Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

C  U H
HILDREN S  SE OF  EALTH 

C S W
ARE  ERVICES  HILE IN 

F C :  N Y
OSTER  ARE EW  ORK

Inspector General 
June 2005 
OEI-02-00-00362  Office of Inspector General 

http://oig.hhs.gov 
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 nationwide network of audits, 
investigations, and inspections conducted by the following operating components: 
Office of Audit Services 
The OIG's Office of Audit Services provides all auditing services for HHS, either by 
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 responsibilities and are intended to provide independent 
assessments of HHS programs and operations in order to reduce waste, abuse, and 
mismanagement and to promote economy and efficiency throughout the department. 
Office of Evaluation and Inspections 
The OIG's Office of Evaluation and Inspections (OEI) conducts short-term management 
and program evaluations (called inspections) that focus on issues of concern to the 
department, the Congress, and the public. The findings and recommendations contained 
in the inspections reports generate rapid, accurate, and up-to-date information on the 
efficiency, vulnerability, and effectiveness of departmental programs.  The OEI also 
oversees State Medicaid fraud control units, which investigate and prosecute fraud and 
patient abuse in the Medicaid program. 
Office of Investigations
The OIG's Office of Investigations (OI) conducts criminal, civil, and administrative 
investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries 
and of unjust enrichment by providers.  The investigative efforts of OI lead to criminal 
convictions, administrative sanctions, or civil monetary penalties. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to 
OIG, rendering advice and opinions on HHS programs and operations and providing all 
legal support in OIG's internal operations.  The OCIG imposes program exclusions and 
civil monetary penalties on health care providers and litigates those actions within the 
department.  The OCIG also represents OIG in the global settlement of cases arising 
under the Civil False Claims Act, develops and monitors corporate integrity agreements, 
develops compliance program guidances, renders advisory opinions on OIG sanctions to 
the health care community, and issues fraud alerts and other industry guidance.    E X E C U T I V E   S U M M A R Y
OBJECTIVE 
To determine whether children in New York foster care have Medicaid 
coverage and are receiving health care services. 
BACKGROUND 
It is estimated that 532,000 children are in foster care nationwide, and 
many of them are reportedly in poor health.  Compared with children 
from the same socioeconomic background, children in foster care suffer 
much higher rates of serious emotional and behavioral problems, 
chronic physical disabilities, birth defects, developmental delays, and 
educational difficulties. 
Almost all children in foster care are eligible for Medicaid services and 
for Medicaids Early and Periodic Screening, Diagnosis, and Treatment 
(EPSDT) program.  Among other things, the EPSDT requires each State 
to make preventive health care and follow-up services available to 
Medicaid-eligible individuals under the age of 21. 
This inspection focuses on the State of New York and is part of a larger 
body of work in which eight States are being evaluated.  The analysis is 
based on a review of Medicaid claims and case file records relating to   
50 children in New York foster care over a 26-month period, as well as 
interviews with foster care agency staff and caregivers.  
FINDINGS 
All children in the sample we reviewed have Medicaid coverage and 
are receiving health care services. All 50 children have a Medicaid 
identification number and all had at least 1 Medicaid claim between 
September 2000 and October 2002.  
One reason supporting this finding is that 43 of the 50 sample children 
benefit from New Yorks Medicaid payment system called the per diem. 
In this system, participating agencies receive periodic (usually monthly) 
fixed payments per child from Medicaid to cover a variety of physician 
and dental services for the children in the agencys care.  This system 
provides flexibility in that it allows foster care agencies to employ 
health care providers onsite or to contract with them. 
  OEI-02-00-00362  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  NEW YORK  i  EE XX EE CC UU TT II VV EE    SS UU MM MM AA RR YY
Many caregivers are not informed about the Medicaid program and 
the EPSDT, and they often do not receive their childrens medical 
histories. Many caregivers say they are not taught how to navigate the 
Medicaid system. For example, 32 say they did not receive an 
explanation as to which services are covered by Medicaid and 23 say 
they did not get a schedule of doctor appointments children need. 
Twenty-one caregivers have not heard of the EPSDT program. Twenty-
four say they have heard of it but only one of them reports that her child 
receives services under the program. 
Further, 20 caregivers say they did not receive any of their childrens 
medical histories. Eight more say they did receive some history, but not 
all of the important information. Three of these caregivers believe that 
their childrens health care was adversely affected because the 
information was missing. 
RECOMMENDATIONS 
The children in our sample are receiving needed services, especially 
preventive care. We believe that New Yorks Medicaid payment system 
likely facilitates the childrens access to health care services. 
Nevertheless, we recommend that the Administration for Children and 
Families (ACF) and the Centers for Medicare & Medicaid Services 
(CMS) work with the New York State Office of Children and Family 
Services and Office of Medicaid Management to further promote access 
to services by addressing potential obstacles, including caregivers 
limited knowledge about the EPSDT and how to navigate the Medicaid 
system. We also recommend that ACF help the State ensure that the 
most complete medical histories are shared with the childrens 
caregivers. 
Agency Comments 
We received comments from ACF and CMS. The full text of the 
comments is included in Appendix D. ACF reports that it is working 
with New York on our recommendation to promote the importance of 
obtaining medical histories for children in foster care. ACF notes that a 
Program Improvement Plan was developed in response to the New York 
Child and Family Service Review conducted by ACF. This plan contains 
action steps that address the gathering of medical information and the 
physical and mental health needs of children served by New Yorks child 
welfare system. ACF says that it monitors progress of the plan with 
quarterly reports. 
OEI-02-00-00362  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  NEW YORK  ii  E X E C U T I V E   S U M M A R Y  
CMS concurs with the recommendation that CMS work with New York 
to further promote access to services.  CMS states that regional staff 
will work with the New York Office of Children and Family Services and 
Office of Medicaid Management to ensure that New Yorks foster care 
staff is educated on Medicaid and the EPSDT program services.  CMS 
also mentions that it is working with ACF to develop interagency multi-
state meetings. According to CMS, these meetings will focus on access 
to Medicaid services for children in foster care and facilitate 
communication between State Medicaid directors and Child Welfare 
directors. 
  OEI-02-00-00362  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  NEW YORK  iii    T A  B L E   O F   C O N T E N T S  
EXECUTIVE SUMMARY ......................................... i 

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

FINDINGS ....................................................... 8 

All sampled children have Medicaid coverage and access to services . . .  8 

Caregivers are not informed about the Medicaid system and often 

 do not receive their childrensm  edical information. . . . . . . . . . . . . . . .  11

RECOMMENDATIONS ......................................... 13 

APPENDIXES .................................................. 14 

Appendix A:  Services Inside and Outside the Per Diem Rate. . . . . . . .  14

Appendix B:  ChildrensD  emographic and Health Characteristics. . . .  15

Appendix C:  Comparison of Children in Samplet o Population. . . . . . .  17

Appendix D:  Agency Comments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  18

ACKNOWLEDGMENTS ......................................... 23
   I N T R O D U C  T I O N
OBJECTIVE 
To determine whether children in New York foster care have Medicaid 
coverage and are receiving health care services. 
BACKGROUND 
It is estimated that 532,000 children are in foster care nationwide,1 and 
many of them are reportedly in poor health.  Compared with children 
from the same socioeconomic background, children in foster care suffer 
much higher rates of serious emotional and behavioral problems, 
chronic physical disabilities, birth defects, developmental delays, and 
educational difficulties.2   According to the New York State Judicial 
Commission on Justice for Children, half of all children in the child 
welfare system nationwide suffer from developmental delays or mental 
health problems that are serious enough to need clinical intervention.3 
In addition to the needs they share with other children, such as 
immunizations, routine well-child examinations, and treatment of 
childhood diseases, children in foster care clearly have a greater need 
for specialized health care services. 
Despite their need, it appears that many children in foster care are not 
receiving adequate health care.  It is estimated that 60 percent of all 
children in out-of-home care have moderate to severe mental health 
problems, yet less than one-third of those children receive mental health 
services.4   A Government Accountability Office (GAO) report issued in 
May 1995, entitled Health Needs of Many Young Children are 
Unknown and Unmet, found that a significant proportion of young 
children in foster care did not receive critical health-related services in 
the three locations studied (Los Angeles County, New York City, and 
1 Retrieved on June 23, 2004, from: 
http://www.acf.hhs.gov/programs/cb/dis/afcars/publications/afcars.htm. 
2Health Care ofYoung Childrenin Foster Care, Committee on Early Childhood, Adoption 
and Dependent Care, American Academy of Pediatrics, Policy Statement, Volume 109, 
Number 3, March 2002, pp. 536-541. 
3 Pamphlet on Ensuring the Healthy Development of Foster Care Children, New York 
State Permanent Judicial Commission on Justice for Children, 1999, page 4. 
4 Fact Sheet:  The Health of Children in Out-Of-Home Care, Child Welfare League of 
America, retrieved March 14, 2003, from: 
http://www.cwla.org/programs/health/healthcarecwfact.htm. 
  OEI-02-00-00362  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  NEW YORK  1  III NNN TTT RRR OOO DDD
 UUU CCC TTT III OOO NNN
Philadelphia County).5  In fact, GAO estimated that only 1 percent of 
these children received Early and Periodic Screening, Diagnostic, and 
Treatment (EPSDT) services. 
Medicaid for Children in Foster Care 
The Medicaid program provides health care to specified groups of needy 
individuals. It is administered by the Centers for Medicare & Medicaid 
Services (CMS) and jointly funded by the Federal and State 
governments. Within broad national guidelines, each State establishes 
its own Medicaid eligibility standards; determines the type, amount, 
duration, and scope of services; sets the rate of payment for services; 
and administers its own State Medicaid program.6 
Almost all children in foster care are eligible for Medicaid services. 
Pursuant to section 1902 (a)(10)(A)(i)(I) of the Social Security Act (the 
Act), children in foster care covered under Title IV-E of the Act are 
eligible for Medicaid. Children in foster care who are not eligible for 
Title IV-E services usually qualify for Medicaid through other eligibility 
categories set forth by each State. In fiscal year 2000, Medicaid 
payments for children in foster care nationwide were over $3.3 billion.7 
Early and Periodic Screening, Diagnosis, and Treatment 
The EPSDT is a Federal entitlement to comprehensive medical services 
for Medicaid-eligible children under the age of 21. While States have 
the flexibility to design their own Medicaid programs, the EPSDT 
program requires each State to provide coverage for comprehensive and 
preventive child health services to Medicaid-eligible individuals under 
the age of 21. In general, the EPSDT treatment services include 
periodic screening, vision, dental, and hearing services and all other 
services available under the Medicaid program. Treatment or medical 
care must be provided for any physical or mental conditions discovered 
by the screening services. 
5 HealthyNeeds ofManyYoungChildrenare Unknownand Unmet,General Accounting 
Office, GAO/HEHS-95-114, 1995, pp. 2 and 5. 
6 Retrieved from CMS Web site on March 14, 2003: 
http://www.cms.hhs.gov/medicaid/mover.asp. 
7Medicaid Expenditures for Federal Fiscal Year 2000, ByType of Service for Maintenance 
Assistance StatusandBasis ofEligibility All States; Medicaid Statistical Information 
System Report for Federal fiscal year 2000. National Total for Foster Care children, 
page 3, retrieved from CMS Web site on March 13, 2003: 
http://www.cms.gov/medicaid/msis/00total.pdf. 
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Under EPSDT, States must set distinct periodicity schedules for 

screening, dental, vision, and hearing services.  Services must be 

provided at intervals that meet reasonable standards of medical 

practice.  States must consult with recognized medical organizations 

involved in child health care, such as the American Academy of 

Pediatrics, in developing reasonable standards.8

New York 
Child Welfare. The New York State Office of Children and Family 
Services (OCFS) in the Department of Family Assistance is responsible 
for the States children in foster care.  At the time of this inspection, 
New York had approximately 57,000 children in foster care.  New Yorks 
foster care system is decentralized so child welfare programs are State-
supervised and county-administered.  New York State is divided into 
58 local social services districts.  One of these districts includes the five 
boroughs of New York City.  Almost one-third of the States children in 
foster care reside in New York City.  Outside of New York City, each 
district corresponds to 1 of the 57 counties that make up the remainder 
of the State. 
In each district, children are placed either under the direct care of the 
local district or under the care of a contracted foster care agency, 
commonly referred to as a voluntary agency.  These agencies provide 
services under contract with a local district.  Nearly 80 percent of the 
children in foster care are under the care of voluntary agencies 
statewide. OCFS is responsible for licensing, inspecting, supervising, 
and monitoring them. In 2002, there were 153 such foster care agencies 
in New York. 
Pursuant to OCFS, each child in foster care has a case planner and a 
case manager.  The case planner has the primary responsibility of 
providing, arranging, coordinating, and evaluating the provision of 
services to the child and family.  When a child is placed with a 
voluntary agency, the case planner is a member of the agencys staff.  
Case managers, on the other hand, are employees of the local social 
services district.  They are responsible for authorizing the provision of 
services, approving the client eligibility determination, and approving 
service plans. When the child is placed in the care of the local district, 
the case manager is also the case planner. 
8 Retrieved from CMS Web site March 28, 2003: http://www.cms.gov/medicaid/epsdt/. 
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Medicaid Program. The New York State Department of Health is 
responsible for the States Medicaid program.  Within this Department, 
the Office of Medicaid Management manages the Medicaid program, 
which is administered by local social services office. 
As in all States, children in New York foster care who meet Title IV-E 
requirements are eligible for Medicaid coverage. For children in New 
York foster care who do not meet IV-E requirements, Medicaid 
eligibility is determined by State standards and based, in part, on the 
childs income. Medicaid must be authorized for 12-month periods in all 
foster care cases that are Medicaid eligible.9 
In fiscal year 2001, Medicaid expenditures for children in New York 

foster care were approximately $395 million.  

Managed Care. Children placed in the care of voluntary agencies are 
excluded from participating in managed care.10  Children under direct 
care, however, may be eligible for enrollment in a Medicaid managed 
care plan at the option of each local district.  Districts may opt not to 
enroll children in managed care for a number of reasons, such as 
distance from providers or the special medical needs of the child.  Of the 
58 social service districts, 5 enroll children in managed care.  The New 
York City district is not one of the five. 
New Yorks Medicaid Payment System. Voluntary agencies have the option 
of receiving a Medicaid payment per child, commonly referred to as the 
per diem, to pay for their childrens health care or having the children 
receive care through Medicaid fee-for-service.  
These payments cover many physician and dental services. They also 
cover most prescription and non-prescription drugs, home health, 
medical supplies, eye care, and mental health/behavioral health 
services.  Agencies may have medical professionals on staff or contract 
with local providers to care for the children.  In 2002, 96 of the  
153 voluntary agencies in New York State chose to receive the per diem.  
Agencies use the per diem to pay health care providers directly for 

rendered services.11   See Appendix A for services included and not 

included in the per diem rate.  If a child needs services not included

9 NYS OCFS Eligibility Manual for Child Welfare Programs, June 2003, pp.4-4, 4-5. 

10New York Social Services Law, Title 11, section 364-j 3(d)(xi). 

11 NYS OCFS Eligibility Manual for Child Welfare Programs, June 2003, p. 4-2. 

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under the payment system, the child may go to a Medicaid provider. 

The provider would then bill Medicaid directly for these services. 

The per diem rate paid to the agency varies by agency and by the types 
of programs within the agency.  The rate is based on the agencys 
historic costs of providing medical care, subject to certain ceilings.  Each 
agency receiving a per diem is required to submit a medical services 
expenditure distribution sheet to the Department of Health annually.  It 
is a summary of all medical costs incurred by the foster care agency. 
The annual cost is the basis for determining rates for subsequent years. 
Per diem payments totaled $221,000 for the children in our sample from 
September 2000 through October 2002.  In general, per diem payments 
were made to agencies monthly for each child in their care.  The average 
per diem payment for the children in the sample was $263 per month. 
New York has formed a workgroup to look at standards of care, cost of 
care, and what services should and should not be included in the per 
diem rate. The workgroup includes representatives from OCFS, the 
Division of Budget, the Office of Mental Health, the Office of Alcohol 
and Substance Abuse Services, the Department of Health, Office of 
Mental Retardation and Developmental Disabilities, and the Council on 
Children and Families. 
METHODOLOGY 
This inspection is based on information gathered from multiple sources: 
a review of Medicaid claims and case file records relating to 50 children 
in New York foster care over a 26-month period; a review of Federal and 
State laws, regulations, and policies; and interviews with Federal and 
State agency officials, foster care agency staff, and caregivers.  
Reasons for State Selection 
This inspection focuses on the State of New York and is part of a larger 
body of work in which eight States are being evaluated.  New York was 
selected because of its size, decentralized child welfare system, and 
geographic location. 
Sample 
The 50 children in the sample were randomly selected from a population 
of 41,232 children in continuous foster care placement for at least   
6 months prior to September 30, 2002.  See Appendixes B and C for a 
more detailed description of children in the sample and a comparison of 
the children in the sample to the population. 
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It should be noted that, because of our sample size, we do not project our 
estimates to the universe of all children in New York foster care. Our 
purpose was to gain an understanding of how children in foster care 
receive medical care. 
Review of Medicaid Claims Data, Case File Information, and Federal and 
State Laws and Policies 
Medicaid Claims Data. New Yorks Office of Medicaid Management 
provided a Medicaid claims history of 26 months for each of the  
50 children in our sample.  The data include claims with service dates 
from September 2000 through October 2002.  None of the children were 
enrolled in managed care at the time of the sample selection, so the 
Medicaid histories contain no managed care encounter data.  All claims 
discussed in this report are fee-for-service. 
In reviewing the Medicaid claims, we paid particular attention to the 
types of service, claims coded as EPSDT, dates of service, and settings, 
where available. Medicaid claims data were organized into broad 
categories for analysis, such as preventive care, office visits, dental, and 
mental health.  We excluded claims that were not health care related, 
such as those for transportation.  We determined the periods of time the 
child was in foster care based on information given by the OCFS and the 
childs foster care agency.  Claims for services provided when the child 
was not in foster care were excluded.   
Case File Information. Forty-five of the fifty sampled children were placed 
in the care of voluntary agencies. These children, unlike the five in the 
direct care of a local district, could receive medical services paid by the 
per diem.  Services provided under the per diem, along with any other 
services the child receives, are recorded in the childs case file by the 
voluntary agency.  The children in direct care receive health care 
services through Medicaid fee-for-service.  We did not collect their case 
files because the services they received are evident from their Medicaid 
claims histories. 
We collected the medical portion of the case file from September 2000 
through October 2002 for each of the 45 children placed in the care of a 
voluntary agency.  The case files did not distinguish between Medicaid 
services and those that are paid for by the State or other non-Medicaid 
sources, such as Head Start.  Therefore, our analysis includes services 
that may not have been paid by Medicaid. 
In the case file review, just as in the Medicaid claims review, we 
excluded services that were not health care related or were provided 
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while the child was not in foster care.  For each child, the health care 
services found in the case files were compared to the childs Medicaid 
claims history. To prevent counting a service more than once, if the 
same service was found in the claims and the case file, that service was 
counted in the claims data and not counted in the case file review data.   
Law and Policy Reviews. We reviewed Federal and State laws, 
regulations, and policies pertaining to the provision of health care to 
children in foster care.  
Interviews 
Foster Care Agency Interviews.  We conducted interviews, either in person 
or by telephone, with foster care agency staff responsible for each of the 
50 children in our sample.  We interviewed each childs case planner, 
who, as previously noted, has the primary responsibility of providing, 
arranging, coordinating, and evaluating the provision of services to the 
child and family.  In some interviews with voluntary agencies, a member 
of the agencys health care staff joined the case planner. We use the 
term agency to refer to the case planner and health care staff 
representing the child. 
The interviews focused on agency staff s understanding of Medicaid and 
experiences accessing health care services for the child in our sample. 
We also discussed any barriers to health care faced by the child and by 
children in foster care in general. 
Caregiver Interviews.  We interviewed the caregivers for 49 of the children 
in our sample.  We were unable to reach one caregiver. We use the term 
caregiver to refer to a foster parent or residential facility staff member 
who is responsible for the child.  Forty of the children were in family 
care and nine were in residential care.  Like the caseworker interviews, 
our interviews with caregivers focused on training, Medicaid, and 
procuring health care services for the child in our sample.  
Federal and State Agency Officials. We held several meetings, both in 
person and by telephone, with officials from CMS, the Administration 
for Children and Families (ACF), New Yorks OCFS, and New Yorks 
Office of Medicaid Management.  Our discussions covered a wide 
spectrum of information to help us understand how the States foster 
care and Medicaid systems are organized and administered.   
This inspection was conducted in accordance with the Quality 
Standards for Inspections issued by the Presidents Council on Integrity 
and Efficiency. 
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 F I N D I N G S
All children in the sample have Medicaid  All the children in the sample have 
coverage and are receiving health care services  Medicaid coverage.  All 50 children 
have a Medicaid identification 
number, and all had at least 1 Medicaid claim filed for a service 
provided between September 2000 and October 2002.     
Forty-seven children in the sample received preventive care services. 
The EPSDT program requires each State to provide coverage for 
comprehensive and preventive child health services.  Forty-seven of the 
fifty sampled children received at least one preventive health care 
service during the study period, according to the Medicaid claims and 
the case file documentation.  The number of preventive care services per 
child ranged from 1 to 15.   
The sampled children received a variety of services in addition to 
preventive care.  Forty-two children received office visit services.  These 
services typically included treatment of an illness or injury.  Forty-two 
children received diagnostic services, such as lab tests.  Thirty-six 
children received all three of these services:  preventive, office, and 
diagnostic.  The number of total health care services per child ranged 
from 5 to 786 over the study period.  Table 1 (shown on next page) lists 
the services received by the children in the sample.  
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T able 1:  N u m b er and T yp e of H ealth C are Services 
N um   be r of C hi ldren W ith at 
Service T ype    L east O n e S ervice  T otal N um ber of S ervices 
Preventive  47  164 
Office Visit  42  201 
Lab W ork/Diagnostic  42  216 
Dental  36  153 
Mental Health  36  1,835 
Hearing/Speech  32  422 
Vision  30  74 
Im m unizations  27  112 
Emergency Services  19  82 
Other  9  25 
Physical/Occupational Therapy  7  756 
Case Management  6  30 
Hospital Services  5  15 
Supplies  3  8 
Source: Office of Evaluation and Inspections Medicaid Claims Data and Case File Review. 
Caregivers and foster care agencies report their children have access to the 
health care they seek. 
Forty-six of forty-nine caregivers and 46 of 50 agencies interviewed 
report that the children in foster care receive the health care services 
they seek. Caregivers also say that finding providers for the children in 
the sample is not difficult. Forty-five caregivers report no problems 
finding doctors, dentists, or any other type of health care professionals. 
Of the four caregivers who report problems, two say finding a dentist 
who accepts Medicaid is difficult, one reports problems finding a dentist 
and a doctor, and the fourth reports problems finding a therapist. 
In total, caregivers and agencies describe five instances where they 
could not eventually get the care they sought for their children.  In two 
of these instances, a provider was available but the child refused 
treatment. In another instance, the providers waiting list was 
reportedly too long.  The remaining instances involve disagreement over 
treatment plans or difficulty getting prescription drugs. 
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 SS  
Caregivers and agencies report that eight children in the sample receive 
non-Medicaid health care services in addition to Medicaid services. 
Caregivers say that they pay for medications, medical care, or mental 
health care themselves. A few agencies say children in foster care 
receive counseling at a boys club, while another agency says the child in 
its program receives counseling and therapy through school. Several 
agencies point out that, in general, when a child needs health care 
services not covered by Medicaid, the foster care agency will pay for the 
services. 
According to caregivers and agencies, nine children in the sample are 
enrolled in some type of program that improves their access to health 
care. These programs include early intervention and specialized day 
care centers, which provide mental health care, speech therapy, or 
physical or occupational therapy. 
Most caregivers and agencies report that they have received training about 
health problems that often affect children in foster care. 
According to the Foster Care Program Placement Agreement, OCFS has 
the responsibility to provide training opportunities for foster parents 
and foster parents are responsible for attending training sessions. 
Thirty-nine of the forty-nine caregivers say they have received training 
about health issues relevant to children in foster care. This training 
covers topics such as mental/behavioral health, obtaining certain 
medical services, HIV/AIDS, and asthma. Thirty-three of the fifty 
agencies say they have received similar training. Forty-four children in 
the sample have either a caregiver or agency reporting that they 
received this training. Twenty-eight children have both a caregiver and 
an agency reporting that they received training. 
According to caregivers and agencies, 36 of the 50 sampled children 
have a variety of ongoing medical or mental health problems. These 
problems include asthma, attention deficit disorder, post-traumatic 
stress disorder, and depression. 
Forty-three children in the sample are covered by New Yorks Medicaid 
payment system, called the per diem. 
As explained in the background section of this report, the per diem is 
paid to voluntary agencies in New York State for medical services 
necessary to meet the needs of the children in their care. Forty-three of 
the fifty children in the sample were covered by the per diem during the 
study period. Of the remaining seven children, five were in direct care 
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and therefore excluded from the per diem, and two were placed out-of-
State for a time during the study. 
New Yorks Office of Medicaid Management reports that the per diem 
gives localities the flexibility to provide services within the community.  
The agencies can have onsite medical staff or contract out, therefore 
ensuring a sufficient number of providers.  All the voluntary agencies 
representing the children in the sample report that their agency has 
health professionals on staff.  These professionals include nurses, 
mental health professionals, and physicians who often provide for the 
children or act as a resource for caregivers.  Fifteen agencies and eight 
caregivers say that having a medical department or doctors onsite 
improves access to health care services. 
Thirty-four of the forty-three children covered by the per diem also had 
Medicaid fee-for-service health care claims.  The remaining nine 
children covered by the per diem appear to have had all their health 
care services paid for by the per diem.  A child could have fee-for-service 
claims while under the per diem for a variety of reasons.  In addition to 
the routine care generally paid for by the per diem, the child may need 
care from a specialist or certain type of facility that is outside the per 
diem.  These services are paid under Medicaid fee-for-service.  (See 
Appendix A for a list of services that are inside or outside the per diem.) 
Caregivers say they are not taught 
Many caregivers are not informed about the Medicaid 
how to navigate the Medicaid 
program or the EPSDT, and they often do not receive 
system. 
their childrens medical information 
Caregivers report that they do not get information about Medicaid that 
could help them access Medicaid services for their children.  For 
example:  
o 	 Thirty-three caregivers say they did not receive telephone 
numbers to call if they had questions about Medicaid.  
o 	 Thirty-two caregivers say they did not receive an explanation as to 
which services are covered under Medicaid. 
o 	 Thirty caregivers say they did not receive a list of doctors who 
accept Medicaid. 
o 	 Twenty-three caregivers say they did not receive a schedule of the 
doctor appointments children need. 
  OEI-02-00-00362  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  NEW YORK  11  F	 I N D I N G S  
o 	 Fourteen caregivers say they did not receive any of this 
information. Five caregivers say they received all of this 
information. 
Not all caregivers and agencies know about the EPSDT. 
Twenty-one caregivers have not heard of the EPSDT or any of the 
programs other names in New York, such as Child/Teen Health Plan or 
Child Health Assurance Program. Twenty-four caregivers say they 
have heard of the EPSDT (or one of its other names), but only one of 
them reports that her child receives services under the program. 
Twenty-seven agencies have not heard of the EPSDT.  Twenty-two 
agencies say they have heard of the program but only six of them report 
that their children receive services under the program.  
Caregivers often do not receive their childs medical history. 
Twenty caregivers say they did not receive any of their childrens 
medical histories.  Eight more say they did receive some history but not 
all of the important information.  In contrast, one agency reports that it 
did not receive a medical history.  Five agencies say they did not receive 
all the important information about their childrens medical history. 
According to the Foster Care Program Placement Agreement, OCFS has 
the responsibility to provide foster parents with all pertinent 
information concerning youth placed in their home.  
Three caregivers believe the missing information adversely affected the 
health care of their children.  One caregiver says that she had no record 
of her childs immunizations so the child had to start from scratch. 
Another caregiver says she would have been better able to care for her 
child had she known the child came from an abusive home.  The third 
caregiver says it would have been helpful to know that her child was 
born prematurely. 
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 R E C O M M E N  D A T  I O N S  
The children in our sample are receiving needed services, especially 
preventive care.  We believe that New Yorks Medicaid payment system, 
the per diem, likely facilitates the childrens access to health care 
services. Nevertheless, we recommend that ACF and CMS work with 
the New York State OCFS and Office of Medicaid Management to 
further promote access to services by addressing potential obstacles, 
including caregivers limited knowledge about the EPSDT and how to 
navigate the Medicaid system. We also recommend that ACF help the 
State ensure that the most complete medical histories are shared with 
the childrens caregivers. 
Agency Comments 
We received comments from ACF and CMS.  The full text of the 
comments is included in Appendix D.  ACF reports that it is working 
with New York on our recommendation to promote the importance of 
obtaining medical histories for children in foster care.  ACF notes that a 
Program Improvement Plan was developed in response to the New York 
Child and Family Service Review conducted by ACF.  This plan contains 
action steps that address the gathering of medical information and the 
physical and mental health needs of children served by the New York 
State child welfare system.  ACF says that it monitors progress of the 
plan with quarterly reports. 
CMS concurs with the recommendation that CMS work with New York 
to further promote access to services.  CMS states that regional staff 
will work with the New York OCFS and Office of Medicaid Management 
to ensure that the New York foster care staff is educated on Medicaid 
and the EPSDT program services.  CMS also mentions that it is 
working with ACF to develop interagency multistate meetings.  
Pursuant to CMS, these meetings will address access to Medicaid 
services for children in foster care and facilitate communication between 
State Medicaid directors and Child Welfare directors. 
  OEI-02-00-00362  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  NEW YORK  13    A P P E N D I X   ~   A
Services Inside and Outside the Medicaid Per Diem Rate 
Service 
Physician Administrative  In the Rate 
Nurses  In the Rate 
Physician Specialists  In the Rate 
Physicians  In the Rate 
Article 28 Freestanding Clinics  In the Rate 
Psychiatrists  In the Rate 
Psychologists  In the Rate 
Certified Social Workers  In the Rate 
OMH Licensed Vol Clinics  In the Rate 
OMRDD Licensed Vol Clinics   In the Rate 
OASAS Licensed Clinics  In the Rate 
Dentists  In the Rate 
Dental Freestanding Clinics  In the Rate 
Prescription Drugs*  In the Rate 
Non-Prescription Drugs*  In the Rate 
Medical Supplies  In the Rate 
Durable Medical Equipment  In the Rate 
Home Health PCA/HHA/LPN/RN   In the Rate 
Laboratory  In the Rate 
X-ray  In the Rate 
Transportation  In the Rate 
Eye Care  In the Rate 
OT/PT Speech and Audiology  In the Rate 
Service 
Article 28 Outpatient Departments  Out of Rate 
Emergency Room  Out of Rate 
School-Based Health Clinics  Out of Rate 
Family Planning Clinics  Out of Rate 
OMH Partial Hospital  Out of Rate 
OMH Day Treatment  Out of Rate 
OMH State Clinics  Out of Rate 
OMR/OASAS State Operated Clinics  Out of Rate 
General Inpatient  Out of Rate 
OMH Inpatient  Out of Rate 
OMRDD Inpatient  Out of Rate 
OASAS Inpatient  Out of Rate 
Dental Outpatient Departments  Out of Rate 
Early Intervention  Out of Rate 
School Supportive Health Services  Out of Rate 
Case Management  Out of Rate 
*The per diem covers most prescription and non-prescription drugs. 
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Children's Demographic and Health Characteristics 
The table below illustrates the demographic and health characteristics of the 50 children in the 
sample, including the number of months they were in foster care from September 2000 through 
October 2002. Placement setting refers to the type of foster care placement at the time of the 
interviews. 
Agency or Caregiver Agency or Caregiver Reports  Months in Care 
Age  Placement  Reports Child has  Child has Mental Health  During Study 
ID  Sex  (years)  Setting  Medical Problem(s)  Problem(s)  Period 
1  Male  16  Residential  Y  Y  26 
2  Female  16  Family  Y  Y  26 
3  Male  17  Residential  N  Y  26 
4 M  ale   11 F amily   Y   Y   18  
5  Female  14  Family  Y  N  12 
6 M  ale   5 F amily   N   Y   24  
7  Female  4  Family  Y  Y  26 
8 M  ale   7 F amily   N   N   26  
9  Female  6  Family  N  Y  26 
10  Male  8  Family  Y  Y  26 
11  Male  15  Residential  N  Y  13 
12  Female  5  Family  N  Y  26 
13  Male  18  Residential  N  Y  26 
14  Male  13  Kinship  N  N  26 
15  Female  2  Family  Y  N  23 
16  Male  15  Family  Y  Y  26 
17  Male  16  Family  Y  Y  10 
18  Male  1  Kinship  N  N  10 
19  Female  6  Kinship  Y  N  26 
20  Male  17  Trial Discharge  Y  Y  26 
21  Male  17  Kinship  Y  Y  19 
22  Male  6  Family  N  Y  26 
23  Male  10  Residential  Y  Y  26 
24  Male  8  Residential  Y  Y  10 
25  Female  10  Family  N  N  26 
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Children's Demographic and Health Characteristics (continued) 
Agency or Caregiver Agency or Caregiver Reports  Months in Care 
Age  Placement  Reports Child has  Child has Mental Health  During Study 
ID  Sex  (years)  Setting  Medical Problem(s)  Problem(s)  Period 
26  Female  17  Family  N  N  26 
27  Female  9  Family  N  N  13 
28  Male  2  Family  Y  N  26 
29  Female  2  Family  Y  N  8 
30  Male  19  Residential  N  N  26 
31  Female  11  Family  N  Y  26 
32  Male  7  Kinship  Y  N  26 
33  Female  11  Family  N  N  23 
34  Female  4  Family  N  N  26 
35  Female  5  Trial Discharge  N  N  12 
36  Male  1  Family  Y  N  12 
37  Male  8  Kinship  N  N  25 
38  Female  4  Kinship  Y  N  26 
39  Female  4  Family  Y  N  26 
40  Female  20  Family  Y  N  26 
41  Male  7  Kinship  Y  Y  26 
42  Male  9  Family  Y  Y  26 
43  Female  11  Family  N  N  10 
44  Male  9  Family  Y  Y  26 
45  Male  15  Family  N  N  8 
46  Female  18  Kinship  N  Y  25 
47  Male  13  Residential  N  Y  8 
48  Female  12  Kinship  N  N  26 
49  Male  14  Residential  N  Y  10 
50  Female  6  Kinship  Y  N  26 
Source: New York State Office of Medicaid Management, January 2003 
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Comparison of Children in Sample to Population 
The table shows characteristics of children in the sample and of the population of 
children in New York foster care for at least 6 continuous months. 
Comparison of Children in Sample to Population 
Sample  Population 
Percent of  Percent of 
Count  Total  Count  Total 
GENDER 
Male  28  56%  21,665  53% 
Female  22  44%  19,567  47% 
Total  50  100%  41,232  100% 
AGE 
0-2  5  10%  4,730  11% 
3-5  7  14%  5,679  14% 
6-9  13  26%  7,394  18% 
10-13  9  18%  8,343  20% 
14-17  12  24%  11,343  28% 
18+  4  8%  3,743  9% 
Total  50  100%  41,232  100% 
Source: New York State OCFS, 2002 
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 A P P E N D I X ~ D  

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 A P P E N D I X ~ D  

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 A P P E N D I X ~ D  

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 A C K N O W L E D G M E N T S
This report was prepared under the direction of Jodi Nudelman, Acting 
Regional Inspector General for Evaluation and Inspections in the New 
York regional office.  Other principal Office of Evaluation and 
Inspections staff who contributed include: 
Nancy T. Harrison, Team Leader 
Nicole Gillette, Lead Analyst 
Laura Torres, Program Analyst 
Thomas Zimmermann, Program Analyst 
Linda Hall, Program Specialist 
Elise Stein, Director, Public Health and Human Services Branch 
Technical Assistance 
Barbara Tedesco, Mathematical Statistician 
OEI-02-00-00362  NEW YORK FOSTER CARE CHILDRENS USE OF HEALTH CARE SERVICES  23