Department  of  Health  and  Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
INTERSTATE  COMPACT  ON  ADOPTION

AND  MEDICAL  ASSISTANCE

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OEI-02-95-00040  OFFICE  OF  INSPECTOR  GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as amended, 
is to protect the integrity of the Department of Health and Human Services (HHS) programs as well as 
the health and welfare of beneficiaries served by those programs.  This statutory mission is carried out 
through a nationwidenetwork of audits, investigations,and inspectionsconductedby three OIG operating 
components: theOfficeofAuditServices,theOfficeofInvestigations,andtheOfficeofEvaluationand 
Inspections.  The OIG also informs the Secretary of HHS of program and management problems and 
recommends courses to correct them. 
OFFICE  OF  AUDIT  SERVICES 
The OIGSOfficeofAuditServices(OAS)providesall auditingservicesfor HHS, eitherby conducting 
audits with its own audit resources or by overseeing audit work done by others.  Audits examine the 
performance of HHS programs and/or its grantees and contractors in carrying out their respective 
responsibilitiesandare intendedto provideindependentassessmentsofHHSprogramsandoperationsin 
order to reduce waste, abuse, and mismanagementand to promote economy and efficiency throughout 
the Department. 
OFFICE  OF  INVESTIGATIONS 
The OIGSOffice of Investigations(01) conductscriminal, civil, and administrativeinvestigationsof 
allegations of wrongdoing in HHS programs or to HHS beneficiaries and of unjust enrichment by 
providers.  The investigativeeffortsof01 leadto criminalconvictions,administrativesanctions,or civil 
moneypenalties. The01alsooverseesStateMedicaidfraudcontrolunitswhichinvestigateandprosecute 
fraud and patient abuse in the Medicaid program. 
OFFICE  OF  EVALUATION  AND  INSPECTIONS 
The OIGSOffice of Evaluationand Inspections(OEI) conductsshort-term managementand program 
evaluations(calledinspections)thatfocusonissuesofconcernto the Department,the Congress,andthe 
public. Thefindingsandrecommendationscontainedintheseinspectionreportsgeneraterapid, accurate, 
andup-to-dateinformationon the efficiency,vulnerability,andeffectivenessof departmentalprograms. 
This report was prepared in the New York regional office under the direction of Alan S. Meyer, Ph.D., 
Regional Inspector General.  Project staff included: 
REGION 11  HEADQUARTERS 
Nancy Harrison, Project Leader  Tina Fuchs 
Demetra Arapakos  W. Mark Krushat 
Renee Dunn  Dave Wright 
For additional copies of this report, please contact the New York regional office at (212) 264-1998.  Department  of  Health  and  Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
INTERSTATE  COMPACT  ON  ADOPTION 
AND  MEDICAL  ASSISTANCE  EXECUTIVE  SUMMARY 
PURPOSE 
To assess how membership  in the Interstate  Compact  on Adoption  and Medical  Assistance 
(ICAMA) affects States efforts to protect  the interests  of special needs adopted children  who 
move from one State to another. 
BACKGROUND 
Adopted  Children with Special Needs 
The Administration  for Children  and Families  (ACF) has asked the Office of Inspector 
General  (OIG) to look at a number  of issues regarding  interstate  compacts,  including the 
advantages  to State membership  in the Interstate  Compact  on Adoption and Medical 
Assistance  and how non-member  States are handling  cases of special needs adopted children. 
The Adoption Assistance  and Child Welfare  Act established  a federally  aided adoption 
assistance program  under  IV-E of the Social Security Act that provides  contributions  to State 
subsidies given to parents  who adopt special needs children.  These children  are entitled  to 
adoption assistance payments  and medical  assistance  (Medicaid),  both of which offset some 
of the extra expense of raising  a special needs child.  If children  are covered  by IV-E and 
move to another  State, they must be issued a Medicaid  card by the State to which they move. 
Interstate Agreements 
A State enters  into adoption assistance  agreements  with adoptive parents  which must contain 
provisions for the protection  . . . of the interests  of the child in cases where the adoptive 
parents  and child move to another  State.   A State may enter  into an interstate  compact  or 
use some other mechanism  to fulfill this requirement.  The States, however,  are not required 
to join  a compact  and no guidelines  or definitions  are offered  for the other mechanisms  they 
may employ. 
The Interstate  Compact  on Adoption and Medical  Assistance  (ICAMA) established  a formal 
mechanism  to ensure that Title IV-E children  continue  to receive  medical  and other services 
on an interstate  basis,  as envisioned  under the Adoption Assistance  Act.  The compact  has 
the force of law within and among member  States.  Currently,  30 States are members  of 
ICAMA. 
We gathered  information  from the ICAMA administrators  in all 29 States that were members 
of the compact  and representatives  from 21 non-member  States in 1995.  We also 
interviewed  selected advocacy  groups,  ACF staff, American  Public Welfare  Association 
representatives,  and a few adoptive parents  to gain their  insights on issues of IV-E children 
moving. 
i  FINDINGS 
ICAMA Membership  Provides  States with Significant  Administrative  Advantages  in 
Maintaining  Medical Assistance for  Adopted  Children with Special Needs 
Member  States benefit from the following  administrative  advantages:  active involvement  in 
assisting IV-E children,  an accessible  contact person,  standard  forms and instructions,  the 
ability to issue timely Medicaid  cards,  good coordination,  and an active Secretariat.  As a 
result,  virtually  all member  States are satisfied with the compact.  In contrast,  most non-
member  States do not enjoy these benefits. 
Despite  the Advantages  of Compact Membership,  More  Than Hay  of the Non-Member 
States See No Need to Join 
Most non-member  States are satisfied with their system and think it is easy for IV-E children 
who move into their State to get a new Medicaid  card.  Many non-member  States are 
reluctant  to join the compact.  They feel the compact  offers these children  no additional 
medical  or financial  benefits.  Non-member  States point to increased  staff time and ICAMA 
dues as disadvantages  to joining. 
Some non-member  States nevertheless  feel positively  about the compact,  noting possible 
advantages  of an improved  or quicker process  in handling IV-E cases and a contact person. 
In fact,  four non-member  States are planning  to join the compact  and six more  say it is 
possible they will join  in the future. 
CONCLUSION 
Overall,  we conclude  that compact  membership  is advantageous  to States and families  with

IV-E children.  We recognize  that it is each States prerogative  to join  the compact.  We also

recognize  that such considerations  as a States size and organizational  structure  may

discourage  the State from joining.  However,  even if a State elects not to join the compact,  it

may still benefit by adopting  some of the compacts  procedures,  such as designating  a contact

person to whom other States and family members  can turn for information  and assistance.

States that elect not to join might also consider  using mechanisms  for further  educating

parents  and local Medicaid  workers  about IV-E benefits  and the obligations  that States have

to IV-E children  moving  across State lines.

The ACF may want to inform all States of the administrative  benefits  of compact

membership  and the resulting  benefits to IV-E families.  We suggest that ACF work with the

compacts  Secretariat  and adoption advocacy groups to disseminate  this information.  We

believe that compact membership  is worthwhile  and encourage  the States that are planning  to

join to do so as expeditiously  as possible.

ii  COMMENTS 
We received  favorable  comments  from ACF on the draft report.  They believe  it will be a 
useful tool for them to encourage  State membership  and to positively  impact on States 
efforts to protect  the interests  of adopted children  with special needs.  The actual comments 
received  are included  in Appendix B. 
... 
111  TABLE  OF  CONTENTS

EXECUTIVE  SUMMARY

INTRODUCTION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

FINDINGS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..4

  ICAMA Provides States with Significant Advantages  . . . . . . . . . . . . . . . . . . . 4

  Non-member  states  see  No  Needto  Join  . . . . . . . . . . . . . . . . . . .  . . . . .  10

CONCLUSION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  . . . . . . . . .  11

APPENDICES  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  . . .  ..<  . . . . . .  . .

A:  Population  Data of Member  and Non-member  States  . . . . .  ,...  . . . . . . .  A-1

Map ofMember  States  . . . . . . . . . . . . . . . . . . . . . . . . . . . .  . . . . . . . .  A-4

B:  Comments  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..B-l
 INTRODUCTION

PURPOSE 
To assess how membership  in the Interstate  Compact  on Adoption  and Medical  Assistance 
(ICAMA) affects States efforts to protect  the interests  of special needs adopted children  who 
move from one State to another. 
BACKGROUND 
The Administration  for Children  and Families  (ACF) has asked the Office of Inspector 
General  (OIG) to look at a number  of issues regarding  interstate  compacts,  including the 
advantages  to State membership  in ICAMA and how non-member  States are handling  cases 
of special needs adopted children. 
The Adoption  Assistance  and Child Welfare Act 
In 1980 Congress  amended  Title IV of the Social Security  Act with the Adoption Assistance 
and Child Welfare  Act (P. L. 96-272).  The Adoption Assistance  Act established  a federally 
aided adoption assistance  program  under Title IV-E of the Social Security Act.  It provides 
Federal  contributions  to State subsidies given to parents  who adopt special needs children. 
Special needs children  (hereafter  referred  to as Title IV-E children)  are children  who are 
eligible  for Aid to Families  with Dependent  Children  or Supplemental  Security Income  and 
who are defined by the State as having special needs.  Special needs refers  to factors that 
make a child difficult to place for adoption,  such as having emotional  or behavioral 
problems,  being part of a large  sibling group,  being a member  of a minority,  having 
developmental  problems  or having serious medical  conditions.  Title IV-E children  are 
entitled to adoption  assistance  payments  and medical  assistance  (Medicaid),  both of which 
offset some of the extra expense  of raising  a special needs child. 
In order for a State to receive  Federal  contributions  it must enter  into adoption assistance 
agreements  with the adoptive parents.  A State that does so is called the adoption  assistance 
State.  These written  agreements  must meet certain  Federal  requirements,  such as specifying 
the nature and amount of any adoption assistance  payments  and services  to be provided.  The 
agreement  must also contain  provisions for the protection  . . . of the interests  of the child in 
cases where the adoptive parents  and child move to another  State while the agreement  is 
effective.   A State may enter  into an interstate  compact  or use some other mechanism  to 
fulfill this requirement.  The Adoption Assistance Act directs  the Secretary  of Health  and 
Human Services to encourage  and assist States to enter  into interstate  compacts  so that the 
interests  of Title IV-E children  are adequately  protected  if the child moves to another  State. 
The States, however,  are not required  to join  a compact  and no guidelines  or definitions  are 
offered  for the other mechanisms  they may employ. 
It is important  that a child continue  to receive  adoption assistance payments  and medical 
assistance  (Medicaid)  when they move to a new State just  as they would if they moved from 
1  one place to another within the same State.  Continuation  of the adoption assistance  payments 
is not a problem  since the adoption assistance  State (the State the child moves from) can 
easily mail the payments  to the childs address  in the new State (hereafter  referred  to as 
residence State).  Continuing  medical  assistance,  however,  is more complicated.  It is 
almost impossible  to find health care providers  who will accept another  States Medicaid 
card.  Therefore,  the child needs a new card issued in the new residence  State as soon as 
possible.  Ideally,  there  should be no delay. 
Interstate  Compact on Adoption  and Medical Assistance 
In the absence of Federal  guidelines,  nine States,  with ACFS help,  adopted the Interstate

Compact  on Adoption and Medical  Assistance  (ICAMA)  in 1986.  The compact  established  a

formal mechanism  to ensure that Title IV-E children  continue  to receive  medical  and other

services  on an interstate  basis,  as envisioned  under the Adoption  and Assistance  Act.  The

compact has the force of law within and among member  States.  It provides  uniform

procedures  and forms to conduct  interstate  transactions.  Each member  State must designate  a

compact  administrator  who is responsible  for the operation  of the compact.  The

administrator  processes  ICAMA  forms and serves as an information  resource.  Currently,  30

States are members  of ICAMA.  Appendix  A contains population  data of member  and non-

member  States.

The compact  is administered  by the Association  of Administrators  of the Interstate  Compact

on Adoption  and Medical  Assistance  (AAICAMA) under  a cooperative  agreement  with ACF.

The American  Public Welfare  Association  (APWA) acts as the compacts  Secretariat  under  a

subcontract  with the AAICAMA.  The Secretariat  provides  technical  assistance  to compact

members  and helps handle  interstate  problems  involving the provision  of services  and

benefits  for interjurisdictional  adoption cases falling under  the compact,

Consolidated  Omnibus Reconciliation  Act 
The Consolidated  Omnibus Reconciliation  Act (COBRA) of 1986 mandated  that residence 
States confer Medicaid  eligibility  to children  who have Title IV-E adoption assistance 
agreements  with another  State.  This means that children  covered  by an adoption  assistance 
agreement  in one State must be issued a Medicaid  card by the State to which they move. 
COBRA did not, however,  provide  interstate  administrative  guidance  for this transfer 
process.  COBRA also gives States the option of providing  Medicaid  to children  who are not 
IV-E eligible but who are adopted pursuant  to State-funded  adoption  subsidy programs  and 
meet certain  criteria. 
METHODOLOGY 
We conducted  telephone  interviews  in 1995 with the ICAMA  administrators  in all 29 States 
that were then members.  Texas has just recently joined  the compact,  bringing  the total 
membership  up to 30 States.  At the time of data collection,  however,  Texas was not a 
member  and therefore  is treated  as a non-member  State in this report.  We asked each 
administrator  about the process  that takes place when Title IV-E children  move into and out 
2
 of his or her State.  We also discussed the administrators  experiences  with ICAMA,  the 
advantages  and disadvantages  of being a compact  member,  and how the compact  could be 
improved. 
In this inspection,  States belonging  to the compact  are referred  to as member  States while 
States not in the compact  are called non-member  States. 
We also conducted  telephone  interviews  with an adoption specialist,  or other representative 
from the States office responsible  for youth and family services,  from 21 of the 22 non-
member  States,  including Washington,  D. C.  One State refused to be interviewed.  We 
discussed what the States are doing to protect  the interstate  interests  of Title IV-E children 
and how those processes  are working.  We also asked the 21 non-member  States why they 
had not joined  the compact  and what they see as the compacts  advantages  and disadvantages. 
We asked each State to provide  us with any written policies  and procedures  they use in 
processing  interstate  cases.  We developed  a review  sheet to evaluate  the States written 
policies  and procedures  to determine  their clarity,  thoroughness,  and degree  of detail.  We 
also asked for other supporting  documentation.  This included  any cost-benefit  analysis they 
may have done regarding  membership  in the compact  (no State had done any),  any data they 
may have on how many days it takes the State to issue a Medicaid  card to incoming Title IV
E children,  and the numbers  of IV-E children  they have moving  into or out of their State. 
The APWA provided  additional  data on the numbers  of IV-E children  who have moved 
across State lines.  (See Appendix  A). 
We constructed  an index of State involvement  in IV-E cases using data from the telephone 
interviews  and written  policies  and procedures.  This index was based on four key variables: 
whether the State, at the State level,  is generally  aware that a IV-E child has moved  into the 
State; whether the State, at the State level,  knows when a child moves out; whether  the State 
in some way notifies the family that they are IV-E and are entitled  to medical  assistance  in 
their new State; and whether the State or local level sends paperwork  to the new State for 
families moving out.  A State earned  one point for a positive  action on each variable.  For 
instance,  if a State usually  sends the familys  adoption assistance  agreement  to the State the 
family is moving to, the State would earn one point for that variable.  Since there  were four 
variables,  scores could range from O to 4 points. 
Finally,  we interviewed  selected advocacy  groups,  ACF staff, an APWA representative,  and 
three parents  who have adopted a total of ten IV-E children  to gain their insights on issues of 
IV-E children  moving.  The experiences  of the parents  interviewed  include the four possible 
moving scenarios:  member  State to member  State; member  State to non-member  State; non-
member  to member;  and non-member  to non-member. 
This inspection  was conducted  in accordance  with the Quality  Standards  for  Inspections 
issued by the Presidents  Council  on Integrity  and Efficiency. 
3
 FINDINGS

ICAMA  MEMBERSHIP  PROVIDES  STATES  WITH  SIGNIFICANT 
ADMINISTRATIVE  ADVANTAGES  IN MAINTAINING  MEDICAL  ASSISTANCE 
FOR  ADOPTED  CHILDREN  WITH  SPECIAL  NEEDS 
Member  States benefit from the following  administrative  advantages  in their efforts to 
maintain IV-E childrens  medical  assistance:  active involvement,  a contact person,  standard 
forms and instructions,  the ability to issue timely medical  cards,  good coordination,  and an 
active Secretariat.  As a result,  virtually  all member  States are satisfied with the compact. 
Member  States are More Actively  Involved  than Non-member  States in Assisting  IV-E 
Children 
Interviews  with States and a review  of member  State procedures  show that member  States are 
actively  involved in ensuring  that IV-E children  maintain  their medical  assistance  when they 
move across  State lines.  The States compact  administrator  takes an active role whether  the 
IV-E child is moving out of or into his or her State.  Most compact  administrators  report 
spending less than two hours a week on compact  duties.  When a IV-E child moves out of a 
member  State, the administrator  verifies  the childs IV-E status and sends the appropriate 
paperwork  to the new State of residence.  When a IV-E child moves into a member  State, 
the administrator  is usually  notified and facilitates  the issuing of new Medicaid  cards.  If a 
IV-E child moves from one member  State to another the transition  can be completed  by mail, 
and the family does not have to go to any Medicaid  offices in either  State. 
Non-member  States,  on the other hand,  often do not know when a IV-E child leaves their 
State.  When they are aware  a child is moving out, over half of the non-member  States (11 
of 21) advise the family to go to the Medicaid  office in the new residence  State to apply for a 
Medicaid  card,  thus placing  the responsibility  for maintaining  assistance  on the family.  In 
five non-member  States,  when a IV-E child moves out, the local offices will notify their 
State office,  and one of the two offices will send some paperwork,  such as a letter  regarding 
IV-E status,  to the new residence  State. 
Two-thirds  of the non-member  States say they are usually unaware  on a State level when a 
IV-E child moves into their State, especially  from other non-member  States, because  it is 
handled  at a local level.  In many cases,  the State may only become  aware of the case if the 
family or adoption  assistance  State calls with a complaint.  Often the State office,  when 
aware a IV-E child is moving  in, will refer  the case to the local office.  In many instances, 
however,  the family has to find their own way to the local office.  Only three  non-member 
States say they will issue the Medicaid  card and take care of the case at the State level. 
The index of State involvement  we have developed,  as described  in the Methodology,  is 
based on two indicators  of active notification  and two indicators  of awareness  at the State 
level.  State scores on the index show the contrast  between  active member  States and much 
less active non-member  States.  Based on one point for each indicator  in which the State is 
4  actively  involved,  possible  scores range from zero to four.  We consider  scores of three  or 
more to indicate relatively  high involvement  and scores of two or less to show relatively  low 
involvement.  As Table  1 below shows, 93 percent  of the member  States score three  or more 
compared  to only 29 percent  of the non-member  States.  Conversely,  71 percent  of the non-
member  States score relatively  low on the index while only four percent  of member  States 
do.  A major  reason the non-member  States score lower is that while most member  States 
(79 percent)  usually handle IV-E cases at the State level,  fewer non-member  States do (33 
percent). 
Table  1 
Scores on Index of Active State Involvement  with IV-E Cases 
I  I  I  II 
SCORE  MEMBER  STATES  NON-MEMBER  STATES  TOTAL 
4  26  (90%)  1  (5%)  27 
3  1  (3%)  5  (24%)  6 
2  1  (3%)  10  (48%)  11 
1  0  4  (19%)  4 
0  0  1  (5%)  1 
nla  1* (3%)  o  1 
TOTAL  29 (100%)#  21  (loo%)#  50 
II  ,  1  ,  {1 
*One member  State could not be scored due to lack of information 
# Percentages  do not add up to 100 due to rounding 
Handling  IV-E cases at the local level creates  more opportunity  for problems  and 
inconsistency.  One problem  non-member  States identify is that families have difficulty 
finding the appropriate  office to go to in their State, thereby  delaying  the process  of getting a 
new card.  A few non-member  States point out that in non-member  States the office that 
handles IV-E is not always located in the adoptions unit and,  therefore,  is more difficult  to 
track  down. 
Some member  States say it is not uncommon  for non-member  States to advise a IV-E family 
to go to a local Medicaid  office in their residence  State but not tell them the child has IV-E 
status.  One adoptive mother  tells the story of going to the local office in her new residence 
State, which is a non-member,  and having to fill out a Medicaid  application.  She was told 
that eligibility  depended  on income.  The mother  was sophisticated  enough  in IV-E matters  to 
know the case worker  was mistaken.  Once the supervisor  was brought  in, the case was 
handled properly.  Unfortunately,  if a IV-E family is not familiar  with the law,  or is not 
aware their child is IV-E,  the child may not receive  a new Medicaid  card.  One State tells a 
story of a family that moved from a non-member  State and lived in the new State for 2 years 
before  learning  they could get Medicaid  in the residence  State.  Another  State recalls  a case 
of a IV-E child being in her State for 8 or 9 months before  the family happened  to visit a 
local office and learned  the child was eligible  for Medicaid. 
5
 Non-member  States are more  likely than member  States to feel handling cases of IV-E 
children  moving  is burden.  Seven (33 percent)  of the 21 non-member  States say it is a 
burden  compared  with 3 (10 percent)  of the 29 member  States.  All but one of the non-
member  States feeling burdened  handle the IV-E cases on the local level. 
In Contrast to Non-member  States,  Member  States Have an Accessible  Contact Person 
The process  for continuation  of medical  assistance  is made easier,  both for States and IV-E 
children,  by the existence  of an ICAMA contact person  in each member  State.  Along with 
other compact  duties,  the compact  administrator  serves as the contact person  whom States 
and IV-E families  can contact  for information  and assistance.  A majority  of member  States 
(18 of 29) say that having a contact person  available  to answer questions and provide 
assistance  makes the move easier for IV-E families  and lessens the stress of the move.  Some 
non-member  States (4 of 21) agree,  saying IV-E children  in their State would benefit  from 
having a contact person  if the State joined  ICAMA. 
Most member  States (24) believe that having a contact person  is one of the biggest 
advantages  to compact membership  in that it helps facilitate  communication  between  States. 
Many member  States say that having a contact  is also one of the reasons why they prefer  to 
work with member  States over non-member  States when dealing with IV-E children. 
Many member  States (12) consider  not having a contact  in non-member  States a major 
problem,  one that could make a move more difficult  for a IV-E family.  Several member 
States complain  of spending many hours on the phone trying  to track down the right person 
to talk with about a IV-E case,  especially  in States that handle IV-E at the local level.  This 
was confirmed  during  this study when we often experienced  problems  finding the person 
responsible  for IV-E cases in non-member  States.  Reaching  these people  in member  States, 
in comparison,  was much easier. 
Member  States Have Standard Forms, Instructions  and Procedures,  While Those Used by 
Non-member  States are Inconsistent 
Standard forms and instructions  facilitate  a smooth administrative  process  when IV-E 
children  move between  member  States.  All member  States follow standard procedures  and 
use the same four ICAMA  forms to process  incoming  or outgoing IV-E children.  These 
forms serve the following  functions:  to report  on the IV-E childs  status; to take the place of 
a Medicaid  application  in the residence  State; to notify States and adoptive  families  that the 
necessary  information  has been sent to the new residence  State so Medicaid  cards can be 
issued; and to give notice to the adoption assistance  State that a Medicaid  case has been 
opened in the new residence  State.  The ICAMA forms have clear guidelines  for their 
completion  and distribution,  and instructions  for sending the appropriate  supporting 
documentation,  such as the current  adoption assistance  agreement.  The Association  of 
Compact  Administrators  and the Secretariat  are currently  working  on further  streamlining  the 
forms. 
6
 While all member  States use ICAMA forms,  about half (14 of 29) have additional  policies 
and procedures  to clarify  the process  in their State.  Most of these policies  and procedures 
clearly  detail the steps to be taken when a IV-E child moves into or out of the State. 
Policies  from 6 of the  14 member  States are comprehensive  with precise  instructions. 
About half of the non-member  States (10 of 21) also have written policies  and procedures. 
Although most of the  10 outline the steps to follow when a IV-E child moves into or out of 
the State, only half specify the documentation  to expect from an adoption assistance  State. 
Three  of the  10 States have comprehensive  policies  and procedures  with precise  instructions. 
All the written policies  and procedures  we received  from States verify the information  we 
were told in the telephone  interviews. 
Membership  Helps States Issue  Timely Medicaid  Cards 
Since member  States recognize  ICAMA  forms as eligibility  for Medicaid,  the card can be 
issued without delay when both States are members  of the compact.  When States do not use 
standard  forms and procedures  it is more probable  that the documentation  the child brings to 
the new residence  State will be incomplete  and the family will experience  delays in getting a 
new card in the new State,  whether member  or non-member.  Fourteen  member  States say it 
takes longer to issue cards to children  from non-member  States.  They say the children 
coming  from these States often do not have proper  documentation  of IV-E status and getting 
the documentation  can be time-consuming,  especially  if there  is no contact person  in the 
adoption assistance  State.  One member  State reports  that when a child comes without a copy 
of the adoption assistance  agreement  it can take more than 6 months to get the necessary 
documentation  to issue a new card. 
Five non-member  States agree that not getting the proper  documentation  poses problems  for 
their State in issuing new cards.  They also feel getting the documentation  is burdensome. 
Non-member  States do not agree,  however,  that it generally  takes longer to issue cards to 
children  coming  from other non-member  States.  Almost all of them (19) say it takes the 
same amount of time to issue cards to children  coming from non-member  States as it does 
for children  coming from member  States.  Five of these non-member  States say that their 
local offices issue cards,  thereby  making  it difficult  to say how long it takes.  Only two non-
member  States say it takes longer when they are dealing with a child from a non-member 
State. 
Most States have guidelines  or requirements  that they must issue Medicaid  cards to those 
eligible  within a given timeframe,  such as 1 month or 45 days.  States do not keep data on 
how long it takes to issue individual  cards.  Many States issue cards only at certain  times of 
the month.  For instance,  one State may issue cards on the 15th of every month so if 
someone applies on the 8th and is deemed eligible,  he or she may get the card in a week.  If 
that same person  had applied on the 20th,  he or she would have to wait until the  15th of the 
following month to receive  the card.  All States report  some way of accommodating  an 
emergency  if the applicant  cannot wait to get the card. 
7
 Comparison  of issuance time before  and after membership  in the compact  is limited due to 
the way cards are issued and the lack of systematic  data.  Of the 17 member  States that could 
compare,  just  over half (9) say it took longer for their State to issue a Medicaid  card before 
their State joined  the compact than it does now.  Eight member  States think it takes the same 
amount of time.  The remaining  12 member  States could not say how long it took to issue a 
card before the compact. 
Most member  States (23) feel that,  since they joined  the compact,  it has been easier  for IV-E 
children  who move into their State to get a Medicaid  card.  The main reasons  for this, 
according  to the States,  is the improved  administrative  process  and contact person.  Three 
notice no change and the remaining  States could not offer an opinion.  All member  States 
agree,  however,  that IV-E children  benefit from the compact.  They think it offers better 
service to families,  which is why most member  States joined. 
The majority  of member  States (18) say there  are no problems  issuing a new card to IV-E 
children  who move into their State.  The problems  they do see mostly involve  insufficient 
documentation  from other States, usually non-members. 
Coordination  is Easier with Member  States 
Membership  in ICAMA  facilitates  coordination  among States.  In contrast  to non-member 
States, when a IV-E child moves out of a member  State, that member  State will notify the 
residence  State the child is coming.  Almost all (27) member  States and  17 non-member 
States report  that when a IV-E child moves from a member  State into theirs,  they find out 
from the other States compact  administrator.  Member  States point out that they can begin 
the necessary  paperwork  right away if they know a child is coming.  This helps ensure no 
lapse in assistance  for the child.  On the other hand,  most member  States say they usually 
find out about children  moving from a non-member  State only when the family visits the 
local office in the new State.  Non-member  States also say that they are usually unaware 
when a IV-E child moves into their  State from another  non-member  State.  When they do 
find out, it is through  their local office or the other non-member  State might call them. 
Twenty-one  member  States believe  the compact usually helps resolve problems  between 
States.  The compact  has the force of law in and among member  States so these States can 
turn to the compact  and its standards  when questions arise,  which might happen when an 
inexperienced  compact  administrator  is learning  the process. 
Coordination  is more difficult  when a non-member  State is involved in a move.  Problems 
between  States are more likely to occur if one of those States is a non-member.  While only 
a few (4) non-member  States complain  of problems  with member  States,  almost three  times 
as many (11) non-member  States complain  of problems  with non-member  States.  The 
contrast  is even greater  with member  States: 4 member  States report  major problems  with 
other member  States while 21 report  major problems  with non-member  States.  Problems 
often involve the lack of a contact person  and incomplete  IV-E documentation. 
8
 A majority  of both member  (24) and non-member  States (12) prefer  to work with member 
States over non-member  States.  They give the following  reasons:  the ICAMA members  are 
easy to work with and are very helpful;  member  States have a contact person;  member  States 
send the correct  paperwork;  and member  States are more knowledgeable  about IV-E.  No 
State, member  or non-member,  prefers  to work with non-member  States over member  States. 
An Active  Secretariat  is Another  Compact Benefit 
The compacts  Secretariat  helps States to better  serve IV-E children.  All States that 
volunteer  an opinion,  21 members  and 4 non-members,  feel positively  about the Secretariat. 
According  to these States,  the Secretariat  helps resolve  compact  issues,  offers technical 
assistance  to member  and non-member  States,  and disseminates  information  on a variety  of 
adoption matters  in the form of issue briefs.  States appreciate  the Secretariats  annual 
conference  that addresses  many adoption issues.  Member  States,  non-member  States,  child 
welfare  advocates,  adoptive parents,  and other concerned  parties  attend the conference  and 
are given the opportunity  to learn and network. 
Member  States are Satisfied  with Compact 
Almost all member  States are satisfied with the compact:  20 are very satisfied,  while 8 are 
somewhat satisfied and 1 State is neither  satisfied nor dissatisfied.  None are dissatisfied. 
Member  States cite many advantages  to compact  membership,  such as an improved 
administrative  process  when IV-E children  move,  information  sharing and networking,  and 
better  service  for families.  Most member  States (20) say the compact  has no disadvantages. 
Six member  States cite the annual dues as a disadvantage. 
Membership  does not present  an administrative  hardship  for States.  Most member  States 
(26) do not feel managing  the compact  is burdensome.  The three member  States that say it 
is burdensome  blame  it on lengthy forms,  which are currently  being revised.  Over half of 
the member  States (16) report  spending  1 hour or less a week performing  ICAMA  duties. 
Another  five spend between  1 and 2 hours.  The number  of IV-E children  in their  State does 
not seem to have an effect on the amount of time spent.  Of those 23 member  States with 
data,  5 of the 6 with the largest IV-E population  say they spend 1 hour or less on ICAMA. 
Almost all member  States (27) feel all States should be ICAMA members.  When asked for 
suggestions  for improving  the compact,  14 member  States call for increased  membership. 
Another  suggestion made by many is for all member  States to elect the COBRA option and 
grant Medicaid  eligibility  to non-IV-E  special needs children.  These children  are deemed 
special needs by their State, but since they are not IV-E,  they are not covered  by the 
Adoption Assistance  and Child Welfare  Act and therefore  not guaranteed  Medicaid  eligibility 
when they move to another  State.  In many cases,  member  States have agreed  to offer 
eligibility  to non-IV-E children  who come from other States that will reciprocate  and offer 
eligibility  to their non-IV-E  cases.  Some member  States cite this reciprocity  as another 
compact  advantage. 
9
 DESPITE  THE  ADVANTAGES  OF  COMPACT  MEMBERSHIP,  MORE  THAN  HALF 
OF  THE  NON-MEMBER  STATES  SEE  NO  NEED  TO  JOIN 
Non-member  States tend to be large,  such as California,  Florida,  Illinois,  New York,  and 
Ohio.  (See Appendix  A).  Two-thirds  of the non-member  States handle interstate  IV-E cases 
at the local level.  Only one-third  handle them at the State level. 
Most Non-member  States are Satisfied  with their System 
More than half of the non-member  States (12 of 21) say they experience  no problems  in 
issuing a new Medicaid  card.  In general,  non-member  States (17) are satisfied with how 
they are handling IV-E cases.  Several could not offer any suggestions  for improving  their 
system.  A few suggest adding staff. 
Most (18) non-member  States think it is easy for IV-E children  who move into their  State to 
get a new Medicaid  card.  Many of these States (8 of 18) cite a lack of complaints  as 
evidence.  Others  say it is easy because their State has a good process.  Some non-member 
States (four) concede that it is easy only if the family knows where to go and difficult  if they 
do not. 
Many Non-member  States are Reluctant  to Join the Compact 
When asked why they have not joined  ICAMA,  12 States (57 percent)  say they see no need 
to become members  because  they are already  handling their IV-E cases and they have no 
problems  issuing a new medical  card.  They feel the compact  would not benefit IV-E 
children.  They say that, by law, IV-E children  are eligible  for Medicaid  in their residence 
State and the compact  offers these children  no additional  medical  or financial benefits.  Some 
of them feel that there  are too few children  involved to justify  the possible  increased 
administrative  costs.  Others point to difficulty  with their  State legislature  as an obstacle to 
joining the compact.  However,  some of these same States do admit that membership  might 
make the IV-E process  smoother. 
Eight non-member  States say a disadvantage  to joining  the compact  is the amount of staff 
time they feel is needed to administer  the compact.  A comparison  of hours spent in both 
member  and non-member  States,  however,  shows non-member  States report  they spend 
roughly the same amount of hours handling IV-E cases as member  States.  Dues is another 
concern  among non-member  States.  ICAMA dues are $3000 a year,  $1500 of which is 
reimbursed  by the Federal  government. 
Non-member  States give a variety  of incentives the compact  would need to offer to get their 
State to join,  including  staff, money,  more services  for children,  or some other benefit that 
would convince  the decision makers  in the State to join. 
10
 However,  a Few States Plan to Join and Others are Considering It 
Some non-member  States nevertheless  feel positively  about the compact.  More than half (16) 
of the non-member  States note advantages  to ICAMA.  The most frequently  mentioned 
advantage  is an improved  or quicker process  in handling IV-E cases.  Another  frequently 
mentioned  advantage  is the contact person  the compact  requires.  Some States say joining  the 
compact might improve  information  sharing,  provide  better  service to children,  and facilitate 
getting the correct,  complete  paperwork.  In fact,  for these same reasons,  four non-member 
States are planning to join  the compact  and six more say it is possible they will join  in the 
future. 
CONCLUSION 
Overall,  we conclude  that compact  membership  is advantageous  to States and families  with

IV-E children.  We recognize  that it is each States prerogative  to join  the compact.  We also

recognize  that such considerations  as a States size and organizational  structure  may

discourage  the State from joining.  However,  even if a State elects not to join  the compact,  it

may still benefit by adopting  some of the compacts procedures,  such as designating  a contact

person  to whom other States and family members  can turn for information  and assistance.

States that elect not to join  might also consider  using mechanisms  for further  educating

parents  and local Medicaid  workers  about IV-E benefits  and the obligations  that States have

to IV-E children  moving across  State lines.

The ACF may want to inform all States of the administrative  benefits  of compact

membership  and the resulting  benefits  to IV-E families.  We suggest that ACF work with the

compacts  Secretariat  and adoption advocacy  groups to disseminate  this information.  We

believe that compact  membership  is worthwhile  and encourage  the States that are planning  to

join to do so as expeditiously  as possible.

COMMENTS 
We received  favorable  comments  from ACF on the draft report.  They believe  it will be a 
useful tool for them to encourage  State membership  and to positively  impact on States 
efforts to protect  the interests  of adopted children  with special needs.  The actual comments 
received  are included  in Appendix  B. 
11
 APPENDIX  A 
Population  Data  of Member  and  Non-member  States+ 
State  Population  # of IV-E  # of IV-E  Total  IV-E 
(Member  States  1990  children  out  children  in  adopted 
are in bold)  of State  1994  State  1994  children 
Alabama  4,040,587  25  197  222 
Alaska  550,043  96  215  311 
Arizona  3,665,228  107  721  828 
Arkansas  2,350,725  5  249  254 
California  29,760,021  *  *  13109 
Colorado  3,294,394  177  1127  1304 
Connecticut  3,287,116  *  *  * 
Delaware  666,168  41  147  188 
D.C.  606,900  *  *  * 
Florida  12,937,926  *  *  4026 
Georgia  6,478,216  116  922  1038 
Hawaii  1,108,229  35  84  119 
Idaho  1,006,749  57  174  231 
Illinois  11,430,602  583  4076  4659 
Indiana  5,544,159  *  *  892 
Iowa  2,776,755  *  *  * 
Kansas  2,477,574  *  *  * 
Kentucky  3,685,296  231  845  1076 
Louisiana  4,219,973  50  1145  1195 
Maine  1,227,928  *  *  * 
Maryland  4,781,468  *  *  * 
Massachusetts  6,016,425  355  *  * 
A-1
 State  Population  # of IV-E  # of IV-E  Total  IV-E 
(Member  States  1990  children  out  children  in  adopted 
are in bold)  of State  1994  State  1994  children 
Michigan  9,295,297  *  * * 
Minnesota  4,375,099  217  1053  1270 
Mississippi  2,573,216  20  220  240 
Missouri  5,117,073  *  * * 
Montana  799,065  *  * * 
Nebraska  1,578,385  97  456  553 
Nevada  1,201,833  64  133  197 
New Hampshire  1,109,252  *  *  325 
New Jersey  7,730,188  346  1891  2237 
New Mexico  1,515,069  159  650  809 
New York  17,990,455  *  * * 
North Carolina  6,628,637  *  * * 
North Dakota  638,800  27  116  143 
Ohio  10,847,115  *  * * 
Oklahoma  3,145,585  69  611  680 
IOregon  2,842,321  353  1503  1856 
Pennsylvania  11,881,643  *  * * 
Rhode Island  1,003,464  82  506  588 
South Carolina  3,486,703  50  716  766 
&
South Dakota  696,004  98  321  419 
,
rennessee  4,877,185  50  723  773 
rexas  16,986,510  502  2921  3423 
(Utah  1,722,850  11
 363  374 
1 Vermont  562,758  40  360  400 
Virginia  6,187,358  *  * * 
1Washington  4,866,692  *  * * 
A-2
 State  Population
 #of  IV-E
 #of  IV-E  Total  IV-E 
(Member  States  1990
 children  out
 children  in  adopted 
are in bold)
 of State  1994
 State  1994  children 
West Virginia  1,793,477  32
 136  168

Wisconsin  4,891,769  100
 1609  1709

Wyoming  453,588  *
 *  83

+  Table is based on 1990 census data and State-reported  data of IV-E children  as of June,

1994

* Data not available 
A-3
 MAP  OF  MEMBER  STATES 
.6 
.  . 
. 
A 
A-4  APPENDIX  B 
B-1  ,	
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DEPAR~  OF HEALTH & HUMAN SERVIC= 
%,-
ADMINISmAmON  FOR CHILDREN AND FAMILIES 
Office of the AssistantSecfetafy,Suite600 
370 LEnfat Promenade,S.W. 
WashiWfon, D.C. 20447 
May  13,  1996 
TO:	 June  Gibbs  Brown 
Inspector  General 
FROM:  Mary  Jo  Bane 
Assistant  Secretary  kT~----
for  Children  and  Families 
SUBJECT :  OIG  Draft  Report:  !llnterState  compact  on  Adoption  and 
Medical  Assistance,?  0EI-02-96-OO040 
Congratulations  on  a  well  done  draft  report.  Your  conclusion

that  Interstate  Compact  on  Adoption  and  Medical  Assistance

ntembershi.p  provides  states  with  Significant  zidmi.ni,strative

advantages  in  maintaining  medical  assistance  for  title  IV-E

adopted  children  with  special  needstl  supports  our  work  to

encourage  States  to  join  the  Compact.

Over the past three  years,  Childrens  Bureau  staff  have  worked

very  closely  with  the  Compact  secretariat  through  a  cooperative

agreement.  We  have  been  very  pleased  with  the  increase  in  mexob=

States,  the  excellent  rnateri.als  produced  to  keep  members

informed,  and  the  Secretariats  demonstrated ability  to  resolve

problems  between  States  (both  member  and  non-member)  that  impact

on  services  for  title  IV-E  children  and  their  adoptive  families.

We  have  encouraged  States to join the Compact through our 
Regional  Office staff and at meetings  with the States.  Your 
published  report will give us an excellent tool to use and 
disseminate  among member and non-member States to encourage 
membership  and to positively impact on their States efforts to 
protect  the interests of children with special needs and their 
adoptive  families when they move  from  one  state  to  another.