'''VICCS.
SERVICES
DEPARTMENT OF HEALTH &. HUMAN  Office of Inspector General
:..".no Washington, D.C. 20201
2 4 2004
AUG 
TO: Wade F. Horn, Ph.
Assistant Secretay for
Children and Families
Mark B. McClellan, M.D., Ph.
Administrator
Centers for M dicar
;ticaid Services
FROM: Dara Corrga
Acting Principal Deputy Inspector General
SUBJECT: OIG Final Report: "Children s Use of Health Care Services While in Foster
Care: North Dakota " OEI-07-00-00643
Attched is a final report that assesses whether sampled children in the North Dakota
foster care program are receiving health care services that fulfill Federal and State
requirements. We conducted this inspection in response to concerns about the health care
that children in foster care are receiving. This report is one of a series of 
inspections that
focus on children s use of health care services while in foster care in eight States:
Georgia, Ilinois, Kansas, New Jersey, New York, North Dakota, Oregon, and Texas.
We determined that all 50 of the children in our sample had Medicaid coverage and
Medicaid claims for health care services. Thirty-five of the fifty sampled children
received their most recent required Early and Periodic Screening, Diagnosis
, and
Treatment (EPSDT) examination, and 30 of 38 sampled children required to receive
EPSDT dental services had received their most recent EPSDT dental service. Some
sampled children waited months after entering foster care to receive an initial
comprehensive medical examination recommended by the State. We also found that
mental health needs were not documented for 12 of the 34 sampled children who received
mental health services as Federal law requires. Such documentation is importt to 
ensure children receive appropriate and necessary services timely. Finally, Federal law
and State policy require that foster care providers  (i. , foster parents or residential care
facility staff receive medical information about the child in their care, yet 9 of the 48
foster care providers interviewed reported never receiving this information.
We recommend that the Administration for Children and Families (ACF) work with the
North Dakota Division of Children and Family Services to examine how initial
comprehensive medical examinations for children entering foster care are being provided;
ensure that case plans reflect required mental health needs; and promote the importance
of caseworkers obtaining medical information for children in foster care and giving the Page 2 - Wade F. Horn, Ph.D. and Mark B. McClellan, M. , Ph.
medical information to foster care providers, in accordance with Federal requirements.
We recommend that the Centers for Medicare & Medicaid Services (CMS) work with the
North Dakota Division of Medical Services to develop a method for notifying foster care
providers of when required EPSDT services are due; and to increase the number of dental
providers accepting Medicaid in North Dakota. We also recommend that ACF and 
CMS
work with the North Dakota Department of Human Services to coordinate State agency
efforts to educate caseworkers and foster care providers regarding the 
importnce and
availability of EPSDT medical examinations; to ensure caseworkers and foster care
providers understad the difference between comprehensive EPSDT examinations and
medical examinations for specific health conditions; and to educate caseworkers and
foster care providers regarding State EPSDT frequency schedules for dental services.
In response to our recommendations, ACF noted that it is actively working with the
North Dakota Division of Medical Services to promote the importance of obtaining
medical histories and providing medical information to foster care providers and that
these issues are being addressed in the Program Improvement Plan developed in response
to a Child and Family Services Review. They also note that only 79 percent of 
the cases
reviewed during the on-site portion ofthe Child and Family Services Review
substantially achieved the outcome measure which determines if children receive
adequate services to meet their physical and mental health needs. CMS generally
concured with our recommendations but clarified that they should be carried out by joint
action of the North Dakota Divisions of Medical Services and Children and Family
Services. CMS stated that their regional office staff is available to provide techncal
assistance to both Divisions, as appropriate.
Please send us your final management decision, including any action plan, as appropriate
within 60 days. If you have any questions or comments about this report, please do not
hesitate to call me or your staff may contact Elise Stein, Director, Public Health and
Human Services Branch, at (202) 619-2686 or through e-mail (Elise.Stein(goig.hhs.gov
To facilitate identification, pl se refer tOJepQrtm.1IIlb J QEI-Q'Z..OO..Dit643 in all
correspondence.
Attchment  
 Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
 
CHILD  RENS USE OF HEALTH 
 
C S W I
ARE  ERVICES  HILE  N 
 
 
F C :  N D  
OSTER  ARE ORTH  AKOTA
 
  
Inspector General 
 
AUGUST 2004 
OEI-07-00-00643  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 (OAS) 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 model compliance plans, renders advisory opinions on OIG sanctions to the 
health care community, and issues fraud alerts and other industry guidance. 
  (cid:19) A B S T R A C T  
 
In response to concerns about the health care children in foster care are 
receiving, we conducted a series of studies in eight States to assess 
whether sampled children in foster care are receiving health care 
services that fulfill Federal and State requirements.  This study 
determined that all 50 sampled children in the North Dakota foster care 
program had Medicaid coverage and claims.  Thirty-five sampled 
children received their most recent required Early and Periodic 
Screening, Diagnosis, and Treatment (EPSDT) examinations and 30 of 
38 children required to receive dental services had their most recent 
EPSDT dental service.  We also found that some children waited 
months after entering foster care to receive a comprehensive medical 
examination recommended by the State.  In addition, 9 of 48 foster care 
providers (i.e., foster parents or residential care facility staff) reported 
never receiving a medical history for the sampled child in their care,  
and mental health needs were undocumented in the case plans for 12 of 
the 34 sampled children receiving mental health services, both of which 
are required to meet Federal requirements.   
We recommend that the Administration for Children and Families 
and the Centers for Medicare & Medicaid Services work with the 
North Dakota Department of Human Services to address shortcomings. 
 
  OEI-07-00-00643  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  NORTH DAKOTA  i  (cid:19) E X E C U T I V E   S U M M A R Y  
OBJECTIVE 
To determine whether sampled children in the North Dakota foster care 
program receive health care services. 
BACKGROUND 
Sections 472(h) and 1902(a)(10)(A)(i)(I) of the Social Security Act (the 
Act) require States to provide Medicaid or Medicaid-equivalent coverage 
to children eligible to receive Title IV-E funds.  North Dakota is the 
focus of this inspection and is one of a series of eight States chosen to 
represent a diverse cross-section of foster care nationwide.  All 
Title IV-E children in the North Dakota foster care program are eligible 
for Medicaid.  Federal Early and Periodic Screening, Diagnosis, and 
Treatment (EPSDT) guidelines require each State to make preventive 
health care services available to Medicaid-eligible individuals under the 
age of 21 and establish State guidelines regarding the intervals for 
providing EPSDT examinations that meet reasonable standards of 
medical and dental practice, as outlined in Sections 1902(a)(43) and 
1905(r) of the Act. 
This inspection is based on information gathered from multiple sources.  
We reviewed Federal and State policies; analyzed child-specific 
Medicaid claims data and case file documentation for 50 randomly 
sampled children in the North Dakota foster care program; interviewed 
foster care providers (i.e., foster parents or residential care facility 
staff), caseworkers responsible for children in our sample, State child 
welfare and medical services staff, Child Welfare Program Directors 
representing 4 Native American Nations, and other State agency 
officials.  Our analysis focused on a 3-year Medicaid claims history for 
the period November 1, 1999 to November 1, 2002. 
FINDINGS 
All 50 sampled children had Medicaid coverage and claims for 
health care services. 
Each of the 50 sampled children was enrolled in the Medicaid program, 
had a Medicaid card or number, and had at least 1 Medicaid claim 
during the period covered by our study. 
 
  OEI-07-00-00643  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  NORTH DAKOTA  ii  E X E C U T I V E   S U M M A R Y  
Thirty-five of the fifty sampled children received their most recent 
EPSDT medical examination, within State-established frequency 
guidelines. 
Overall, 35 sampled children received their most recent EPSDT medical 
examination, within State-established guidelines, based on their age 
and length of time in foster care.  Six children who did not receive an 
EPSDT examination remained in compliance with the State guidelines 
based on their age or the date they entered foster care.  However, eight 
children who should have received an EPSDT examination, did not.  
Some foster care providers stated that they did not believe EPSDT 
examinations were necessary because the child was receiving care for a 
specific condition.  The only systematic notification foster care providers 
received regarding required EPSDT services was an annual letter from 
the Division of Medical Services reminding them that EPSDT services 
are available. 
Thirty of thirty-eight sampled children required to receive an EPSDT 
dental examination received their most recent EPSDT dental 
examination, within State-estabished frequency guidelines. 
The EPSDT frequency guidelines adopted by North Dakota require that 
all children over 3 years of age receive dental services every 6 months.  
Thirty-eight of the sampled children were over age 3 and, because they 
had been in foster care more than 6 months, were required to have 
received dental services.  Thirty of these thirty-eight children received 
their most recent required dental service within State-established 
EPSDT frequency guidelines.  Based on the State-established 
guidelines, the 38 children should have received at least 121 dental 
services.  However, only 64 of these 121 dental services were received 
timely, and 57 were received outside the required timeframe or not 
received at all.  Thirteen of the forty-nine caseworkers for children in 
our sample reported a severe shortage of dentists willing to treat 
Medicaid patients. 
Some sampled children waited months after entering foster care to 
receive a comprehensive medical examination recommended by the 
State. 
Federal law requires States to ensure that all children in foster care are 
provided quality services that protect their health.  North Dakotas 
foster care policy recommends that children receive an initial medical 
examination upon entry into foster care.  We found that some sampled 
children waited months before receiving an EPSDT medical  
  OEI-07-00-00643  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  NORTH DAKOTA  iii  E X E C U T I V E   S U M M A R Y  
examination.  While 31 of 38 sampled children who entered foster care 
during the period covered by our study received an EPSDT medical 
examination, they waited 2 to 435 days from entry before their health 
needs were comprehensively assessed.  The lack of a specific 
requirement for an initial medical examination may have contributed to 
the remaining seven children who entered foster care during the study 
period not having received an EPSDT medical examination, despite 
having been in foster care between 106 and 715 days. 
Mental health needs were not documented for 12 of 34 sampled 
children receiving mental health services, as required. 
In meeting Federal requirements to ensure that children in foster care 
placements are provided quality services that protect their health, 
North Dakota requires that individual case plans for children in foster 
care include their mental health needs.  Our case file and claims data 
review indicated that 34 of the 50 sampled children received mental 
health services during the period covered by our study.  However, the 
need for mental health services was not documented in the case plans 
for 12 of these 34 children.   
Nine of forty-eight foster care providers reported never receiving 
medical information for the sampled children in their care. 
Federal law requires that the health records of children in foster care be 
reviewed, updated, and supplied to the foster care provider at the time 
of placement.  Of the 48 foster care providers we interviewed, 9 reported 
never receiving medical information for the sampled children in their 
care.  However, caseworkers for eight of these nine children reported 
receiving or compiling medical information on the sampled children. 
RECOMMENDATIONS 
The Administration for Children and Families (ACF) should work with 
the North Dakota Division of Children and Family Services to:   
(cid:137)  Examine how initial comprehensive medical examinations 
for children entering foster care are being provided. 
(cid:137)  Ensure case plans reflect mental health needs, as required. 
(cid:137)  Promote the importance of caseworkers obtaining medical 
information for children in foster care, and supplying the 
foster care providers with the information, in accordance 
with Federal requirements. 
  OEI-07-00-00643  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  NORTH DAKOTA  iv  EE XX EE CC UU TT II VV EE    SS UU MM MM AA RR YY   
The Centers for Medicare & Medicaid Services (CMS) should work with 
the North Dakota Division of Medical Services to: 
(cid:137)  Develop a method for notifying foster care providers when 
required EPSDT services are due. 
(cid:137)  Increase the number of dentists accepting Medicaid in 
North Dakota.  
ACF and CMS should work with the North Dakota Department of 
Human Services to coordinate State agency efforts to: 
(cid:137)  Educate caseworkers and foster care providers regarding the 
importance and availability of EPSDT medical 
examinations. 
(cid:137)  Ensure caseworkers and foster care providers understand 
the difference between comprehensive EPSDT examinations 
and medical examinations for specific health conditions. 
(cid:137)  Educate caseworkers and foster care providers on State 
EPSDT frequency guidelines for dental services. 
AGENCY COMMENTS 
ACF noted that it is working with the North Dakota Department of 
Human Services to promote the importance of obtaining medical 
histories and providing medical information to foster care providers and 
that these issues are being addressed in the Program Improvement Plan 
developed in response to a Child and Family Services Review.  It also 
notes that only 79 percent of the cases reviewed during the on-site 
portion of the Child and Family Services Review substantially achieved 
the outcome measure which determines if children receive adequate 
services to meet their physical and mental health needs. 
CMS generally concurred with our recommendations, but clarified that 
the recommendations should be carried out by joint action of the 
North Dakota Divisions of Medical Services and Children and Family 
Services.  CMS stated that its regional office staff is available to provide 
technical assistance to both Divisions, as appropriate. 
  OEI-07-00-00643  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  NORTH DAKOTA  v  (cid:19) T A B L E   O F   C O N T E N T S  
ABSTRACT ....................................................... i 
 
EXECUTIVE SUMMARY ........................................ ii 
 
INTRODUCTION ................................................ 1 
 
 
FINDINGS ....................................................... 9 
  Medicaid coverage for children in foster care.....................................9 
  Receipt of EPSDT medical examinations..........................................10 
  Receipt of EPSDT dental services.....................................................11 
  Comprehensive medical examinations ...............................12 
  Documentation and receipt of mental health services.....................13 
  Medical information for foster care providers..................................14 
 
 
RECOMMENDATIONS ......................................... 15 
 
 
APPENDICES .................................................. 17 
  A:  Demographic Characteristics of Sampled Children....................17 
  B:  Medicaid Claims for Sampled Children ..........................19 
  C:  EPSDT Services for Sampled Children...........................21 
  D:  Agency Comments - ACF..........................................23 
  E:  Agency Comments - CMS..........................................27 
 
 
ACKNOWLEDGMENTS ......................................... 29 
 
  (cid:19) I N T R O D U C T I O N  
OBJECTIVE 
To determine whether sampled children in the North Dakota foster care 
program receive health care services. 
BACKGROUND 
There are an estimated 542,000 children in foster care nationwide,1  
many of whom are reportedly in poor health.  To determine if children 
in foster care are receiving mandated health care services, we selected 
eight States for review.2   The States were chosen to represent a diverse 
cross-section of foster care nationwide.  North Dakota was chosen for its 
small population size, geographic location, rural setting, county- 
administered child welfare system, Native American population, and 
fee-for-service provision of Medicaid services.  North Dakota had 
1,129 children in foster care at the end of fiscal year (FY) 2000, based on 
the most recent Federal data available at the time of our study.3   The 
Administration for Children and Families (ACF) has regulatory 
oversight of the Title IV-E foster care program, including approval of 
State plans to ensure State foster care programs are operating within 
Federal guidelines.  Within the North Dakota Department of Human 
Services, the Division of Children and Family Services manages the 
Title IV-E foster care program. 
Compared with other children from the same socioeconomic 
backgrounds, children in foster care suffer much higher rates of serious 
physical and psychological problems.4   Vision, hearing, and dental 
problems are prevalent in the foster care population, and physical 
 
1 Department of Health and Human Services, Administration for Children and Families, 
Adoption and Foster Care Analysis and Reporting System Report for the period ending 
September 30, 2001.  Retrieved April 5, 2004 from 
http://www.acf.hhs.gov/programs/cb/publications/afcars/report8.htm. 
2 Other States selected for review are Georgia, Illinois, Kansas, New Jersey, New York, 
Oregon, and Texas. 
3 Department of Health and Human Services, Administration for Children and Families, 
Foster Care: Entries, Exits, and In Care on the Last Day.  The 1,129 children in foster 
care include children in both the Title IV-E and non-Title IV-E foster care programs.  
Retrieved April 5, 2004 from http://www.acf.dhhs.gov/programs/cb/dis/tables/entryexit2002.htm. 
4 Casey Family Programs, National Center for Resource Family Support, Health Care 
Issues for Children in Foster Care, March 25, 2002.  Retrieved October 17, 2002 from 
http://www.casey.org/cnc/documents/health care issues.pdf. 
  OEI-07-00-00643  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  NORTH DAKOTA  1  I N T R O D U C T I O N  
health problems (e.g., delayed growth and development, malnutrition, 
and asthma) affect 30 to 40 percent of children in the child welfare 
system.5  
Children in foster care have greater health care needs, yet many foster 
care providers (we use the term foster care provider to refer to foster 
parents or residential care facility staff) reported having difficulty 
finding health care professionals who were willing to care for these 
children.6   The health care available for children in foster care is often 
characterized by lack of access; lack of information sharing among 
health care professionals; and long delays in obtaining services.7   
Furthermore, studies have shown that low percentages of children in 
foster care are actually receiving services.  Therefore, concern exists 
that children with the greatest health care needs may not be receiving 
needed services. 
The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) 
program is designed to screen for, diagnose, and treat medical 
conditions in Medicaid-eligible individuals under age 21 that might 
otherwise go undetected or untreated.  However, a General 
Accountability Office report released in July 2001 states that available 
data from short range studies show that the percentage of children in 
the general population receiving EPSDT services is very low.8    
Periodic dental care is also included as part of EPSDT, and must be 
performed by a dentist.  North Dakota EPSDT dental examinations are 
required for every child in accordance with the frequency guidelines 
developed by the State.  Dental frequency guidelines must be 
established by the State after consultation with recognized dental 
organizations involved in child health care.   
 
5 Factsheet: The Health of Children in Out of Home Care.  Child Welfare League of 
America.  Retrieved October 17, 2002 from 
http://www.cwla.org/programs/health/healthcarecwfact.htm. 
6 Chernoff, R. et. al., Assessing the Health Status of Children Entering Foster Care,  
   Pediatrics, 93:2, 1994. 
7 Health Care of Young Children in Foster Care.  Pediatrics, 109:3, 2002.  Retrieved  
   May 12, 2003 from http://www.aap.org/policy/re0054.html. 
8 Medicaid: Stronger Efforts Needed to Ensure Childrens Access to Health Screening 
Services.  General Accountability Office, GAO-01-749, July 2001. 
  OEI-07-00-00643  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  NORTH DAKOTA  2  II NN TT RR OO DD UU CC TT II OO NN   
Medicaid for Children in Foster Care 
All children in the North Dakota Title IV-E foster care program are 
eligible for Medicaid.  Sections 472(h) and 1902(a)(10)(A)(i)(I) of the 
Social Security Act (the Act) require States to provide Medicaid or 
equivalent health insurance coverage to all children in foster care, 
including those eligible to receive Title IV-E foster care program 
maintenance funds.  Federal EPSDT guidelines require each State to 
make comprehensive and preventive child health services available to 
Medicaid-eligible individuals under the age of 21, as outlined in 
Sections 1902(a)(43) and 1905(r) of the Act.  Within a broad framework, 
each State establishes its own Medicaid eligibility standards; 
determines the type, amount, duration, and scope of Medicaid services; 
sets the rate of payment for services to Medicaid patients; and 
administers its own Medicaid program.9     
In FY 2000, Medicaid payments for children in foster care nationwide 
totalled over $3.3 billion.10   North Dakota Medicaid expenditures for 
this population totalled approximately $10.7 million in 2000.11   The 
Centers for Medicare & Medicaid Services (CMS) is responsible for the 
Federal oversight of individual State Medicaid programs.  Within the 
North Dakota Department of Human Services, the Division of Medical 
Services manages the State Medicaid program. 
North Dakota Health Tracks 
In accordance with Federal law, participation in the Medicaid program 
requires States to establish EPSDT services for all Medicaid-eligible 
individuals under 21 years of age.12   State EPSDT programs must 
provide medical, hearing, vision, and dental screenings, and other 
necessary health care and treatment at intervals established by the 
State that meet reasonable standards of practice published by 
 
9  Retrieved September 12, 2002 from http://cms.hhs.gov/medicaid/mover.htm 
 and http://cms.hhs.gov/medicaid/eligibility/criteria.asp. 
10 Department of Health and Human Services, Medicaid Statistical Information System 
 (MSIS) Report Fiscal Year 2000:  All States.   Retrieved August 6, 2003, from 
  http://www.cms.gov/medicaid/msis/00nd.pdf. 
11 Department of Health and Human Services, Medicaid Statistical Information System 
 (MSIS) Report Fiscal Year 2000:  North Dakota.  Retrieved April 5, 2004, from  
  http://www.cms.gov/medicaid/msis/00nd.pdf.  
12 Section 1905(r) of the Social Security Act. 
 
  OEI-07-00-00643  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  NORTH DAKOTA  3  I N T R O D U C T I O N  
recognized health care organizations.  North Dakota has established the 
Health Tracks program to meet Federal EPSDT requirements.   
The current frequency schedule established for the Health 
Tracks program requires a complete physical examination 
at 1, 2, 4, 6, 9, 12, 15, and 18 months of age; during each year that the 
child is 2, 3, 4, 5, 6, 8, and 10 years of age; and during each year of the 
childs life thereafter through the age of 21.  The Health Tracks program 
does not require EPSDT services for children 7 and 9 years of age.  
Health Tracks program guidelines require that vision and hearing 
screenings be included as part of every EPSDT physical examination for 
all children over 6 years of age.  Health Tracks also requires a complete 
dental examination every 6 months, separate from the medical 
examination, for all children over 3 years of age. 
North Dakota requires State child welfare staff (e.g., eligibility 
specialists or caseworkers) to inform the guardians of all Medicaid- 
eligible children of the availability of health services and to document 
that such services were offered.  Foster care providers are generally 
responsible for ensuring the children in their care receive these 
examinations.  North Dakota recommends, but does not require, that 
children receive a medical examination upon entry into foster care in 
addition to the health care services provided in accordance with the 
Health Tracks frequency guidelines.13   
While Section 1905(r)(1)(B)(i) of the Social Security Act requires that 
mental health development be included in EPSDT screenings, 
North Dakota imposes no specific requirements for mental health 
screenings or the provision of mental health services for children in 
foster care beyond requiring that legal custodians provide for the 
physical, mental, and moral welfare of the children in their custody.14   
Case plans are required to address clinically diagnosed disabling 
conditions.15    
Section 471(a)(22) of the Act requires States to develop a State plan that 
includes standards to ensure that children in foster care placements in 
public and private agencies are provided quality services that protect 
 
13 North Dakota Department of Human Services (NDDHS), Service Chapter 623 05 05-60. 
14 NDDHS 624-05-05-11. 
15 NDDHS 624-05-05-20. 
 
  OEI-07-00-00643  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  NORTH DAKOTA  4  I N T R O D U C T I O N  
their safety and health.  Sections 422(b)(10)(B)(ii) and 475(5)(D) of the 
Act require procedures to ensure that health records for children in 
foster care be reviewed, updated, and supplied to the foster care 
provider at the time of placement.  According to Section 475(1)(C) of the 
Act, health records should include, to the extent available and 
accessible, the names and addresses of the childs health care 
professionals, a record of the childs immunizations, the childs known 
medical problems, the childs medications, and any other relevant 
health information concerning the child determined to be appropriate by 
the State agency. 
To meet Federal requirements, North Dakota requires that a 
permanency plan (case plan) addressing each childs medical and 
mental health needs, and a record of the childs immunizations and 
known medical problems, be developed within 30 days of a childs entry 
into foster care.  The case plans are required to be reviewed and 
updated quarterly and should include all available health records.  The 
health information contained in the case plans is to be supplied to the 
foster care providers.16    
METHODOLOGY 
This inspection focused on the receipt of health care and dental services 
that meet EPSDT guidelines; the receipt of mental health services; and 
the provision of medical information to foster care providers.  This study 
did not address follow-up care or the appropriateness of ongoing health 
care in meeting the needs of children in foster care.  The inspection is 
based on information gathered from multiple sources:  reviews of 
Federal and State policies; child-specific Medicaid claims data for 
50 randomly sampled children; case file documentation for 49 of the 
50 sampled children (case file information for 1 sampled child was not 
provided); interviews with caseworkers and foster care providers for the 
49 sampled children for which case files were received; and interviews 
with North Dakota State agency and Native American Nation officials. 
Reasons for State Selection 
North Dakota was selected for its small population size, geographic 
location, rural setting, county-administered child welfare system,  
 
16 NDDHS 624-05-05-17. 
  OEI-07-00-00643  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  NORTH DAKOTA  5  I N T R O D U C T I O N  
Native American population, and fee-for-service provision of Medicaid 
services. 
Sample 
Children who met the following criteria were included in the study 
population:  (1) were in foster care on January 22, 2003; (2) resided in 
North Dakota; (3) were eligible for Title IV-E foster care program 
maintenance funds; and (4) had been in continuous out-of-home foster 
care placements for at least 6 months.  The Division of Children and 
Family Services provided us with a list of the 381 children who met 
these criteria.  We selected a simple random sample of 50 children from 
this list.  Appendices A, B, and C provide information on the children 
included in our study, and the services they received. 
Review of Policies, Medicaid Data, and Case File Documentation 
Policy Review -- We reviewed Federal and State foster care, Medicaid, 
and EPSDT program policies.  The North Dakota Health Tracks 
program meets Federal EPSDT requirements.  Therefore, we used 
Health Tracks guidelines to determine whether children in foster care 
were receiving required EPSDT medical and dental services timely. 
Medicaid Claims Data Review -- The Division of Medical Services provided 
us with up to 3 years of Medicaid claims data for each of the children in 
our sample.  The data included Medicaid claims for physician, dental, 
pharmaceutical, and mental health services paid between 
November 1, 1999 and November 1, 2002, the most recent 3-year period 
for which claims data was available.  We paid particular attention to the 
types of services provided and service dates.  We included only those 
Medicaid claims for services provided after the childs most recent entry 
into foster care.  For sampled children entering foster care on or after 
November 1, 1999, we analyzed Medicaid claims data from the date 
they entered foster care through November 1, 2002.  All Medicaid 
services provided to sampled children were included in our analysis.  
However, sampled children who had been in foster care less than 
6 months during our claims window were not considered out of 
compliance if they had not received the EPSDT service.  Appendix B 
provides information regarding the Medicaid services each sampled 
child received.  
Case File Documentation -- We requested case file documentation from 
the Division of Children and Family Services local offices for all of the 
children in our sample, including documentation of medical, dental, and 
mental health services provided, the childs medical history, the childs 
  OEI-07-00-00643  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  NORTH DAKOTA  6  I N T R O D U C T I O N  
initial and most recent case plan, duration of the childs stay in foster 
care, and information regarding the childs health and general well-
being.  We received and reviewed information for 49 children; despite 
repeated requests, we were not provided with the documentation for 
1 child. 
We also received and reviewed caseworker or residential treatment 
center notes for some of the sampled children indicating that the 
children had been referred for or scheduled to receive medical, dental, or 
mental health services or that they had actually received the services.  
However, in the absence of a Medicaid claim or other supporting 
documentation (e.g., an EPSDT form signed by a physician or other 
health care professional), we were unable to include the noted services 
in our analysis. 
Interviews   
Foster Care Provider Interviews -- We conducted structured interviews 
with 48 of the foster care providers (i.e., foster parents or residential 
care facility staff) responsible for the children in our sample (8 in person 
and 40 by telephone) between April 15, 2003 and May 29, 2003.  We 
were unable to interview two foster care providers because we were 
unable to obtain the case file containing contact information for one 
sampled child and the caseworker failed to provide the foster parent 
contact information for another child within the timeframe of our study.  
The interviews with foster care providers focused on the Medicaid 
program and the services available, the training they received related to 
the health and well-being of children, and their experiences procuring 
health care services for the children in our sample. 
Caseworker Interviews  -- We conducted structured telephone interviews 
with 49 of the caseworkers assigned to the children in our sample 
between March 27, 2003 and May 22, 2003.  We did not receive the case 
file for one child and therefore lacked the information needed to contact 
the caseworker.  Each of these interviews focused on the caseworkers 
understanding of the Medicaid program and the services available, the 
training they received related to the health and well-being of children, 
their experiences accessing health care services, and any barriers to 
obtaining needed health care.  Each caseworker spoke specifically about 
the sampled childs case, and generally about his or her own experiences 
working in foster care.  We analyzed the caseworkers responses and 
compared them to those of the foster care providers, noting any 
consensus or disagreement within and between the two groups. 
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State Agency and Native American Nation Officials -- To enhance our 
understanding of the States foster care and Medicaid programs, we 
consulted, both in person and by telephone, with State staff and Child 
Welfare Program Directors for the Spirit Lake Sioux, Standing Rock 
Sioux, Three Affiliated Tribes, and Turtle Mountain Chippewa Nations.   
This inspection was conducted in accordance with the Quality 
Standards for Inspections issued by the Presidents Council on Integrity 
and Efficiency.
  OEI-07-00-00643  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  NORTH DAKOTA  8  (cid:19) F I N D I N G S  
All 50 sampled children had Medicaid coverage  Federal law requires that all 
and claims for health care services.  children eligible for the              
Title IV-E foster care program be 
provided Medicaid or Medicaid-equivalent services.17   In North Dakota, 
all children in foster care are eligible for Medicaid, including Early and 
Periodic Screening, Diagnosis, and Treatment (EPSDT) services.18   
Each of the 50 sampled children had Medicaid coverage and at least 
1 Medicaid claim for health care services during the 3-year period 
covered by our study.  Table 1 details the various types of Medicaid-
covered services and the number of claims by type of service provided 
for the 50 sampled children. 
Table 1:  Number and Type of Medicaid Claims for 50 
Sampled Children
Number of 
Total Number of 
Claim Type Children with at 
Claims
Least One Claim
Physician Office 46 407
Prescription Drug 45 1001
Laboratory 30 139
Dental 33 346
Hospital/ASC* 30 443
Optometry/Audiology 30 157
Mental Health 34 617
Diagnostic 9 27
Physical/Occupational 
8 133
Therapy
Supplies 18 227
Transportation 13 60
Early Intervention** 2 21
Case Management*** 22 449
Medication Review 15 94
Total 4121
*  Ambulatory Surgical Center which includes emergency room visits. 
** Includes respite care, speech and language, nursing, nutritional, and developmental services. 
Source: Office of Evaluation and Inspections, analysis of North Dakota Medicaid claims 
data2003.
***Includes 41 Medicaid claims for Targeted Case Management.  The remaining Case Management claims are 
for child protective services and residential care services case management. 
 
    A detailed list of selected services for each of the 50 sampled children is located in Appendix B. 
 
17 Section 1902(a)(43) of the Social Security Act. 
18 NDDHS 623-05-05-63. 
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Thirty-five of fifty sampled children received  EPSDT medical examinations are 
their most recent EPSDT medical examination,  intended to screen for and identify 
health care needs that may not be 
within State-established frequency guidelines. 
detected during a medical 
examination for a specific condition.  All age-appropriate EPSDT 
examinations must be completed in accordance with the State-established 
EPSDT frequency guidelines.  Overall, 35 sampled children received their 
most recent EPSDT medical examination, within State-established 
guidelines.  Six sampled children had been in foster care less than the time 
period specified by the State frequency guidelines for their age group and 
were not required to receive EPSDT services during the period covered by 
our study.  However, based on their age and length of time in foster care, 
and the State EPSDT frequency guidelines, eight children who should have 
received an EPSDT medical examination did not. 
Based on their age and the length of time they were in foster care, 25 of the 
50 sampled children were required to receive at least 1 EPSDT medical 
examination during the period covered by our review.  Collectively, these 
25 children were required to receive 49 EPSDT examinations.  However, 
only 30 of these 49 required examinations were received. 
Caseworkers or foster care providers for sampled children indicated that 
some EPSDT examinations were not performed because they believed them 
to be unnecessary.  Some reported that the children were receiving routine 
medical care through their primary care physicians or the residential 
treatment centers in which some children were placed.  Other caseworkers 
and foster care providers reported the children had recently been treated 
for a specific health care problem.  Some children missed required EPSDT 
screenings because their caseworkers or foster care providers believed no 
services were necessary during the required times.   
The lack of systematic reminders also may be critical in explaining why 
children did not receive required EPSDT examinations.  In accordance with 
State foster care policy, all children entering foster care must be made 
aware of Health Tracks services.  However, no systematic or standardized 
monitoring is done to ensure children actually receive the required Health 
Tracks services.  Further, foster care providers are not systematically 
notified of services that are due or lacking.  The only notification foster care 
providers received regarding EPSDT services was an annual letter from the 
Division of Medical Services reminding them that EPSDT services are 
available.   
  OEI-07-00-00643  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  NORTH DAKOTA  10  FF II NN DD II NN GG SS   
Thirty of thirty-eight sampled children  The EPSDT frequency guidelines 
required to receive an EPSDT dental  adopted by North Dakota require 
that all children over 3 years of age 
examination received their most recent EPSDT 
receive dental services at least every 
dental examination, within State-established 
6 months.  Thirty-eight of the 
frequency guidelines. 
sampled children had been in foster 
care at least 6 months during the period covered by our study.  Thirty of 
these thirty-eight children received their most recent required dental 
service in accordance with the State-established EPSDT frequency 
guidelines.19   Two of the thirty-eight children had received a dental 
service at some time since entering foster care but did not receive their 
most recent service in accordance with the State-established frequency 
guidelines.  Six children had received no EPSDT dental services.  
Overall, the 38 children should have received at least 121 dental 
services to meet the State-established EPSDT guidelines.  Sixty-four of 
these one hundred twenty-one services were received timely, and 
57 were received outside the required timeframe or not received at all.   
EPSDT dental services were not required during our study period for 
the remaining 11 sampled children.  Six of these eleven children were 
under age 3 at the end of the claims window and not required to receive 
EPSDT dental services based on the frequency guideline.  Five of the 
eleven were in foster care less than 6 months during the period covered 
by our Medicaid claims (i.e., the child entered foster care between 
May 1, 2002 and July 22, 2002). 
There are a variety of reasons children in foster care may not have 
received required EPSDT dental services.  Twenty-one of the 
forty-nine caseworkers and 23 of the 48 foster care providers were 
unfamiliar with the EPSDT program or unaware of the dental 
frequency guidelines.  Thirteen of the forty-nine caseworkers 
interviewed reported a severe shortage of dentists willing to treat 
Medicaid patients, which may contribute to foster care providers 
difficulty in accessing dental services.  In addition, 31 caseworkers and 
18 foster care providers reported that dentists willing to treat Medicaid 
patients had long waiting lists for appointments and that many dentists 
were not accepting new Medicaid patients. 
 
19 Recent dental services include dental services provided during the last 6 months of our 
Medicaid claims data or services provided in the last 6-month period based on the State  
EPSDT frequency guidelines. 
  OEI-07-00-00643  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  NORTH DAKOTA  11  F I N D I N G S  
Some sampled children waited months after  Section 471(a)(22) of the Act 
entering foster care to receive the  requires that States ensure all 
children in foster care are 
comprehensive medical examination 
provided quality services that 
recommended by the State. 
protect their health.  
North Dakota State foster care policy recommends that children receive 
an initial medical examination upon entry into foster care.20   We found 
that some children wait months before their health needs are 
comprehensively assessed.  Thirty-eight sampled children entered foster 
care during the period covered by our Medicaid claims 
(November 1, 1999 to November 1, 2002).  Thirty-one of these children 
received an EPSDT examination, which we used as evidence of receipt 
of a comprehensive medical examination, with at least two children 
waiting over 430 days to receive their first examination (see Table 2).  
Table 2:  Days to First Comprehensive EPSDT Medical 
Examination
Days to First  Days to First 
Number of 
Comprehensive  Comprehensive 
Age Children in 
Medical Exam  Medical Exam 
Age Group
(Range) (Median)
0 - 6 months 3 2 - 117 27
7 - 23 months 1 127 127
2 - 5 years 8 22 - 431 67.5
6 - 9 years 7 6 - 435 118
10 - 21 years 12 10 - 203 113
Total 31 2 - 435 109
Source: Office of Evaluation and Inspections, analysis of Medicaid claims data and 
casefiledocumentation.
Initial medical examinations being recommended versus required may 
have contributed to the remaining seven children who entered foster 
care during the study period not having received an EPSDT medical 
examination, despite having been in foster care between 106 and 
715 days (see Table 3). 
 
20 NDDHS 623-05-05-63. 
 
  OEI-07-00-00643  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  NORTH DAKOTA  12  F I N D I N G S  
 
Table 3:  Days in Foster Care Without a Comprehensive EPSDT Medical Exam 
Number of  Days Without  Days Without 
Age  Children in  Comprehensive  Comprehensive Medical 
Age Group  Medical Exam (Range)  Exam (Median) 
0 - 6 months  0  0  0 
7 - 23 months 0  0  0 
2 - 5 years  1  113  113 
6 - 9 years  2  155 - 444  299 
10 - 21 years  4  106 - 715  208 
Total  7  106 - 715  193 
Source: Office of Evaluation and Inspections, analysis of Medicaid claims data and case file 
documentation.
 
Mental health needs were not documented for  Section 475(1)(B) of the Act 
12 of 34 sampled children receiving mental  requires that a case plan be 
developed for each child that 
health services, as required. 
enters foster care, and that the  
plan ensures that services address the childs needs, including mental 
health, while the child is in foster care.  North Dakota requires that 
individual case plans for children in foster care include their mental 
health needs.21   Further, case plans must address clinically diagnosed 
disabling conditions (e.g., attention deficit or hyperactive disorders, 
conduct disorders, emotional disturbances, and mental retardation).22  
Each child in foster care is to be provided with needed mental health 
services identified in his/her case plan. 
Thirty-four of the fifty sampled children received at least one mental 
health service during the time period covered by our review.  The 
receipt of mental health services were documented by Medicaid claims 
for 33 of the sampled children and by case file documentation for 
1 child.  However, the need for mental health services was not 
documented in the case plans for 12 of the 34 sampled children who 
received mental health services.  A lack of documentation in the case 
 
21 NDDHS 624-05-05-20.  
22 NDDHS 624-05-05-20.   
 
  OEI-07-00-00643  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  NORTH DAKOTA  13  F I N D I N G S  
plans could result in children not continuing to receive services.  If the 
child is placed with another foster care provider or assigned a new 
caseworker unaware of his/her mental health needs, services may not be 
continued without documentation.  
 
Section 475(5)(D) of the Act 
Nine of the forty-eight foster care providers 
requires the health records of 
reported never receiving medical information 
children in foster care be 
for the children in their care. 
reviewed, updated, and supplied 
to the foster care provider with whom the child is placed at the time of 
each placement in foster care.  North Dakota requires that the health 
information contained in the case plans be supplied to foster care 
providers.23   However, of the 48 foster care providers we interviewed, 
9 reported never receiving medical information for the sampled children 
in their care.  Caseworkers for eight of the nine children placed with 
these foster care providers indicated they had compiled or received some 
medical information for the sampled children.  This indicates a problem 
in the communication of medical information from caseworkers to foster 
care providers. 
Some of the foster care providers who did not receive medical 
information when the child was placed with them were unaware that 
they should have it or could ask for it.  While we do not know why 
medical information contained in these case files was not given to the 
foster care providers, failure to provide available medical information to 
foster care providers could result in childrens medical needs not being 
met.   
 
23 NDDHS 624-05-05-17. 
  OEI-07-00-00643  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  NORTH DAKOTA  14  (cid:19) R E C O M M E N D A T I O N S  
RECOMMENDATIONS 
States are required to ensure that all children in foster care are 
provided quality health care services that protect their health.  The 
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) 
program is intended to detect various health needs.  However, if 
children do not receive the required services or do not receive those 
services timely, their health needs may go undetected and untreated.    
The Administration for Children and Families (ACF) should work with 
the North Dakota Division of Children and Family Services to: 
(cid:137)  Examine how initial comprehensive medical examinations 
for children entering foster care are provided. 
(cid:137)  Ensure case plans reflect mental health needs, as required. 
(cid:137)  Promote the importance of caseworkers obtaining medical 
information for children in foster care and supplying foster 
care providers with the information, in accordance with 
Federal requirements. 
The Centers for Medicare & Medicaid Services (CMS) should work with 
the North Dakota Division of Medical Services to: 
(cid:137)  Develop a method for notifying foster care providers of when 
required EPSDT services are due. 
(cid:137)  Increase the number of dental providers accepting Medicaid 
in North Dakota. 
ACF and CMS should work with the North Dakota Department of 
Human Services to coordinate State agency efforts to: 
(cid:137)  Educate caseworkers and foster care providers regarding the 
importance and availability of EPSDT medical 
examinations. 
(cid:137)  Ensure caseworkers and foster care providers understand 
the difference between comprehensive EPSDT examinations 
and medical examinations for specific health conditions. 
(cid:137)  Educate caseworkers and foster care providers on State 
EPSDT frequency guidelines for dental services. 
 
 
  OEI-07-00-00643  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  NORTH DAKOTA  15  R E C O M M E N D A T I O N S  
 
AGENCY COMMENTS 
ACF noted that it is working with the Department of Human Services to 
promote the importance of obtaining medical histories and providing 
medical information to foster care providers and that these issues are 
being addressed in the Program Improvement Plan developed in 
response to a Child and Family Services Review.  They also note that 
only 79 percent of the cases reviewed during the on-site portion of the 
Child and Family Services Review substantially achieved the outcome 
measure which determines if children receive adequate services to meet 
their physical and mental health needs. 
CMS generally concurred with our recommendations but clarified that 
the recommendations should be carried out by joint action of the 
North Dakota Divisions of Medical Services and Children and Family 
Services.  CMS stated that its regional office staff is available to provide 
technical assistance to both Divisions, as appropriate. 
  OEI-07-00-00643  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  NORTH DAKOTA  16  (cid:19) A P P E N D I X   ~   A  
Demographic Characteristics of Sampled Children 
The table below provides the demographic characteristics of each of the 50 sampled 
children and his or her foster care placement history as of May 2003. 
Months Since  Placements  Caseworkers  Months 
Placement  Entries into  Months Since Last 
ID Sex Age Foster Care Entry  Since Last  Since Last Entry Caseworker With 
Setting Foster Care (1) Placement (4)
(2) Entry (3) (5) Case (6)
1 F 17 Therapeutic 1 15 2 4 1 18
2 M 17 Residential 2 89 29 6 4 43
3 F 17 Residential 2 14 2 10 4 14
4 M 16 Therapeutic 1 10 2 4 1 13
5 M 15 Kinship 3 26 10 12 4 6
6 M 15 Residential 2 12 2 8 1 12
7 M 15 Residential * 42 1 42 2 24
8 F 15 Residential 1 28 2 9 * 8
9 F 13 Family 1 9 1 9 1 10
10 M 14 Family 13 52 15 14 2 14
11 M 12 Therapeutic 1 29 6 3 2 14
12 M 12 Therapeutic 1 54 6 11 2 5
13 F 12 Kinship 2 52 4 4 1 48
14 F 14 Residential 5 67 7 15 6 24
15 F 12 Family 2 17 2 11 1 17
16 M 11 Family 1 29 2 25 2 9
17 F 11 Family 1 20 1 20 1 20
18 F 10 Therapeutic 1 92 1 92 2 120
19 F 12 Family 1 62 1 62 * 18
20 M 11 Family 3 26 12 6 4 6
21 M 10 Family 1 92 4 9 4 70
22 M 9 Family 2 20 1 20 1 20
23 M 8 Family 1 12 2 10 1 20
24 M 8 Family 1 22 2 17 3 90
25 F 11 Family 2 9 1 9 1 61
26 F 10 Family 1 26 4 18 2 8
27 F 7 Unknown 1 13 2 5 2 2
28 F 6 Kinship 1 35 3 17 3 21
29 M 12 Family 1 21 2 4 1 22
30 F 17 Residential 4 15 3 11 2 13
31 M 6 Family 1 14 3 13 1 14
32 F 5 Family * 35 * 24 2 24
33 M 5 Family 2 21 2 12 1 21
34 F 5 Family 1 57 4 45 2 42
35 M 16 Residential 2 18 4 6 3 7
36 F 4 Family 1 21 2 4 1 21
37 F 4 Family 2 9 1 9 1 9
38 M 3 Family 1 29 2 13 2 6
39 F 3 Family 2 12 1 12 2 9
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Entries Into  Months Since  Placements  Caseworkers  Months 
Placement  Months Since Last 
ID Sex Age Foster Care  Foster Care  Since Last  Since Last  Caseworker 
Setting Placement (4)
(1) Entry (2) Entry (3) Entry (5) With Case (6)
40 M 3 Family 2 11 4 5 1 11
41 F 5 Kinship 1 22 1 22 1 22
42 M 10 Family 4 11 2 4 1 11
43 F 2 Family 1 25 2 7 2 18
44 F 1 Family 1 19 1 19 1 19
45 M 1 Family 1 14 1 14 1 14
46 F 17 Family 1 90 16 8 5 6
47 M 17 Therapeutic 1 12 1 12 1 16
48 F 16 Residential 1 22 3 9 2 24
49 F 15 Family 2 46 6 16 2 16
50*
 
KEY 
(1)  Entries into Foster Care --  number of times a child has entered State custody. 
(2)  Months Since Foster Care Entry --  length of time from the date of the childs most recent entry into foster care 
until May 2003, when interviews were conducted with caseworkers and foster care providers, or the date the 
child left care if that date precedes May 2003. 
(3)  Placements Since Last Entry --  number of placements, in all settings (e.g., Foster Home, Residential Care  
Facility), the child experienced during his/her most recent entry into foster care.  
(4)  Months Since Last Placement -- length of time from the dae of the most recent placement to the date the foster 
care provider was interviewed. 
(5)  Caseworkers Since Last Entry --  number of caseworkers assigned responsibility for the child since his/her last 
entry into foster care, including family caseworkers and child-specific caseworkers. 
(6)  Months Caseworker With Case  number of months the most recent caseworker had been assigned 
responsibility for the child, which may be larger than the number of Months Since Foster Care Entry, 
because some caseworkers were working with the child before the child officially entered foster care 
(e.g., through the juvenile justice system, family preservation services). 
(*)  Unknown. 
OEI-07-00-00643  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  NORTH DAKOTA  18  (cid:19) A P P E N D I X   ~   B  
Medicaid Claims for Sampled Children 
The table below indicates each of the 50 sampled childrens paid Medicaid claims for 
physician and office visits, dental services, prescription medications, and mental health 
services while they were in foster care from November 1, 1999 to November 1, 2002. 
Number of Medicaid Claims*
EPSDT and  Mental 
Dental  Prescription 
OIG ID Physician's  Health 
Services Medications
Office Visits Services
1 5 11 4 0
2 5 3 50 64
3 2 1 11 3
4 0 0 4 0
5 5 19 4 1
6 2 0 2 1
7 3 4 0 22
8 5 11 6 8
9 1 4 4 4
10 11 25 2 38
11 4 9 19 3
12 12 28 142 88
13 21 12 7 25
14 9 11 62 51
15 1 9 11 15
16 7 15 44 24
17 7 0 2 6
18 12 15 185 0
19 2 7 2 0
20 10 11 18 28
21 1 0 3 4
22 4 6 4 21
23 7 4 9 2
24 3 0 2 0
25 0 0 3 5
26 8 11 11 44
27 1 0 0 0
28 14 14 8 0
29 0 10 0 11
30 7 0 4 10
31 7 9 1 7
32 2 13 2 0
33 8 3 3 0
34 19 0 57 0
35 5 8 25 20
OEI-07-00-00643  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  NORTH DAKOTA  19  A P P E N D I X ~ B  
 
Number of Medicaid Claims*
EPSDT and 
Prescription  Mental Health 
OIG ID Physician's  Dental Services
Medications Services
Office Visits
36 8 15 3 8
37 2 0 0 1
38 3 0 0 0
39 3 0 1 0
40 3 0 2 3
41 3 6 1 0
42 0 0 13 5
43 52 0 24 0
44 36 0 10 0
45 24 0 5 0
46 5 8 14 3
47 3 4 38 6
48 18 8 47 20
49 26 12 30 46
50 11 20 102 20
Total 407 346 1001 617
KEY 
* The Number of Medicaid Claims includes only services for which a Medicaid claim was paid.  
Services documented in the case file for which no Medicaid claims were paid are not included. 
 
OEI-07-00-00643  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  NORTH DAKOTA  20  (cid:19) A P P E N D I X   ~   C  
EPSDT Services for Sampled Children 
The table below reflects EPSDT services received by each of the 50 sampled children from 
November 1, 1999 to November 1, 2002 or from entry into care to November 1, 2002, 
whichever is shorter. 
Days to First Service (4) Services Current (5)
Medical  Case Plan  Days Since 
OIG ID History in  Completed in  Foster Care  EPSDT 
EPSDT Medical Dental Dental
Casefile (1) 30 Days (2) Entry (3) Medical
1 N Y 441 10 23 B A
2 Y N 2658 199 65 A C
3 N N 407 23 128 B A
4 N Y 295 56 X B D 
5 Y Y 776 117 112 A A
6 Y Y 347 X 36 D A
7 N Y 1265 156 152 A C
8 N N 853 203 128 A C
9 Y Y 272 48 92 B B
10 N Y 1571 261 322 A A
11 Y Y 862 X 607 C A
12 Y Y 1634 267 177 A A
13 N Y 1549 500 393 A A
14 Y Y 2017 196 169 C A
15 N N 504 182 105 B A
16 N Y 874 21 250 A A
17 N Y 602 X X D C
18 N N 2746 X 191 C A
19 N N 1863 329 337 A A
20 Y Y 776 118 112 B A
21 N N 2755 X X C C
22 N Y 610 435 69 A A
23 Y Y 360 150 13 B A
24 N Y 654 288 X B C
25 Y Y 264 X X D D
26 N Y 766 6 115 A A
27 N Y 383 109 X B C
28 Y Y 1060 134 134 B A
29 N Y 626 167 164 B A
30 N N 436 109 X B C
31 Y Y 427 41 55 B A
32 N Y 1037 61 257 A C
33 N Y 644 431 317 A A
34 Y Y 1707 378 X C C
35 N N 549 148 79 B A
36 Y Y 615 22 40 B A
37 N N 279 X X D D
38 Y Y 868 127 X A D
39 Y Y 369 66 66 B B
40 N Y 334 69 X B D
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Days to First Service (4) Services Current (5)
Medical  Case Plan  Days Since 
OIG ID History in  Completed in  Foster Care  EPSDT  EPSDT 
Dental Dental
Casefile (1) 30 Days (2) Entry (3) Medical Medical
41 Y Y 653 429 478 B A
42 Y Y 319 X 103 D B
43 Y N 740 117 X C D
44 N Y 558 2 X C D
45 N Y 418 27 X C D
46 Y Y 2687 1044 33 A A
47 N Y 370 X 158 D A
48 N Y 661 57 45 A A
49 Y Y 1369 532 178 A C
 50*
 
KEY 
(1)  Medical History in Casefile -- casefile documentation provided by the caseworker included a medical history.   
 
(2)  Case Plan Completed in 30 Days -- case plan was completed within 30 days 
Y -- case plan completed within 30 days.   
N -- case plan not completed within 30 days. 
 
(3)  Days Since Foster Care Entry -- number of days the sampled child had been in foster care at the time the 
foster care provider was interviewed. 
 
(4)  Days to First Service: 
A number indicates the number of days between November 1, 1999 (the beginning date for Medicaid 
claims included in our study) or the date the child entered foster care (if the child entered foster care after 
November 1, 1999) and the date the child received his/her first EPSDT medical or dental service. 
X -- child did not receive this type of service within the period covered by our review. 
 
(5)  Services Current: 
A - The most recent required service was received. 
B - One or more services were received, but had they not been provided the child would not have been out   
 of compliance based on age or length of time in foster care. 
C - A recent required service was not received. 
D - No services were received. but none were required during our claims window (i.e., the length of time 
the child had been in foster care and the period covered by our claims window did not extend the full 
length of time covered by the EPSDT frequency guideline for the childs age, or the child was under 
3 years of age and not required to receive dental services). 
 
*Unknown.
OEI-07-00-00643  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  NORTH DAKOTA  22  (cid:19) A P P E N D I X   ~   D  
Agency Comments - ACF 
 
OEI-07-00-00643  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  NORTH DAKOTA  23  A P P E N D I X ~ D  
 
OEI-07-00-00643  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  NORTH DAKOTA  24  A P P E N D I X ~ D  
 
OEI-07-00-00643  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  NORTH DAKOTA  25  A P P E N D I X ~ D  
 
OEI-07-00-00643  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  NORTH DAKOTA  26  (cid:19) A P P E N D I X   ~   E  
Agency Comments - CMS 
OEI-07-00-00643  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  NORTH DAKOTA  27  A P P E N D I X ~ E  
 
 
OEI-07-00-00643  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  NORTH DAKOTA  28  (cid:19) A C K N O W L E D G M E N T S  
 
This report was prepared under the direction of Brian T. Pattison,  
Regional Inspector General for Evaluation and Inspections in the   
Kansas City regional office, and Gina Maree, Assistant Regional Inspector 
General.  Other principal Office of Evaluation and Inspections staff who 
contributed include: 
Deborah Walden, Team Leader 
Linda Paddock, Project Leader 
Michala Walker, Program Analyst 
Brian Whitley, Program Analyst 
Steve Milas, Program Analyst 
Zula Crutchfield, Program Analyst 
Elander Phillips, Program Analyst 
Linda Hall, Program Specialist (Washington, DC) 
Barbara Tedesco, Mathematical Statistician (Baltimore, Md.) 
OEI-07-00-00643  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  NORTH DAKOTA  29