Health Conditions, Utilization, and Expenditures of Children in Foster Care. Medicaid Eligibility Dynamics

09/19/1999

Research has shown that continuous health insurance coverage improves access to health care among low-income children (Weissman et al. 1999; Burstin et al. 1998/99; Berman et al. 1999). Lack of continuity in coverage, that is, coverage for less than the full year, can lead to discontinuities in access to health care, including both primary and specialty care. For foster care children, transitions in health insurance coverage (or discontinuation of coverage altogether) can lead to changes in providers, which in turn can lead to duplication of tests and immunizations, changes in treatment protocols, and missed opportunities for care.

We examined the continuity of Medicaid coverage for foster care children, compared to that of children in other groups (Table III.4 and Figure III.3). (We cannot discern from Medicaid enrollment data whether children who disenrolled from Medicaid obtained other coverage or became uninsured.) Across the three states, about 7 in 10 foster care children were enrolled continuously in Medicaid for all of 1994. Only about 1 in 10 were enrolled for less than half the year. The average length of enrollment was 10.3 to 10.6 months. Children receiving SSI benefits and those in families receiving adoption assistance more often had continuous Medicaid coverage than foster care children. Eighty to 90 percent of SSI and adoption assistance children were enrolled for 12 months. In general, continuity of Medicaid coverage among foster care children was similar to that among AFDC children, except in Florida, where turnover among AFDC children was quite high (only 56 percent were enrolled the full year).(3) These results reflect the orientation of AFDC and foster care to provide temporary services during times of crisis, whereas SSI and adoption assistance are targeted to children who stay eligible for long periods of time (SSI due to disability and adoption assistance usually until the child reaches age 18).

Table III.4:
Continuity of Medicaid Coverage, by Category of Medicaid Eligibility, 1994.
    Category of Medicaid Eligibility
 All Children(a) Foster care Adoption Assistance AFDC SSI
Length of Medicaid Eligibility in 1994
California (N=3,603,056) (N=111,236) (N=18,922) (N=2,095,890) (N=68,667)
Total 100.0% 100.0% 100.0 100.0 100.0
1 to 5 months 19.7 12.7 8.6 9.7 7.3
6 to 11 months 22.8 17.1 12.3 16.4 10.5
12 months 57.4 70.2 79.1 73.9 82.1
Mean (in months) 9.4 10.3 10.8 10.6 11.0
Florida (N=1,247,470) (N=14,011) (N=6,545) (N=638,259) (N=60,813)
Total 100.0% 100.0% 100.0% 100.0% 100.0%
1 to 5 months 25.0 9.5 5.0 19.3 8.1
6 to 11 months 28.2 18.2 6.0 24.8 10.7
12 months 46.9 72.3 89.0 55.9 81.3
Mean (in months) 8.8 10.6 11.3 9.5 10.9
Pennsylvania (N=860,223) (N=28,390) (N=3,847) (N=456,127) (N=38,177)
Total 100.0% 100.0% 100.0% 100.0% 100.0%
1 to 5 months 14.5 9.5 3.8 11.3 4.7
6 to 11 months 18.4 17.7 5.9 14.2 7.9
12 months 67.1 72.8 90.4 74.5 87.4
Mean (in months) 10.1 10.6 11.5 10.5 11.3
Percent with 12 Months Continuous Coverage Over a 24-month Period
California 73.0 83.1 87.8 83.9 89.2
Florida 64.5 84.8 92.6 70.5 87.7
Pennsylvania 77.6 77.6 94.8 82.2 91.9
Source:  HCFA State Medicaid Research Files.
Note:  Numbers may not sum to total due to rounding.
a.  Includes children in other categories of Medicaid eligibility.

Figure III.3
Continuous 12-Month Medicaid Coverage, by Category of Medicaid Eligibility, 1994

Figure III.3: Continuous 12-Month Medicaid Coverage, by Category of Medicaid Eligibility, 1994.

We also examined continuity of Medicaid coverage over a 24-month period to determine whether patterns of coverage differed over a longer time horizon. As expected, continuity improved over a two-year period, such that 83 percent of foster care children in California, 85 percent in Florida, and 78 percent in Pennsylvania had 12 months of continuous coverage within a 24-month period. Nevertheless, foster care children were less likely to have continuous coverage than the other groups, with the exception of AFDC children in Florida who still had a very high rate of turnover. When children entered foster care, were they newly enrolled in Medicaid or did they have Medicaid coverage through another eligibility category? The percent without prior Medicaid coverage when foster care eligibility began ranged from 27 percent in Florida to 45 percent in California (Table III.5). Among those with prior Medicaid coverage, the largest share across all three states came from AFDC. Thus, the majority of foster care children were known to the "Medicaid system" at the time their foster care eligibility began.

Table III.5:
Medicaid Status of Children in Months 1, 3, 6, and 12 Before Entering and After leaving Foster Care Eligibility, 1994-1995.(a)
  California (N = 44,525) Florida (N = 5,383) Pennsylvania (N = 10,979)
Medicaid Status Before Entering Foster Care Month 1 Month 3 Month 6 Month 12 Month 1 Month 3 Month 6 Month 12 Month 1 Month 3 Month 6 Month 12
Total 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
Not Enrolled in Medicaid 44.6 40.5 41.5 45.6 27.1 31.1 36.5 42.3 30.8 35.6 38.1 40.1
Enrolled in Medicaid
  • Foster care
-- 4.5 8.7 9.4 -- 1.5 4.5 5.2 -- 2.0 5.7 8.1
  • Adoption Assistance
0.1 0.1 0.1 0.1 1.3 1.3 1.2 0.9 0.4 0.4 0.4 0.4
  • AFDC
29.2 37.2 37.8 36.5 36.1 41.8 39.6 37.8 38.5 42.4 41.2 38.4
  • SSI
0.7 1.0 0.9 0.8 0.6 0.7 0.7 0.7 3.6 3.7 3.6 3.1
  • Other
25.3 16.6 10.9 7.7 34.9 23.5 17.5 13.1 26.7 16.1 11.1 9.8
  California (N = 43,315) Florida (N = 5,044) Pennsylvania (N = 10,075)
Medicaid Status After Leaving Foster Care Month 1 Month 3 Month 6 Month 12 Month 1 Month 3 Month 6 Month 12 Month 1 Month 3 Month 6 Month 12
Total 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
Not Enrolled in Medicaid 36.5 38.4 42.4 51.4 48.4 43.5 42.0 42.8 52.2 51.1 49.8 51.7
Enrolled in Medicaid
  • Foster care
-- 4.2 9.2 10.6 -- 1.3 5.2 7.6 -- 2.1 6.3 9.4
  • Adoption Assistance
0.7 0.8 0.8 0.8 17.2 17.2 17.1 17.1 4.6 4.6 4.6 4.5
  • AFDC
16.0 19.8 20.1 18.9 24.1 26.5 25.2 22.4 27.5 28.2 26.1 21.9
  • SSI
3.3 3.5 3.5 3.5 3.7 4.2 4.6 5.1 3.3 3.6 4.0 4.5
  • Other
43.5 33.4 24.1 15.0 6.6 7.2 6.0 4.9 12.4 10.4 9.3 8.0
Source:  HCFA State Medicaid Research Files.
Note:  Numbers may not sum to total due to rounding.
a.  Data for Pennsylvania are for 1993-1994.

At the other end of the continuum, when children left foster care, what happened to their Medicaid eligibility? We see from the bottom panel of Table III.5 that one-third to one-half were not enrolled in Medicaid the month after their foster care eligibility ceased. Among those remaining on Medicaid, most became eligible for AFDC (or resumed AFDC), except in California, where most entered an "other" category while awaiting a final eligibility determination. In California, we observe a gradual increase in the number not enrolled in Medicaid following the end of foster care eligibility as a final eligibility determination was made. Additionally, 11 percent returned to foster care by the end of the 12- month period.

In Florida, discontinuation of Medicaid coverage among foster care children held steady at 42 to 48 percent over the 12-month period. About one in seven appear to have been adopted and were receiving adoption assistance. One in four obtained AFDC coverage. At the end of the 12-month period, foster care children in Florida were more likely than those in other states to be enrolled in Medicaid. That seems to be due to the higher rate of eligibility due to adoption assistance in Florida, compared to the other two states.

In Pennsylvania, about half of those leaving foster care were not enrolled in Medicaid the month after foster care eligibility ended, and this pattern held throughout the 12-month period. In general, the patterns after 12 months were similar to those in California.