Youth aging out of foster care 
can experience barriers to health and behavioral health coverage and services, which can 
exacerbate disparities in health and social outcomes.  As a primary source of health coverage for 
youth formerly in foster care, Medicaid is uniquely positioned to support both the health, 
including behavioral health, and healthcare of this population.  Ensuring continued coverage for 
these youth as they leave the foster care system and transition to adulthood is critical to 
addressing health and social inequities.  
 
3 Among children involved in the child welfare system, 51 percent had four or more adverse childhood experiences, 
as compared to 13 percent of the general child population.  Research suggests children with four or more adverse 
childhood events are 12 times more likely to have poor health outcomes later in life. See Stambaugh, L.F., 
Ringeisen, H., Casanueva, C.C., Tueller, S., Smith, K.E., & Dolan, M. (2013).  Adverse childhood experiences in 
NSCAW.  OPRE Report #2013-26, Washington, DC: Office of Planning, Research and Evaluation, Administration 
for Children and Families, U.S. Department of Health and Human Services.  Available at: 
https://www.acf.hhs.gov/sites/default/files/documents/opre/aces_brieaf_final_7_23_13_2.pdf.  
4 Salazar, A. M., Keller, T. E., Gowen, L. K., & Courtney, M. E. (2013).  Trauma exposure and PTSD among older 
adolescents in foster care.  Social Psychiatry and Psychiatric Epidemiology, 48(4), pp. 545-551.  Available at: 
https://doi.org/10.1007/s00127-012-0563-0; and Casanueva, C. W. E., Smith, K., Dolan, M., Ringeisen, H., Horne, B. 
(2012).  NSCAW II wave 2 report: Child well-being.  OPRE Report #2012-38, Washington, DC: Office of Planning, 
Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services.  
See Exhibit 25.  Available at: 
https://www.acf.hhs.gov/sites/default/files/documents/opre/nscaw_report_w2_ch_wb_final_june_2014_final_report.pd
f.  
5 Slater, E. M. (2016).  Youth with disabilities in the United States Child Welfare System.  Children and Youth Services 
Review (64), pp.155-165.  Available at: https://doi.org/10.1016/j.childyouth.2016.03.012; 
https://www.acf.hhs.gov/sites/default/files/documents/cb/nytd_data_brief_7.pdf; and 
https://www.acf.hhs.gov/sites/default/files/documents/cb/afcarsreport28.pdf. 
6 Foster Care Dynamics in Urban and Non-Urban Counties, Office of the Assistant Secretary for Planning and 
Evaluation. (January 2002).  Available at: https://aspe.hhs.gov/reports/foster-care-dynamics-urban-non-urban-
counties.  
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing 
requirements under the law.   Page 4  State Health Official 
 
 
The FFCC group, codified at section 1902(a)(10)(A)(i)(IX) of the Act and 42 C.F.R.  435.150, 
was created by sections 2004(a)(3) and 10201(a)(1) of the Affordable Care Act (ACA), Pub. L. 
111-148.  Currently, eligibility in the FFCC group is available to individuals who:  
 
  Are under age 26;  
  Are not eligible for or enrolled in another mandatory eligibility group;7,8  
  Were in foster care under the responsibility of the state in which the individual is seeking 
Medicaid eligibility upon attaining age 18 (or such higher age as the state has elected in 
its title IV-E plan);9 and 
  Were enrolled in Medicaid in such state while in such foster care.10  
 
The addition of this mandatory group furthered the overall goal of the ACA to expand access to 
health coverage, including for people under age 26.  Other provisions of the ACA allowed young 
adults under age 26 to maintain coverage under their parents or guardians health insurance plan 
(to the extent that such plan extends coverage to dependents).  For youth formerly in foster care, 
this new Medicaid eligibility group provided parity with the option afforded to other young 
adults to retain coverage under their parents private insurance.  
 
 
7 The mandatory eligibility groups are: Supplemental security income (SSI) beneficiaries, certain individuals treated 
as SSI beneficiaries, and low-income individuals 65 years old or older or who have blindness or disabilities in states 
that apply more restrictive methodologies than the SSI program; children receiving assistance under title IV-E of the 
Act; parents and caretaker relatives; individuals receiving transitional medical assistance; extended Medicaid due to 
spousal support collection; infants and children under age 19; and pregnant individuals.  See Sections 
1902(a)(10)(A)(i)(I)-(VII) of the Act.  
8 If an individual meets the requirements for both the FFCC group and the adult group (described in section 
1902(a)(10)(A)(i)(VIII) of the Act), the individual is enrolled in the FFCC group.  See Clause (XVII) in the matter 
following section 1902(a)(10)(G) of the Act. 
9 States may elect to end federally-funded foster care assistance at age 18 or an older age up to age 21.  In states that 
end such assistance at an age above 18, an individual who is in foster care upon turning age 18 and who ages out of 
foster care in the state prior to reaching the states maximum age for foster care assistance is eligible for the FFCC 
group (if the individual meets the other eligibility requirements).  See section 475(8) of the Act.  
10 States have the option to extend eligibility in the FFCC group to individuals enrolled in Medicaid at any point 
during the foster care period during which they turned age 18 or aged out at a higher age.  States also have the 
option to extend eligibility in the FFCC group to individuals placed by their states foster care agency in another 
state and who were enrolled in Medicaid in that other state while in such foster care placement.  42 C.F.R.  
435.150(c).   
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing 
requirements under the law.   Page 5  State Health Official 
 
Under the current statute and regulations, the FFCC group is limited to individuals who were in 
foster care in the same state in which they seek to establish eligibility in the FFCC group.11  
Using authority provided under section 1115 of the Act, CMS has provided states with an option 
to extend Medicaid coverage to individuals under age 26 who were in foster care in another state 
when they turned 18 or aged out of foster care, and who had been enrolled in Medicaid in the 
other state while in such foster care.  A number of states have received such authority.12  
 
SUPPORT Act Changes  
 
The SUPPORT Act makes two important changes to the eligibility requirements for the FFCC 
group.  These changes will become effective, with certain limitations, on January 1, 2023 (see 
the discussion of the effective date below).  
 
First, section 1002(a)(1)(A) of the SUPPORT Act eliminates the requirement that an individual 
not be eligible for another mandatory eligibility group (other than the adult group) to be eligible 
for the FFCC group.  Specifically, section 1002(a)(1)(A) of the SUPPORT Act amends section 
1902(a)(10)(A)(i)(IX)(bb) of the Act to replace are not described in or enrolled under any of 
subclauses (I) through (VII) of [section 1902(a)(10)(A)(i)] with are not described in and are 
not enrolled under any of subclauses (I) through (VII) of [section 1902(a)(10)(A)(i)]. . . 
(Emphasis added).  This change means that a person may be enrolled in the FFCC group even if 
the individual meets the eligibility requirements for a separate mandatory group described in 
section 1902(a)(10)(A)(i) of the Act, so long as the individual is not actually enrolled in such 
group.  This change will help streamline states enrollment processes and reduce burdens for 
states and beneficiaries by eliminating states need to screen individuals who were formerly in 
 
11 See Medicaid and Childrens Health Insurance Programs: Eligibility Notes, Fair Hearing and Appeal Processes 
for Medicaid and Other Provisions Related to Eligibility and Enrollment for Medicaid and CHIP Final Rule, 81 FR 
86382, November 30, 2016.  Available at: https://www.govinfo.gov/content/pkg/FR-2016-11-30/pdf/2016-
27844.pdf.  
12 See Section 1115 Demonstration Opportunity to Allow Medicaid Coverage to Former Foster Care Youth Who 
Have Moved to a Different State November 21, 2016, page 1.  Available at: https://www.medicaid.gov/federal-
policy-guidance/downloads/cib112116.pdf.  
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing 
requirements under the law.   Page 6  State Health Official 
 
foster care for eligibility for any other category prior to enrolling individuals into the FFCC 
group.13  
 
Second, sections 1002(a)(1)(B) and (C) of the SUPPORT Act require that states cover under the 
FFCC group individuals who aged out of foster care in a state other than the state where they 
currently live and are seeking Medicaid coverage.  Specifically, sections 1002(a)(1)(B) and (C) 
of the SUPPORT Act amend sections 1902(a)(10)(A)(i)(IX)(cc) and (dd), respectively, of the 
Act to replace each reference to the State with a reference to a State (Emphasis added).  This 
means that all states must now cover, in the FFCC group, individuals who aged out of foster care 
in a state other than the one in which they are seeking Medicaid, as long as they otherwise meet 
the eligibility requirements for this group (e.g., age, citizenship or immigration status).   
 
These changes will apply exclusively to individuals who turn 18 on or after January 1, 2023.  
This means that, under these two SUPPORT Act changes to the FFCC group requirements, 
individuals who turn 18 on or after January 1, 2023, will be eligible in the FFCC group if they 
meet all of the below requirements:  
 
  Are under age 26;  
  Are not enrolled in an eligibility group described in section 1902(a)(10)(A)(i)(I)-(VII) of 
the Act14 (even if they meet the eligibility requirements for such group);  
  Were in foster care under the responsibility of any state upon attaining age 18 (or such 
higher age as the state has elected in its title IV-E plan); and  
  Were enrolled in Medicaid in any state while in such foster care.  
 
Territories and the District of Columbia (D.C.) 
 
 
13 For example, if the state agency has information available to it that shows an individual qualifies for the FFCC 
group, the agency does not need to collect additional information from that individual on factors of eligibility for 
other mandatory eligibility groups, such as pregnancy or parenting status, and verify income.  The state may enroll 
the individual directly in the FFCC group.  For more information, see Application Changes below. 
14 The explanatory notes to the description of the FFCC group, footnotes 7 through 10 of this letter, apply equally to 
the updated eligibility requirements.  Note that the prohibition on enrolling an individual eligible for the FFCC 
group into the adult group (described in section 1902(a)(10)(A)(i)(VIII)) and referenced in footnote 8 of this letter 
continues to apply under the SUPPORT Act changes described here.   
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing 
requirements under the law.   Page 7  State Health Official 
 
These SUPPORT Act changes apply equally to states, D.C., and the United States territories.  
Therefore, an individual who ages out of foster care in D.C. or a territory and moves to a state 
and applies for Medicaid is treated in the same manner as though the individual moved from 
another state.  Likewise, the treatment of an individual who ages out of foster care in a state and 
moves to D.C. or a territory, or an individual who ages out of foster care and moves between 
territories or between D.C. and a territory, is the same.  
 
Effective Date 
 
Section 1002(a)(2) of the SUPPORT Act directs that the changes to the FFCC eligibility group  
both related to eligibility for another mandatory eligibility group and also aging out of foster care 
from another state  described above shall take effect with respect to foster youth who attain 18 
years of age on or after January 1, 2023 (Emphasis added).  This means that: (1) the original 
eligibility requirements for the FFCC group will continue to apply for youth formerly in foster 
care who turn 18 prior to January 1, 2023; and (2) all of the new requirements will apply 
exclusively to those who turn 18 on or after January 1, 2023.   
 
Note that states may use section 1115 demonstration authority to address the eligibility 
differences resulting from implementation of the effective date.  See below for further discussion 
of section 1115 demonstration opportunity.  
 
Examples 
 
Kaylie is both in foster care under the responsibility of State A and enrolled in State As 
Medicaid program.  If Kaylie ages out of foster care upon turning age 18 on December 31, 2022, 
and then moves to State B, she will be ineligible for the state plan FFCC group in State B.  
Because Kaylie turned 18 prior to January 1, 2023, and aged out of foster care in another state, 
she does not meet the eligibility requirements for the state plan FFCC group in State B under the 
original terms of section 1902(a)(10)(A)(i)(IX) of the Act, which only provide eligibility in the 
group to individuals who were in foster care under the responsibility of the same state in which 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing 
requirements under the law.   Page 8  State Health Official 
 
such individuals seek Medicaid eligibility.15  In addition, if Kaylie remains a resident of State A, 
she will also not qualify for the FFCC group in State A if, during her status as a youth formerly 
in foster care, the state determines that she meets the eligibility requirements for a separate 
eligibility group described in section 1902(a)(10)(A)(i)(I)-(VII) of the Act.  In this situation, 
Kaylie would be enrolled in the eligibility group for which the state has determined she is 
eligible.16  If Kaylie is enrolled in but ultimately loses eligibility for a group described in section 
1902(a)(10)(A)(i)(I)-(VII) of the Act, she will be eligible in State As FFCC group, so long as 
she is under the age of 26.  
 
Jayden is also in foster care under the responsibility of State A and enrolled in State As 
Medicaid program.  If Jayden turns 18 on January 1, 2023, and ages out of foster care in State A 
and then moves to State B and applies for Medicaid, he will be eligible for the FFCC group in 
State B.  Because Jayden attained age 18 on or after January 1, 2023, his Medicaid eligibility will 
be subject to the requirements under the SUPPORT Acts amendments to the FFCC group, 
including mandatory eligibility for coverage if he was enrolled in Medicaid while in foster care 
in any other state prior to aging out of such foster care.  In addition, because the SUPPORT Act 
amendments will apply in Jaydens case, whether or not Jayden moves to State B from State A, 
the fact that he may meet the eligibility requirements for a separate mandatory group described 
in section 1902(a)(10)(A)(i)(I)-(VII) of the Act will not be a barrier to his eligibility for or 
enrollment in the FFCC group.  
 
Considerations for Implementation 
 
CMS understands that the SUPPORT Act amendments will require that states employ separate 
eligibility rules for the FFCC group beginning on January 1, 2023, and that this will present 
administrative challenges.  To address these challenges, states may utilize authority under section 
 
15 We note that if State B has a section 1115 demonstration to cover youth formerly in foster care from another state, 
Kaylie could potentially qualify for coverage under such states demonstration.  
16 States should use information provided by the child welfare agency or otherwise available to the Medicaid agency 
(e.g., electronic data sources or other case records) to determine eligibility for all groups, consistent with the 
eligibility hierarchy.  If the information available to the state is incomplete or unverified, states may enroll the 
individual in the former foster care group but should provide notice and opportunity for the individual to provide 
additional information if coverage in another group might be beneficial to the individual.  If the state does not have 
information indicating the youth is pregnant or a parent, the state does not need to verify income information and 
may enroll the individual in the former foster care group.  
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing 
requirements under the law.   Page 9  State Health Official 
 
1115 of the Act to align the eligibility rules for youth formerly in foster care who turn age 18 
before January 1, 2023, to those who turn age 18 on or after January 1, 2023, so that states can 
effectively apply the SUPPORT Acts FFCC group eligibility changes to all individuals. Using 
the examples above, this option will allow State B to provide coverage to youth formerly in 
foster care, such as Kaylie, who turned 18 before January 1, 2023. 
 
Section 1115 Demonstration Opportunity 
 
States that currently have a section 1115 demonstration to cover youth formerly in foster care 
from another state will begin to enroll those individuals who turn 18 on or after January 1, 2023, 
into the state plan FFCC group.  States may continue to utilize their section 1115 demonstrations 
to cover this population of youth formerly in foster care from another state until the state has 
fully effectuated coverage of demonstration enrollees into the FFCC state plan group.  However, 
section 1115 demonstration authority is still needed to provide coverage to youth formerly in 
foster care who reached age 18 prior to January 1, 2023, and who remain ineligible for state plan 
FFCC group coverage.  States with such section 1115 demonstrations that cover this population 
of youth formerly in foster care from another state may continue operating these demonstrations 
until all enrollees reach age 26.  
 
States that do not have an existing section 1115 demonstration to cover youth formerly in foster 
care from other states who turn 18 prior to January 1, 2023, may consider a new section 1115 
demonstration or an amendment to an existing section 1115 demonstration to cover these 
individuals not eligible for the FFCC group in the state plan until they reach age 26.17  Any 
youth formerly in foster care from other states who turn (or turned) 18 prior to January 1, 2023, 
may be eligible for coverage under this section 1115 option, once the state receives approval of 
the section 1115 demonstration or amendment. 
 
States with an existing section 1115 demonstration to cover youth formerly in foster care from 
other states should consult their CMS Project Officer for technical assistance on any changes that 
 
17 Beginning January 1, 2031, the requirements of the FFCC group, as changed by the SUPPORT Act amendments, 
will apply to all youth formerly in foster care under age 26 without the need to vary rules based on when they turned 
18.  
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing 
requirements under the law.   Page 10  State Health Official 
 
may be needed to their approved section 1115 demonstration to align with the SUPPORT Act 
changes.  CMS encourages states that are interested in utilizing section 1115 demonstration 
authority to align the eligibility rules for youth formerly in foster care through December 31, 
2030, to contact CMS for technical assistance with developing section 1115 applications that 
align with the SUPPORT Act changes as well as with the applicable federal transparency 
requirements for new section 1115 demonstration requests (per 42 C.F.R. 431.412) or for section 
1115 demonstration amendments (pursuant to the demonstrations Special Terms and 
Conditions). 
 
Application Changes 
 
CMS encourages states to streamline existing enrollment processes to promote continuity of 
coverage, remove enrollment barriers, and ensure timely access to Medicaid coverage for youth 
formerly in foster care.  Individuals who remain in the state in which they age of out foster care 
should remain continuously enrolled in Medicaid through their transition out of foster care and at 
least up to age 26.  We remind states that aging out of foster care is an anticipated change in 
circumstances affecting eligibility.  Consequently, states must attempt to redetermine eligibility 
without contacting the individual, if able to do so, and request only the information needed to 
redetermine eligibility without requiring the individual to complete a full application.18  Youth 
formerly in foster care would need to complete a new Medicaid application if they become a 
resident of another state or in the event they need to re-enroll in Medicaid due to a break in 
coverage. 
 
Since the SUPPORT Act amends eligibility rules for the FFCC group based on the age of the 
individual, states will need to evaluate both their paper and online single, streamlined 
applications19 and may need to modify such applications to ensure that they are collecting 
sufficient information to determine eligibility for the FFCC group once the SUPPORT Act 
changes are effective. Unless a state has an approved section 1115 demonstration to align the 
eligibility rules for youth formerly in foster care, states will need to make sure that their 
 
18 42 C.F.R.  435.916(d). 
19 42 C.F.R.  435.907(b)(2). 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing 
requirements under the law.   Page 11  State Health Official 
 
applications continue to collect information necessary to determine eligibility for individuals 
who turn age 18 before January 1, 2023, and who aged out of the same state in which they are 
applying for health coverage, as they remain subject to the eligibility requirements for the FFCC 
group consistent with the current statutory and regulatory requirements (described on page 3 of 
this letter).  Specifically, states without an approved section 1115 demonstration to align 
eligibility rules for youth formerly in foster care will need to retain questions (1) to deny 
eligibility in the FFCC group for individuals who aged out of foster care in another state if they 
turned 18 on or before December 31, 2022, and (2) to screen youth formerly in foster care for 
eligibility under the mandatory groups described in section 1902(a)(10)(A)(i)(I)-(VII) of the Act, 
if the individual turned 18 on or before December 31, 2022.  
 
As states evaluate what revisions are needed to their applications, we remind states that single, 
streamlined applications may only require information that is necessary to determine eligibility, 
and may be no more burdensome than the single, streamlined application developed by the 
Secretary.20  Online applications must utilize dynamic functionality, targeting questions only as 
required and as necessary based on the circumstances of the applicant. 
 
To effectuate the SUPPORT Act requirements, the application must collect a date of birth and 
information regarding whether or not these individuals were enrolled in foster care at age 18 or 
older, depending on the maximum age established in the state.  States will also need to identify if 
these individuals were enrolled in Medicaid when they aged out of foster care or, for those states 
that have elected the option to extend eligibility in the FFCC group to individuals who were 
enrolled in Medicaid at any point during their foster care, such Medicaid enrollment.  To ensure 
applications collect needed information, states may also need to factor in verification policies for 
youth formerly in foster care (as discussed below on pages 9 and 10).  Because these individuals 
may be enrolled in the FFCC group without being assessed for eligibility on another basis, we 
strongly recommend states implement strategies to ensure the applications request only 
information needed to determine eligibility and minimize requests for information pertaining to 
the determination of eligibility for other mandatory groups, such as whether the applicant is a 
 
20 See 42 C.F.R  435.907(e)(1); 435.907(b)(2). 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing 
requirements under the law.   Page 12  State Health Official 
 
parent or caretaker relative of a dependent child or if they are pregnant (and if so, how many 
babies are expected).  
 
Facilitating Enrollment at Application  
 
For online applications, states must evaluate the flow of questions presented and underlying 
system logic to ensure that the individual is only required to provide the information necessary to 
determine eligibility for the FFCC group based on age and the eligibility criteria described in this 
letter.  To illustrate this functionality, an individual who turns 18 on or after January 1, 2023, is 
not required to be determined ineligible for other mandatory eligibility groups in order to enroll 
in the FFCC group.  Therefore, the online application and underlying logic must be programmed 
in a way that these applicants will not be required to provide information used to determine 
eligibility for the other mandatory groups, such as whether they are a parent or caretaker relative 
of a dependent child or if they are pregnant.  
 
In paper applications, states are encouraged to add instructions to direct individuals who attest to 
having aged out of foster care to skip questions used to determine eligibility for other mandatory 
eligibility groups, including but not limited to questions pertaining to pregnancy status, whether 
the individual is the primary caretaker of a dependent child, and income.  
 
In addition to being required to facilitate eligibility for the FFCC group through the single, 
streamlined application, states are encouraged to consider creating a separate, simplified 
application for youth formerly in foster care.  The simplified application should solicit only 
information necessary to determine eligibility to get more youth enrolled in coverage.  A 
simplified application is a tool that can remove barriers for some individuals who may be 
deterred by a longer application.  It may be used by trusted partners such as state child welfare 
agencies, advocates, and others who assist youth formerly in foster care to promote enrollment.  
States may also create consumer assistance tools that are particularly valuable to these applicants 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing 
requirements under the law.   Page 13  State Health Official 
 
and provide needed assistance (e.g., online application help text or call center scripts that 
include accurate information on the FFCC eligibility group).21  
 
CMS is committed to strengthening and simplifying the enrollment process for youth formerly in 
foster care and to supporting states in making necessary changes to their applications, as well as 
eligibility and enrollment processes, to implement the SUPPORT Act changes.  CMS is available 
to provide technical assistance to states on the development of simplified applications and on 
modifications to existing single, streamlined applications.  States are not required to submit a 
state plan amendment (SPA) to implement revisions to single, streamlined applications as a 
result of section 1002(a) of the SUPPORT Act, nor are the simplified applications described in 
this letter subject to CMS review or approval.  
 
Verification Plan Procedure 
 
States will likely need to update their verification processes to address how they will verify that 
an individual was receiving Medicaid while in foster care prior to aging out of foster care in 
another state.  Additionally, states may want to take the opportunity to streamline their 
verification processes for all youth formerly in foster care.  States are encouraged to accept self-
attestation of former foster care and/or Medicaid enrollment status, particularly for youth who 
were enrolled in Medicaid in another state while in foster care at the time of age-out.  This will 
minimize burden on new applicants and states alike, as this verification approach limits 
documentation requests of youth formerly in foster care, and there is not a consistent, 
streamlined way across states to connect with child welfare and Medicaid agencies.  Further, 
states that enroll all foster care children (including state-funded foster care children) in Medicaid 
may assume that an applicant indicating they were formerly in foster care in the state was also 
enrolled in Medicaid.22  In addition, because there is no income test, and because previous foster 
 
21 See slides 32-33, Centers for Medicare & Medicaid Services, Ensuring Continuity of Coverage for Foster Youth 
Aging Out of Foster Care and Young Adults Eligible for the Former Foster Care Group (September 2019). 
Available at: https://www.medicaid.gov/state-resource-center/mac-learning-collaboratives/downloads/foster-care-
ensuring-coverage-continuity.pdf. 
22 Centers for Medicare & Medicaid Services, Ensuring Access to Medicaid Coverage for Former Foster Care Youth 
(July 2017).  Available at: https://www.medicaid.gov/state-resource-center/mac-learning-
collaboratives/downloads/foster-care-ensuring-access.pdf.  
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing 
requirements under the law.   Page 14  State Health Official 
 
care and Medicaid enrollment status are not factors of eligibility subject to change, states do not 
need to re-verify these factors of eligibility when redetermining eligibility for enrolled youth.23 
 
States that do not accept self-attestation to verify former foster care and/or Medicaid enrollment 
status may adopt strategies to facilitate the verification process.  States are encouraged to 
develop contacts with their counterparts in other states to support timely verification of prior 
foster care and Medicaid enrollment status.  While federal law requires state child welfare 
agencies to provide any official documentation necessary to prove former foster care status for 
young adults aging out of foster care (who were in foster care for more than 6 months),24 many 
individuals may not have easy access to such documentation.  States must assist applicants in 
obtaining such documentation, if needed, to determine eligibility.  States should also establish 
guidelines and clear information that offer flexibility for applicants to provide alternative 
verification documentation to facilitate enrollment.  For example, if young adults no longer have 
court papers or other information issued by the child welfare agency documenting their status as 
formerly in foster care, a statement from the applicant, a former foster parent, or a caseworker 
could suffice.  
 
States should document their policies for verifying former foster care and Medicaid enrollment 
status in their state verification plan documents.  Since the FFCC group is a non-modified 
adjusted gross income (non-MAGI) group, states may address verification practices for this 
group where they document non-MAGI verification policies.  Some states have elected to 
document their policies for verifying former foster care status in their MAGI verification plans.  
CMS formally reviews MAGI verification plans and posts these documents to Medicaid.gov.25  
While CMS does not formally review separate non-MAGI verification plans at this time, 
documentation of such policies is necessary for audit purposes, including the Payment Error Rate 
Measurement (PERM) and Medicaid Eligibility Quality Control (MEQC) programs.  CMS is 
available to work with states on updates to their verification plans.  
 
23 Centers for Medicare & Medicaid Services, CMCS Informational Bulletin, Medicaid and Childrens Health 
Insurance Program (CHIP) Renewal Requirements, page 4 (December 2020).  Available at 
https://www.medicaid.gov/federal-policy-guidance/downloads/cib120420.pdf. 
24 See section 475(5)(I) of the Act.  Documentation that a child was previously in foster care added by section 
50753(e) of the Bipartisan Budget Act of 2018 (Pub. L. 115-123), effective February 9, 2018. 
25 See https://www.medicaid.gov/medicaid/eligibility/medicaidchip-eligibility-verification-plans/index.html.  
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing 
requirements under the law.   Page 15  State Health Official 
 
 
Updates to Presumptive Eligibility  
 
States are required to ensure that qualified hospitals participating in hospital presumptive 
eligibility (HPE) are able to make presumptive eligibility (PE) determinations for all populations 
identified in 42 C.F.R.  435.1103 covered under the state plan, including the FFCC group.26  
Similarly, states operating an optional PE program are required to ensure that all qualified 
entities are able to make PE determinations for the FFCC group if the state elects to provide PE 
for this population.27  In order to implement the SUPPORT Act changes, states with hospitals 
participating in HPE and entities that have opted to provide PE for the FFCC group must update 
their PE application or enrollment forms, as well as any materials used to train hospitals or other 
qualified entities, to ensure eligibility is appropriately assessed for the FFCC group.  Any 
updated application and provider training materials will need to reflect the existing limitations on 
eligibility for individuals who turn 18 prior to January 1, 2023, and the new requirements that 
will apply exclusively to those who turn 18 on or after January 1, 2023.  One example is that 
states will need to revise a PE application that asks, Was anyone who is applying for 
presumptive eligibility for Medicaid in foster care in the state at age 18? to determine eligibility 
based on the age of the individual.  States will also need to revise a PE application that asks 
whether the individual was in foster care under the responsibility of the state in which the 
individual is seeking PE upon attaining age 18, or in foster care under the responsibility of any 
state immediately prior to reaching such states maximum foster care age.  
  
States will not be required to submit a SPA to implement modifications to the HPE or PE 
application or provider training materials as a result of section 1002(a) of the SUPPORT Act.  
CMS is available to provide technical assistance to states as they review their HPE and/or regular 
PE applications and provider training materials to incorporate changes made by the SUPPORT 
Act.  
 
 
26 42 C.F.R.  435.1110(c)(1); Medicaid and CHIP FAQs: Implementing Hospital Presumptive Eligibility Programs.  
January 2014.  Available at: https://www.medicaid.gov/state-resource-center/faq-medicaid-and-chip-affordable-
care-act-implementation/downloads/faqs-by-topic-hospital-pe-01-23-14.pdf.  
27 42 C.F.R.  435.1103(b). 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing 
requirements under the law.   Page 16  State Health Official 
 
Eligibility and Enrollment Systems 
 
States that do not utilize section 1115 demonstration authority to align the eligibility 
requirements for youth formerly in foster care regardless of when they turn age 18 will need to 
make enhancements to their eligibility and enrollment systems to recognize when an individual 
turned age 18 (before January 1, 2023, or on/after January 1, 2023) in order to: (1) determine 
eligibility correctly for individuals who aged out of foster care in a different state and (2) apply 
the correct hierarchy of eligibility groups, depending on the individuals date of birth.28  
 
Enhanced federal financial participation (FFP) is available at a 90 percent matching rate for the 
design, development, or installation of improvements to Medicaid eligibility determination 
systems, in accordance with applicable federal requirements, including changes related to 
determinations of eligibility to implement the FFCC eligibility policy changes.29  Enhanced 75 
percent FFP is also available for operations of such systems, in accordance with applicable 
federal requirements.30  Receipt of these enhanced funds is conditioned upon states meeting a 
series of standards and conditions to ensure investments are efficient and effective.  
 
Other activities important to implementing the requirements of the SUPPORT Act, such as 
eligibility policy development and outreach, may be claimed under Medicaid at the 50 percent 
administrative matching rate, in accordance with regular claiming policies for such 
administrative activities.31  
 
SPA Submission  
 
 
28 States use information available to the Medicaid agency to conduct the eligibility determination. See slides 20-23, 
Centers for Medicare & Medicaid Services, Ensuring Access to Medicaid Coverage for Former Foster Care Youth 
(July 2017).  Available at: https://www.medicaid.gov/state-resource-center/mac-learning-
collaboratives/downloads/foster-care-ensuring-access.pdf. 
29 See section 1903(a)(3)(A)(i) of the Act and 42 C.F.R.  433.15(b)(3), 80 FR 75817-75843; 
https://www.medicaid.gov/stateresource-center/faq-medicaid-and-chip-affordable-care-act-
implementation/downloads/affordable-care-act-faq-enhancedfunding-for-medicaid.pdf; 
https://www.medicaid.gov/federal-policy-guidance/downloads/SMD16004.pdf. 
30 See section 1903(a)(3)(B) of the Act and 42 C.F.R.  433.15(b)(4). 
31 See section 1903(a)(7) of the Act and 42 C.F.R.  433.15(b)(7). 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing 
requirements under the law.   Page 17  State Health Official 
 
Because the eligibility state plan page for the FFCC group will be inaccurate once the SUPPORT 
Act requirements take effect on January 1, 2023, CMS has updated the Medicaid state plan 
template for the eligibility group in the MACPro system.  Each state must submit this Medicaid 
SPA to update its state plan to be consistent with the SUPPORT Act amendments.  In order for 
the FFCC SPA to have an effective date of January 1, 2023, states will need to submit their 
SPA no later than March 31, 2023, in accordance with CMS SPA regulations (42 C.F.R.  
430.12 and 430.20).  
 
As noted above, states are not required to submit SPAs to reflect changes to applications or 
presumptive eligibility state plan pages to implement the changes required by the SUPPORT Act 
discussed in this letter.  
 
Workarounds Prior to Systems Changes 
 
States may be faced with numerous competing priorities and challenges as they prepare to 
implement these SUPPORT Act changes.  Still, we remind states that they must begin 
implementing the new requirements as soon as possible.  Because states may need to make 
systems changes to determine eligibility of all youth formerly in foster care, we have developed 
several mitigation strategies and workarounds that states may use until they implement necessary 
changes.  We explain these strategies in a technical assistance slide deck for states, titled 
Medicaid Coverage of Youth Formerly in Foster Care  Changes under Section 1002(a) of the 
SUPPORT Act.  A link to the slide deck is found here: 
https://www.medicaid.gov/medicaid/eligibility/downloads/former-foster-care-coverage-
changes.pdf.  States that have not yet implemented needed system changes should review these 
strategies and workarounds to ensure compliance with the requirements and prompt enrollment 
of eligible individuals into Medicaid.  
 
 
 
 
 
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing 
requirements under the law.   Page 18  State Health Official 
Closing 
CMS is committed to working with state partners to reduce enrollment barriers and improve 
access to care for youth formerly in foster care.  CMS is available to provide continued technical 
assistance to states when implementing section 1002(a) of the SUPPORT Act.  If you have 
questions about the state plan requirements discussed in this letter, please contact Sarah 
Lichtman Spector, Director of the Division of Medicaid Eligibility Policy, Children and Adults 
Health Programs Group, at Sarah.Spector@cms.hhs.gov.  If you have any questions about a 
potential section 1115 demonstration project to facilitate ongoing Medicaid enrollment for this 
population, please contact Jennifer Kostesich, State Demonstrations Group, at 
Jennifer.Kostesich@cms.hhs.gov.  
Sincerely, 
Daniel Tsai 
Deputy Administrator and Director 
Cc: 
National Association of Medicaid Directors  
National Academy for State Health Policy  
National Governors Association  
American Public Human Services Association  
Association of State and Territorial Health Officials  
Council of State Governments  
National Conference of State Legislatures  
Academy Health 
State Child Welfare Agency Directors  
National Association of State Alcohol and Drug Abuse Directors 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing 
requirements under the law.   Page 19  State Health Official 
 
National Association of State Mental Health Program Directors 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing 
requirements under the law.   Appendix 
 
Resources for Ensuring Access and Continuity of Coverage for Youth Formerly in Foster 
Care  
 
Ensuring Continuity of Coverage for Foster Youth Aging Out of Foster Care and Young 
Adults Eligible for the Former Foster Care Group (September 2019) 
 
This Medicaid and CHIP Coverage Learning Collaborative deck provides an overview of 
changes made to the FFCC group under the SUPPORT Act, reviews requirements and best 
practices related to eligibility and enrollment of youth formerly in foster care, and shares best 
practices for conducting outreach to youth formerly in foster care.  The guidance in the deck 
includes requirements for redetermining eligibility at the time youth age out of foster care to 
ensure continuity of coverage, steps to enroll otherwise eligible individuals who move to a new 
state or need to re-enroll in coverage, and best practices for verifying former foster care status 
when a new application is needed. 
 
States may access the September 2019 slide deck at: 
https://www.medicaid.gov/state-resource-center/mac-learning-collaboratives/downloads/foster-
care-ensuring-coverage-continuity.pdf. 
 
Ensuring Access to Medicaid Coverage for Former Foster Care Youth (June 2017)  
 
This Medicaid and CHIP Coverage Learning Collaborative deck provides an overview of 
coverage in the FFCC group and steps for states to process applications and renewals for youth 
formerly in foster care who turn 18 before January 1, 2023.  The deck also includes guidance that 
is applicable to enrolling youth formerly in foster care regardless of when they aged out of foster 
care, including accepting self-attestation of former foster care status and Medicaid enrollment. 
 
States may access the June 2017 slide deck at: 
https://www.medicaid.gov/state-resource-center/mac-learning-collaboratives/downloads/foster-
care-ensuring-access.pdf. 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless 
specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing 
requirements under the law.