Youth Transitioning from Foster Care: Background and Federal Programs

Summary: While many young people have access to emotional and financial support systems throughout their early adult years, older youth in foster care and those who are emancipated from care often lack such security. This can be an obstacle for them in developing independent living skills and building supports that might ease their transition to adulthood. Older foster youth who return to their parents or guardians may continue to experience poor family dynamics or lack supports, and studies have shown that recently emancipated foster youth fare poorly relative to their counterparts in the general population on measures such as education and employment.

Summary: The federal government recognizes that older youth in foster care and those who have been emancipated, or aged out, are vulnerable to negative outcomes and may ultimately return to the care of the state as adults through the public welfare, criminal justice, or other systems. The U.S. Department of Health and Human Services (HHS) administers the primary federal programs that are targeted to these youth. These include the federal foster care program and the John H. Chafee Program for Successful Transition to Adulthood program ("Chafee program"), both of which are authorized under Title IV-E of the Social Security Act.

Summary: Foster care is a temporary living arrangement intended to ensure a child's safety and well-being until a permanent home can be re-established or newly established. Under the Title IV-E foster care program, a public child welfare agency must work to ensure that each child who enters foster care is safely returned to his/her parents, or, if this is determined not to be possible or appropriate (by a court), to find a new permanent home for the child. Jurisdictions (states, territories, and tribes) may seek reimbursement for youth to remain in care up to age 21. Approximately half of all states extend care to that age. In addition, the foster care program has certain protections for older youth. For example, jurisdictions must annually obtain the credit report of each youth in care who is age 14 and older. They must also assist youth with developing a transition plan that is in place 90 days before aging out. The law requires that a youth's caseworker—and as appropriate, other representative(s) of the youth—assist and support him/her in developing the plan. The law requires that the plan be guided by the youth, and should include specific options on housing, health insurance, education, local opportunities for mentors, and other supports.

Summary: The Chafee program provides supports and services to youth ages 14 to 21 who are or were in foster care (with some exceptions). Youth in states that extend foster care to age 21 can be served under the program until age 23. The program authorizes funds to be used for providing assistance in obtaining a high school diploma, career exploration, training in daily living skills, training in budgeting and financial management skills, and preventive health activities, among other purposes. States must meet certain requirements, including that not more than 30% of Chafee funds are used for room and board expenses. The Chafee Education and Training Voucher (ETV) provides funding for Chafee-eligible youth to attend institutions of higher education. Youth can receive up to $5,000 annually for up to five years (consecutive or nonconsecutive) until they reach age 26. The Chafee law directs HHS to collect outcome and other information for current and former foster youth, and HHS established the National Youth in Transition Database (NYTD) for this purpose.

Summary: Along with the foster care and Chafee programs, other federal programs are intended to help youth currently and formerly in foster care make the transition to adulthood. Federal law authorizes funding for states and local jurisdictions to provide workforce support and housing to older foster youth and youth emancipating from care. Further, beginning on January 1, 2014, eligible young people who were in foster care at age 18 are covered under a mandatory Medicaid pathway until age 26. Youth in foster care or recently emancipated youth are also specifically eligible for certain educational supports.

Y oung people who have spent time in foster care as teenagers often face challenges during the transition to adulthood. Compared to their counterparts in the general population, these youth fare poorly in education, employment, and other outcomes. The federal government recognizes that foster youth may ultimately return to the care of the state as adults through the public welfare, criminal justice, or other systems. In response, federal policy has focused on supporting youth while they are in foster care and in early adulthood.

This report provides background to Congress on teens and young adults in and exiting from foster care, and the federal support available to them. It begins with a discussion of the characteristics of youth who have had contact with the child welfare system, including those who entered care and those who exited care via "emancipation." This process means that youth reached the state legal age of adulthood without being reunified with their families or placed in new permanent families. The report then discusses child welfare programs authorized under Title IV-E of the Social Security Act—specifically the Foster Care Maintenance Payments Program ("foster care program") and the John H. Chafee Program for Successful Transition to Adulthood ("Chafee program")—that are intended to help prepare youth for adulthood. The foster care program provides reimbursement to states for providing foster care, including, at state option, to youth between the ages of 18 and 21. It also includes certain requirements that are intended to support older youth in care. The Chafee program is the primary federal program that funds supportive services for teens and young adults during the transition from foster care.

The text box below summarizes recent developments in the Chafee program. Appendix A includes funding data for the Chafee program. Appendix B includes a summary of other federal programs, outside of child welfare law, that address older youth in foster care and those who have aged out.

Who Are Older Youth in Foster Care and Youth Aging Out of Care?

Children and adolescents can come to the attention of state child welfare systems due to abuse, neglect, or other reasons such as the death of a parent or child behavioral problems. Some children remain in their own homes and receive family support services, while others are placed in out-of-home settings. Such settings usually include a foster home, the home of a relative, or group care (i.e., non-family settings ranging from those that provide specialized treatment or other services to more general care settings or shelters). A significant number of youth spend at least some time in foster care during their teenage years. They may stay in care beyond age 18, typically up to age 21, if they are in a state that extends foster care.

The U.S. Department of Health and Human Services (HHS), which administers child welfare funding, collects data from states on the number and characteristics of children in foster care. On the last day of FY2017, approximately 122,000 youth ages 13 through 20 comprised 27% of the national foster care caseload. Youth ages 13 through 20 made up 28% of the exits from foster care in FY2017. Most of these youth were reunified with their parents or primary caretakers, adopted, or placed with relatives. However, 19,945 youth aged out that year, or were "emancipated" because they reached the legal age of adulthood in their states, usually at age 18.

Youth who spend their teenage years in foster care and those who age out of care face challenges as they move to early adulthood. While in care, they may miss opportunities to develop strong support networks and independent living skills that their counterparts in the general population might more naturally acquire. Even older foster youth who return to their parents or guardians can still face obstacles, such as poor family dynamics or a lack of emotional and financial support, that hinder their ability to achieve their goals as young adults. These difficulties are evidenced by the fact that youth who have spent at least some years in care during adolescence exhibit relatively poor outcomes across a number of domains. Two studies—the Northwest Foster Care Alumni Study and the Midwest Evaluation of the Adult Functioning of Former Foster Youth—have tracked these outcomes.

The Northwest Foster Care Alumni Study and the Midwest Evaluation of the Adult Functioning of Former Foster Youth have tracked outcomes for a sample of foster youth across several areas and compared them to those of youth in the general population. The studies indicate that youth who spent time in foster care during their teenage years tended to have difficulty as they entered adulthood and beyond. The Northwest Study was retrospective; it looked at the outcomes of young adults who had been in foster care and found that they were generally more likely to have mental health and financial challenges than their peers. They were just as likely to obtain a high school diploma but were much less likely to obtain a bachelor's degree. The Midwest Evaluation followed youth over time to examine the extent to which outcomes in early adulthood are influenced by the individual characteristics of youth or their out-of-home care histories. The study examined the outcomes of youth who were in foster care at age 17, and tracked them through age 26. Compared to their counterparts in the general population, youth in the Midwest study fared poorly in education, employment, and other outcomes.

Despite these findings, many former foster youth have overcome obstacles, such as limited family support and financial resources, and have met their goals. For example, youth in the Northwest study obtained a high school diploma or passed the general education development (GED) test at close to the same rates as 25 to 34 year olds generally (84.5% versus 87.3%). Further, youth in the Midwest Evaluation were just as likely as youth in the general population at age 23 or 24 to report being hopeful about their future.

National Youth in Transition Database (NYTD)

States have reported to HHS since FY2010 on the characteristics and experiences of certain current and former foster youth through the National Youth in Transition Database (NYTD). Among other data, states must report on a cohort of foster youth beginning when they are age 17, and then later at ages 19 and 21. Information is collected on a new group of foster youth at age 17 every three years. While the first cohort of NYTD respondents had some positive outcomes by age 21, about 43% reported experiencing homelessness by that age and over one-quarter had been referred for substance abuse assessments or counseling at some point during their lifetimes. States must also report on the supports that eligible current and former foster youth—generally those ages 14 to 21, and sometimes older—receive to support their transition to adulthood. An analysis of NYTD data for FY2015 found that less than a quarter of youth who received a transition service received services for employment, education, or housing.

Overview of Federal Support for Foster Youth

The Children's Bureau at HHS' Administration for Children and Families (ACF) administers programs that are targeted to foster youth and authorized under Title IV-E of the Social Security Act, including the federal foster care program and the Chafee program (which includes the Education and Training Voucher (ETV) program).

Under the federal foster care program, states may seek reimbursement for youth to remain in care up to age 18, or up to age 21 at state option. In addition, the program has protections in place to help meet the needs of older youth. Title IV-E entitlement (or mandatory) funding for foster care is authorized on a permanent basis (no year limit) and is provided in annual appropriations acts. Congress typically provides the amount of Title IV-E foster care funding (or "budget authority") that the Administration estimates will be necessary for it to provide state or other Title IV-E agencies with the promised level of federal reimbursement for all of their eligible Title IV-E foster care costs under current law.

Separately, the Chafee program provides funding to states for services and supports to help youth who are or were in foster care make the transition to adulthood. It is available up to age 21 (or age 23 under certain circumstances). The ETV component includes a separate authorization for discretionary funding to support Chafee-eligible youth in attending an institution of higher education for up to five years (consecutive or nonconsecutive) until they reach age 26. Chafee program funding is mandatory and has no year limit. The ETV program is funded through discretionary appropriations, also with no year limit.

Figure 1 summarizes the programs and the Title IV-E requirements on older youth in foster care and those leaving foster care. Any state, territory, or tribe seeking federal funding under Title IV-E must have a federally approved Title IV-E plan that meets all the requirements of the law.

As discussed in Appendix B , other federal programs are intended to help current and former youth in foster care make the transition to adulthood. Federal law authorizes funding for states and local jurisdictions to provide workforce support and housing to this population. States must also provide Medicaid coverage to youth who age out of foster care until they reach age 26. Federal support is available to assist youth in pursuing higher education.

Historically, states have been primarily responsible for providing child welfare services to families and children. When a child is in out-of-home foster care, the state child welfare agency, under the supervision of the court (and in consultation with the parents or primary caretakers in some cases), serves as the parent and makes decisions on the child's behalf to promote his/her safety, permanence, and well-being. In most cases, the state relies on public and private entities to provide these services. The federal government plays a role in shaping state child welfare systems by providing funds, which are linked to certain requirements under Title IV-E of the Social Security Act. Title IV-E requires states to follow certain case planning and management practices for all children in care ( Figure 1 shows these requirements related to youth in foster care). Though not discussed in this report, Title IV-B of the Social Security Act, which authorizes funding for child welfare services, includes provisions on the oversight of children in foster care and support for families more broadly.

The federal foster care program reimburses states and some territories and tribes (hereinafter, "states") for a part of the cost of providing foster care to eligible children and youth who have been removed by the state child welfare agency due to abuse or neglect. The courts have given care and placement responsibility to the state. Under the program, a state may seek partial federal reimbursement to "cover the cost of (and the cost of providing) food, clothing, shelter, daily supervision, school supplies, a child's personal incidentals, liability insurance with respect to a child, and reasonable travel to the child's home for visitation and reasonable travel for the child to remain in the school in which the child is enrolled at the time of placement."

Federal reimbursement to states under Title IV-E may be made only on behalf of a child who meets multiple federal eligibility criteria, including those related to the child's removal and the income and assets of the child's family. For the purposes of this report, the most significant eligibility criteria for the federal foster care program are the child's age and placement setting. States may also seek reimbursement on behalf of Title IV-E eligible children for costs related to administration, case planning, training, and data collection.

Beginning with FY2020, states can seek federal support for up to 12 months of (1) in-home parent skills-based programs and (2) substance abuse and mental health treatment services for any child a state determines is at "imminent risk" of entering foster care, any pregnant or parenting youth in foster care, and the parents or kin caregivers of these children. Also as of FY2020, any state electing to provide these prevention services and programs under its Title IV-E program will be entitled to receive federal funding equal to at least 50% of its cost, as long as the services and programs meet certain evidence-based standards, and the spending is above the state's maintenance of effort (MOE) level.

Since FY2011, states have had the option to seek reimbursement for the cost of providing foster care to eligible youth until age 19, 20, or 21. These youth must be

completing high school or a program leading to an equivalent credential, enrolled in an institution that provides post-secondary or vocational education, participating in a program or activity designed to promote or remove barriers to employment, employed at least 80 hours per month, or exempted by their state from these requirements due to a medical condition as documented and updated in their case plan.

In program guidance, HHS advised that states can make remaining in care conditional upon whether youth are eligible under only specified eligibility criteria. For example, states could extend care only to those youth enrolled in post-secondary education. Still, the guidance advises that states should "consider how [they] can provide extended assistance to youth age 18 and older to the broadest population possible consistent with the law to ensure that there are ample supports for older youth." In other guidance, HHS has advised that youth can remain in foster care at this older age even if they are married or enlist in the military.

As of May 2019, HHS had approved Title IV-E state plans for 28 states, the District of Columbia, and nine tribal nations to extend the maximum age of federally funded foster care (see Figure 2 ). In general, the jurisdictions make foster care available to youth until they reach age 21 (except for Indiana, which extends foster care until age 20) and allow them to remain in care under any of the eligibility conditions specified in law (except for Tennessee, West Virginia, Wisconsin, the Eastern Band of Cherokee, and the Penobscot Indian Nation). A recent survey conducted by Child Trends, a nonprofit research organization, found that youth who are eligible to remain in care typically decide to leave earlier than the maximum age for foster care in their state by one to three years.

HHS has advised that young people can leave care and later return before they reach the maximum age of eligibility in the state (with certain requirements pertaining to how long youth can leave for and remain eligible for foster care maintenance payments). In addition, state and tribal child welfare agencies can choose to close the original child abuse and neglect case and reopen the case as a "voluntary placement agreement" when the young person turns 18 or if they re-enter foster care between the ages of 18 and 21. In these cases, the income eligibility for Title IV-E would be based on the young adult's income only. HHS has further advised that states can extend care to youth ages 18 to 21 even if they were not in foster care prior to 18, but are not required to do so.

Federal reimbursement of part of the costs of maintaining children in foster care may be sought only for children placed in foster family homes or child care institutions. Title IV-E does not currently include a definition of "foster family"; however, as of FY2020 the following definition of "foster family home" will go into effect: the home of an individual who is licensed as a foster parent, and who is residing with and providing 24-hour substitute care for not more than six children (with some exceptions) placed in foster care in the individual's licensed home. A "child care institution" is defined in law as a private institution, or a public institution that accommodates no more than 25 children, that is approved or licensed by the state. However, if a child in foster care is at least 18 years old, he/she may be placed in a "setting in which the individual is living independently" that meets standards established by the HHS Secretary (it does not have to meet state licensing rules). A child care institution may never include "detention facilities, forestry camps, training schools, or any other facility operated primarily for the detention of children who are determined to be delinquent."

In program instructions issued by HHS, the department stated that it did not have plans to issue regulations that describe the kinds of living arrangements considered to be independent living settings, how these settings should be supervised, or any other conditions for a young person to live independently. The instructions advised that states have the discretion to develop a range of supervised independent living settings that "can be reasonably interpreted as consistent with the law, including whether or not such settings need to be licensed and any safety protocols that may be needed." States appear to allow youth ages 18 and older to live in a variety of settings. For example, Florida defines an independent living setting as a licensed foster home, licensed group home, college dormitory, shared housing, apartment, or other housing arrangement if the arrangement is approved and is acceptable to the youth, with the first choice being a licensed foster home.

Federal child welfare provisions under Title IV-B and Title IV-E of the Social Security Act require state child welfare agencies, as a condition of receiving funding under these titles, to provide certain case management services to all children in foster care. These include

monthly case worker visits to each child in care; a written case plan for each child in care that documents the child's placement and steps taken to ensure his/her safety and well-being, including by addressing their health and educational needs; and procedures ensuring a case review is conducted at least once every six months by a judge or an administrative review panel, and at least once every 12 months by a judge or administrative body who must consider the child's permanency plan.

As part of the annual hearing, the court or administrative body must ensure that the permanency plan addresses whether—and, as applicable, when—the child will be returned to his/her parents, placed for adoption (with a petition for termination of parental rights filed by the Title IV-E agency), referred for legal guardianship, or placed in another planned permanent living arrangement. A court or administrative body may determine that a child's permanency plan is "another planned permanent living arrangement" only if the Title IV-E agency documents for the court a compelling reason why every other permanency goal is not in the child's best interest. Further, the court or administrative body conducting the hearings is to consult, in an age-appropriate manner, with the child regarding the proposed permanency plan or transition plan.

As shown in Figure 1 , certain other provisions in Title IV-E apply to youth ages 14 and older. For example, the written case plan must include a description of the programs and services that will help the child prepare for a successful transition to adulthood.

John H. Chafee Foster Care Program for Successful Transition to Adulthood (Chafee Program)

The John H. Chafee Foster Care Program for Successful Transition to Adulthood, authorized under Section 477 of Title IV-E of the Social Security Act, provides services to older youth in foster care and youth transitioning out of care. This section provides an overview of the program, as well as information about program eligibility, youth participation, program administration, funding, data collection, and training and technical assistance.

The Foster Care Independence Act of 1999 ( P.L. 106-169 ) replaced the prior-law Independent Living Program that was established in 1986 ( P.L. 99-272 ). The 1999 law created the John H. Chafee Foster Care Independence program and doubled the annual mandatory funds available to states for independent living services from $70 million to $140 million. It also established new purpose areas, activities to be funded, and related requirements. The program has been amended five times, to (1) add the Education and Training Voucher (ETV) program for funding higher education opportunities ( P.L. 107-133 ), (2) expand eligibility for the Chafee and ETV programs to youth who exit foster care at age 16 or older for adoption or kinship guardianship ( P.L. 110-351 ), (3) ensure that foster youth are informed about designating others to make health care treatment decisions on their behalf ( P.L. 111-148 ), (4) increase funding for the Chafee program and add a purpose area about supporting activities that are developmentally appropriate ( P.L. 113-183 ), and (5) change data collection requirements and multiple purpose areas that address program eligibility ( P.L. 115-123 ).

The purposes of the Chafee program are to

support all youth who have experienced foster care at age 14 or older in their transition to adulthood through transitional services such as assistance in obtaining a high school diploma and post-secondary education, career exploration, vocational training, job placement and retention, training and opportunities to practice daily living skills (such as financial literacy training and driving instruction), substance abuse prevention, and preventive health activities (including smoking avoidance, nutrition education, and pregnancy prevention); help youth who have experienced foster care at age 14 or older achieve meaningful, permanent connections with a caring adult; help youth who have experienced foster care at age 14 or older engage in age- or developmentally appropriate activities, positive youth development, and experiential learning that reflects what their peers in intact families experience; provide financial, housing, counseling, employment, education, and other appropriate support and services to former foster care youth between the ages of 18 and 21 (or up to age 23 in states that have extended foster care to age 21 using federal, state, or other funds, as determined by the HHS Secretary) to complement their own efforts to achieve self-sufficiency and to ensure that program participants recognize and accept their personal responsibility for preparing for and then making the transition from adolescence to adulthood; make education and training vouchers, including postsecondary training and education, available to youth who have aged out of foster care; provide Chafee-funded services to youth who have left foster care for kinship guardianship or adoption after turning 16; and ensure that youth who are likely to remain in foster care until age 18 have regular, ongoing opportunities to engage in age- or developmentally appropriate activities.

States may use Chafee funding to provide supports that are described in the purpose areas and other parts of the law. They may dedicate as much as 30% of their program funding toward room and board for youth ages 18 to 21 (or up to age 23 in states that have extended foster care to age 21 using federal, state, or other funds, as determined by the HHS Secretary). Room and board are not defined in statute, but they typically include food and shelter, and may include rental deposits, rent payments, utilities, and the cost of household startup purchases. Chafee funds may not be used to acquire property to provide housing to current or former foster youth. As described in HHS guidance, states may use Chafee funding to establish trust funds for youth eligible under the program.

The Chafee program authorizes discretionary funding for the ETV program at $60 million annually, with no end year specified. The program is intended to provide financial support for the cost of attendance to Chafee-eligible youth enrolled at an institution of higher education, as defined by the Higher Education Act of 1965 (HEA), either on a full-time or part-time basis. The law refers to this support as a "voucher," which must not exceed the lesser of $5,000 or the cost of attendance. Youth are eligible to receive ETVs for five years until age 26, regardless of whether they attend in consecutive years or not and are making satisfactory progress toward completion of their program.

Funding received through the ETV program does not count toward the student's expected family contribution, which is used by the federal government to determine a student's need for federal financial aid. However, the total amount of education assistance provided under the ETV program and other federal programs may not exceed the total cost of attendance, and students cannot claim the same education expenses under multiple federal programs. The state child welfare agency is to take appropriate steps to prevent duplication of benefits under the Chafee ETV program and other federal programs, and to coordinate the program with other appropriate education and training programs. A current fiscal year's ETV funds may not be used to finance a youth's educational or vocational loans incurred prior to that year.

To be eligible for Chafee and ETV funds, a state must submit a five-year plan (as part of what is known as the Child and Family Service Plan, or CFSP, and annual updates to that plan via the Annual Progress and Service Report, or APSR) to HHS that describes how it intends to carry out its Chafee-funded program. The plan must be submitted on or before June 30 of the calendar year in which it is to begin. States may make amendments to the plan and notify HHS within 30 days of modifying it. HHS is to make the plans available to the public.

The Chafee program addresses eligibility under the purpose areas and in provisions on the ETV program. The program, including the ETV program, is available to youth

in foster care between the ages of 14 and 21; who aged out of foster care and are between the ages of 18 and 21 (or up to age 23 in states that extend foster care to age 21); who left foster care at age 16 or older for kinship guardianship or adoption until they reach age 21 (or up to age 23 in states that extend care to age 21); who had been in foster care between the ages of 14 and 21 and left foster care for some other reason besides aging out of foster care, kinship guardianship, or adoption; and who are likely to remain in foster care until age 18 years (see the purpose area about "regular, ongoing opportunities to engage in age- or developmentally appropriate activities").

The Chafee program requires states to ensure that Chafee-funded services serve children of "various ages" and in "various stages of achieving independence" and use objective criteria for determining eligibility for benefits and services under the program. Former foster youth continue to remain eligible until age 21 (or age 23, if applicable) for services if they move to another state. The state in which the former foster youth resides—whether or not the youth was in foster care in that state—is responsible for providing independent living services to him/her.

The number of youth who receive independent living program assistance from Chafee funds and other sources (state, local, and private) is collected by HHS via states through the National Youth in Transition Database (NYTD, discussed further in " Data Collection "). In FY2017, approximately 111,700 youth received an independent living service. Separately, states reported to HHS that they provided ETV vouchers to 16,400 youth in FY2008; 16,650 youth in FY2009; 17,400 youth in program year (PY) 2010; 17,100 youth in PY2011; 16,554 youth in PY2012; 16,548 youth in PY2013; 15,514 youth in PY2014, and 14,619 youth in PY2015.

The Chafee program requires a state to certify that each federally recognized Indian tribe in it has been consulted about the state's Chafee-funded programs and that there have been efforts to coordinate the programs with these tribal entities. In addition, the Chafee program specifies that the "benefits and services under the programs are to be made available to Indian children in the state on the same basis as to other children in the state." "On the same basis" has been interpreted by HHS to mean that the state will provide program services equitably to children in both state custody and tribal custody.

The Chafee program requires states to ensure that youth in Chafee-funded programs participate directly in "designing their own program activities that prepare them for independent living" and that they "accept personal responsibility for living up to their part of the program." This language builds on the positive youth development approach to serving young people. Youth advocates that support this approach view youth as assets and promote the idea that they should be engaged in decisions about their lives and communities.

States have taken various approaches to involving young people in decisions about the services they receive. Most states have also established formal youth advisory boards to provide a forum for youth to become involved in issues facing those in care and aging out of care. Youth-serving organizations for current and former foster youth, such as Foster Club, provide an outlet for young people to become involved in the larger foster care community and advocate for other children in care. States are not required to utilize life skills assessments or personal responsibility contracts with youth to comply with the youth participation requirement, although some states use these tools to assist youth in making the transition to adulthood.

States administer their Chafee-funded programs in multiple ways. Some programs are overseen by the state program that addresses older and former foster youth, with an independent living coordinator and other program staff. For example, in Maine the state's independent living coordinator oversees specialized life skills education coordinators assigned to cover all of the state's Department of Health and Human Services district offices. In some states, like California, each county administers its own program with some oversight and support from a statewide program. Other states, including Florida, use contracted service providers to administer their programs. Many jurisdictions have partnered with private organizations to help fund and sometimes administer some aspect of their independent living programs. For example, the Jim Casey Youth Opportunities Initiative has provided funding and technical assistance to multiple cities to provide financial support and training to youth exiting care.

The state with the placement and responsibility for a youth in foster care is to provide the voucher to that youth. The state must also continue to provide a voucher to any youth who is currently receiving one and moves to another state for the sole purpose of attending an institution of higher education. If a youth moves permanently to another state after leaving care and subsequently enrolls in a qualified institution of higher education, the state where he or she resides would provide the voucher.

Generally, states administer their ETV program through their program that addresses older and former foster youth. However, some states administer the ETV program through their financial aid office (e.g., California Student Aid Commission) or at the local level (e.g., Florida, where all child welfare programs are administered through community-based agencies). Some states contract with a nonprofit service provider, such as Foster Care to Success.

States and counties may use ETV dollars to fund the vouchers and the costs associated with program administration, including for salaries, expenses, and training of staff. States are not permitted to use Title IV-E foster care or adoption assistance program funds for administering the ETV program. However, they may spend additional funds from state sources or other sources to supplement the ETV program or use ETV funds to expand existing postsecondary funding programs. Several states have scholarship programs, tuition waivers, and grants for current and former foster youth that are funded through other sources.

Chafee and ETV funds are distributed to each state based on its proportion of the nation's children in foster care. States must provide a 20% match (in-kind or cash) to receive their full federal Chafee and ETV allotment. The Chafee program includes a "hold harmless" clause that precludes any state from receiving less than the amount of general independent living funds it received under the former independent living program in FY1998 or $500,000, whichever is greater. There is no hold harmless provision for ETV funds. States may use Chafee and ETV funds to supplement, and not supplant, any other funds that are available for the types of activities authorized under the Chafee program. Territories with an approved Title IV-E plan may also apply for Chafee funding. Currently, Puerto Rico and the U.S. Virgin Islands have approved plans.

An Indian tribe, tribal organization, or tribal consortium may apply to HHS and receive a direct federal allotment of Chafee and/or ETV funds. To be eligible, a tribal entity must be receiving Title IV-E funds to operate a foster care program under a Title IV-E plan approved by HHS or via a cooperative agreement or contract with the state. Successful tribal applicants receive an allotment amount(s) out of the state's allotment for the program(s) based on the share of all children in foster care in the state under tribal custody. Tribal entities must satisfy the Chafee program requirements established for states, as HHS determines appropriate.

Four tribes—the Prairie Band of Potawatomi (Kansas), Santee Sioux Nation (Nebraska), Confederated Tribe of Warm Springs (Oregon), and Port Gamble S'Klallam Tribe (Washington)—receive Chafee and ETV funds. A state must certify that it will negotiate in good faith with any tribal entity that does not receive a direct federal allotment of child welfare funds but would like to enter into an agreement or contract with the state to receive funds for administering, supervising, or overseeing Chafee and ETV programs for eligible Indian children under the tribal entity's authority.

Appendix B provides the Chafee and ETV allotments for each state, four tribes, Puerto Rico, and the U.S. Virgin Islands in FY2018 and FY2019. Though not shown in the table, Chafee funds are often combined with state, local, and other funding sources.

States and tribes have two fiscal years to spend their Chafee and ETV funds. If a jurisdiction does not apply for all of its allotment, the remaining funds may be redistributed among states that need these funds as determined by HHS. Table A-2 shows the percentage and share of funds returned for both programs from FY2005 through FY2014, as well as a list of jurisdictions that have returned these funds. FY2014 is the most recent year available.

HHS was recently given authority to reallocate funds that are not spent within the two-year period to states and tribes that apply for the funding. If funds are reallocated, the statute specifies that the funds should be redistributed among the states and tribes that apply for any unused funds, provided HHS determines the state or tribe would use the funds according to the program purposes. Further, HHS is directed to allocate the funds based on the share of children in foster care among the states and tribes that successfully appl y for the unused funds. Any unspent funds can be made available to the applying states or tribes in the second fiscal year following the two-year period in which funds were originally awarded . Any redistributed funds are considered part of the state 's or tribe's allotment for the fiscal year in which the redistribution is made .

Training and technical assistance grants for the Chafee and ETV programs had been awarded competitively every five years, most recently for FY2010 through FY2014. The National Child Welfare Resource Center for Youth Development (NCWRCYD), housed at the University of Oklahoma, provided assistance under the grant. Beginning with FY2015, HHS has operated the Child Welfare Capacity Building Collaborative via a contract with ICF International, a policy management organization, to provide training and technical assistance on a number of child welfare issues, including youth development.

The Chafee program required that HHS consult with state and local public officials responsible for administering independent living and other child welfare programs, child welfare advocates, Members of Congress, youth service providers, and researchers to

"develop outcome measures (including measures of educational attainment, high school diploma, avoidance of dependency, homelessness, non-marital childbirth, incarceration, and high-risk behaviors) that can be used to assess the performance of states in operating independent living programs"; identify the data needed to track the number and characteristics of children receiving services, the type and quantity of services provided, and state performance on the measures; and develop and implement a plan to collect this information beginning with the second fiscal year after the Chafee law was enacted in 1999.

In response to these requirements, HHS created the National Youth in Transition Database (NYTD). The final rule establishing NYTD became effective April 28, 2008, and it required states to report data on youth beginning in FY2011. HHS uses NYTD to engage in two data collection and reporting activities. First, states collect demographic data and information about receipt of services on eligible youth who currently receive independent living services. This includes youth regardless of whether they continue to remain in foster care, were in foster care in another state, or received child welfare services through an Indian tribe or privately operated foster care program. Second, states track information on outcomes of foster youth on or about their 17 th birthday, around their 19 th birthday, and around their 21 st birthday.

Consistent with the authorizing statute for the Chafee program, HHS is to penalize any state not meeting the data collection procedures for the NYTD from 1% to 5% of its annual Chafee fund allotment, which includes any allotted or re-allotted funds for the general Chafee program only. The penalty amount is to be withheld from the current fiscal year award of the funds. HHS is to evaluate a state's data file against data compliance standards, provided by statute. However, states have the opportunity to submit corrected data. The text box indicates new information that HHS must report to Congress.

The authorizing statute for the Chafee program requires HHS to conduct evaluations of state (or tribal) programs funded by the Chafee program deemed to be "innovative or of national significance." The law reserves 1.5% of total Chafee funding annually for these evaluations, as well as related technical assistance, performance measurement, and data collection. HHS conducted an evaluation of promising independent living programs from approximately 2007 to 2012, and is in the process of identifying new ways of conducting research in this area.

Multi-Site Evaluation of Foster Youth Programs

For the initial evaluation, HHS contracted with the Urban Institute and its partners to conduct what is known as the Multi-Site Evaluation of Foster Youth Programs. The goal of the evaluation was to determine the effects of programs funded by the Chafee authorizing law in achieving key outcomes related to the transition to adulthood. HHS and the evaluation team initially conducted an assessment to identify state and local programs that could be evaluated rigorously, through random assignment to treatment and control groups, as required under the law. Their work is the first to involve random assignment of programs for this population.

The evaluation team examined four programs in California and Massachusetts—an employment services program in Kern County, CA; a one-on-one intensive, individualized life skills program in Massachusetts; and a classroom-based life skills training program and a tutoring/mentoring program, both in Los Angeles County, CA. The evaluation of the Los Angeles and Kern County programs found no statistically significant impacts as a result of the interventions; however, the life skills program in Massachusetts, known as Outreach, showed impacts for some of the education outcomes that were measured. The Outreach program assists youth who enroll voluntarily in preparing to live independently and in having permanent connections to caring adults upon exiting care.

Outreach youth were more likely than their counterparts in the control group to report having ever enrolled in college and staying enrolled. Outreach youth were also more likely to experience outcomes that were not a focus of the evaluation: these youth were more likely to remain in foster care and to report receiving more help in some areas of educational assistance, employment assistance, money management, and financial assistance for housing. In short, the Outreach youth may have been less successful on the educational front if they had not stayed in care. Youth in the program reported similar outcomes as the control group for multiple other measures, including in employment, economic well-being, housing, delinquency, and pregnancy.

HHS has contracted with the Urban Institute and Chapin Hall for additional research on the Chafee program. Citing the lack of experimental research in child welfare, the research team is examining various models in other policy areas that could be used to better understand promising approaches of working with older youth in care and those transitioning from care. Researchers have identified a conceptual framework that takes into account the many individual characteristics and experiences that influence a youth's ability to transition successfully into adulthood. The research team has also classified the various types of programs that foster youth could access to help in the transition, and the extent to which they are ready to be evaluated. In addition, researchers have published a series of briefs that discuss outcomes and programs for youth in foster care in the areas of education, employment, and financial literacy. The briefs discuss that few programs have impacts for foster youth in these areas. The briefs also address issues to consider when designing and evaluating programs for youth in care.

Appendix A. Funding for the John H. Chafee Foster Care (Chafee) Program for Successful Transition to Adulthood and Education and Training Voucher (ETV) Program

Appendix B. Other Federal Support for Older Current and Former Foster Youth

In addition to the child welfare programs under Title IV-E of the Social Security Act, other federal programs provide assistance to older current and former foster youth. This appendix describes Medicaid pathways for foster youth who emancipated; educational, workforce, and housing supports; and a grant to fund training for child welfare practitioners working with older foster youth and youth emancipating from care.

The Centers for Medicare and Medicaid Services (CMS) at HHS administers Medicaid, a federal-state health program jointly financed by HHS and the states. Medicaid law provides for mandatory and optional pathways for youth who have aged out of foster care.

As of January 1, 2014, certain former foster youth are eligible for Medicaid under a mandatory pathway created for this population in the Affordable Care Act (ACA, P.L. 111-148 ). Former foster youth are eligible if they

were "in foster care under the responsibility of the State" upon reaching age 18 (or up to age 21 if the state extends federal foster care to that age); were enrolled in Medicaid while in foster care; and are not eligible or enrolled in other mandatory Medicaid coverage groups.

The ACA specifies that income and assets are not considered when determining eligibility for this group. Nonetheless, foster youth with annual incomes above a certain level may be required to share in the costs of their health care.

In addition to the law, CMS has provided additional parameters on the new pathway via a final rule promulgated in November 2016 and policy guidance. The final rule specifies that former foster youth are eligible regardless of whether Title IV-E foster care payments were made on their behalf. States may not provide Medicaid to individuals who left foster care before reaching age 18 via this pathway. Further, states may not provide Medicaid coverage to former foster youth who move from another state; however, states could apply to HHS under a waiver to provide such coverage via the research and demonstration waiver authority for the Medicaid program.

The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act ( P.L. 115-271 ) amended the Medicaid statute on the former foster youth pathway. It will permit states, as of January 2023, to use state plan authority for providing coverage to former foster youth who move across state lines. The law directs HHS, within one year of the its enactment, to issue guidance to states on best practices for removing barriers and ensuring timely coverage under this pathway, and on conducting related outreach and raising awareness among eligible youth.

Consistent with existing regulations, the final rule affirms that states may not terminate Medicaid eligibility for foster youth who reach age 18 without first determining whether they are eligible for other mandatory Medicaid eligibility pathways available to adults (e.g., the coverage pathway for pregnant women).

The pathway for former foster youth appears largely to supersede an optional pathway also provided for this population. The 1999 law ( P.L. 106-169 ) that established the Chafee program also created a new optional Medicaid eligibility pathway for "independent foster care adolescents"; this pathway is often called the "Chafee option." The law further defined these adolescents as individuals under the age of 21 who were in foster care under the responsibility of the state on their 18 th birthday. The law permits states to restrict eligibility based on the youth's income or resources, and whether or not the youth had received Title IV-E funding.

As of late 2012, more than half (30) of all states had extended the Chafee option to eligible youth. Of these states, five reported requiring youth to have income less than a certain level of poverty (180% to 400%). Four states permitted youth who were in foster care at age 18 in another state to be eligible under the pathway. States also reported whether the youth is involved in the process for enrolling under the Chafee option. In 15 states, youth are not directly involved in the enrollment process. For example, some states automatically enroll youth. In the other 15 states, youth are involved in enrollment with assistance from their caseworker or they enroll on their own. Most states that have implemented the Chafee option require an annual review to verify that youth continue to be eligible for Medicaid. States generally have a hierarchy to determine under which pathway youth qualify. For example, in most states, youth who qualify for the Chafee option and receive Supplemental Security Income (SSI) would be eligible for Medicaid under the SSI Medicaid pathway.

Federal funding and other supports for current and former foster youth are in place to help these youth aspire to, pay for, and graduate from college. The Higher Education Act (HEA) authorizes financial aid and support programs that target this and other vulnerable populations.

For purposes of applying for federal financial aid, a student's expected family contribution (EFC) is the amount that can be expected to be contributed by a student and the student's family toward his or her cost of education. Certain groups of students are considered "independent," meaning that only the income and assets of the student are counted. Individuals under age 24 who are or were orphans, in foster care, or wards of the court at age 13 or older are eligible to apply for independent student status. The law does not specify the length of time that the youth must have been in foster care or the reason for exiting as factors for independent student status eligibility. However, the federal financial aid form, known as the Free Application for Federal Student Aid (FAFSA), instructs current and former foster youth that the financial aid administrator at their school may require the student to provide proof that they were in foster care.

As required by the FY2014 appropriations law (2014, P.L. 113-76 ), the Department of Education (ED) modified the FAFSA form so that it includes a box for applicants to identify whether they are or were in foster care, and to require ED to provide these applicants with information about federal educational resources that may be available to them.

The Higher Education Act provides that youth in foster care, including youth who have left foster care after reaching age 16, and homeless children and youth are eligible for what are collectively called the federal TRIO programs. The programs are known individually as Talent Search, Upward Bound, Student Support Services, Educational Opportunity Centers, and McNair Postbaccalaureate. The TRIO programs are designed to identify potential postsecondary students from disadvantaged backgrounds, prepare these students for higher education, provide certain support services to them while they are in college, and train individuals who provide these services. HEA directs the Department of Education (ED), which administers the programs, to (as appropriate) require applicants seeking TRIO funds to identify and make services available, including mentoring, tutoring, and other services, to these youth. TRIO funds are awarded by ED on a competitive basis. In addition, HEA authorizes services for current and former foster youth (and homeless youth) through TRIO Student Support Services—a program intended to improve the retention and graduation rates of disadvantaged college students—that include temporary housing during breaks in the academic year. In FY2019, Congress appropriated $1.1 billion to TRIO programs.

Separately, HEA allows additional uses of funds through the Fund for the Improvement of Postsecondary Education (FIPSE) to establish demonstration projects that provide comprehensive support services for students who were in foster care (or homeless) at age 13 or older. FIPSE is a grant program that seeks to support the implementation of innovative educational reform ideas and evaluate how well they work. As specified in the law, the projects can provide housing to the youth when housing at an educational institution is closed or unavailable to other students. Congress appropriated $6 million in FY2018 and $5 million in FY2019 for FIPSE.

Workforce Innovation and Opportunity Act Programs

The Workforce Innovation and Opportunity Act (WIOA) authorizes job training programs to unemployed and underemployed individuals through the Department of Labor (DOL). Two of these programs—Youth Activities and Job Corps—provide job training and related services to targeted low-income vulnerable populations, including foster youth. The Youth Activities program focuses on preventive strategies to help in-school youth stay in school and receive occupational skills, as well as on providing training and supportive services, such as assistance with child care, for out-of-school youth. Job Corps is an educational and vocational training program that helps students learn a trade, complete their GED, and secure employment. To be eligible, foster youth must meet age and income criteria as defined under the act. Young people currently or formerly in foster care may participate in both programs if they are ages 14 to 24. In FY2018, Congress appropriated $903 million to Youth Activities and $1.7 billion to Job Corps.

Current and former foster youth may be eligible for housing subsidies provided through programs administered by the Department of Housing and Urban Development's (HUD's) Family Unification Vouchers program (FUP vouchers). The FUP vouchers were initially created in 1990 under P.L. 101-625 for families that qualify for Section 8 tenant-based assistance and for whom the lack of adequate housing is a primary factor in the separation, or threat of imminent separation, of children from their families or in preventing the reunification of the children with their families. Amendments to the program in 2000 under P.L. 106-377 made youth ages 18 to 21 eligible for the vouchers for up to 18 months if they are homeless or are at risk of becoming homeless at age 16 or older.

The Housing Opportunity Through Modernization Act ( P.L. 114-201 ), enacted in July 2016, extended the upper age of eligibility for FUP vouchers, from 21 to 24, for youth who emancipated from foster care. It also extended assistance under the program for these youth from 18 to 36 months and allows the voucher assistance to begin 90 days prior to a youth leaving care because they are aging out. It also requires HUD, after consulting with other appropriate federal agencies, to issue guidance to improve coordination between public housing agencies, which administer the vouchers, and child welfare agencies. The guidance must address certain topics, including identifying eligible recipients for FUP vouchers and identifying child welfare resources and supportive families for families and youth (including the Chafee program). As of the date of this report, HUD has not issued such guidance. In correspondence with CRS, HUD explained that it has requested funding for this work, and until those funds can be secured, HUD and HHS staff are studying how youth and families are served by FUP.

FUP vouchers were initially awarded from 1992 to 2001. Over that period, approximately 39,000 vouchers were distributed. Each award included five years of funding per voucher and the voucher's use was restricted to voucher-eligible families for those five years. At the end of those five years, public housing authorities (PHAs) were eligible to convert FUP vouchers to regular Section 8 housing vouchers for low-income families. While the five-year use restrictions have expired for all family unification vouchers, some PHAs may have continued to use their original family unification vouchers for FUP-eligible families and some may have chosen to use some regular-purpose vouchers for FUP families (but the extent to which this happened is unknown). Congress appropriated $20 million for new FUP vouchers in each of FY2008 and FY2009; $15 million in FY2010, $10 million in FY2017, and $20 million in FY2018 and FY2019. Congress has specified that amounts made available under Section 8 tenant-based rental assistance and used for the FUP vouchers are to remain available for the program.

A 2014 report on the FUP program examined the use of FUP vouchers for foster youth. The study was based on a survey of PHAs, a survey of child welfare agencies that partnered with PHAs that served youth, and site visits to four areas that use FUP to serve youth. The survey of PHAs showed that slightly less than half of PHAs operating FUP had awarded vouchers to former foster youth in the 18 months prior to the survey. PHAs reported that youth were able to obtain a lease within the allotted time, and many kept their leases for the full 18-month period they were eligible for the vouchers. In addition, 14% of total FUP program participants qualified because of their foster care status. According to the study, this relatively small share was due to the fact that less than half of PHAs were serving youth, and these PHAs tended to allocate less than one-third of their vouchers to youth, among other findings.

Older current and former foster youth may be eligible for housing services and related supports through the Runaway and Homeless Youth program, administered by HHS. The program is comprised of three subprograms: the Basic Center program (BCP), which provides short-term housing and counseling to youth up to the age of 18; the Transitional Living program (TLP), which provides longer-term housing and counseling to youth ages 16 through 22; and the Street Outreach program (SOP), which provides outreach and referrals to youth who live on the streets. Youth transitioning out of foster care may also be eligible for select transitional living programs administered by HUD, though the programs do not specifically target these youth. The program was funded at $127 million in FY2019.

The Foreclosure Prevention Act of 2008 ( P.L. 110-289 ) was signed into law on July 30, 2008, and enables owners of properties financed in part with Low-Income Housing Tax Credits (LIHTCs) to claim as low-income units those occupied by low-income students who were in foster care. Owners of LIHTC properties are required to maintain a certain percentage of their units for occupancy by low-income households; students (with some exceptions) are not generally considered low-income households for this purpose. The law does not specify the length of time these students must have spent in foster care nor require that youth are eligible only if they emancipated.


Department of Veterans Affairs’ Potential Role in Addressing the COVID-19 Outbreak

Summary: The Department of Veterans Affairs (VA) provides a range of benefits to eligible veterans and their dependents. The department carries out its programs nationwide through three administrations and the Board of Veterans' Appeals (BVA). The Veterans Health Administration (VHA) is responsible for health care services and medical and prosthetic research programs. The Veterans Benefits Administration (VBA) is responsible for, among other things, providing disability compensation, pensions, and education assistance. The National Cemetery Administration (NCA) is responsible for maintaining national veterans cemeteries; providing grants to states for establishing, expanding, or improving state veterans cemeteries; and providing headstones and markers for the graves of eligible persons, among other things.

Summary: With a vast integrated health care delivery system spread across the United States, VHA is also statutorily required to serve as a contingency backup to the Department of Defense (DOD) medical system during a national security emergency and to provide support to the National Disaster Medical System and the Department of Health and Human Services (HHS), as necessary, in support of national emergencies (also referred to as the "Fourth Mission" of the VHA).

Summary: Based on limited information from VA, this report provides an overview of VA's response to the Coronavirus Disease 2019 (COVID-19) pandemic that is affecting communities throughout the United States. It also discusses recent congressional action as it pertains to the veterans' benefits and services, as well as the supplemental appropriations for the department.

The Department of Veterans Affairs (VA) provides a range of benefits and services to veterans who meet certain eligibility criteria. These benefits and services include, among other things, hospital and medical ca re; disability compensation and pensions; education; vocational rehabilitation and employment services; assistance to homeless veterans; home loan guarantees; administration of life insurance, as well as traumatic injury protection insurance for servicemembers; and death benefits that cover burial expenses.

In addition to providing health care services to veterans and certain eligible dependents, the VHA is statutorily required to serve as a contingency backup to the Department of Defense (DOD) medical system during a national security emergency and to provide support to the National Disaster Medical System and the Department of Health and Human Services (HHS) as necessary in response to national crises. The department is also required to take appropriate actions to ensure VA medical centers are prepared to protect veteran patients and staff during a public health emergency.

On December 31, 2019, the World Health Organization (WHO) was informed of a cluster of pneumonia cases in Wuhan City, Hubei Province of China. Illnesses have since been linked to a disease caused by a previously unidentified strain of coronavirus, designated Coronavirus Disease 2019, or COVID-19. On January 30, 2020, an Emergency Committee convened by the WHO Director-General declared the COVID-19 outbreak to be a Public Health Emergency of International Concern (PHEIC). On January 31, the Secretary of Health and Human Services (HHS) declared a public health emergency under Section 319 of the Public Health Service Act (42 U.S.C. 247d). On March 11, 2020, the WHO characterized the COVID-19 outbreak as a pandemic. Two days later, on March 13, the President declared the COVID-19 outbreak a national emergency, beginning March 1, 2020.

The VHA plays a significant role in the domestic response to a pandemic. It is one of the largest integrated direct health care delivery systems in the nation, caring for more than 7.1 million patients in FY2020 and providing 123.8 million outpatient visits at approximately 1,450 VA sites of care. The VHA employs a workforce of 337,908 full-time equivalent employees (FTEs), largely composed of health care professionals. In addition, the VHA has a statutory mission to contribute to the overall federal emergency response capabilities.

This report provides an overview of VA's response thus far to this rapidly evolving COVID-19 pandemic. It does not provide an exhaustive description of all of the department's activities, and it is based on very limited publicly available information from VA. It is organized as follows: first, it provides details on VHA's, VBA's, and NCA's response activities; second, it provides details on VA's emergency preparedness ("Fourth Mission") activities to provide support to the overall federal emergency response; and lastly, it briefly describes congressional activity as it pertains to VA and veterans. The Appendix provides a summary of VHA's emergency authorities.

Medical Care for Veterans During the COVID-19Â Outbreak

VHA's provision of medical care to veterans in response to the COVID-19 outbreak includes implementing mitigation strategies at VHA facilities, as well as testing and treating veterans diagnosed with or suspected of having COVID-19. (A general description of medical care to veterans is provided in other CRS reports. )

In late February 2020, VA provided information to congressional oversight committees on the number of positive and presumptive positive cases of COVID-19. On March 13, 2020, the department began publishing this information publicly on its website, which it updates on a regular basis. The number of positive diagnoses is likely to grow as testing for COVID-19 becomes more widespread.

VA has reported on the measures it has taken to contain and mitigate further exposure. It has issued guidance for patients, implemented mitigation strategies at VHA facilities, and begun testing patients who present symptoms consistent with COVID-19.

VA is advising veterans who may be sick or who are exhibiting flu-like symptoms not to come to a VA facility. Instead, patients are advised to call their health care providers, even if they already have a scheduled appointment. Alternatively, patients can send a secure message through the VHA online portal, My HealtheVet, or schedule a telehealth appointment.

In addition, VA is advising patients to budget additional time for appointments due to enhanced screening measures at VA facilities. These enhanced screening measures, as well as other mitigation strategies at VHA facilities, are described below.

On March 10, 2020, VA announced safeguards to protect nursing home residents and spinal cord injury patients. As of that date, no visitors are allowed at either VA nursing homes or spinal cord injury/disorder (SCI/D) centers. The only exception to this policy is if a veteran is in the last stages of life, in which case VA allows visitors in the veteran's room only. VA is not accepting any new admissions to nursing homes and is limiting new admissions to SCI/D centers.

VA began implementing enhanced screening procedures at all sites of care to screen for respiratory illness and COVID-19 exposure. Enhanced screening procedures are determined at the local level, so they vary at each facility. However, VA has designed standardized screening questions for each facility.

Each VA medical center is implementing a two-tiered system to mitigate the potential for spread of the virus, creating a zone for active COVID-19 cases and a passive zone for care unrelated to COVID-19. VA has canceled all elective surgeries and limited routine appointments.

This section describes the current VA policy on testing patients for COVID-19 and treatment following a COVID-19 diagnosis.

On March 13, 2020, the department began publishing the number of positive cases of COVID-19, and the number of tests conducted, on its public website, which it updates on a regular basis. Individual medical centers have discretion on where to send samples for testing. Samples can be tested at the Palo Alto VA Medical Center, state public health labs, or private labs.

Individual providers decide whether to test for COVID-19 on a patient-by-patient basis. However, VA has advised providers that patients must be exhibiting respiratory symptoms and have another factor, such as recent travel or known exposure to someone who tested positive.

Generally, diagnostic testing is a covered service under VA's standard medical benefits package, which is available to all veterans enrolled in the VA health care system. Some veterans are required to pay copayments for care that is not related to a service-connected disability. However, routine lab tests are exempt from copayments. VA has not announced whether cost-sharing for the COVID-19 diagnostic test is included under the exemption for routine lab tests.

The Families First Coronavirus Response Act ( P.L. 116-127 ), enacted on March 18, 2020, allows VA to waive any copayment or other cost-sharing requirements charged to veterans for COVID-19 testing or medical visits during any period of this public health emergency. VA has not publicly announced whether cost-sharing for the COVID-19 diagnostic test will be waived for all veterans who are subject to cost-sharing. (For a discussion of P.L. 116-127 , see the " Congressional Response " section of this report.)

VA has not indicated whether it has developed a treatment plan for patients diagnosed with COVID-19. Treatment depends largely on the severity of symptoms that each patient experiences.

VA is handling coverage and cost of treatment for COVID-19 as it would for any other treatment for a condition that is not service-connected. Treatment for COVID-19 is a covered benefit under the VA standard medical benefits package. However, some veterans may have to pay copayments for both outpatient and inpatient care.

Normal coverage rules apply for veterans who report to urgent care or walk-in clinics. To be eligible, a veteran must be enrolled in the VA health care system and must have received VA care in the past 24 months preceding the episode of urgent or walk-in care. Eligible veterans needing urgent care must obtain care through facilities that are part of VA's contracted network of community providers. These facilities typically post information indicating that they are part of VA's contracted network. If an eligible veteran receives urgent care from a noncontracted provider or receives services that are not covered under the urgent care benefit, the veteran may be required to pay the full cost of such care. Certain veterans are required to pay copayments for care obtained at a VA-contracted urgent care facility or walk-in retail health clinic.

In addition, normal rules apply for veterans who report to non-VA emergency departments. To be eligible for VA payment or reimbursement, a veteran's non-VA care must meet the following criteria:

The emergency care or services were provided in a hospital emergency department or a similar facility that provides emergency care to the public. The claim for payment or reimbursement for the initial evaluation and treatment was for a condition of such a nature that a prudent layperson would have reasonably expected that delay in seeking immediate medical attention would have been hazardous to life or health. A VA or other federal facility or provider was not feasibly available and an attempt to use them beforehand would not have been considered reasonable by a prudent layperson. At the time the emergency care or services were furnished, the veteran was enrolled in the VA health care system and had received medical services from the VHA within the 24-month period preceding the furnishing of such emergency treatment. The veteran was financially liable to the provider of emergency treatment for that treatment. The veteran had no coverage under a health plan contract that would fully cancel the medical liability for the emergency treatment. If the condition for which the emergency treatment was furnished was caused by an accident or work-related injury, the veteran is required pursue all claims against a third party for payment of such treatment first.

Veterans experiencing homelessness live in conditions that could make them particularly vulnerable to COVID-19. Those who are unsheltered lack access to sanitary facilities. For those sleeping in emergency shelters, conditions may be crowded, with short distances between beds, and there may be limited facilities for washing and keeping clean.

While VA itself administers programs to assist veterans experiencing homelessness, there are several grants for nonprofit and public entities to provide housing and services to homeless veterans. These include the Homeless Providers Grant and Per Diem program (transitional housing and services), the Supportive Services for Veteran Families (short- to medium-term rental assistance and services), and Contract Residential Services (housing for veterans participating in VA's Health Care for Homeless Veterans program).

VA released guidance on March 13, 2020, for its grantees that administer programs for veterans who are homeless. The guidance suggests grantees take a number of actions:

Develop a response plan, or review an existing plan, and coordinate response planning with local entities, including health departments, local VA medical providers, and Continuums of Care. Plans should address staff health, potential staff shortages, and acquisition of food and other supplies, as well as how to assist veteran clients. Prevent infection through methods recommended by the CDC, such as frequent handwashing, wiping down surfaces, and informing clients about prevention techniques. In congregate living facilities, such as those provided through VA's Grant and Per Diem program, keep beds at least three feet apart (preferably six, if space permits), sleep head-to-toe, or place barriers between beds, if possible. Develop questions to ask clients about their health to determine their needs and how best to serve them. For new clients, interviews should occur prior to entry into a facility (such as over the phone), if possible, or in a place separate from other clients. If a client' answers to questions indicate risk of COVID-19, separate them from other program participants (have an isolation area, if possible), clean surfaces, and reach out to medical professionals. If isolation is not practical, reach out to other providers who might be able to isolate.

On March 18, 2020, the Veterans Benefits Administration (VBA) announced via Facebook and Twitter that all regional offices will be closed to the public starting March 19. While the regional offices are to remain open to ensure the continuity of benefits, the offices are to no longer accept walk-ins for claims assistance, scheduled appointments, counseling, or other in-person services. VBA is directing veterans who have claims-specific questions or any questions to use the Inquiry Routing & Information System (IRIS) or to call 1-800-827-1000.

A March 16, 2020, Government Executive news article explained that VBA is facing "network operationality" issues after several regional offices told their employees to telework full time. VBA headquarters, in Washington, DC, then rescinded the telework directives due to the information technology issues. VBA is to continue performing tests on the network throughout the week. According to the article, a VA spokesperson said that regional office directors are to make decisions on work flexibility based on "the circumstances in their communities" but must discuss all plans with "central office leadership."

In FY2020, over 900,000 individuals are expected to receive veterans educational assistance from the GI Bills (e.g., the Post-9/11 GI Bill), Veteran Employment Through Technology Education Courses (VET TEC), Veterans Work-Study, Veterans Counseling, and VetSuccess on Campus (VSOC). As a result of COVID-19, some participants' training and education may be disrupted, and some participants may receive a lower level of or no benefits. These concerns may directly affect beneficiaries in several ways, including the following:

Some students may be required to stop out, discontinue working, or take a leave of absence as a result of their own illness. Some training establishments, educational institutions, and work-study providers may close temporarily or permanently. Some training establishments, educational institutions, and work-study providers may be required to reduce participants' hours, enrollment rate, or rate of pursuit. Some educational institutions may transition some courses to a distance learning format. Some educational institutions may require students living on campus to move off campus. Individuals receiving benefits in foreign countries may encounter any of the above circumstances while residing in a foreign country whose COVID-19 situation may differ from that in the United States, or may stop out, discontinue working, or take a leave of absence and return to the United States.

A related issue is that, in the past, GI Bill benefits could not be paid for pursuit of online courses that had not been previously approved as online courses. Given this limitation, VA requested that school-certifying officials "temporarily refrain from making any adjustments to enrollment certifications" pending subsequent VA guidance and/or legislative action.

On March 12, 2020, VA reminded GI Bill participants and school-certifying officials of its ability to continue paying benefits as participants and institutions react to the COVID-19 emergency. In particular, VA may continue to pay GI Bill benefits for up to four weeks following the temporary closure of an educational institution under an established policy based on an executive order of the President, or due to an emergency situation. Other limitations noted in the correspondence would be alleviated by recently passed legislation (see the " Congressional Response " section of this report for a discussion of S. 3503 ).

The National Cemetery Administration (NCA) has provided limited information for the survivors and dependents of veterans who have passed away and are scheduled to be buried in National Cemetery. As of March 18, 2020, NCA has provided some guidance for both families and funeral directors regarding interments and services for veterans.

For f amilies and v isitors . VA National Cemeteries remain open to visitors and for interments, but visitors should follow their local communities' restrictions on visitations and travel. For families who prefer to inter now but hold the committal service at a later date, NCA says it will work to accommodate those requests. For families who prefer to have the committal service now, NCA asks them to adhere to CDC recommendations for group gatherings.

For f uneral d irectors . NCA is asking funeral directors to follow the CDC guidelines and recommendations on group gatherings for families who proceed with full committal services. In addition, NCA informed organizers that it has discouraged all cemetery personnel from handshaking and any unnecessary physical contact with family members and funeral organizers. NCA is to work with the funeral directors and families to accommodate future committal services for those who decide to postpone.

NCA has set up an "Alerts" web page for the public to check cemetery operating status and is directing the public to its Facebook and Twitter pages for the most recent operating information.

Emergency Preparedness ("Fourth Mission")

In 1982, the Department of Veterans Affairs (VA)-Department of Defense (DOD) Health Resources Sharing and Emergency Operations Act ( P.L. 97-174 ) was enacted to serve as the primary health care backup to the military health care system during and immediately following an outbreak of war or national emergency. Since then, Congress has provided additional authorities to VA to "use its vast infrastructure and resources, geographic reach, deployable assets, and health care expertise, to make significant contributions to the Federal emergency response effort in times of emergencies and disasters."

Among other authorities, VHA may care for nonveterans, as well as veterans not enrolled in the VA health care system. This applies in situations where the President has declared a major disaster or emergency under the Robert T. Stafford Disaster Relief and Emergency Assistance Act (42 U.S.C. Â§5121 et seq.) (the Stafford Act), or where the HHS Secretary has declared a disaster or emergency activating the National Disaster Medical System established pursuant to Section 2811(b) of the Public Health Service Act (42 U.S.C. Â§300hh-11(b)). The President's March 13, 2020, declaration of a national emergency under Section 501(b) of the Stafford Act allows VA to use this authority.

According to VA, during declared major disasters and emergencies, service-connected veterans receive the highest priority for VA care and services, followed by members of the Armed Forces receiving care under 38 U.S.C. Section 8111A, and then by individuals affected by a disaster or emergency described in 38 U.S.C. Section 1785 (i.e., individuals requiring care during a declared disaster or emergency or during activation of the National Disaster Medical System [NDMS]). In general, care is prioritized based on clinical needâthat is, urgent, life-threating medical conditions are treated before routine medical conditions (see the Appendix ).

During a disaster or emergency, VA can support HHS by providing resources to civilian health care systems. Furthermore, VA's National Acquisition Center can assist with acquisition and logistical support, such as by providing ventilators, medical equipment and supplies, and pharmaceuticals. Generally, if a state, tribal, or territorial government needs resources, they can request assistance from the federal government through their local HHS Regional Emergency Coordinator (REC). The HHS REC is to then submit a task order to the HHS Secretary's Operations Center (SOC) to be fulfilled by HHS, VA, or another federal agency. VA cannot receive direct requests for assistance from state and local governments.

On March 14, 2020, the House passed the Families First Coronavirus Response Act ( H.R. 6201 ). The Senate passed the measure on March 18, and the President signed it into law the same day as P.L. 116-127 . The act provides $30 million for VHA's medical services account to fund health services and related items pertaining to COVID-19. In addition, the act provides $30 million for VHA's medical community care account. These funds are available until September 30, 2022. Among other things, the act allows VA to waive any copayment or other cost-sharing requirements for COVID-19 testing or medical visits during any period of this public health emergency.

S. 3503 , as passed by the Senate on March 16, 2020, and then passed by the House on March 19, 2020, allows VA to continue to provide GI Bill benefits from March 1, 2020, through December 21, 2020, for courses at educational institutions that are converted from in-residence to distance learning by reason of an emergency or health-related situation. S. 3503 further permits VA to pay the Post-9/11 GI Bill housing allowance as if the courses were not offered through distance learning throughout the same period. With the exception of those covered under this S. 3503 exemption, Post-9/11 GI Bill participants enrolled exclusively in distance education are eligible for no more than one-half the national average of the housing allowance.

Emergency Supplemental Appropriations Request60

On March 17, 2020, the Administration submitted to Congress a supplemental appropriations request. The Administration seeks $16.6 billion for FY2020 for VA's response to the COVID-19 outbreak. This includes $13.1 billion for the medical services account. According to the request, this additional amount would provide funding for "healthcare treatment costs, testing kits, temporary intensive care unit bed conversion and expansion, and personal protective equipment." The request also includes $2.1 billion for the medical community care account to provide three months of health care treatment provided in the community in response to COVID-19. VA assumes that about 20% of care for eligible veterans will be provided in the community, since community care facilities would be at full capacity with nonveteran patients. Furthermore, the request includes $100 million for the medical support and compliance account for the provision of 24-hour emergency management coordination overtime payments; for costs associated with travel and transport of materials; and to enable VHA' s Office of Emergency Management to manage its response to COVID-19. The emergency supplemental appropriations request also includes $175 million for the medical facilities account to upgrade VA medical facilities to respond to the virus. The request also includes $1.2 billion for the information technology systems account to upgrade telehealth and related internet technology to deliver more health care services remotely.