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 Navigating the ACA: Mapping Medicaid for Adolescent Health

By Jane Park, MPH
Project Coordinator, National Adolescent and Young Adult Health Information Center

Much of implementation of the Patient Protection and Affordable Care Act of 2010 (the ACA) is happening at the state level. State Title V MCH programs are uniquely positioned to help ensure that ACA implementation meets the needs of adolescents and young adults. Below we highlight some ACA provisions relevant to adolescents and young adults, taken from a longer brief,1 and offer ideas for how state MCH programs can address the needs of young people. This article does not address the intricacies of children and youth with special health care needs, however, AMCHP has a fact sheet Health Care Reform: What’s in it for Children and Youth with Special Health Care Needs? written by Meg Comeau from the Catalyst Center, that provides more in-depth analysis on these issues.

Individual Mandate
Beginning in 2014, most individuals will be required to have health insurance coverage that meets certain criteria and may be fined if they do not obtain this coverage. For adolescents under age 18, their parents will generally be responsible for meeting this requirement, while most young adults age 18 and older will have this responsibility.

Private Insurance
Most private health plans are prohibited from excluding people with preexisting conditions from coverage (effective in 2010 for under age 18 and in 2014 for over age 18). The Insurance Marketplaces (AKA health insurance exchanges) will allow individuals, families, and small businesses to shop for and purchase health insurance coverage beginning October 2013 with coverage starting January 2014. Tax credits and cost-sharing assistance will help defray costs of care and premiums for most lower-income populations who purchase insurance through the marketplace’s individual market. Beginning in 2014, non-grandfathered health plans in the marketplace must cover a set of 10 Essential Health Benefits (EHB), which are based on state-specific EHB benchmark plans. These include services that are especially important for young people, such as mental health and substance abuse disorder services, preventive and wellness services and chronic disease management, and pediatric services, including oral and vision care. All private plans must cover a range of preventive services without cost sharing; key services for youth include immunizations, screening for sexually transmitted infections, depression, and alcohol and tobacco use.

Two ACA provisions are specific to young adults. First, The "Age 26 Provision," effective September 2010, requires most health plans to allow adult children to remain on their parents’ plan up to age 26. Second, states may choose to offer Catastrophic Coverage to young adults under age 30. This coverage generally includes low premiums, high deductibles, and minimal coverage of ambulatory care and coverage of recommended preventive services without cost sharing.

Medicaid Expansions
For children ages six to 18, states are required to expand eligibility to 133 percent of the federal poverty level (FPL). States may choose to expand Medicaid up to 133 percent FPL for most adults. The ACA also includes several other provisions related to Medicaid, including a requirement that states continue coverage of youth aging out of foster care until age 26.

Next Steps
The growth and development of these transitional years brings opportunities and challenges for promoting health. This is a period of increasing independence, when many youths experiment with and settle into adult roles. Health may be affected by daily health habits adopted by youth (e.g., diet and exercise patterns), and by behaviors in areas such as sexual activity, substance use and driving. Many youths with special health care needs (YSHCN) take a greater role in managing their health and health care. The adolescent and young adult years also are critical with regard to mental health, as symptoms of most disorders first emerge before age 24.

Adolescents and young adults need a complex set of developmentally appropriate health care services. All youths need access to preventive services, such as screening for risky behaviors and mental health disorders. YSHCN need transition services that enable them – to the extent possible – to take charge of their care, while taking on adult roles. State choices regarding ACA implementation will shape how well the health care system will meet these needs. State MCH programs are in a unique position to ensure that state implementation address these needs. Some key areas where the expertise of Title V MCH programs might provide extra insights and expertise in regards to youth and young adults are:

  • How well do the marketplaces facilitate enrollment in appropriate plans?
    Each state program to support outreach, education and enrollment into health insurance will vary, however Title V MCH programs have historically played an important role in outreach and enrollment for MCH populations, and this could be an important opportunity to continue this role in ensuring that all women, children and their families have the necessary support to navigate the new health insurance coverage landscape when the marketplaces open in October 2013.
  • What services are included in the essential health benefits package in each state?
    Given the unique health needs of adolescents and young adults, state MCH programs should familiarize themselves with the essential health benefits that are covered in their state plans to better understand where gaps in coverage might appear.
  • How are states implementing the Medicaid expansions for children and adolescents ages six to 18 and for former foster youth? How easily can these youth be enrolled in Medicaid and gain access to services?
    State MCH programs should understand the "single streamlined application" for which consumers may apply for either affordability programs to purchase health insurance, Medicaid and shop for health insurance.
  • Have states opted to implement the adult Medicaid expansion? If not, are some young adults left uninsured due to a gap between Medicaid and the exchange eligibility levels?
    State MCH programs should understand where these gaps in insurance coverage might arise due to a state choosing not to expand Medicaid coverage. Even if a state has elected to expand Medicaid, state MCH programs should be aware of the possibility of churning between Medicaid and private health insurance due to fluctuations in income levels and determine what role Title V can play in ensuring continuity of care for adolescents and young adults.

  • How will full implementation of the ACA impact school-based health centers?
    Many state Title V programs help fund school-based health centers, which typically provide a combination of primary care, mental health care, substance abuse counseling, case management, dental health, nutrition education, health education and health promotion with an emphasis on age-appropriate services. Through funding made available by the Affordable Care Act, hundreds of thousands more students will receive this important health care to keep them healthy and in school.2 In an era where there will be higher demand for primary care providers, these school-based health centers will provide critical, age-appropriate capacity to adolescents.

1 English A & Park MJ. (2012). The Supreme Court ACA Decision: What Happens Now for Adolescents and Young Adults? Chapel Hill, NC: Center for Adolescent Health & the Law; and San Francisco, CA: National Adolescent and Young Adult Health Information Center, 2012.

2 U.S. Department of Health and Human Services. The Affordable Care Act and the School-Based Health Center Capital Program. Dec. 8, 2011. Access Apr. 22, 2013.

Abigail English, JD, director, Center for Adolescent Health and the Law and Jazmyn Scott, project associate, National Adolescent and Young Adult Health Information Center, division of adolescent and young adult medicine, University of California, San Francisco (who will receive her MPH in May) also contributed to this article.