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ORR Guide to Eligibility, Placement, and Services for Unaccompanied Refugee Minors (URM): Section 3


Published: May 17, 2019
Unaccompanied Refugee Minors

3.1 Statement of Goals and Priorities

The URM Program provides specialized foster care and services, consistent with state and federal child welfare laws and practices, for refugees and other special populations of youth.  Like mainstream foster care, the URM Program promotes the safety, permanency, and well-being of the children and youth in the program and strives to transition URM participants to safe and legally permanent families.  The priority in establishing permanency is reunification with parents or other relatives.  However, not all youth are able to transition into the home of a permanent family for a variety of reasons, including safety concerns.  In such cases, the URM Program provides services that ensure the youth has the appropriate skills to leave the program and enter adulthood on their own.

Regardless of the permanency goal, states and URM providers must prioritize services that will help participants in the URM Program integrate into their communities, with emphasis on those services most likely to help children and youth become independent and self-sufficient, as appropriate to their age, development, and specific needs.

The following ORR guidelines that pertain to services provided to children and youth in the URM Program apply to both States and Replacement Designees, unless specified otherwise.  

3.2 Reserved

3.3 Health Coverage and Services

Access to health coverage is critical to promoting the well-being of children and youth in the URM Program.  As provided by ORR regulations at 45 CFR 400.116, youth must have access to medical assistance until termination of eligibility as described at 45 CFR 400.113(b).  Therefore, a state must ensure that youth have access to health coverage until they turn 18 years old or a higher age prescribed by the state for the availability of foster care.  In addition to health coverage, states must provide information about coverage options or assistance filling out applications and forms.  States must ensure that URM youth, caregivers and provider staff have access to information and training on coverage rules, regardless of the source of coverage.  States should provide information about health insurance coverage to youth who are considering leaving URM placement before attaining the highest age for foster care.1

3.3.1 Standards

  1. Youth must have access to health coverage until termination of eligibility as described at 45 CFR 400.113(b).
  2. ORR-funded health coverage, including supplemental funding, is limited to those youth found ineligible for Medicaid and CHIP as described at 45 CFR 400.100(a)(1).

3.3.2. URM Health Coverage through Medicaid and CHIP

ORR regulation 45 CFR 400.94 requires states to determine whether a URM is eligible for Medicaid and CHIP.

Per 45 CFR 400.100(a)(1), children and youth who are eligible or enrolled in Medicaid or CHIP are not eligible to receive ORR funding for medical expenses.  This ineligibility for funding includes supplementary funding, such as co-pays and out-of-pocket costs not covered by Medicaid.  In addition, ORR has a longstanding policy that ORR funding is not available for the state share of Medicaid or CHIP (60 FR 33588, June 28, 1995).

States may need to coordinate with their state foster care agency and Medicaid office to increase understanding of the services available to youth in their state.  If a state wishes to provide services beyond the range of services provided by Medicaid, the state may need to explore opportunities for private partnership, including pro bono services.  States may not include a line item in their ORR-1 to pay for copays or out-of-pocket medical or dental costs for youth in the URM Program who are eligible or enrolled in Medicaid or CHIP.

While ORR regulations limit ORR-funded health coverage to those found ineligible for Medicaid and CHIP, ORR recognizes that URM youth have unique mental health needs based on their cultural, linguistic, and trauma backgrounds and that those needs may not be met by mental health professionals authorized to bill Medicaid.  After other funding sources are exhausted, ORR regulation 45 CFR 400.116(b) allows states to use ORR funding to supplement mental health services to URM youth, even if they are eligible for Medicaid or CHIP.  This includes services provided by licensed counselors, therapists, and psychologists.

ORR also acknowledges that URM youth enrolled in Medicaid or CHIP may require medical or dental services not covered by Medicaid or CHIP.  The state may request approval to use ORR funding to cover such expenses for treatment and services deemed medically necessary, urgent and/or compelling. The ORR Director or designee will consider whether to provide reimbursement for medical or dental services on a case-by-case basis.

3.3.3 URM Health Coverage through Alternatives to Medicaid and CHIP

If a youth is ineligible for Medicaid and CHIP, the state must find an alternative method to provide health coverage. States may seek reimbursement for costs associated with providing health coverage to children and youth who are ineligible for Medicaid or CHIP.  Alternative coverage is available for a URM youth who:

  • is not eligible for Medicaid or CHIP;
  • has not reached the maximum age for foster care in the state;
  • is in an eligible immigration status;
  • has not reunited with a parent;
  • has not been adopted; and
  • has not united with a non-parental adult with legal custody or guardianship.

Youth may become eligible for different health care coverage options as their age, immigration status, location, or life circumstances (e.g., pregnancy) change.  States must periodically review coverage options and reassess eligibility for Medicaid and CHIP when appropriate.  States must terminate ORR-funded health coverage when the youth is no longer eligible.

There is no correlation between eligibility for ORR-funded health coverage and receipt of ORR-funded Education and Training Vouchers / Independent Living services.

Health Insurance Marketplace

Coverage is also available through the Health Insurance Marketplace for immigrants who are lawfully present, including URMs.  To learn more about the immigration statuses eligible for Marketplace coverage, click here:  https://www.healthcare.gov/immigrants/immigration-status/.  

If a state chooses to use the Health Insurance Marketplace to provide health coverage to a youth who is ineligible for Medicaid or CHIP, the state must assist the youth in applying for advanced premium tax credits and cost-sharing assistance, if eligible.  States can use ORR funding to cover the cost of the unsubsidized portion of the premium and direct medical costs not covered by the plan.  If the youth has complex medical needs, the state should consult their URM Program Analyst before choosing a Marketplace plan.

RMA Workaround

A state may develop a program or "workaround" arrangement to provide medical assistance through its Medicaid agency or other state office and use ORR funding.  

Medical Replacement Designee

In some states, another alternative for a URM not eligible for Medicaid and CHIP is ORR-funded medical assistance through a Medical Replacement Designee (MRD)2.  MRDs are required to provide medical services in accordance with ORR Policy Letter 19-04.   

Enrollment Process

As part of the eligibility determination and enrollment process, the state or agency responsible for the administration of the URM Program must verify eligibility for ORR-funded health coverage in accordance with 3.3.3.  The responsible agency must also confirm for the MRD that the youth received federal approval to enter the URM program and is not living in a different state than where ORR has designated the MRD to provide medical assistance to URM youth.  The MRD must establish a process to ensure that it enrolls URM youth into ORR-funded medical assistance when determined ineligible for Medicaid and CHIP.  This process must include a method for the responsible agency to communicate to the MRD all the necessary information about a URM youth who is ineligible for Medicaid and CHIP.  The MRD may only request the information that is necessary to verify eligibility and enroll the youth in ORR-funded medical assistance.

Eligibility Reverification and Termination

The MRD must annually verify that URM youth remain eligible for ORR-funded medical assistance in accordance with 3.3.3.  The MRD must ask a URM youth to verify that he or she still needs ORR-funded medical assistance. The MRD must give the URM a reasonable amount of time to respond to the verification request.  The MRD must terminate ORR-funded medical assistance if the youth fails to respond to the verification request.  After termination of coverage, the MRD must have a process to re-enroll the youth in ORR-funded medical assistance, if they are still eligible, without submission of a new application. 

The agency responsible for the administration of the URM Program must communicate to the MRD any relevant changes that may affect a youth’s eligibility for ORR-funded medical assistance, within 30 days of knowledge of the change.  If the MRD verifies the change triggers ineligibility for ORR-funded medical assistance, the MRD must provide notification to the youth of intent to terminate coverage.

3.3.4 Reporting

The state or agency responsible for the administration of the URM program must report estimated and incurred costs related to providing such medical assistance on the appropriate URM direct or administrative cost line items on the ORR-1 and ORR-2 report forms. 

The state or agency responsible for the administration of the URM Program must appropriately document Medicaid and ORR-funded medical coverage on the ORR-4 outcomes report.  Medicaid or CHIP recipients who have terminated from all ORR-funded URM services must be reported as terminated from the program via the ORR-3 report.  Youth who later become eligible per 3.3.3 and receive ORR-funded URM medical coverage must be reported via the ORR-3 report as re-entering the URM program.

ORR-funded URM medical coverage must be documented as an independent living service on the ORR-3 placement report.  The responsible agency must continue to report on ORR-funded medical coverage via the ORR-3 and ORR-4 reports until termination of ORR-funded medical coverage.  

The MRD must document ORR-funded medical assistance participation and costs on required ORR grant reports.


1. This policy rescinds State Letter #15-02 and Policy Letter #18-02.
2. When a state withdraws from administering the ORR-funded Refugee Resettlement Program, ORR designates a replacement. ORR may designate a replacement for a specific aspect of the Refugee Resettlement Program, such as medical services (e.g., Refugee Medical Assistance and medical screenings). States may also elect to utilize an MRD to provide health coverage for URMs not eligible for Medicaid or CHIP.

Last Reviewed: May 21, 2019