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 :  T
OSTER  ARE EXAS 
Inspector General 
FEBRUARY 2004 
OEI-07-00-00641  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. 
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. The OI also oversees state Medicaid 
fraud control units, which investigate and prosecute fraud and patient abuse in the Medicaid 
program. 
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.  A B S T R A C T

Our study determined that all 50 sampled children in the Texas 
foster care program received Medicaid services, and the majority 
received their most recent required Early and Periodic Screening, 
Diagnosis, and Treatment (EPSDT) medical examinations. 
However, the percentage of children receiving their required initial 
medical and dental screenings was substantially lower, and 
compliance with guidelines for vision and hearing screenings was 
undocumented. The Office of Inspector General (OIG) also 
determined that case plans were not completed within required 
timeframes for over half of the sampled children, and foster care 
providers for almost half of the children never received a written 
medical history for the children in their care. OIG recommends 
that the Administration for Children and Families (ACF) work with 
the Texas Department of Protective and Regulatory Services to 
increase the number of: initial medical and dental screenings that 
are received within required timeframes; initial case plans that are 
completed within required timeframes; and, foster care providers 
who are supplied available medical information for the children in 
their care, as required by Federal regulations. OIG recommends 
that the Centers for Medicare & Medicaid Services (CMS) work 
with the Texas Department of Health to evaluate the need for 
documentation to ensure compliance with routine EPSDT vision 
and hearing screening guidelines. ACF noted that it is working 
with the State to accomplish goals established in a Program 
Improvement Plan (PIP) developed as a result of a Child and 
Family Services Review. One of the goals of the PIP focuses on the 
health and mental health care of children in the child welfare 
system. CMS concurs with our recommendations and indicates 
that they are available to provide technical assistance to the State 
to promote provider education regarding the frequency schedule 
requirements and appropriate documentation of vision and hearing 
screenings. 
OEI-07-00-00641  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: TEXAS  i  E X E C U T I V E   S U M M A R Y

OBJECTIVE 
To determine whether sampled children in the Texas foster care 
program receive health care services. 
BACKGROUND 
Currently, there are an estimated 534,000 children in foster care 
nationwide, many of whom are reportedly in poor health. 
Compared with children from the sam e socioeconomic backgrounds, 
these children suffer much higher rates of serious physical and 
psychological problems. Texas 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 children in the Texas foster care program are eligible for 
Medicaid. Federal Early and Periodic Screening, Diagnosis, and 
Treatment (EPSDT) guidelines require each State to provide 
coverage of preventive health care services to Medicaid-eligible 
individuals under the age of 21, at intervals which meet reasonable 
standards of medical and dental practice, as outlined in 
Section 1905(r) of the Social Security Act (the Act). In addition, 
Section 471(a)(22) of the Act requires States to develop and 
implement standards to ensure that all children in foster care 
placements are provided quality services that protect their health. 
This inspection is based on information gathered from multiple 
sources: reviews of Federal and State policies; analysis of 
child-specific Medicaid claims data and case file documentation for 
50 randomly sampled children in the Texas foster care program; 
interviews with foster care providers and caseworkers for the 
children in our sample; and interviews with Tex as Department of 
Protective and Regulatory Services, Department of Health, and 
other State agency officials. Our analysis focused on a 3-year 
Medicaid claims history for the period September 1, 1999 through 
August 31, 2002. 
FINDINGS 
All sampled children had Medicaid coverage and claims for 
services 
All of the sampled children had Medicaid coverage and at least one 
Medicaid claim for health care services. 
OEI-07-00-00641  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: TEXAS  ii  EE XX EE CC UU TT II VV EE    SS UU MM MM AA RR YY  
Ninety-four percent of sampled children received their most 
recent EPSDT medical examinations, and 92 percent 
received their most recent EPSDT dental examinations, in 
accordance with State guidelines 
Nearly all of the sampled children had received their most recent 
EPSDT medical and dental examinations at the time of our review. 
A high percentage of the children who had received their most 
recent EPSDT medical and dental services, according to the States 
frequency guidelines, had a foster care provider that knew the 
correct EPSDT frequency schedule for the child in its care. 
Seventy-five percent of sampled children received initial 
medical examinations, and 66 percent of sampled children 
received initial dental examinations, within required 
timeframes 
Substantially fewer sampled children received initial medical and 
dental examinations within required State timeframes than 
children who received EPSDT medical and dental examinations 
that met State frequency guidelines. Data collected by the Office of 
Inspector General suggest that it may be difficult to quickly locate 
dental providers for initial visits. 
Compliance with State guidelines for vision and hearing 
screenings was undocumented 
Texas requires that a hearing and vision screening be performed 
during each EPSDT medical examination. Our review of case file 
documentation provided no evidence of a vision screening for 
58 percent (29/50) of the children in our sample, and no evidence of 
a hearing screening for 66 percent (33/50) of the children in our 
sample at the time of their most recent EPSDT medical 
examination. The Centers for Medicare & Medicaid Services (CMS) 
no longer requires States to submit data on the number of children 
who received a vision or hearing screening through the States 
EPSDT program. Likewise, medical providers in Texas are not 
required to itemize the components of an EP SDT medical 
examination when billing for reimbursement. 
Seventy-six percent of sampled children received Medicaid 
mental health services 
Federal law requires that a case plan be developed for each child in 
Title IV-E foster care that includes a plan for en suring that the 
OEI-07-00-00641  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: TEXAS  iii  EE XX EE CC UU TT II VV EE    SS UU MM MM AA RR YY  
childs needs are addressed while s/he is in foster care. Texas 
requires that a case plan be developed for each child in foster care 
that includes an assessment of the childs mental health needs. For 
the 50 children in our sample, 44 percent (22/50) had initial case 
plans that were completed within the required timeframe (within 
45 days of entering care). Seventy-six percent (38/50) of the 
children in our sample had Medicaid claims for mental health care 
services. The case plans for the 12 children who did not have 
Medicaid mental health claims indicated that their mental health 
needs were assessed, and only 2 indicated a need for services that 
were not received. 
Forty-six percent of foster care providers reported never 
receiving a medical history for the sampled child in their care 
Federal law requires that a childs health records be given to the 
foster care provider at the time of placement. The provision of this 
information is important to ensure that appropriate health care 
services are provided to children in foster care. Foster care 
providers for 46 percent (23/50) of the sampled children reported 
never receiving a medical history for the child in their care. 
However, caseworkers for 19 of these 23 children reported receiving 
or compiling a medical history for the child. Foster care providers 
for children assigned a lower level of care (i.e., children with few or 
no medical and/or mental health problems) were less likely to 
report receiving a medical history for the child in their care than 
providers caring for a child assigned a higher level of care (i.e., a 
child with moderate to severe medical and/or mental health 
problems). 
RECOMMENDATIONS 
To ensure that children in foster care receive health care services in 
accordance with Federal guidelines, we recommend that: 
The Administration for Children and Familes (ACF) work with the 
Texas Department of Protective and Regulatory Services to 
increase the number of 
o	 Initial medical and dental screenings that are received within 
required timeframes 
o	 Initial case plans that are completed within required 
timeframes 
OEI-07-00-00641  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: TEXAS  iv  E X E C U T I V E   S U M M A R Y  
o	 Foster care providers who are supplied available medical 
information for the children in their care 
The Centers for Medicare & Medicaid Services work with the Texas 
Department of Health to 
o	 Evaluate the need for documentation to ensure compliance with 
routine EPSDT vision and hearing screening guidelines 
AGENCY COMMENTS 
ACF indicated that it is working with the Texas Department of 
Protective and Regulatory Services, to assist the State in 
accomplishing goals established in a Program Improvement Plan 
developed as a result of a Child and Family Services Review. Child 
and Family Services Reviews measure individual States 
performance related to the health and well-being of children in the 
child welfare system. ACF stated that indicators in the Child and 
Family Services Review specifically track the areas of concern 
highlighted in this report, and that one of the goals of Texas 
Program Improvement Plan focuses on the health and mental 
health care of children in the child welfare system. Upon 
completion of this plan in March 2005, ACF will conduct another 
Child and Family Services Review. The full text of ACFs 
comments to the draft report is located in Appendix F. 
CMS concurs with our recommendation and indicates that it is 
available to provide technical assistance to the State to promote 
provider education regarding the periodicity schedule 
requirements, and appropriate documentation of vision and hearing 
screenings. The full text of CMSs comments to the draft report is 
located in Appendix G. 
OEI-07-00-00641  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: TEXAS  v  T A B L E   O F   C O N T E N T S

A B S T R A C T  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . .  i

E X E C U T I V E   S U M M A R Y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . .   ii

I N T R O D U C T I O N  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . .   1

F I N D I N G S  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . .   8

All sampled children had Medicaid coverage and claims for services ............. 8

Ninety-four percent of sampled children received their most recent EPSDT 

medical examinations, and 92 percent received their most recent EPSDT 

dental examinations, in accordance with State guidelines............................. 9

Seventy-five percent of sampled children received initial medical 

examinations, and 66 percent of sampled children received initial dental 

examinations, within required timeframes...................................................10

Compliance with State guidelines for vision and hearing screenings was 

undocumented.............................................................................................11

Seventy-six percent of sampled children received 

Medicaid mental health services..................................................................12

Forty-six percent of foster care providers reported never receiving 

a medical history for the sampled child in their care ....................................13

R E C O M M E N D A T I O N S   . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .  15

A P P E N D I C E S   . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . .  17

Appendix A: Texas Foster Care and Medicaid Programs ....................17

Appendix B: Sampled Children ..........................................................18

Appendix C: Medicaid Claims for Sampled Children ..........................20

Appendix D: Level of Care Categories for Texas .................................22

Appendix E: Analysis of Medical History and Level of Care ...............25

Appendix F: Agency Comments -ACF ................................................26

Appendix G:  Agency Comments -CMS...............................................28

A C K N O W L E D G M E N T S  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . .  29

OEI-07-00-00641  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: TEXAS  I N T R O D U C T I O N

OBJECTIVE 
To determine whether sampled children in the Texas foster care 
program receive health care services. 
BACKGROUND 
Currently, there are an estimated 534,000 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. Texas was selected because of its large size, geographic 
location, and fee-for-service provision of Medicaid services. Texas 
had 21,353 children in foster care at the end of the Federal fiscal 
year 2002, based on the most recent Federal data available. 3  The 
Administration for Children and Families (ACF) has regulatory 
oversight of Title IV-E foster care programs, including approval of 
State plans to ensure State foster care programs are operating 
within Federal guidelines. The Texas Department of Protective 
and Regulatory Services manages the States Title IV-E foster care 
program. 
Compared with 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 health 
1Retrieved December 10, 2003 from 
http://www.acf.hhs.gov/programs/cb/dis/afcars/publications/afcars.htm. Currently 
refers to children in foster care on September 30, 2002, the most recent available 
nationwide estimate. 
2Other States selected for review are Georgia, Illinois, Kansas, New Jersey, New 
York, North Dakota, and Oregon. 
3Retrieved December 10, 2003 from 
http://acf.hhs.gov/programs/cb/ddis/tables/entryexit2002.htm. Both Title IV-E 
eligible and non-Title-IV-E eligible children are included in the total 
21,353 children in foster care. 
4Health 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-07-00-00641  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: TEXAS  1  II NN TT RR OO DD UU CC TT II OO NN  
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, 6 yet many 
foster care providers report having difficulty finding health care 
professionals who are willing to care for these children. The health 
care available for children in foster care is often characterized by 
lack of access, lack of information sharing among health providers, 
child welfare workers, and foster care providers, 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 Accounting Office (GAO) 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 
Preventive dental care is also included as part of EPSDT. 
Adherence to American Dental Association recommendations for 
preventive dental care leads to better oral health, and practicing 
preventive behaviors over the long term produces greater benefits 
than doing so over the short term.9 
5Factsheet: The Health of Children in Out-of-Home Care. Child Welfare League of 
America. Retrieved October 21, 2002 from 
http://www.cwla.org/programs/health/healthcarecwfact.htm. 
6Chernoff, R. et. al., Assessing the Health Status of Children Entering Foster Care, 
Pediatrics, 93:2, 1994. 
7Health Care of Young Children in Foster Care. Pediatrics, 109:3, 2002. Retrieved 
October 17, 2002 from http://www.aap.org/policy/re0054.html. 
8Medicaid: Stronger Efforts Needed to Ensure Childrens Access to Health Screening 
Services. General Accounting Office, GAO-01-749, July 2001. 
9Journal of Dental Research, March 2003; 82 (3): 223-7. 
OEI-07-00-00641  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: TEXAS  2  Medicaid for Children in Foster Care 
All children in the Texas 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 (Title XIX 
of the Act), or equivalent health insurance coverage, to children 
eligible to receive Title IV-E foster care program maintenance 
funds. Within broad national guidelines, 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.10  Texas provides Medicaid coverage to all children in 
foster care, regardless of IV-E eligibility status. In 2000, Medicaid 
payments for children in foster care nationwide totaled over 
$3.3 billion.11  Texas Medicaid expenditures to provide health care 
services to children in the Texas foster care program totaled 
approximately $156 million in 2000. 12  The Centers for 
Medicare & Medicaid Services (CMS) is responsible for Federal 
oversight of individual State Medicaid programs. 
States establish EPSDT guidelines in accordance with Federal 
requirements to provide coverage for preventive child health 
services to all Medicaid eligible individuals under the age of 21. 13 
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 recognized health care 
organizations. Texas established the Texas Health Steps program 
to meet Federal EPSDT requirements. The current EPSDT 
frequency schedule for the Texas Health Steps program requires 
that medical screenings occur at: birth; 2 weeks; 2, 4, 6, 9, 12, 15 
10Retrieved November 1, 2002 from http://cms.hhs.gov/medicaid/mover.htm and 
http://cms.hhs.gov/medicaid/eligibility/criteria.asp. 
11Medicaid Statistical Information System (MSIS) Report Fiscal 2000. Retrieved 
December 10, 2003 from http://www.cms.gov/medicaid/msis/00total.pdf. Fiscal 
2001 numbers for all States were not available. 
12Medicaid Statistical Information System (MSIS) Report Fiscal 2000: Texas. 
Retrieved December 10, 2003 from http://www.cms.gov/medicaid/msis/00tx.pdf. 
Fiscal 2001 expenditures for Texas totaled approximately $185 million. Retrieved 
December 10, 2003 from http://www.cms.gov/medicaid/msis/01tx.pdf. 
13Section 1905(r) of the Social Security Act. 
OEI-07-00-00641  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: TEXAS  3  I N T R O D U C T I O N  
and 18 months of age; 2, 3, 4, 5, 6, 8, and 10 years of age; and 
annually between the ages of 10 and 20. Vision and hearing 
screenings are required at each medical checkup, beginning at 
birth. Dental examinations are required every 6 months beginning 
at 1 year of age.  Dental examinations are conducted separately 
from medical checkups. 
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 are provided quality services that protect their safety 
and health. Sections 422(b)(10)(B)(ii) and 475(1)(B) of the Act 
require that a case plan be developed for each child that includes a 
plan for ensuring that the childs needs are addressed while s/he is 
in foster care. The case plan must be developed no more than 
60 days after the childs removal from home. 14 Sections 
422(b)(10)(B)(ii) and 475(5)(D) of the Act require procedures to 
ensure that a childs health records are 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 child's health providers, a record of the child's 
immunizations, the child's known medical problems, the child's 
medications, and any other relevant health information concerning 
the child determined to be appropriate by the State agency. In 
accordance with these Federal laws, the Texas foster care program 
requires: that each child receive a medical examination within 
30 days after the date the child entered State custody, unless the 
child received a medical examination within 30 days before 
entering custody, and a dental examination within 90 days after 
placement;15 that a case plan (Initial Childs Service Plan), which 
includes an assessment of a childs mental health needs, be created 
within 45 days of a childs removal from home; 16 and that the 
childs medical and dental history be supplied to the foster care 
provider before, or at the time of, the childs placement.17 
1445 CFR  1356.21 (g)(2). 
15Texas Department of Protective and Regulatory Services Child Protective Services 
(CPS) Handbook 6520. 
16Texas Department of Protective and Regulatory Services CPS Handbook 6411. 
17Texas Department of Protective and Regulatory Services CPS Handbook 6123.3. 
OEI-07-00-00641  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: TEXAS  4  II NN TT RR OO DD UU CC TT II OO NN  
Each State establishes eligibility standards, determines services, 
sets payment rates, and administers its own foster care and 
Medicaid programs in accordance with general Federal guidelines. 
The resulting diversity produces variations in what types of 
services children receive while in foster care, and when they receive 
services. As such, the experiences reported in this State-specific 
report will be unique to the sampled childrens experiences in 
Texas. 
METHODOLOGY 
This inspection focused on the receipt of Medicaid health care, 
dental, and mental health care services that meet EPSDT 
guidelines; requirements for initial health screenings and mental 
health assessments upon entry into foster care; 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 and case file documentation for 50 randomly 
sampled children; interviews with caseworkers and foster care 
providers for each of 50 children in our sample; and interviews with 
Texas State agency officials. 
Reasons for State Selection 
Texas was selected due to its large size, geographic location, and 
fee-for-service payment of Medicaid health care services (Texas 
does not utilize managed care for children in foster care). The 
Texas Department of Protective and Regulatory Services is 
responsible for the welfare of children in State custody. An 
overview of the administration of child welfare services in Texas is 
included in Appendix A. 
Sample 
Children who met the following criteria were included in the study 
sample: (1) were in foster care on September 30, 2002; (2) resided 
in Texas; and (3) had been in continuous out-of-home foster care 
placements for at least 6 months. The Texas Department of 
Protective and Regulatory Services provided us with a list of the 
9,030 children who met these criteria. We selected a simple 
random sample of 50 children in Texas from the list of children who 
OEI-07-00-00641  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: TEXAS  5  I N T O D U C T I O N  
met the specified criteria. Appendices B and C provide information 
on the children included in our sample. 
Review of State Policy, Medicaid Data, and Case File Documentation 
Policy Review -We reviewed Federal and Texas State foster care 
and Medicaid policies. All Texas children in foster care are eligible 
for Medicaid services, regardless of their Title IV-E foster care or 
other eligibility status (e.g., Temporary Assistance for Needy 
Families). Federal law relating to EPSDT requires that States 
meet reasonable standards of medical and dental practice as 
determined by the State after consultation with recognized medical 
and dental organizations. The Texas Health Steps program 
satisfies the Federal EPSDT requirement. Therefore, we used 
Texas Health Steps policy guidelines to determine whether children 
had received their most recent EPSDT examination within required 
frequency guidelines. 
Medicaid Claims Data Review  The Texas Health and Human 
Services Commission provided us with 3 years of Medicaid claims 
histories for each of the children in our sample.  The data included 
claims for physician, dental, pharmaceutical, and mental health 
services paid between September 1, 1999 and August 31, 2002. We 
paid particular attention to the types of health and mental health 
services provided, dates of service, where the services were 
provided, and diagnoses, where available. We included only those 
Medicaid claims after the childs most recent entry into foster care 
and any claims prior to entry that were pertinent in establishing 
frequency of services (i.e., met Texas Health Steps guidelines). 
Case File Documentation Review -We requested and reviewed case 
file documentation from the Texas Department of Protective and 
Regulatory Services local offices for all the children in our sample. 
Information requested included documentation of medical and 
mental health services provided, the childs initial and most recent 
case plan, duration of the childs stay in foster care, and 
information regarding the childs general well-being. 
Interviews

Foster Care Provider Interviews -We use the term foster care 

provider to refer to a foster parent or a staff member of a 

residential facility who is responsible for the child. One hundred 

percent of the foster care providers responsible for the children in 

our sample responded to our request for an interview. We 

conducted structured interviews with each childs foster care 

OEI-07-00-00641  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: TEXAS  6  I N T R O D U C T I O N  
provider (10 in-person and 40 by telephone) between 

December 30, 2002 and February 6, 2003. The interviews with 

foster care providers focused on Medicaid programs and services 

available, training related to the health and well-being of children, 

and their experiences procuring health care services for the 

children included in our sample.

Caseworker Interviews -We conducted structured telephone 

interviews with each childs current caseworker between 

December 16, 2002 and January 7, 2003. Each of these interviews 

focused on the caseworkers understanding of the Medicaid program 

and services available, training related to the health and well-being 

of the children, his/her experience accessing services for the 

sampled child, and any barriers to health care faced by the child. 

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.

State Agency Officials -To enhance our understanding of the States 

foster care and Medicaid programs, we consulted, both in person 

and by telephone, with Texas Department of Protective and 

Regulatory Services, Texas Health and Human Services 

Commission, and Texas Department of Health officials who are 

responsible for the administration of both the foster care and 

Medicaid programs in Texas. Our discussions covered a wide 

spectrum of information, including the overall provision of Medicaid 

services for children in foster care, the States EPSDT program 

(Texas Health Steps), the structure of the States foster care service 

organization, and Medicaid claims for children in foster care.

This inspection was conducted in accordance with the Quality 

Standards for Inspections issued by the Presidents Council on 

Integrity and Efficiency.

OEI-07-00-00641  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: TEXAS  7  F I N D I N G S

All sampled children had Medicaid coverage  In Texas, all children in foster care 
are eligible for Medicaid, which 
and claims for services 
includes EPSDT services. All 
children in our sample had Medicaid coverage and at least one 
Medicaid claim for health care services between 
September 1, 1999 and August 31, 2002. Table 1 (below) details the 
various types of Medicaid-covered services, and the numbers of 
claims by type of service for the 50 sampled children. 
Table 1: Number and Type of Medicaid Claims 
for 50 Children in Sample* 
Number of children  Total number of 
Claim type 
with at least one claim  claims** 
Physican's office  49  782 
Dental  47  761 
Mental health  38  2,077 
Prescription drug  35  283 
Optometry/Audiology  34  178 
Laboratory test  33  813 
Hospital/ASC***  31  852 
Diagnostic  24  235 
Supplies  23  780 
Medication management  22  288 
Physical/Occupational 
12  833 
therapy 
Transportation  10  128 
Case management  8  33 
Home nursing  6  2,423 
Other  3  4 
Total  10,470 
*Claims for 09/01/99 to 08/31/02, or entry into care to 08/31/02. 
**A detailed list of services for each child is located in Appendix C. 
***Includes emergency room visits. 
Source: OIG analysis of Texas Medicaid claims data 
OEI-07-00-00641  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: TEXAS  8  F I N D I N G S  
Ninety-four percent of sampled children  Federal law requires that State 
received their most recent EPSDT medical  EPSDT programs provide medical, 
hearing, vision, and dental 
examinations, and 92 percent received their 
screenings, and other necessary 
most recent EPSDT dental examinations, in 
health care and treatment at 
accordance with State guidelines 
intervals established by the State 
that meet reasonable standards of 
practice published by recognized health care organizations. The 
Texas Health Steps program meets Federal EPSDT requirements. 
For their most recent EPSDT services, 94 percent (47/50) of the 
children sampled for this inspection received their most recent 
EPSDT medical examinations, and 92 percent (45/49) received their 
most recent EPSDT dental examinations in accordance with Texas 
Health Steps guidelines.18 
We analyzed Medicaid claims and interview data in an attempt to 
identify factors that explain the high (over 90 percent) percentages 
of children that were receiving EPSDT medical and dental 
examinations at the time of our review. Although sev eral factors, 
such as geographical region, caseworker involvement in the childs 
health care, caseworker caseload size, and childs date of entry into 
foster care were analyzed, we detected no differences between 
children who received services within required timeframes and 
those who did not.19  Of the 47 children who were receiving EPSDT 
medical examinations according to the Texas Health Steps 
guidelines, 77 percent (36/47) of their foster care providers knew 
the frequency schedule established by Texas Health Steps. For the 
45 children who were receiving EPSDT dental examinations 
according to Texas Health Steps guidelines, 87 percent (39/45) of 
the providers knew the frequency schedule. While the number of 
children who were not receiving medical and dental examinations 
according to Texas Health Steps guidelines was relatively small 
18Percentage of children receiving dental examinations is based on 49 of the 
50 sampled children. One child was medically exempt from receiving dental 
services and was excluded. 
19Due to the small size of the groups who did not receive medical and dental 
examinations according to State guidelines (3 and 4 children, respectively), 
detecting any statistically significant differences with the larger groups who 
received medical and dental examinations (47 and 45 children, respectively) is 
difficult. 
OEI-07-00-00641  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: TEXAS  9  FF II NN DD II NN GG SS  
(three and four, respectively), we believe it is significant to note 
that only one of the three foster care providers knew the EPSDT 
frequency schedule for medical examinations, and two of the four 
foster care providers knew the EPSDT frequency schedule for 
dental examinations. 
Seventy-five percent of sampled children  The Texas foster care program 
received initial medical examinations, and  requires that each child in foster 
care receive a medical examination 
66 percent of sampled children received 
within 30 days after the date the 
initial dental examinations, within 
child entered State custody, if the 
required timeframes 
child had not received an 
examination within 30 days prior to entering custody, and a dental 
examination within 90 days after placement. Seventy-five percent 
(27/36) of the children in our sample received initial medical 
examinations within 30 days prior to or after entering State 
custody. 20  Sixty-six percent (23/35) of the children in our sample 
received initial dental examinations within 90 days after 
placement.21  These percentages are substantially lower than the 
number of children who received current EPSDT medical and 
dental services that met State frequency guidelines. 
We analyzed Medicaid claims and interview data in an attempt to 
identify factors that would explain the lower percentages of 
children receiving initial examinations within required timeframes, 
compared to those receiving current EPSDT medical and dental 
services that met frequency guidelines. Although several factors, 
such as geographical region, caseworker involvement in the childs 
health care, caseworker caseload size, childs age, childs level of 
care, 22 and childs date of entry into foster care were analyzed, we 
20The percentage of children receiving initial medical examinations is based on a 
subset of 36 sampled children. Fourteen sampled children were excluded because 
they entered foster care outside of the timeframe included in our claims data. 
21The percentage of children receiving initial dental examinations is based on a 
subset of 35 sampled children. Fourteen sampled children were excluded because 
they entered foster care outside of the timeframe included in our claims data, and 
one child was medically exempt from receiving dental services. 
22Level of care is a category of care assigned by the State based on the childs 
clinical, psychosocial, and related needs. See Appendix D for an explanation of 
level of care categories in Texas. 
OEI-07-00-00641  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: TEXAS  10  F I N D I N G S  
found no evidence of differences between children who received 
initial medical and dental examinations within required 
timeframes and those who did not.23  However, 20 percent (10/50) of 
foster care providers reported that dentists willing to accept new 
Medicaid patients were difficult to locate. Data suggest that it may 
be difficult for foster care providers to quickly locate dental 
providers for initial examinations, but dentists will continue to see 
the child once a relationship has been established with the foster 
care provider. If children in foster care are not receiving required 
initial medical services, it causes the State to be out of compliance 
with guidelines established in its State plan, and may delay the 
discovery of serious health care problems. 
Compliance with State guidelines for vision  The Texas Health Steps 
and hearing screenings was undocumented	 program requires that a 
hearing and vision screening 
be performed during each EPSDT medical examination. 
Our review of case file documentation provided no evidence of a 
vision screening for 58 percent (29/50) of the sampled children, and 
no evidence of a hearing screening for 66 percent (33/50) of the 
sampled children at the time of their most recent EPSDT medical 
examination. In addition to a lack of case file documentation, for 
17 of the 29 children in our sample with no evidence of a vision 
screening in their case files, and for 23 of the 33 children in our 
sample with no evidence of a hearing screening, there was no 
indication from the foster care provider that a screening was 
performed. 
Foster care providers indicated that children might receive vision 
and hearing screenings from various sources: at school, through 
local Head Start programs, or through Early Childhood 
Intervention (the States agency that serves families who have 
babies or toddlers with disabilities or developmental delays). 
Foster care providers for 12 of the 29 children lacking evidence of a 
vision screening reported that the child received a separate vision 
23Due to the small size of the groups who did not receive initial medical and dental 
examinations according to State guidelines (nine and twelve children, 
respectively), detecting any statistically significant differences with the larger 
groups who received initial medical and dental examinations (27 and 23 children, 
respectively) is difficult. 
OEI-07-00-00641  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: TEXAS  11  F I N D I N G S  
screening from the most recent EPSDT medical examination. 
Foster care providers for 10 of the 33 children lacking evidence of a 
hearing screening reported the children received a separate hearing 
screening. Nevertheless, the States rules require that vision and 
hearing screenings be conducted as part of every EPSDT medical 
examination. 
Prior to Federal fiscal year (FFY) 1999, CMS required States to 
report the number of children receiving vision and hearing 
screenings through the States EPSDT program as part of the 
States annual report to CMS on EPSDT participation 
(CMS Form 416). However, effective FFY 1999, CMS eliminated 
the requirement to report vision and hearing screenings on 
CMS Form 416 in an attempt to clarify and simplify reporting 
requirements wherever possible. Section 1902(a)(43) of the Social 
Security Act, which requires the annual reporting of EPSDT 
participation for each State, does not specifically require the 
reporting of the number of children receiving vision and hearing 
screenings. Likewise, medical providers in Texas are not required 
to itemize the individual components of an EPSDT medical 
examination, such as developmental assessment, unclothed 
physical inspection, vision screening, hearing screening, etc., when 
they bill for reimbursement. 
The States Medicaid reimbursement for Texas Health Steps 
medical screenings is provided with the understanding that the 
provider is performing all components of an EPSDT examination, 
which, according to Texas Health Steps guidelines, includes a 
vision and hearing screening. The lack of documentation of vision 
and hearing screenings makes it impossible to determine if medical 
providers are performing all of the services for which they are paid, 
and if children are receiving all EPSDT services according to Texas 
Health Steps guidelines. 
Seventy-six percent of sampled children  Federal law requires that a case 
received Medicaid mental health services	 plan be developed for each child in 
Title IV-E foster care that includes 
a plan for ensuring that the childs needs are addressed while s/he 
is in foster care. The Texas Department of Protective and 
Regulatory Services requires that a case plan be developed for each 
child who enters foster care that includes an assessment of the 
childs mental health needs. Case plans that included an 
OEI-07-00-00641  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: TEXAS  12  F I N D I N G S  
assessment of the childs mental health needs had been completed 
for 86 percent (43/50) of the children in our sample, and 76 percent 
(38/50) of the children in our sample had Medicaid claims for 
mental health care services. 
We reviewed case file documentation for the 12 children who did 
not have Medicaid mental health claims to determine if mental 
health care needs for these children were identified. The case plans 
for these 12 children indicated that their mental health needs were 
assessed. Eight of the children had no needs identified, two 
children had mental health needs identified and had scheduled 
appointments outside the timeframe of our claims data, and two 
children had mental health needs identified, and no services were 
received or planned. 
The case plan is the only Federal or State requirement for assessing 
mental health care needs. The Texas Department of Protective and 
Regulatory Services requires that the childs case plan (Initial 
Childs Service Plan) be completed within 45 days of the childs 
removal from home.  For the 50 children in our sample, 44 percent 
(22/50) had initial case plans that were completed within the 
required timeframe established by the State.  It is important that 
initial case plans be completed within required timeframes so that 
needed mental health services can be provided. 
Forty-six percent of foster care providers  Federal law requires that a childs 
reported never receiving a medical history for  health record is reviewed, updated, 
and supplied to the foster care 
the sampled children in their care 
provider at the time of placement. 
Foster care providers for 46 percent (23/50) of the children in our 
sample reported never receiving a medical history for the children 
in their care. However, caseworkers for 19 of these 23 children 
reported receiving or compiling a medical history for the children. 
Foster care providers for children assigned a lower level of care 
(1 through 3), as defined in Appendix D, were less likely to report 
receiving a medical history for the children in their care than those 
providers caring for a child assigned a higher level of care 
(4 through 6).24  Of the 23 foster care providers that reported they 
did not receive a medical history for the sampled children, 74 
24The difference between these two groups was statistically significant. See 
Appendix E. 
OEI-07-00-00641  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: TEXAS  13  F I N D I N G S  
percent (17/23) were caring for children assigned a level of care 1, 2 
or 3, and 26 percent (6/23) of these foster care providers were caring 
for children assigned a level of 4, 5, or 6. Overall, 59 percent 
(17/29) of foster care providers for children in a level of care 1 
through 3 did not receive a medical history, and 29 percent (6/21) of 
foster care providers for children in a level of care 4, 5 or 6 did not 
receive a medical history. Foster care providers and caseworkers 
may not realize the importance of a medical history for children 
with few or no medical conditions. The requirement that foster care 
providers are supplied a medical history for the child in their care 
helps to ensure that all children receive the most effective care 
possible, regardless of a childs level of care. 
Other conditions explaining why foster care providers may not have 
received medical histories include the following: 
o	 Foster parents stated they did not know they should have 
received a medical history for the children in their care. 
o	 Foster parents were unable to obtain medical information 
because the physician for the children in their care was 
concerned about patient confidentiality. 
o	 Private foster care agencies allow foster parents to view a 
childs medical record at the agency office, but will not release 
the information to the foster parent. 
Foster care providers for children in our sample who reported that 
they did not receive a medical history revealed that not having this 
information made it difficult for them to effectively care for the 
children placed in their homes. One foster parent who reported not 
receiving a medical history indicated that it resulted in the child in 
her care having to receive multiple immunizations at one time so 
that he could be enrolled in school. Other foster parents reported 
that children with histories of serious health problems, such as 
collapsed lungs, severe malnutrition, and chronic ear infections, 
had been placed in their care without the foster care providers 
receiving medical histories. 
OEI-07-00-00641  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: TEXAS  14  R E C O M M E N D A T I O N S

RECOMMENDATIONS 
It is important to conduct initial medical, initial dental, and EPSDT 
examinations for children in foster care, in accordance with Federal 
guidelines, in order to detect the health care needs of this 
vulnerable population. Timely completion of initial case plans and 
the provision of available medical information to these childrens 
foster care providers are also important aspects of their care. 
Therefor e, we recommend that: 
ACF work with the Texas Department of Protective and Regulatory 
Services to increase the number of 
o	 Initial medical and dental screenings that are received within 
required timeframes 
o	 Initial case plans that are completed within required 
timeframes 
o	 Foster care providers who are supplied available medical 
information for the children in their care 
In Texas, State regulations require that all EPSDT examinations 
include vision and hearing screenings. Therefore, we recommend 
that: 
CMS work with the Texas Department of Health to 
o	 Evaluate the need for documentation to ensure compliance with 
routine EPSDT vision and hearing screening guidelines 
OEI-07-00-00641  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: TEXAS  15  R E C O M M E N D A T I O N S  
AGENCY COMMENTS 
ACF indicated that it is working with the Texas Department of 
Protective and Regulatory Services to assist the State in 
accomplishing goals established in a Program Improvement Plan 
developed as a result of a Child and Family Services Review. Child 
and Family Services Reviews measure individual States 
performance related to the health and well-being of children in the 
child welfare system. ACF stated that indicators in the Child and 
Family Services Review specifically track the areas of concern 
highlighted in this report, and that one of the goals of Texas 
Program Improvement Plan focuses on the health and mental 
health care of children in the child welfare system. Upon 
completion of this plan in March 2005, ACF will conduct another 
Child and Family Services Review. The full text of ACFs 
comments to the draft report is located in Appendix F. 
CMS concurs with our recommendation and indicates that it is 
available to provide technical assistance to the State to promote 
provider education regarding the periodicity schedule 
requirements, and appropriate documentation of vision and hearing 
screenings. The full text of CMSs comments to the draft report is 
located in Appendix G. 
OEI-07-00-00641  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: TEXAS  16  A P P E N D I X ~ A

Texas Foster Care and Medicaid Programs 
The Health and Human Services Commission is the State agency 
with primary responsibility for ensuring the delivery of all State 
health and human services in Texas. The Health and Human 
Services Commissions State Medicaid Office is responsible for 
administering medical assistance programs for all eligible 
recipients enrolled in the Texas Medicaid program. All children in 
foster care in Texas are eligible for fee-for-service Medicaid. 
The Health and Human Services Commission has oversight 
responsibility for the Texas Department of Protective and 
Regulatory Services. This agency is charged with protecting 
children, elder adults, and persons with disabilities from abuse, 
neglect, and/or exploitation, and with licensing child-care facilities 
and child-placing agencies. Within the Department of Protective 
and Regulatory Services, Child Protective Services manages foster 
care programs in the State. Texass foster care system utilizes both 
public (State-administered) and private (contracted) placement 
agencies, although final responsibility for each child in the 
managing conservatorship (custody) of the State lies with 
Department of Protective and Regulatory Services. Funding for 
foster care services in Texas can come from a variety of sources, 
including Federal, State, county, community, and private funds, 
and there is a great deal of variation in sources of funding and 
methods of service provision by region. 
The Health and Human Services Commission also has oversight 
responsibility for the Texas Department of Health. This agency 
administers the Texas Health Steps program. The Texas Health 
Steps program satisfies the Federal requirement that States 
establish EPSDT programs that provide coverage for preventive 
child health services to all Medicaid eligible individuals under the 
age of 21. All children in foster care in Texas are eligible for Texas 
Health Steps services. 
OEI-07-00-00641  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: TEXAS  17  A P P E N D I X ~ B  
 
Sampled Children 
The table below is merely descriptive in nature and describes the 
demographic characteristics of each sampled child and his or her 
foster care placement history at the end of February 2003. 
 
Entries  Placements  Months since  Caseworkers  Months 
Age  Placement  Months since 
ID Sex into foster  since last  last  since last  caseworker 
(years)  Setting  last entry (2) 
care (1)  entry (3)  placement (2)  entry  with case (2) 
1  F  17  Residential  1  24  3  5  1  24 
2  F  3  Therapeutic  1  12  2  12  1  11 
3  F  15  Therapeutic  1  61  2  54  2  22 
4  F  7  Family  1  11  2  7  1  11 
5  M  11  Therapeutic  1  53  5  4  3  24 
6  M  16  Residential  1  10  5  5  2  4 
7  F  11  Residential  2  65  2  60  3  7 
8  M  10  Family  3  39  2  39  1  38 
9  F  3  Family  1  16  1  16  1  14 
10  M  11  Therapeutic  1  38  2  30  2  4 
11  F  13  Family  1  54  4  24  4  24 
12  M  18  Family  1  29  9  2  2  20 
13  M  13  Family  1  40  1  24  4  16 
14  F  15  Family  1  11  5  9  2  7 
15  M  5  Therapeutic  1  13  2  11  4  13 
16  F  9  Family  1  27  3  21  1  25 
17  F  15  Therapeutic  1  50  7  1  2  1 
18  F  11  Family  1  33  1  33  3  10 
19  F  17  Residential  1  23  12  2  4  2 
20  F  16  Residential  1  36  11  3  3  12 
21  M  15  Therapeutic  1  66  4  18  2  8 
22  M  3  Rehabilitation  1  13  1  13  1  12 
23  F  3  Rehabilitation  1  13  1  13  1  12 
24  M  8  Residential  1  30  4  12  2  30 
25  F  14  Therapeutic  1  16  2  13  2  7 
26  F  4  Rehabilitation  1  17  2  16  (+)  3 
27  M  17  Residential  1  28  7  8  1  28 
28  F  8  Residential  1  14  3  10  2  7 
29  F  2  Family  1  27  4  13  2  7 
30  M  17  Residential  2  12  2  12  1  12 
31  M  4  Rehabilitation  1  39  1  39  1  38 
32  F  1  Family  1  19  2  15  (+)  6 
33  F  17  Residential  1  57  14  1  (+)  15 
  OEI-07-00-00641  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE: TEXAS  18 
  A P P E N D I X ~ B  
Entries  Placements  Months since  Caseworkers  Months 
Age  Placement  Months since 
ID Sex  into foster  since last  last  since last  caseworker 
(years)  Setting  last entry (2) 
care (1)  entry (3)  placement (2)  entry  with case (2) 
34  F  18  Residential  1  58  2  15  2  44 
35  F  3  Therapeutic  3  16  4  9  2  5 
36  F  3  Therapeutic  1  34  1  34  2  6 
37  M  6  Family  1  19  1  19  3  9 
38  F  17  Family  1  46  2  18  2  42 
39  F  18  Residential  1  28  2  19  (+)  3 
40  F  18  Therapeutic  1  75  5  4  3  8 
41  F  15  Residential  1  47  11  5  3  11 
42  M  11  Family  2  14  2  12  3  2 
43  M  3  Family  2  30  4  1  2  26 
44  F  14  Residential  1  12  3  10  3  3 
45  F  3  Family  1  44  2  33  1  43 
46  M  2  Rehabilitation  1  21  2  20  2  4 
47  F  6  Family  1  43  1  43  2  36 
48  F  5  Therapeutic  1  51  1  51  6  6 
49  M  11  Family  1  37  5  7  1  37 
50  M  1  Therapeutic  1  20  2  17  1  12 
KEY 
(1) Entries into foster care refers to the number of times a child 
has entered State custody (i.e., number of foster care episodes). 
(2) Months since last entry is the length of time from the date of 
the childs most recent entry into State custody until January 2003, 
which coincides with the period of interviews with caseworkers and 
foster care providers. Months since last placement is the length of 
time from the date of the most recent placement to the date the 
foster care provider was interviewed. Months caseworker with 
case is the length of time from the date the caseworker initially 
took over the childs case until the date the caseworker was 
interviewed. 
(3) Placements since last entry refers to the number of placement 
settings (e.g., Foster Home A, Foster Home B, Metro Residential 
Facility) a child has experienced during each episode in foster 
care. 
(+) Number of caseworkers since last entry into foster care is 
unknown. 
OEI-07-00-00641  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: TEXAS  19  A P P E N D I X ~ C  
Medicaid Claims for Sampled Children 
The table below indicates each childs receipt of required services 
and total claims for September 1, 1999 to August 31, 2002, or entry 
into care to August 31, 2002, whichever is shorter. 
 
  Number of Medicaid Claims    Initial Exams  Current EPSDT Exams 
Medical history       
Physicians  Dental  Prescription  Mental health 
ID  provided to care  Medical  Dental  Medical  Dental 
office  services  medications  services 
provider         
1  9  19  0  80  Y  Y  Y  N*  Y 
2  3  2  0  0  Y  N  N  Y  Y 
3  5  10  1  1  N      N*  N* 
4  2  21  0  13  N  Y  Y  Y  Y 
5  23  32  4  97  N      Y  N 
6  4  4  0  15  Y  N  N  Y  Y 
7  30  23  0  14  N      N*  Y 
8  19  25  7  72  N  Y  Y  Y  Y 
9  13  2  7  4  Y  Y  N*  Y  Y 
10  1  18  0  29  Y  N  N  N  Y 
11  33  25  0  28  N      Y  Y 
12  9  20  4  67  Y  Y  Y  N*  Y 
13  8  21  5  28  N  Y  Y  N*  Y 
14  1  14  1  21  Y  Y  Y  Y  Y 
15  3  11  9  20  N  N  N  Y  Y 
16  16  9  1  53  N  N  Y  Y  Y 
17  43  49  1  106  Y      Y  Y 
18  11  16  0  62  Y  N*  Y  Y  Y 
19  15  12  7  98  Y  Y  Y  Y  N 
20  17  39  1  88  Y  N*  N  Y  Y 
21  10  28  0  21  N      Y  Y 
22  2  2  4  0  N  N*  Y  N*  Y 
23  0  2  4  0  N  N*  Y  N*  Y 
24  9  10  0  62  N  Y  N  Y  N* 
25  3  8  1  60  N  N*  Y  N*  Y 
26  11  1  6  0  Y  Y  N*  Y  N* 
27  12  22  0  42  Y  Y  Y  Y  Y 
28  3  13  0  33  N  Y  Y  Y  Y 
29  7  2  3  2  Y  Y  N  Y  Y 
30  5  11  0  20  Y  Y  Y  N*  Y 
31  76  8  35  0  N  Y  N  N  Y 
32  15  0  14  0  Y  Y  N  Y  N 
33  16  17  6  101  N      Y  Y 
  OEI-07-00-00641  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE: TEXAS  20 
  A P P E N D I X ~ C  
Number of Medicaid Claims  Initial Exams  Current EPSDT Exams 
Medical history 
Physicians  Dental  Prescription  Mental health 
ID  provided to care  Medical  Dental  Medical  Dental 
office  services  medications  services 
provider 
34  29  25  21  184  Y  N*  Y 
35  8  16  0  26  Y  N  Y  Y  Y 
36  10  2  8  0  Y  Y  E  Y  E 
37  5  7  7  24  N  Y  Y  N  Y 
38  30  17  3  191  Y  Y  Y 
39  12  41  4  87  Y  N  Y  N*  N* 
40  33  32  2  60  N  Y  Y 
41  22  33  8  104  Y  Y  Y 
42  1  8  3  13  N  Y  N*  Y  Y 
43  21  6  8  3  N  Y  Y  Y  N* 
44  12  12  0  34  Y  N*  N  Y  Y 
45  31  6  10  0  N  Y  Y 
46  16  0  24  0  Y  Y  N  Y  N* 
47  7  34  5  0  Y  N*  Y 
48  81  4  35  0  Y  Y  Y 
49  12  22  7  114  Y  N  Y  Y  Y 
50  18  0  17  0  N  N  N  N*  N 
KEY 
Initial Exams: Medical/Dental: Y indicates that initial 
medical/dental examination was received within required 
timeframes. N indicates examination was not received within 
required timeframes. N* indicates that Medicaid claims data did 
not support a positive finding, but evidence was found in the case 
file to support the positive finding. E indicates child was exempt 
from the requirements. 
Current EPSDT Exams: Medical/Dental: Y indicates that an 
EPSDT medical/dental examination was received according to 
Texas Health Steps frequency timeframes. N indicates 
examination was not received according to Texas Health Steps 
frequency timeframes. N* indicates that Medicaid claims data 
did not support a positive finding, but evidence was found in the 
case file to support the positive finding. E indicates child was 
exempt from the requirements. 
OEI-07-00-00641  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: TEXAS  21  A P P E N D I X ~ D

Level of Care Categories for Texas 
The Texas Department of Protective and Regulatory Services 
contracts with a behavioral health care company, Youth for 
Tomorrow, to assist in the implementation of the Level of Care 
(LOC) Service System.25 Youth For Tomorrow uses LOC definitions 
to determine a child's level of care service needs. Clinically-trained 
professionals use these definitions to synthesize their knowledge 
about a child's psychological and social functioning and then assign 
a single LOC rating from LOC 1 services to LOC 6 services. The 
LOC rating is determined in the context of a broad review of the 
clinical information submitted by the Department of Protective and 
Regulatory Services caseworker.26 
Level of Care Definitions for Physical and Mental Health27 
Level of Care 1 Needs

Medically Fragile and Developmentally Delayed:  Medical condition 

is maintained within the normal structure and supervision of a 

family type environment. No additional services are necessary.

Mental Health:  Adequate functioning in all developmental and or 

environmental areas. There may be transient difficulties, 

"every-day" worries, and occasional misbehavior, but would be 

regarded as a "normal" child; responds to "normal" discipline. The 

caregiver provides routine home environment with guidance and 

supervision to meet the needs of the child.

Level of Care 2 Needs

Medically Fragile and Developmentally Delayed:  Medical condition 

is maintained within the normal structure and supervision of a 

family type environment. No additional services are necessary. 

25The Department of Protective and Regulatory Services is currently revising its 
policies to create a new system to replace the LOC service system. Once the new 
policies are developed, the LOC system will no longer be used. The information 
contained in this report reflects policy effective at the time of our review in 2001 
and 2002. 
26Retrieved August 6, 2003, from http://www.yft.org/faq/initial_loc.htm. 
27Retrieved August 6, 2003, from http://www.yft.org/loc_def.htm. 
OEI-07-00-00641  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: TEXAS  22  A P P E N D I X ~ D  
Mental Health:  No more than occasional problems in functioning in 

any area, some acting-out behavior in response to life stresses, but 

these are brief and transient; minimally disturbing to others, and 

not considered deviant by those who know them. The caregiver 

provides routine home environment with supplemental guidance 

and discipline to meet the needs of the child.

Level of Care 3 Needs

Medically Fragile and Developmentally Delayed:  Limited self-care 

skills require minimal medical assistance. Follow-up medical 

services and replacement of medical equipment are routine. The 

child may be ambulatory with assistance. Verbal skills may be 

limited to communicating basic needs. The child may have frequent 

or repetitive minor behavioral problems requiring minimal 

supervision and no more than a minimal risk to self or others. 

Mental Health:  Frequent or repetitive minor problems in one or 

more areas; may engage in non-violent antisocial acts, but is 

capable of meaningful interpersonal relationships. Requires 

supervision in structured, supportive setting with counseling 

available from professional or paraprofessional staff.

Level of Care 4 Needs

Medically Fragile and Developmentally Delayed:  Requires ongoing 

assistance in order to perform essential self-care or independent 

living skills. Medical involvement requires on-site staff skilled in 

providing appropriate medical assistance with a nurse available on 

an on-call basis. Periodic adjustments or replacement of medical 

equipment may be necessary. The child may be non -ambulatory or 

limited to nonverbal communications. The child may have 

substantial behavioral problems that require constant supervision 

and be no more than a moderate risk to self or others. 

Mental Health:  Substantial problems; has physical, mental, or 

social needs and behaviors that may present a moderate risk of 

causing harm to themselves or others, poor or inappropriate social 

skills, frequent episodes of aggressive or other antisocial behavior 

with some preservation of meaningful social relationships; requires 

treatment program in a structured setting with therapeutic 

counseling available by professional staff.

Level of Care 5 Needs

Medically Fragile and Developmentally Delayed:  Requires total 

care with all essential self-help skills. The child may be 

non-ambulatory or confined to bed. Medical involvement may 

OEI-07-00-00641  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: TEXAS  23  A P P E N D I X ~ D  
require 24-hour on-site (campus) medical or nursing supervision 
with continuous medical equipment necessary to sustain life 
support. The child may have severe behavioral problems that 
require close 24-hour supervision and is a severe risk to self or 
others. 
Mental Health:  Severe problems, unable to function in multiple areas. 
Sometimes willing to cooperate when prompted or instructed, but may 
lack motivation or ability to participate in personal care or social 
activities or is severely impaired in reality testing or in communications. 
May exhibit persistent or unpredictable aggression, be markedly 
withdrawn and isolated due to either mood or thought disturbance, or 
make suicidal attempts. Presents a moderate to severe risk of causing 
harm to self or others. Requires 24-hour supervision by multiple staff in 
limited access setting. 
Level of Care 6 Needs 
Medically Fragile and Developmentally Delayed:  N/A 
Mental Health: Very severe impairment(s), disabilities or needs, 
consistently unable or unwilling to cooperate in own care. May be 
severely aggressive or exhibit self-destructive behavior or grossly 
impaired in reality testing, communication, cognition, affect, or 
personal hygiene. May present severe to critical risk of causing 
serious harm to self or others. Needs constant supervision (24-hour 
care) with maximum staffing, in a highly structured setting. 
OEI-07-00-00641  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: TEXAS  24  A P P E N D I X ~ E

Analysis of Medical History and Level of Care 
Level of Care/ 
Did Receive History  Did Not Receive History  Total 
Received Medical History 
Level of care 1-3  12  17  29 
Level of care 4-6  15  6  21 
Total  27  23  50 
p = 0.0354 (degrees of freedom = 1; chi-square = 4.4275) 
OEI-07-00-00641  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: TEXAS  25
 A P P E N D I X ~ F

Agency Comments - ACF 
OEI-07-00-00641  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: TEXAS  26
 A P P E N D I X ~ F  
OEI-07-00-00641  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: TEXAS  27
 A P P E N D I X ~ G

Agency Comments - CMS 
OEI-07-00-00641  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: TEXAS  28
 A C K N O W L E D G M E N T S

This report was prepared under the direction of Brian 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 
Steven Milas, Lead Analyst 
Linda Paddock, Program Analyst 
Michala Walker, Program Analyst 
Brian T. Whitley, Program Analyst 
Linda Hall, Program Specialist (Washington, D.C.) 
Barbara Tedesco, Mathematical Statistician (Baltimore) 
OEI-07-00-00641  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: TEXAS  29