FAQs
Note: The following questions all relate to Medicaid (Title XIX) eligibility and receipt of services by children who are eligible for Title IV-E adoption assistance. In the legal citations following the answers, the letters, “U.S.C.” refers to the United States Code and “C.F.R.” refers to the Code of Federal Regulations. All national laws are found, or codified, in the United States Code. Medicaid and Title IV-E laws are given guiding regulations that are found in the Code of Federal Regulations. You can find the law of the United States Code and regulations of the Code of Federal Regulations at the following links.
United States Code: http://www.gpoaccess.gov/USCODE/index.html
Code of Federal Regulations: http://www.gpoaccess.gov/CFR/INDEX.HTML
Retrieve using CFR citation: http://www.gpoaccess.gov/CFR/retrieve.html
- Is it mandatory for a child to receive Medicaid if the child is eligible for Title IV-E adoption assistance?
Yes, it is mandatory for children to receive Medicaid if they are eligible for Title IV-E adoption assistance. Individuals eligible for Title IV-E adoption assistance are in a Medicaid eligibility group known as “mandatory categorically needy”. This means that their receipt of Medicaid is automatic by virtue of their eligibility for Title IV-E adoption assistance. A separate Medicaid application is unnecessary and precluded by law.
Cite: 42 U.S.C. §1396a (10)(A)(i)(I); 42 C.F.R. §§435.115(1), 435.145, 435.909 and 436.114.
- Is it necessary for an adoption assistance maintenance payment to be made on behalf of a Title IV-E adoption assistance eligible child in order for the child to receive Medicaid?
No, it is not necessary for a child to receive a Title IV-E adoption assistance maintenance payment in order to receive Medicaid. The law only requires that an adoption assistance agreement be in effect under Title IV-E of the Social Security Act, “whether or not adoption assistance is being provided”.
Note: States have various names for an adoption assistance agreement with a maintenance payment of zero. These agreements are often called deferred adoption assistance. States also refer to them as “dormant subsidies”, “zero cash payment agreements”, “agreement only assistance”, “medical/Medicaid only agreements”, and “conditional agreements”. A deferred adoption assistance agreement allows the adoptive family an opportunity to activate assistance and/or add a maintenance payment after adoption finalization if there is a change in the needs of the child.
Cite: 42 U.S.C. §§673(b) and 1396a (10)(A)(i)(I); 42 C.F.R. §§435.115 (e)(1) and 435.145.
- Is a new state of residence required to provide a particular Medicaid service to a child eligible for Title IV-E adoption assistance if the child received the service from the Medicaid program in a previous state of residence?
No, a new state of residence is not required to provide a particular Medicaid service to a Title IV-E adoption assistance eligible child simply because the child was receiving the service in a previous state of residence. States can only provide services as listed in their Medicaid State Plan. If the child received a service in a previous state (“old state”) that is not in the resident state’s Plan, the service cannot be received from the resident state (“new state”).*
There are mandatory Medicaid services that all states must provide and there are services that are optional under Medicaid. States can elect which, if any, optional services they will provide under their Medicaid program. It is possible for a child to have received an optional Medicaid service in one state and move to another state whose Medicaid program does not include that service.
Practice issue: If the language of the adoption assistance agreement states that the Medicaid services of the adoption assistance state are to be provided or if the agreement specifies that a particular medical service would be provided, the adoption assistance state remains responsible for ensuring the receipt of that service.
*Note: Exception to the above answer. Early and Periodic Screening, Diagnosis and Treatment (EPSDT). EPSDT is one of the mandatory services of the Medicaid program. Under EPSDT, if a service is deemed medically necessary for a child to receive, states must cover the service, even if the service is not in the state’s Medicaid State Plan. See Question #4 below for more on EPSDT.
Cite: 42 U.S.C. §§1396d (a)(4)(B) and (r); 42 C.F.R. 441 Subpart B.
- What is EPSDT?
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) is one of the mandatory services of the Medicaid program. Therefore, all states must provide EPSDT services to individuals under the age of 21, even when the service is not in the state’s Medicaid State Plan, if the service is deemed “medically necessary” for the child to receive. This obligation is limited to mandatory and optional services potentially covered by a state’s Medicaid program under the State Plan. States must also make necessary exceptions to across-the board limits in amount, duration, and scope of services.
Note: The Medicaid program is administered by a Federal agency, the Centers for Medicare and Medicaid Services (CMS), in partnership with the states. Information on the EPSDT program can be found on the CMS website at: http://www.cms.hhs.gov/MedicaidEarlyPeriodicScrn/. Information includes the following: Overview, EPSDT Benefits, and State Agency Responsibilities.
Cite: 42 U.S.C. §§1396d (a)(4)(B) and (r); 42 C.F.R. 441 Subpart B.
- If a Title IV-E adoption assistance eligible child is Medicaid eligible in one state and moves to another state in which they are unable to receive Medicaid(for example when states differ in the age to which they provide Medicaid for children receiving adoption assistance), can the child receive a Medicaid service in the new state if the service is deemed medically necessary under EPSDT?
No, a child may not receive a Medicaid service in a state in which they are ineligible for the Medicaid program. EPSDT is not a separate program from Medicaid. EPSDT is a mandatory service of the Medicaid program. A child must be eligible for Medicaid in the new state to be able to receive any Medicaid service, including EPSDT.
The child, however, remains eligible for adoption assistance under Title IV-E and this eligibility carries with it mandatory categorical eligibility for Medicaid (See Question #1 above). Given that the adoption assistance agreement between the family and the adoption assistance state is a contract and the terms of the contract remain in effect regardless of where the family lives, the child may be able to receive medical assistance from the adoption assistance state to fulfill the obligations of the adoption assistance agreement.
Cite: 42 U.S.C. §1396 (a)(10)(A).
- Which state is responsible for providing Medicaid when a Title IV-E adoption assistance eligible child is placed in a Residential Treatment Facility (RTF) outside the state in which they usually reside?
The state in which the RTF is located is responsible for providing Medicaid to a Title IV-E adoption assistance who is receiving care from the facility. Federal law states that Title IV-E adoption assistance eligible children are eligible to receive Medicaid from the state in which they live. Where a child lives can be different than where they reside. Residence is a legal term that is used to describe a physical presence in the state and intent to stay in the state. A child is considered to be living in the RTF during their treatment period and, therefore, the state in which the RTF is located is required to provide Medicaid to a Title IV-E adoption assistance eligible child during their stay.
Note: This answer also applies to residential educational placements out-of-state.
Cite: 42 U.S.C. §§ 673 (b)(1) and 1396a(10)(A)(i)(I); 42 C.F.R. §§ 435.145 and 435.403(g).
- Can Medicaid be terminated for a Title IV-E adoption assistance eligible child if a family does not complete a redetermination of adoption assistance eligibility?
No, Medicaid cannot be terminated under Title IV-E adoption assistance if a family does not complete a redetermination of adoption assistance eligibility. There is no Federal requirement to assess Title IV-E adoption assistance eligibility after the initial state assessment. Medicaid for this population is based on eligibility for Title IV-E adoption assistance and can be terminated only under the following three circumstances:- Child has attained the age of eighteen (or, where the State determines that the child has a mental or physical handicap which warrants the continuation of assistance, the age of twenty-one)
- Parent(s) is no longer legally responsible for the support of the child (legal custody)
- Parent(s) is no longer providing any support* to the child
Since a failure to complete a redetermination of adoption assistance eligibility is not a listed circumstance for termination, Title IV-E adoption assistance eligibility would continue and the child would remain Medicaid eligible and continue to receive Medicaid services.
*Note: Support can be other than financial, such as providing items of clothing or maintenance of the child’s room in the home.
Cite: 42 U.S.C. §673 (a)(4).
Practice issue: Medicaid eligibility, with respect to circumstances that may change, however must be (re)determined at least every 12 months. This requirement extends to all Medicaid recipients, including adoption assistance eligible children. Federal law allows for the greatest ease and least involvement of the family in the (re)determination. As Title IV-E adoption assistance confers automatic eligibility for Medicaid, a child’s continued eligibility for the assistance program is confirmation of continued eligibility for Medicaid. The practice is known as “passive redetermination” and is commonly used to meet the Federal law requiring determinations of eligibility for all Medicaid recipients on an annual basis. See the Federal law at 42 C.F.R. 435.916 Periodic Redeterminations of Medicaid eligibility and 42 C.F.R. 435.902 Simplicity of administration regarding Medicaid program requirements.
- Can Medicaid be terminated or suspended if a state attempts to withhold Title IV-E adoption assistance payments while a child is in a Residential Treatment Facility?
No, Medicaid cannot be terminated or suspended if a state attempts to withhold Title IV-E adoption assistance payments while a child is in a Residential Treatment Facility. Title IV-E adoption assistance can be terminated only under three conditions. (See Question #7 above.) Title IV-E adoption assistance cannot be terminated, suspended, or discontinued for any other reason. Withholding adoption assistance payments due solely to a temporary placement outside the home, as in the circumstance of an RTF placement, is impermissible. As long as a parent continues to provide any support to the child, the child remains eligible for Title IV-E adoption assistance and, is, therefore, Medicaid eligible.
*Note: Support can be other than financial, such as providing items of clothing or maintenance of the child’s room in the home.
Cite: 42 U.S.C. §673 (a)(4).
- Is it possible for a Title IV-E adoption assistance eligible child to receive Medicaid past the age of eighteen?
For children receiving Title IV-E adoption assistance, Medicaid receipt is not considered separately from their adoption assistance eligibility. Adoption assistance eligibility is the basis for Medicaid eligibility for most Title IV-E adoption assistance children.
The real question is, “Can a child receive Title IV-E adoption assistance past the age of eighteen?”
And the answer is, “Yes, a child can receive Title IV-E adoption assistance past the age of eighteen.”
It is the adoption assistance state’s option to continue adoption assistance past the age of eighteen. If the adoption assistance state determines that a child has a mental or physical handicap that warrants the continuation of assistance, the state can continue assistance up to the age of 21. Since children who are Title IV-E adoption assistance eligible are also eligible for Medicaid, the Medicaid would also continue in the state in which the child lives, so long as that state provides Medicaid for this eligibility group past the age of eighteen.
Practice issue: Interstate implications of the extension of Title IV-E adoption assistance past the age of eighteen. It is at the option of the adoption assistance state to extend the receipt of adoption assistance past the age of eighteen. It is mandatory for all states to provide Medicaid through the age of eighteen and it is at state option whether to continue Medicaid past the age of eighteen. States can choose to extend Medicaid coverage through the age of nineteen or twenty, up to the age of 21. If the child lives in a state that ends Medicaid coverage for children receiving adoption assistance at an age lower than the age to which the adoption assistance state extends a child’s adoption assistance, the child may not be able to receive Medicaid from the resident state, unless the child is determined Medicaid eligible in a different category. If the child is eligible for Title IV-E adoption assistance, they are mandatorily eligible for Medicaid, but may need to look to the adoption assistance state for Medicaid coverage.
Cite: 42 U.S.C. §§673 (a)(4), 1396a and 1396d.
- Does Medicaid eligibility end if a Title IV-E adoption assistance eligible child’s adoptive parent(s) dies, or the adoption dissolves?
Yes, Medicaid eligibility through Title IV-E adoption assistance eligibility ends if a child’s adoptive parent(s) dies, or the adoption dissolves and the child is not readopted. The child must be adopted to receive adoption assistance, and the Medicaid that accompanies it. The child may be eligible for Medicaid through another eligibility category, such as Supplemental Security Income for the Aged, Blind, or Disabled (SSI) under Title XVI of the Social Security Act.
Cite: 42 U.S.C. §§673 (a)(4) and 1381-1383(f).
Practice issue -in the event of the death of a parent: If a child initially has two adoptive parents and one parent dies, the name of the deceased parent can be removed from the agreement and adoption assistance can continue if the adoption assistance agreement includes the signatures of both parents. If the child initially had one adoptive parent and the agreement was completed with that parent and that parent dies (or two adoptive parents and both parents die), the child would need to be readopted and another adoption assistance agreement would have to be negotiated in a subsequent adoption.
Practice suggestion: If the child initially has one adoptive parent, and that parent gains a partner or individual who adopts the child, the agreement can be updated with the signature and information of the second adoptive parent. This measure is a safeguard in case one of the parents dies and is survived by the second adoptive parent. In this way, the adoption assistance agreement could remain in effect and the child’s benefits and services could continue uninterrupted.
- Is the child in the question above (Question #10) Medicaid eligible if the child is placed with an aunt and uncle who were made legal guardians of the child in the deceased parent’s will?
No, Medicaid eligibility ends through Title IV-E adoption assistance if a child’s adoptive parent(s) dies, or the adoption dissolves and the child is not readopted. (SeeQuestion #10.) Legal guardianship is not adoption, so Medicaid through the adoption assistance program would end unless and until the child was readopted. However, the child may be eligible for Medicaid through another eligibility category/program, and the adoption assistance state staff can connect the child and family to other federal, state, or non-profit sources to find assistance. Examples include the following:- State Children’s Health Insurance Program (SCHIP)
- Medicaid (income-based and other categorical eligibility)
- Non-profit state or national support and advocacy organizations that address a child’s specific special need(s) can assist adoptive families in locating or funding services.
Examples:- Easter Seals, link: http://www.easterseals.com
- Autism Society of America, link: http://www.autism-society.org
- American Association on Intellectual and Developmental Disabilities: http://www.aamr.org.
- Which state is responsible for providing Medicaid to a Title IV-E eligible child if the child’s adoption dissolves while s/he is living outside the adoption assistance state - the adoption assistance state or the state in which the child currently lives?
No state is responsible for providing Medicaid to a child based on adoption assistance eligibility unless the child is readopted. If the child enters care of a state at the time of disruption (i.e., the adoption process ends prior to finalization) or dissolution (i.e., the adoption fails after finalization), that state is responsible for the application for and determination of Title IV-E adoption assistance eligibility in a subsequent adoption and the provision of Medicaid that would accompany that eligibility.
If a child does not enter custody of a state at the time of disruption or dissolution and is subsequently adopted, the state of the adoptive parents is responsible for the application and drafting of the agreement for Title IV-E adoption assistance and the provision of Medicaid.
Cite: 42 U.S.C. §673 (a)(2)(C)
- Can an Interstate Compact on Adoption and Medical Assistance (ICAMA) member state require documentation of the Title IV-E eligibility determination made by the adoption assistance state in addition to the ICAMA 6.01 form before providing Medicaid in an interstate case?
No, under the ICAMA, an ICAMA member state should not require documentation of the Title IV-E eligibility determination in addition to the ICAMA 6.01 form before providing Medicaid in an interstate case. Under the Compact and member standard practice, a completed ICAMA 6.01 accompanied by a copy of the fully executed adoption assistance agreement is all that is required of the sending state (the adoption assistance state) to send the receiving state (the resident state) in order for the receiving state to initiate Medicaid for a Title IV-E adoption assistance eligible child.
Cite: The Interstate Compact on Adoption and Medical Assistance, Section E of the 6.01 ICAMA form, Certification (Reflecting back to what is listed in Section A. 6, Basis of Medicaid Eligibility
- Can Medicaid be received outside the United States?
Yes, Medicaid can be received outside the United States. Medicaid can be received in U.S. territories. There are Medicaid programs in Guam, Puerto Rico, the American Virgin Islands, the Northern Mariana Islands, and American Samoa.
Note: There are no Medicaid programs in Mexico or Canada.
Cite: 42 C.F.R. §§435-436.
- Can an adoption assistance eligible child maintain a Medicaid card from more than one state?
Medicaid is generally received through an individual’s state of residence. Residence for Title IV-E adoption assistance eligible children is defined as where they live- in general, where they are physically located. A child can only be physically present in one state at a time. Since a child is only in one place at one time and a child is eligible for Medicaid in only one state at any one time, only one Medicaid card would be in effect at a time. Even if a child physically had more than one Medicaid card, only one of the cards would be in effect at a time and the corresponding state would be the state able to claim Federal Financial Participation (FFP), financial reimbursement, at that time.
Note: It is not required for a state to issue a Medicaid card to confirm an individual’s Medicaid enrollment. States can create a Medicaid case number that families can use to receive services prior to the production of a Medicaid card. Additionally, a state may issue more than one card, such as an eligibility card issued by the state’s Medicaid program and a managed care enrollment card issued by the child’s managed care organization.
Possession of a Medicaid card does not necessarily guarantee that the child is currently enrolled in that state’s Medicaid program. Providers are encouraged to verify an individual’s current Medicaid enrollment before rendering services, using the state Medicaid program’s eligibility verification system. Out-of-state providers may be enrolled in a state’s Medicaid program, especially in border areas, and are able to provide Medicaid services through multiple states’ Medicaid programs.
Cite: 42 U.S.C. §§ 673(b)(1) and 1396a(10)(A)(i)(I); 42 C.F.R. §§ 435.145 and 435.403(g).
Special Note on Title IV-E Assistance: Title IV-E Subsidized Guardianship Waivers
The Federal government funds what are referred to as “waiver projects”. Examples include waivers for Medicaid and for child welfare. The programs are called “waiver” because the Federal government allows the project to 'waive' certain Federal, statutory rule(s) such as the requirement that all eligible persons within a state be offered the same services. The child welfare waivers are “1130 waivers”, named for the section in the Social Security Act in which they are codified. The waivers allow states to spend Federal Title IV-E funds for supports and services other than foster care and adoption assistance maintenance.
Public Law 103-432 in 1994 introduced Federal waivers for child welfare programs. Waivers were offered to promote innovation in child welfare practice to improve outcomes. Waivers had to be cost-neutral to the government and include a third-party evaluation of efficacy. The Adoption and Safe Families Act (ASFA) of 1997 extended and expanded the authority to use waivers for child welfare programs. Most projects were approved for a five year application, with the possibility of extension at the discretion of the Secretary of the Department of Health and Human Services.
Though the federal statute authorizing demonstration waivers was not reauthorized in 2006, there are several states whose waivers are still in effect. The waiver that affects interstate issues in foster care and adoption is the project aimed at increasing permanency through subsidized guardianship. These children eligible under a Title IV-E waiver, and, as such, are Title IV-E eligible and therefore, Medicaid eligible. The following questions address the provision of Medicaid to children receiving Title IV-E under a subsidized guardianship waiver.
- Are children under a Title IV-E guardianship waiver eligible for Title XIX Medicaid in the state that determined the child to be eligible for subsidized guardianship (i.e., the guardianship state)?
Yes, children under a Title IV-E guardianship waiver are eligible for Title XIX Medicaid in their guardianship state or in any state in which they live if different than the guardianship state. All Title IV-E children, including children under guardianship waivers, are treated like other Title IV-E eligible children in that they are in what is known as a Medicaid “mandatory categorically needy” eligibility group. This means that they are part of an eligibility group that all states are required to include in their Medicaid coverage.
Cite: 42 U.S.C. §1396a (10)(A)(i)(I).
- If a child under a Title IV-E guardianship waiver moves from their guardianship state to another state, are they eligible for Title XIX Medicaid from their new state of residence?
Yes, a child under a Title IV-E guardianship waiver who moves from the child’s guardianship state to another state is eligible for Title XIX Medicaid from the new state in which the child lives. Title IV-E recipients are “mandatory categorically needy” and their eligibility for Title IV-E confers automatic eligibility for Medicaid in any state where they live.
Cite: 42 U.S.C §§ 673(b)(1) and 1396a(10)(A)(i)(I); 42 C.F.R. §435.145.