Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
F C C  U
OSTER  ARE  HILDREN S  SE 
M S
OF  EDICAID  ERVICES IN 
O
REGON 
Inspector General 
June 2004 
OEI-02-00-00363  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.  ,t"'C'S. 
DEPARTMENT OF HEALTH &, HUMAN SERVICES  Office of Inspector General 
.l.""JO  Washington , D. C. 20201 
2004 
JUN  - 8 
TO:	 Wade F. Horn, Ph. 
Assistant Secretary for Children and Families 
FROM: 
SUBJECT:	 OIG Final Report: "Foster Care Children s Use of Medicaid Services in 
Oregon " OEI-02-00-00363 
Attached for your review is a final report that assesses whether sampled Oregon foster 
care children are receiving Medicaid health care services. We conducted this inspection 
in response to concerns about the health care that foster care children are receiving. 
Oregon is one of eight States being evaluated. 
Our analysis of2 years of Medicaid claims for a random sample of 50 Oregon foster care 
children and interviews with their caseworkers and caregivers reveal that the children in 
the sample have Medicaid coverage and access to services. Targeted case management is 
the most common and most costly Medicaid claim for children in our sample. Yet
, we
found that recipients do not receive any extra, or even ordinary, health care as a result of 
targeted case management. Twenty of the 50 sampled foster care children 
do not have 
. preventive care claims during the study period. This lack 
of preventive care may be due 
in part, to the belief of some Oregon offcials that Oregon is not bound by any Early and 
Periodic Screening, Diagnosis, and Treatment (EPSDT) requirements. In fact
, Oregon is
bound by EPSDT requirements and is relieved only from its obligation to pay for services 
required to treat a condition identified during an EPSDT screening that are beyond the 
scope of the benefits package available to an individual receiving Medicaid. 
For some 
foster care children in the sample, caregivers have diffculty obtaining medical records 
and accessing dental and mental health services. In addition
, sampled children placed 
out-of-State experience problems obtaining medical coverage. 
We believe that the Administration for Children and Families (ACF) and the Centers for 
Medicare & Medicaid Services (CMS) should work with the State of Oregon to ensure 
that all eligible foster care children receive appropriate health care services. Accordingly, 
we recommend that CMS review the use of targeted case management for foster care  Page 2 - Wade F. Horn, Ph.D. and Mark B. McClellan, M.  , Ph. 
children in Oregon to ensure that it is consistent with State plan provisions and current 
CMS requirements for this service. CMS may want to review the use of targeted 
case 
management for foster care children in other States to determine the nature and cost of 
this service. Also , CMS should work with Oregon to clarify the intent of Oregon s lll5 
waiver and the State s obligations under EPSDT. ACF and CMS should work with 
Oregon to promote preventive health care that is consistent with EPSDT guidelines. 
Finally, ACF should work with Oregon and involved paries, such as the State child 
welfare administrators and the administrators of the Interstate Compact on the Placement 
of Children, to address the health care needs of foster care children placed across State 
lines. 
In response to our recommendations, CMS is completing a policy letter to the State 
Medicaid Directors that wil define targeted case management activities that can be 
claimed for Federal financial paricipation from the Medicaid program; adding 
two 
authorities to Oregon s waiver list that wil clarify the intent; and working with 
the State 
to promote preventive health care that is consistent with EPSDT guidelines. ACF reports 
that it is actively working with Oregon in the areas of managed care, training, and follow-
up care. ACF plans to form a panel of State child welfare administrators, State foster 
care managers, State adoption managers, and Interstate Compact on the Placement of 
Children administrators to address the issues of placing foster care children across State 
lines. We also received comments from the State of Oregon. Oregon stated that they 
plan to continue to work with ACF and CMS to 
clarfy current policies and practices and 
to improve future program delivery. 
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 one of your staff may contact Elise Stein, Director, Public Health 
and Human Services Branch, at (202) 619-2686 or through e-mail 
Elise.Stein(loig.hhs.gov). To facilitate identification, please refer to report number 
OEI-02-00-00363 in all correspondence. 
Attachment    A B S T R A C T  
We reviewed a random sample of 50 children in foster care and 
found that they have Medicaid coverage and access to services. 
Targeted case management is the most common and most costly 
Medicaid claim for children in our sample. Yet, we found that 
recipients do not receive any extra, or even ordinary, health care 
as a result of receiving targeted case management. Twenty of 
the 50 sampled foster care children did not have preventive care 
claims during the study period. This lack of preventive care 
may be due, in part, to the belief of some Oregon officials that 
Oregon is not bound by any Early and Periodic Screening, 
Diagnosis, and Treatment (EPSDT) requirements. In fact, 
Oregon must comply with EPSDT requirements and pay for 
preventive care unless the EPSDT screening identifies a 
condition that is beyond the scope of the benefits package 
available to an individual. For some foster care children in the 
sample, caregivers have difficulty obtaining medical records and 
accessing dental and mental health services. In addition, 
sampled children placed out-of-State experience problems 
obtaining medical coverage. The Centers for Medicare & 
Medicaid Services (CMS) and the Administration for Children 
and Families (ACF) concurred with OIG recommendations that: 
CMS review the use of targeted case management; CMS clarify 
the intent of the EPSDT portion of Oregons 1115 waiver; ACF 
and CMS remind Oregon to cover and pay for preventive health 
care consistent with EPSDT; and ACF address the health care 
needs of foster care children placed across State lines. 
OEI-02-00-00363  FOSTER CARE CHILDRENS USE OF MEDICAID SERVICES IN OREGON  i  E X E C U T I V E   S U M M A R Y
 
OBJECTIVE 
To determine whether Oregons foster care children are 
receiving Medicaid health care services. 
BACKGROUND 
Currently, there are an estimated 534,000 children in foster care 
nationwide, and many of them are reportedly in poor health. 
Compared with children from the same socioeconomic 
background, foster care children suffer much higher rates of 
serious emotional and behavioral problems, chronic physical 
disabilities, birth defects, and developmental delays. Despite 
their need, it appears that many foster care children are not 
receiving adequate health care. 
This inspection focuses on the State of Oregon and is part of a 
larger body of work in which eight States are being evaluated. 
The analysis includes 2 years of Medicaid claims for 50 Oregon 
foster care children and interviews with their caseworkers and 
caregivers. 
FINDINGS 
Forty-nine of 50 foster care children in the sample have 
Medicaid coverage and access to services 
The foster care children in the sample in Oregon have medical 
coverage and are accessing health care services. During the 2-
year inspection period, the vast majority of children in the 
sample (49 out of 50) have at least 1 Medicaid claim for the time 
they were in foster care. Overall, the number of Medicaid claims 
per child in the sample ranges from 0 to 472. The majority of 
caseworkers and caregivers report that their foster care children 
have access to needed medical care. 
Targeted case management is the most common and most 
costly Medicaid claim for Oregon foster care children in the 
sample 
Representatives of Oregon Medicaid define targeted case 
management services as assisting an individual in gaining 
access to additional services. Targeted case management claims 
account for 75 percent of all Medicaid health care payments for 
OEI-02-00-00363  FOSTER CARE CHILDRENS USE OF MEDICAID SERVICES IN OREGON  ii  EE XX EE CC UU TT II VV EE    SS UU MM MM AA RR YY  
the sample Oregon foster care children. Over the study period, 
Oregon's State Office for Services to Children and Families 
collected approximately $604 to $800 per month, per foster care 
child from Medicaid for targeted case management. These 
payments total $710,420 for our sample. We estimate the total 
payments for targeted case management for our sample 
universe to be approximately $71 million over the study period. 
It appears that recipients do not receive any extra, or even 
ordinary, health care as a result of receiving targeted case 
management. 
Twenty of the 50 foster care children in the sample do not 
have preventive care claims 
Twenty children in the sample show no preventive claims at all 
over 2 years. Eighteen of these 20 have been in continuous 
foster care for a year or more. None of the 50 children have 
Early and Periodic Screening, Diagnosis, and Treatment 
(EPSDT) claims. The lack of preventive care claims may be due 
to Oregon's lack of a clear periodicity schedule for preventive 
care and the belief of some State officials that Oregon is not 
bound by any EPSDT requirements. In addition, we found that 
confusion exists regarding the EPSDT portion of the States 
Section 1115 waiver, which relieves Oregon only from its 
obligation to pay for services required to treat a condition 
identified during an EPSDT screening that are beyond the scope 
of the benefits package available to an individual receiving 
Medicaid. 
Some children face problems due to incomplete medical 
records, access to certain health care services, and out-of-
State medical coverage 
Medical records for children in the sample are often incomplete, 
and it appears that caseworkers may not be transferring the 
medical history to caregivers. Foster care children also face 
difficulties accessing dental and mental health services, 
although most children are able to get needed care eventually. 
Problems include wait time for appointments, lack of Medicaid 
providers, dissatisfaction with quality of care, and trouble 
determining which dentists in the area are Medicaid providers. 
In addition, foster care children placed out-of-State have 
difficulty obtaining medical coverage in their new State. 
OEI-02-00-00363  FOSTER CARE CHILDRENS USE OF MEDICAID SERVICES IN OREGON  iii  EE XX EE CC UU TT II VV EE    SS UU MM MM AA RR YY  
RECOMMENDATIONS 
We believe that the Administration for Children and Families 
(ACF) and the Centers for Medicare & Medicaid Services (CMS) 
should work with the State of Oregon to ensure that all eligible 
foster care children receive appropriate health care services. 
Accordingly, we recommend that: 
o	  CMS review the use of targeted case management for foster 
care children in Oregon to ensure that it is consistent with 
State plan provisions and current CMS requirements for this 
service. CMS may also want to consider reviewing the use of 
targeted case management for foster care children in other 
States to determine the nature and the cost of this service. 
o	  CMS work with Oregon to clarify the States waiver and the 
States obligations under EPSDT. CMS should also revise 
the incorrect citation in the EPSDT portion of Oregons 1115 
waiver. 
o	  ACF and CMS work with Oregon to promote preventive 
health care that is consistent with EPSDT guidelines. 
o	  ACF work with Oregon and involved parties, such as the 
State child welfare administrators and the administrators of 
the Interstate Compact on the Placement of Children 
(ICPC), to address the health care needs of foster care 
children placed across State lines. 
Agency Comments 
We received comments from CMS and ACF. The full text of the 
comments are included in Appendix G. CMS concurs with our 
recommendations. In regard to targeted case management 
(TCM), CMS notes that it is completing a major policy letter to 
the State Medicaid Directors that will define TCM activities that 
can be claimed for Federal financial participation from the 
Medicaid program.  We encourage CMS to issue this policy 
letter as soon as possible and to share it with all State child 
welfare agencies as well as the State Medicaid Directors. 
We are pleased that CMS is adding two authorities to the list of 
waived statutory provisions for Oregon that will clarify the 
terms of the waiver. CMS will also work with Oregon to ensure 
OEI-02-00-00363  FOSTER CARE CHILDRENS USE OF MEDICAID SERVICES IN OREGON  iv  E X E C U T I V E   S U M M A R Y  
the State understands that Oregon has obligations under the 
EPSDT program. 
CMS agrees to work with the State to promote preventive health 
care that is consistent with EPSDT guidelines. It is our hope 
that these efforts will include the formulation of a clear 
periodicity schedule, as required by the EPSDT program. 
In its comments, ACF notes that it is actively working with 
Oregon in the areas of managed care, training, and follow-up 
care. We encourage ACF to continue its current efforts. We also 
encourage ACF to address actively the issue of preventive care 
for foster care children, possibly through the Oregon Program 
Improvement Plan. The Oregon Program Improvement Plan 
was developed as a result of an ACF Child and Family Services 
Review, which measures individual States performance related 
to the health and well being of children in the child welfare 
system. Action Step 23.2.3 in the Oregon Program Improvement 
Plan calls for a clear policy for children receiving adequate, 
timely, necessary and culturally-competent mental health, 
medical and dental services. We believe preventive care should 
be thoroughly addressed in this policy. 
ACF plans to form a panel of State child welfare administrators, 
State foster care managers, State adoption managers, and ICPC 
administrators. This panel will identify barriers, issues and 
suggested resolutions related to placing children across State 
lines.  We encourage the timely formation of this panel and 
look forward to receiving the panels findings. 
We also received comments from the State of Oregon. The full 
text of these comments can be found in Appendix G. The State 
responded that a medical chart review would have given a more 
accurate assessment of the services provided. The State believes 
that the text of the EPSDT portion of the 1115 waiver is correct 
and that the State carefully administers the targeted case 
management program. Oregon commented that the medical 
service problem in interstate placements needs to be addressed 
at the national level. Oregon plans to continue to work with 
ACF and CMS to clarify current policies and practices and to 
improve future program delivery. 
OEI-02-00-00363  FOSTER CARE CHILDRENS USE OF MEDICAID SERVICES IN OREGON  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 IN G S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . .   7
 
Foster children have Medicaid coverage and access to services........ 7
 
Targeted case management is the most common and costly claim...9
 
Many children do not have preventive care claims ......................... 11
 
Some children face problems............................................................13
 
R E C O M M E N D A T I O N S  . . . . . . . . . . . . . . . . . . . . . . . . . . . .  16 
 
A P P E N D I C E S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . .   18 
 
Appendix A: Oregon Administrative Rules......................................18
 
Appendix B: Comparison of Sample to Universe ............................. 22
 
Appendix C: Demographics ............................................................. 23
 
Appendix D: Description of 50 Foster Children in Sample ............ 25
 
Appendix E: Medicaid Claims for Sample ....................................... 26
 
Appendix F: Oregon Waiver, Excerpts from Social Security Act .... 27
 
Appendix G: Comments ................................................................... 28
 
A C K N O W L E D G M E N T S  . . . . . . . . . . . . . . . . . . . . . . . . . . .  46 
 
OEI-02-00-00363  FOSTER CARE CHILDRENS USE OF MEDICAID SERVICES IN OREGON  VI
  I N T R O D U C T I O N
 
OBJECTIVE 
To determine whether Oregons foster care children are 
receiving Medicaid health care services. 
BACKGROUND 
Currently, there are an estimated 534,000 children in foster care 
nationwide,1 and many of them are reportedly in poor health. 
Compared with children from the same socioeconomic 
background, foster care children suffer much higher rates of 
serious emotional and behavioral problems, chronic physical 
disabilities, birth defects, developmental delays, and educational 
difficulties. 2  According to one source, half of all children in the 
child welfare system suffer from developmental delays or mental 
health problems that are serious enough to need clinical 
intervention.3  In addition to the needs they share with other 
children, such as immunizations, routine well-child 
examinations, and treatment of childhood diseases, foster care 
children clearly have a greater need for specialized health care 
services. 
Despite their need, it appears that many foster care children are 
not receiving adequate health care. Many foster parents report 
difficulty in finding health care professionals who are willing to 
care for their children. It is estimated that 60 percent of all 
children in out-of-home care have moderate to severe mental 
health problems, yet less than one-third of those children receive 
mental health services.4  A General Accounting Office (GAO) 
report issued in May 1995, entitled Health Needs of Many 
Young Children are Unknown and Unmet, found that a 
significant proportion of young foster care children did not 
receive critical health-related services in the three locations 
1 Retrieved from http://www.acf.dhhs.gov/programs/cb/dis/afcars/cwstats.htmlon 
1/27/04 
2 Health Care of Young Children in Foster Care, Committee on Early Childhood, 
Adoption and Dependent Care, American Academy of Pediatrics, Pediatrics, 
Volume 109, Number 3. March 2002, pp 536-541 
3 Pamphlet on Ensuring the Healthy Development of Foster Care Children, New 
York State Permanent Judicial Commission on Justice for Children, 1999, page 4 
4 Factsheet: The Health Of Children In Out-Of-Home Care. Child Welfare League of 
America. Retrieved 3/14/2003 from: 
http://www.cwla.org/programs/health/healthcarecwfact.htm 
OEI-02-00-00363  FOSTER CARE CHILDRENS USE OF MEDICAID SERVICES IN OREGON  1  II NN TT RR OO DD UU CC TT II OO NN  
studied (Los Angeles County, New York City, and Philadelphia 
County).5  In fact, GAO estimated that only 1 percent of these 
children received Early and Periodic Screening, Diagnosis, and 
Treatment (EPSDT) services. 
Medicaid for Foster Care Children 
The Medicaid program provides health care to specified groups 
of needy individuals. It is administered by the Centers for 
Medicare & Medicaid Services (CMS) and jointly funded by the 
Federal and State Governments. Within broad national 
guidelines, each of the States does the following: establishes its 
own Medicaid eligibility standards; determines the type, 
amount, duration, and scope of services; sets the rate of 
payment for services; and administers its own State Medicaid 
program.6 
Almost all foster care children are eligible for Medicaid services. 
According to section 1902 (a)(10)(A)(i)(I) of the Social Security 
Act, foster care children covered under Title IV-E of the Social 
Security Act are eligible for Medicaid. Foster care children who 
are not eligible for Title IV-E usually qualify for Medicaid 
through other eligibility categories set forth by each State. In 
fiscal year 2000, Medicaid payments for foster care children 
nationwide were over $3.3 billion.7 
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT). 
EPSDT is a Federal entitlement to comprehensive medical 
services for Medicaid-eligible children under the age of 21. 
While States have the flexibility to design their own Medicaid 
programs, the EPSDT program requires each State to provide 
coverage for comprehensive and preventive child health services 
to Medicaid-eligible individuals under the age of 21. In general, 
EPSDT treatment services include all mandatory and optional 
services available under the Medicaid program. Diagnostic 
services are covered whenever there is a medical need to conduct 
further examination. Treatment or medical care must be 
5 Healthy Needs of Many Young Children are Unknown and Unmet, General Accounting Office , 
GAO/HEHS-95-114, 1995, pages 2 and 5 
6 Retrieved 3/14/2003 from: http://www.cms.hhs.gov/medicaid/mover.asp 
7 Medicaid Expenditures for Federal Fiscal Year 2000, By Type of Service for 
Maintenance Assistance Status and Basis of Eligibility All States; MSIS Report for 
Federal fiscal year 2000. National Total for Foster Care children, page 3. Retrieved 
from CMS website on 3/13/03: http://www.cms.gov/medicaid/msis/00total.pdf 
OEI-02-00-00363  FOSTER CARE CHILDRENS USE OF MEDICAID SERVICES IN OREGON  2  II NN TT RR OO DD UU CC TT II OO NN  
provided for any physical or mental conditions discovered by the 
screening services. 
Under EPSDT, States must set distinct periodicity schedules for 
screening, dental, vision and hearing services, and services must 
be provided at intervals that meet reasonable standards of 
medical practice. States must consult with recognized medical 
organizations involved in child health care, such as the 
American Academy of Pediatrics, in developing reasonable 
standards. 8 
Oregon 
Child Welfare -Oregon's foster care system is centrally managed. 
At the time of this inspection, the State had just fewer than 
7,400 children in foster care.9  Also, at that time, the Oregon 
State Office for Services to Children and Families was 
responsible for administering child welfare programs, including 
foster care and adoptions. Since the inspection was conducted, 
Oregon has reorganized its social service system. The Children, 
Adults and Families group within the Department of Human 
Services is currently responsible for administering child welfare 
programs.  During our study period, Oregon had 16 districts 
with 42 child welfare offices and employed about 949 child 
welfare caseworkers. Caseworkers in child welfare offices are 
responsible for the placement, monitoring, and coordination of 
services for foster care children. 
Oregon Medicaid - The Office of Medical Assistance Programs 
(OMAP) is also within the Department of Human Services. 
OMAP administers the Medicaid program in Oregon and is 
responsible for the Medicaid claims data. 
In Oregon, Medicaid is administered through the Oregon Health 
Plan (OHP). OHP offers three types of basic medical coverage: a 
fee-for-service plan; a managed care plan; and a primary care 
case management plan. 
Oregon Administrative Rules state that foster care children 
have the right to "ordinary medical, dental, psychiatric, 
psychological, and hygienic care and treatment when the child's 
8 Retrieved from CMS Website 3/28/03: http://www.cms.gov/medicaid/epsdt/ 
9 Child Welfare Outcomes 1999: Annual Report, Section IV-C, State data pages, 
Oregon (from AFCARS database, FY 99) 
http://www.acf.dhhs.gov/programs/cb/publications/cwo99/statedata/or.htm 
OEI-02-00-00363  FOSTER CARE CHILDRENS USE OF MEDICAID SERVICES IN OREGON  3  I N T R O D U C T I O N  
condition requires it."10  Also under Oregon Administrative 
Rules, all foster care children in the care and custody of the 
Department of Human Services receive the State's medical plan 
benefits. A small number of these children have too much 
income, such as survivor benefits, to be eligible for Medicaid 
under Title XIX. In these cases, health benefits are paid with 
State funds.11 
Waivers -Under section 1115 of the Social Security Act, which 
provides the Secretary of the Department of Health and Human 
Services (HHS) with authority to authorize experimental, pilot, 
or demonstration projects that are likely to assist in promoting 
the objectives of the Medicaid statute, HHS approved waivers 
for the OHP Demonstration Project. 
HHS granted Oregon a partial waiver of the EPSDT 
requirement in 1995. The Section 1115 waiver allows Oregon to 
eliminate certain health care services in order to extend 
Medicaid coverage to more people. The text of the waiver states 
that Oregon is no longer obligated to pay for services required to 
treat a condition identified during an EPSDT screening that are 
beyond the scope of the benefit package available to an 
individual receiving Medicaid. 
Oregon now offers a benefits package under the OHP that is 
based on a list of primary and acute medical and mental illness 
conditions and services ranked by the Health Services 
Commission in Oregon.12  It is called the prioritized list of 
services and is approved by CMS. 
METHODOLOGY 
This inspection is based on information gathered from multiple 
sources: Medicaid claims data; a review of Federal and State 
laws, regulations, and policies; and interviews with State agency 
officials, caseworkers, and caregivers. 
10 See Appendix A, Oregon Administrative Rules (OAR): 413-010-0180 
11 See Appendix A, OAR 416-610-0140 
12 From Centers for Medicare & Medicaid Services website, retrieved 3/18/2003: 
http://www.cms.gov/medicaid/1115/default.asp; 
http://www.cms.gov/medicaid/1115/orfact.asp 
OEI-02-00-00363  FOSTER CARE CHILDRENS USE OF MEDICAID SERVICES IN OREGON  4  I N T R O D U C T I O N  
Reasons for State Selection 
This inspection focuses on the State of Oregon and is part of a 
larger body of work in which eight States are being evaluated. 
Oregon was selected because of its size, centralized child welfare 
system, and geographic location. 
Sample 
Our population consisted of 5,004 Oregon children in continuous 
foster care placement for at least 6 months prior to July 2002. 
From this population, a simple random sample of 50 children 
was selected. See Appendices B through D for a comparison of 
the children in the sample to the population and a more detailed 
description of children in the sample. 
The size of the sample limits our ability to estimate the 
population from the sample. However, in the case of the amount 
spent for targeted case management claims, the variability of 
these amounts was relatively small (either $674 or $800, 
depending on what month the claim was submitted). Since the 
variability was small, we were able to produce an estimate of 
the amount spent on targeted case management claims in the 
population using standard statistical formulas for a simple 
random sample. 
Review of Medicaid Claims Data and State Laws and Policy 
Medicaid Claims Data - Oregon Medicaid provided a claims 
history for 2 years for all of the children in our sample. The 
data include claims with service dates between July 2000 and 
July 2002. Encounter data for children in managed care are 
also included in these data. We refer to all fee-for-service claims 
and managed care encounters as "claims," unless otherwise 
specified. 
In reviewing the Medicaid claims, we paid particular attention 
to the types of services, dates of service, and settings, where 
available. Medicaid claims data are organized into broad 
categories for analysis. We excluded claims that were not health 
care related, such as those for transportation and photocopying 
of medical records. We determined the periods of time the child 
was in foster care, based on information given by the State 
Medicaid office and caseworkers. We excluded claims with a 
service date for a time our data clearly show that the child was 
not in foster care. If it was not clear that the child was in foster 
OEI-02-00-00363  FOSTER CARE CHILDRENS USE OF MEDICAID SERVICES IN OREGON  5  III NNN TTT RRR OOO DDD UUU CCC TTT III OOO NNN  
care during a certain period of time, we included Medicaid 
claims corresponding to that time in our analysis. 
Law and Policy Reviews -We reviewed Federal and State laws 
and policies pertaining to the health care of foster care children. 
Interviews 
Caseworker Interviews - We interviewed caseworkers for the 
children in the sample either in person or by telephone. We 
spoke with 45 caseworkers, representing 47 children. (Two 
caseworkers were responsible for more than one child in the 
sample). Three caseworkers refused to cooperate, despite our 
repeated attempts to interview them and our repeated attempts 
to enlist the State's help in encouraging caseworker cooperation. 
The caseworkers we spoke with were the ones responsible for 
the children at the time the sample was pulled. Each interview 
focused on the caseworker's understanding of Medicaid, his or 
her experience accessing services for the sampled foster care 
children, and any barriers faced by foster care children in 
general for the time period of our inspection. Caseworkers also 
provided a written placement history for each child. 
Caregiver Interviews -We interviewed caregivers for 44 of the 50 
children in our sample. We were unable to reach and gain the 
cooperation of six caregivers. We use the term "caregiver" to 
refer to a foster parent or staff member of a residential facility 
who is responsible for the child. The caregivers we spoke with 
were the ones responsible for the children at the time the 
sample was pulled. Like the caseworker interviews, our 
interviews with caregivers focused on training, Medicaid, and 
procuring health services for the child for the time period of our 
inspection. 
State Agency Officials - We held several meetings, both in person 
and by telephone, with officials from the Oregon State 
Department of Human Services, State Office for Children and 
Family Services (now Children, Adults and Families group). 
Our discussions covered a wide spectrum of information to help 
us understand how the State's foster care and Medicaid systems 
are organized. 
This inspection was conducted in accordance with the Quality 
Standards for Inspections issued by the President's Council on 
Integrity and Efficiency. 
OEI-02-00-00363  FOSTER CARE CHILDRENS USE OF MEDICAID SERVICES IN OREGON  6  F I N D I N G S
 
Forty-nine of 50 foster care children in the sample  The children in the sample in 
Oregon have medical coverage, 
have Medicaid coverage and access to services	 
which is required by Federal 
and State laws. Forty-nine out of 50 foster care children in the 
sample have at least 1 Medicaid claim between July 2000 and 
July 2002. Caseworkers and/or caregivers reported that 47 of 
the children in the sample had Medicaid coverage in Oregon at 
the time of the interview. The caseworkers and caregivers for 
the remaining children could not confirm Medicaid coverage. 
Most children in the sample have access to Medicaid services 
An analysis of Medicaid claims shows that the children in the 
sample are accessing health care services. As seen in Table 1, 
the majority of children in the sample (44 out of 50) have at 
least 1 office visit claim in a 2-year period while they were in 
foster care. The children in the sample with an office visit claim 
have an average of over six office visits each. In addition, 80 
percent of the children in the sample have a labwork or 
diagnostic claim. 
Overall, the number of Medicaid claims per child in the sample 
ranges from 0 to 472. The majority of caseworkers and 
caregivers believe that their foster care children have access to 
needed medical care. Eighty-seven percent of the caseworkers 
and 82 percent of the caregivers interviewed report that their 
child receives needed medical care. 
Further, despite reported barriers to access that will be 
discussed later, foster care children seem to be accessing mental 
health services in addition to other medical services. Thirty-
three children in the sample (66 percent) have 2,079 mental 
health claims over the 2-year inspection period. 
OEI-02-00-00363  FOSTER CARE CHILDRENS USE OF MEDICAID SERVICES IN OREGON  7  F I N D I N G S  
Table 1: Number and Type of Medicaid Claims for 50 Children 
in Sample 
Number of Children 
Total Number of 
with at Least One 
Claim Type  Claims 
Claim 
Targeted case management  49  962 
Office visit  44  295 
Labwork/Diagnostic  40  374 
Mental health  33  2079 
Prescription drug  31  683 
Immunization  30  199 
Preventive  30  59 
Dental  28  314 
Emergency Room  23  59 
Supplies  22  86 
School-based services  19  54 
Vision  18  99 
Physical/Occupational therapy  8  138 
Hospital  7  29 
Clinic  7  24 
Hearing/Speech  6  27 
Other  4  10 
Home visit  3  5 
Total  5,496 
Source: OIG Analysis of Oregon Medicaid Claims Data 
The foster care children in the sample have a variety of reported 
conditions. According to caseworkers and caregivers, 82 percent 
(41 out of 50) of the children in our sample have a medical or 
mental health problem. These problems include asthma, 
seizures, depression, anxiety, developmental delays, and abuse. 
See Appendix D for a description of reported medical and mental 
health problems of children in the sample. 
OEI-02-00-00363  FOSTER CARE CHILDRENS USE OF MEDICAID SERVICES IN OREGON  8  F I N D I N G S  
Foster care children in Oregon sometimes receive health care services 
outside of Medicaid 
According to caregivers and caseworkers, 19 children receive 
health care services paid for by a source other than Medicaid. 
These other services are paid for by foster parents, branch 
funds, or by schools or non-profit organizations. Branch offices 
have State funds available to them to be used for services not 
covered by Medicaid. Most of the additional services received 
were related to mental health treatments or prescription drugs. 
Case management is allowable 
Targeted case management is the most common 
under Medicaid (section 
and most costly Medicaid claim for Oregon 
1905(a)(19) of the Social Security
foster care children in our sample 
Act), and defined in section 
1915(g)(2) as services which will assist an individual eligible 
under the State plan in gaining access to needed medical, social, 
educational and other services.  Representatives of Oregon 
Medicaid define targeted case management services as assisting 
an individual in gaining access to additional services. 
Targeted case management claims account for the majority of 
Medicaid payments for Oregon foster care children. Forty-nine 
out of 50 foster care children in our sample have a Medicaid 
claim for targeted case management services paid to Oregon's 
State Office for Services to Children and Families. These 
targeted case management payments occur virtually every 
month the children are in care during the 2-year study period. 
This includes children in fee-for-service and managed care 
plans. 
Oregons State Office for Services to Children and Families 
collected approximately $604 to $800 per month per foster child 
for targeted case management over the study period. By way of 
comparison, Medicaid pays $101 for Medicaid managed care per 
month per foster child in Oregon. In total, the State collected 
$710,420 from Medicaid for targeted case management for the 
50 children over the 2-year study period. (See Appendix E.) 
This amount represents an estimated 75 percent of all Medicaid 
health care payments for these children over this period. 
We estimate targeted case management payments for our 
sample population to be $71 million over the study period (plus 
OEI-02-00-00363  FOSTER CARE CHILDRENS USE OF MEDICAID SERVICES IN OREGON  9  F I N D I N G S  
or minus $7 million at the 95 percent confidence level). Our 
population is a subgroup of all Oregon children in foster care 
(5,004 out of 7,400). 
The State collects the same amount for each child each month 
the child is in foster care. For instance, all targeted case 
management claims in November 2000 are $800 each. All 
targeted case management claims in December 2001 are $674 
each. The type and degree of physical and mental health 
impairments among children showing these targeted case 
management claims vary widely. While some children appear to 
have complex medical and emotional problems, others appear to 
have none. In fact, six children have no reported physical or 
mental health impairments at all; yet, they each have a targeted 
case management claim every month along with the rest of the 
sample. 
It appears that recipients do not receive any extra, or even 
ordinary, health care as a result of receiving targeted case 
management. As noted earlier, Oregon Medicaid 
representatives define targeted case management services as 
assisting an individual in gaining access to additional services. 
Yet, some children show repeated targeted case management 
claims during long stretches of time without any other Medicaid 
services. For example, 1 child has a targeted case management 
claim every month for 21 consecutive months with only 1 other 
Medicaid claim for that entire time period. This child's 
caseworker and caregiver report that the child does not receive 
other health care services outside of Medicaid. In addition, 17 
children in the sample show no preventive care claims but have 
targeted case management claims for virtually every month that 
they were in foster care. 
OEI-02-00-00363  FOSTER CARE CHILDRENS USE OF MEDICAID SERVICES IN OREGON  10  F I N D I N G S  
Twenty of the 50 foster care children in the sample  Sampled children lack EPSDT 
do not have preventive care claims  claims andpreventive care 
The children in the sample 
may not be receiving an appropriate level of preventive care 
even though preventive care is covered under the Oregon Health 
Plan. The Medicaid data show no claims at all for EPSDT 
services for the children in our sample. Twenty children also 
show no preventive care claims over the 2-year study period. 
Eighteen of these children have been in continuous foster care 
for a year or more. Table 2 provides the ages for these 18 
children. 
Table 2:  Number of Children in 
Continuous Foster Care for 
At Least One Year with No 
Preventive Claims 
Number of Children 
Without Preventive 
Age  Claims 
4  2 
6  3 
7  2 
10  1 
12  2 
13  1 
15  1 
16  4 
17  2 
Total  18 
Source: OIG Analysis of Oregon Medicaid Data 
The EPSDT program requires that each State establish a 
periodicity schedule at intervals that meet reasonable standards 
of medical practice. Oregon's prioritized list of Medicaid services 
includes preventive care, but it does not provide a specific 
schedule for these services, nor does it provide recipients or 
providers with a clear periodicity schedule for preventive care. 
OEI-02-00-00363  FOSTER CARE CHILDRENS USE OF MEDICAID SERVICES IN OREGON  11  FF II NN DD II NN GG SS  
Confusion exists regarding the EPSDT portion of the State's waiver 
and implementation 
There appears to be confusion regarding the breadth of the 
EPSDT portion of the 1115 waiver. We learned during 
interviews that some State representatives are under the 
impression that Oregon is waived from all EPSDT requirements, 
which, in fact, it is not. Since EPSDT requires periodic health 
screenings of children, the belief that Oregon is not bound by 
EPSDT may contribute to the lack of preventive care we see in 
the sample children. 
The EPSDT portion of Oregons Section 1115 waiver eliminates 
the requirement that the State must pay for services to treat a 
condition identified during an EPSDT screening that are beyond 
the scope of the benefit package available to the individual. 
(The benefit package is Oregons Health Services Commission 
Prioritized List of Health Services.) However, the waiver 
approval incorrectly cites the section of the Social Security Act 
that is being waived as section 1902(a)(43)(A). Section 
1902(a)(43)(A) is the requirement that States must inform 
Medicaid-eligible children of the EPSDT benefits available to 
them. (Appendix F includes the full text of the EPSDT portion 
of the waiver and the Social Security Act citation.) 
Oregons Department of Human Services has recently 
commented that the State believes that the text of the waiver is 
correct and that the State is waived from payments of conditions 
identified during an EPSDT screening.  The States comments 
do not address other EPSDT requirements. CMS, also in recent 
comments, explains Oregons responsibilities. CMS states that 
the intent of the waiver was that Oregon would not pay for 
treatment of conditions identified as part of an EPSDT 
screening if the treatment of that condition was not covered on 
the Prioritized List of Health Care Services. When granting this 
waiver, CMS intended that Oregon would be required to comply 
with all other requirements of the entire EPSDT program. 
OEI-02-00-00363  FOSTER CARE CHILDRENS USE OF MEDICAID SERVICES IN OREGON  12  F I N D I N G S  
Medical records are often incomplete
Some children face problems due to incomplete 
Caregivers may not be able to 
medical records, access to certain health care  meet their legal obligation if 
services, and out-of-State medical coverage  they do not receive available 
medical records. Oregon 
requires caregivers to maintain a health care record for the 
child, including medical history and immunization records for a 
period of 3 years. If a child moves, records must be transferred 
to the child's new home. (See Appendix A, OAR 309-046-0190 
(11).) 
Caseworkers may not be transferring medical histories to 
caregivers. Nineteen of the 44 caregivers interviewed say they 
did not receive any of their foster child's medical history at all. 
Yet, 46 out of the 47 caseworkers interviewed indicate that they 
had received at least some medical history on the foster child in 
the sample. 
Some children encounter problems accessing dental and mental 
health services 
Difficulties accessing dental and mental health services are 
reported, although most children are able to get needed care 
eventually. Caregivers for 16 children report a problem 
accessing needed dental care. Problems include wait time for 
appointments, lack of Medicaid providers, dissatisfaction with 
quality of care, and trouble determining which dentists in the 
area were Medicaid providers. Twelve of the 16 children who 
experienced a problem report eventually being able to get the 
care they needed. For example, some caseworkers find 
alternative sources of funding in the community for braces or 
other cosmetic dental procedures. When asked about all foster 
care children, not just children in our sample, nearly half the 
caseworkers interviewed mention that foster care children in 
general have problems accessing dental care. 
Of the 35 children in the sample with a reported mental health 
problem, caregivers of 14 complain about mental health services. 
Specifically, the caregivers of seven of these children feel that 
the treatment that their child receives is inadequate. The 
caregivers of the remaining children encounter problems or 
barriers accessing mental health services, such as wait time for 
appointments, lack of Medicaid providers, lack of 
services/coverage, and difficulty finding good quality of care. 
OEI-02-00-00363  FOSTER CARE CHILDRENS USE OF MEDICAID SERVICES IN OREGON  13  F I N D I N G S  
Caseworkers, too, cite problems with mental health services. 
Caseworkers for 16 children feel that foster care children in 
general, not just those in the sample, experience barriers 
accessing mental health services. 
Caregivers and caseworkers also report problems accessing 
prescription medications. Nine children in the sample 
experience problems getting needed prescriptions. Eight of the 
nine children are eventually able to get the prescriptions they 
need. 
Foster care children placed out-of-State experience problems 
accessing care 
Our data show that five children in the sample were placed out-
of-State for at least some portion of the 2-year inspection period. 
One of the 5 was out of State for 22 months of the inspection 
period. The other four were out of State for less than 1 year. 
It appears from the claims data that all five out-of-State 
children had Medicaid coverage in Oregon while they were 
living in Oregon. Yet, only one of them seems to have Medicaid 
coverage in the other State in which they were placed. Three of 
the five caregivers cite problems getting a Medicaid card as a 
barrier to the child's access to health care. 
All 50 States, including Oregon, are members of the Interstate 
Compact on the Placement of Children (ICPC), which requires 
that a foster child placed over State lines receive adequate 
protections and support services. It establishes procedures for 
placement and compels the placing agency, sometimes called the 
sending agency, to maintain responsibility for the child. The 
language of the ICPC, however, does not specifically require that 
a foster child placed over State lines receive a Medicaid card in 
his/her new State. According to Oregons Department of Human 
Services Client Services Manual, the sending agency is 
responsible for arranging for medical coverage for the child 
before the child is placed in another State. 
Caseworker involvement with the five out-of-State children in 
our sample varies. Two caseworkers say that they do not know 
if their child has a Medicaid card. The caregivers for these 
children report that their Oregon caseworker is not involved in 
their childs health care. Two other caseworkers are more 
involved. For example, one caseworker says she knows that the 
OEI-02-00-00363  FOSTER CARE CHILDRENS USE OF MEDICAID SERVICES IN OREGON  14  F I N D I N G S  
child does not have Medicaid coverage, and it is her 
responsibility to get it, but she has not been successful yet. The 
child has been without coverage for over a year, and the 
caregiver is paying for all of the child's medical care out-of-
pocket. A second caseworker reports difficulties in getting a 
Medicaid card in the new State and directing the child to the 
right place to get care. The caseworker for the remaining child, 
according to the caregiver, is involved in the childs health care, 
although the child does not yet have a Medicaid card in the new 
State. 
Despite a lack of medical coverage, all five caregivers of the out-
of-State children say that their foster care child has received a 
well-child exam while in their care. In some cases, the caregiver 
pays out-of-pocket for this care. These services are not captured 
in Medicaid claims data. 
OEI-02-00-00363  FOSTER CARE CHILDRENS USE OF MEDICAID SERVICES IN OREGON  15  R E C O M M E N D A T I O N S
 
We believe that the Administration for Children and Families 
(ACF) and CMS should work with the State of Oregon to ensure 
that all eligible foster care children receive appropriate health 
care services. Accordingly, we recommend that: 
o	  CMS review the use of targeted case management for foster 
care children in Oregon to ensure that it is consistent with 
State plan provisions and current CMS requirements for this 
service. CMS may also want to consider reviewing the use of 
targeted case management for foster care children in other 
States to determine the nature and the cost of this service. 
o	  CMS work with Oregon to clarify the States waiver and the 
States obligations under EPSDT. CMS should also revise 
the incorrect citation in the EPSDT portion of Oregons 1115 
waiver. 
o	  ACF and CMS work with Oregon to promote preventive 
health care that is consistent with EPSDT guidelines. 
o	  ACF work with Oregon and involved parties, such as the 
State child welfare administrators and the administrators of 
ICPC, to address the health care needs of foster care 
children placed across State lines. 
Agency Comments 
We received comments from CMS and ACF. The full text of the 
comments are included in Appendix G. CMS concurs with our 
recommendations. In regard to targeted case management 
(TCM), CMS notes that it is completing a major policy letter to 
the State Medicaid Directors that will define TCM activities that 
can be claimed for Federal financial participation from the 
Medicaid program which are integral and inseparable functions 
of the foster care and child welfare programs, and the social 
service block grant (Social Security Act (the Act) titles IVB, IVE 
and XX).  We encourage CMS to issue this policy letter as soon 
as possible and to share it with all State child welfare agencies 
as well as the State Medicaid Directors. 
We are pleased that CMS is adding two authorities to the list of 
waived statutory provisions for Oregon that will clarify the 
terms of the waiver. CMS will also work with Oregon to ensure 
the State recognizes that the current waiver...is not a waiver of 
the requirements of the entire EPSDT program, but rather for 
OEI-02-00-00363  FOSTER CARE CHILDRENS USE OF MEDICAID SERVICES IN OREGON  16  R E C O M M E N D A T I O N S  
the payment of treatment for conditions identified as part of an 
EPSDT screening, if such conditions are not covered by the 
Prioritized List. 
CMS agrees to work with the State to promote preventive health 
care that is consistent with EPSDT guidelines. It is our hope 
that these efforts will include the formulation of a clear 
periodicity schedule, as required by the EPSDT program. 
In its comments, ACF notes that it is actively working with 
Oregon in the areas of managed care, training, and follow-up 
services. The action steps for these efforts are included in the 
Oregon Program Improvement Plan, developed in response to an 
ACF Child and Family Services Review. These reviews measure 
individual States performance related to the health and well-
being of children in the child welfare system. We encourage 
ACF to continue its current efforts. We also encourage ACF to 
address actively the issue of preventive care for foster care 
children. Action Step 23.2.3 in the Oregon Program 
Improvement Plan calls for a clear policy for children receiving 
adequate, timely, necessary and culturally competent mental 
health, medical and dental services. We believe preventive care 
should be thoroughly addressed in this policy. 
ACF plans to form a panel of State child welfare administrators, 
State foster care managers, State adoption managers, and ICPC 
administrators. This panel will identify barriers, issues and 
suggested resolutions related to placing children across State 
lines.  We encourage the timely formation of this panel and 
look forward to receiving the panels findings. 
We also received comments from the State of Oregon. The full 
text of these comments is included in Appendix G. Oregon 
states that a file review would give a more accurate assessment 
of services provided. Oregon believes that the text of the EPSDT 
portion of the 1115 waiver is correct and that the State carefully 
administers the targeted case management program. Oregon 
commented that the medical service problem in interstate 
placements needs to be addressed at the national level. Oregon 
plans to continue to work with ACF and CMS to clarify current 
policies and practices and to improve future program delivery. 
OEI-02-00-00363  FOSTER CARE CHILDRENS USE OF MEDICAID SERVICES IN OREGON  17  A P P E N D I X ~ A
 
Oregon Administrative Rules (OAR) 
413-010-0180 Basic Rights of Children in the State Office for Services 
to Children and Familiess (SOSCF's) Custody. 
Each child placed in the legal custody of SOSCF has the 
following rights: 
(1) To be physically placed in the least restrictive environment 
that can appropriately meet the child's needs; 
(2) To be provided basic needs such as adequate food, clothing, 
and shelter; 
(3) To receive care, supervision, and discipline, and to be taught 
to act responsibly and respect the rights of others; 
(4) To be provided ordinary medical, dental, psychiatric, 
psychological, and hygienic care and treatment when the child's 
condition requires it; 
(5) To be provided with free and appropriate education; 
(6) To be protected from physical and sexual abuse, emotional 
abuse and exploitation; 
(7) To be provided services which will reunite the child with his 
or her own family except when there is clear evidence that the 
family will not protect the child's welfare; 
(8) To be provided services to develop a safe, permanent 
alternative to the child's own family, when suitable family 
resources are not available; 
(9) To be accorded the least restrictive legal status that is 
consistent with the child's need for protection or the protection 
of the community, and to receive advocacy and/or legal 
representation, when needed, to assure that the child's best 
interests are presented to the court; 
(10) To receive respect and be nurtured in accordance with his or 
her background, religious heritage, race and culture; 
(11) To visit and communicate with members of his or her family 
within reasonable guidelines as set by the service plan and by 
the court; 
(12) To be involved, in accordance with his or her age and ability 
and with the law, in making major decisions that affect his or 
her life; 
OEI-02-00-00363  FOSTER CARE CHILDRENS USE OF MEDICAID SERVICES IN OREGON  18  A P P E N D I X ~ A  
(13) To receive encouragement and be afforded reasonable 
opportunities to participate in sports, youth activities in school 
and neighborhood, and other enrichment programs; 
(14) To earn and keep his or her own money and to receive 
guidance in managing resources to prepare him or her for 
independence. 
416-610-0140 GA Medical Policy 
All children in paid substitute care who do not meet the 
eligibility requirements for Title XIX, will be eligible for General 
Assistance (GA) medical through OMAP. 
309-046-0190 Standards and Practices for Care and Services: 
(11) Child Records. A record shall be developed, kept current 
and available on the premises for each child admitted to the 
foster home: 
(a) General Information. The provider shall maintain a record 
for each child in the home. The record must include: 
(A) The child's name, date of entry into the foster home, date of 
birth, gender, religious preference, and guardianship status; 
(B) The name, addresses, and telephone number of the child's 
guardian, family, advocate, or other significant person; 
(C) The name, address, and telephone number of the child's 
preferred primary health provider, designated back up health 
care provider and/or clinic, dentist, preferred hospital, medical 
card number and any private insurance information, and 
Oregon Health Plan choice; 
(D) The name, address, and telephone number of the child's 
school program; and 
(E) The name, address, and telephone number of the CMHP 
case manager and representatives of other agencies providing 
services to the child. 
(b) Child records shall be available to representatives of the 
Division and SOSCF conducting inspections or investigations, as 
well as to the child, if appropriate, and the guardian, or other 
legally authorized persons. 
OEI-02-00-00363  FOSTER CARE CHILDRENS USE OF MEDICAID SERVICES IN OREGON  19  A P P E N D I X ~ A  
(c) Child records shall be kept for a period of three years. If a 
child moves or the foster home closes, copies of pertinent 
information shall be transferred to the child's new home. 
(d) Medical Information shall include: 
(A) History of physical, emotional and medical problems, 
accidents, illnesses or mental status that may be pertinent to 
current care; 
(B) Current orders for medications, treatments, therapies, use 
of restraints, special diets and any known food or medication 
allergies; 
(C) Completed Medication Administration Records (MAR) from 
previous months; 
(D) Pertinent medical information such as hospitalizations, 
accidents, immunization records including Hepatitis B status 
and previous TB tests, incidents or injuries affecting the health, 
safety or emotional well-being of the child; and 
(E) Documentation or other notation of guardian consent for 
medical treatment that is not routine, including surgery and 
anesthesia. 
(e) Individual Support Plan. The child's ISP is prepared by the 
ISP team, and addresses each child's behavior, medical and 
support needs. The ISP shall be developed within 60 days of 
placement and updated annually or whenever the child's needs 
change. The ISP shall describe the child's behavior, medical, 
support needs and capabilities, and will include by whom, when, 
and how often care and services will be provided. 
(f) Financial records: 
(A) A separate financial record must be maintained for each 
child if the provider manages or handles the child's money. 
(B) Each child's financial record shall document the receipt of 
the room and board fee that is paid to the provider at the 
beginning of each month. 
(C) Any single item over $50 purchased with the child's 
personal funds, unless otherwise indicated in the child's ISP, 
will be documented including receipts, in the child's financial 
record. 
OEI-02-00-00363  FOSTER CARE CHILDRENS USE OF MEDICAID SERVICES IN OREGON  20  A P P E N D I X ~ A  
(D) The child's ISP team will address how the child's personal 
spending money will be managed and documented. 
(E) If the child has a separate commercial bank account, records 
from that account must be maintained with the financial record. 
OEI-02-00-00363  FOSTER CARE CHILDRENS USE OF MEDICAID SERVICES IN OREGON  21  A P P E N D I X ~ B
 
Comparison of Children in Sample to Universe of Oregon Foster Care 
Children in Continuous Care for 6 Months 
As shown in the table below, gender and ages of the children in 
the sample are similar to that of the universe of all Oregon 
foster care children in continuous care for 6 months prior to 
sample selection. Slightly more than half of the sample and 
universe are male. Thirty percent of both the sample and 
universe are age 5 or under, roughly 34 percent are between the 
ages of 6 and 12, about 36 percent are age 13 or over. 
Comparison of Children in Sample to Universe 
50 Children in Sample  Universe 
Count  % of Total  Count  % of Total 
GENDER 
Male  27  54%  2619  52% 
Female  23  46%  2385  48% 
Total  50  100%  5004*  100% 
AGE 
0-2  10  20%  647  13% 
3-5  5  10%  859  17% 
6-9  10  20%  981  20% 
10-12  7  14%  861  17% 
13-17  18  36%  1484  30% 
18+  0  0%  172  3% 
Total  50  100%  5004*  100% 
Source: Oregon Medicaid Data 
* The universe of foster care children in continuous foster care for 6 
months prior to sample selection was 5,004 children.  The total 
number of foster care children in care at the time of sample 
selection was approximately 7,400. 
OEI-02-00-00363  FOSTER CARE CHILDRENS USE OF MEDICAID SERVICES IN OREGON  22  A P P E N D I X ~ C  
Demographics 
The table below shows demographic and health characteristics 
of each of 50 sampled children, including the amount of time 
they were in foster care during our 2-year study period.  
Placement setting refers to the type of foster care placement the 
child was in at the time our sample was pulled in July 2002.    
 
Caseworker or 
Caseworker or 
Age  Placement  Caregiver Reported  Amount of Time in 
ID  Sex  Caregiver Reported 
(years)  Setting  Mental Health  Care (Months) 
Medical Problem(s) 
Problem(s) 
1  M  15  Residential  Y  Y  24 
2  M  12  Family  N  Y  19 
3  M  15  Family  Y  Y  24 
4  M  11  Family  N  Y  24 
5  F  6  Family  N  N  23 
6  M  16  No Information  Y  Y  24 
7  M  13  Family  Y  Y  24 
8  M  4  Kinship  Y  N  24 
9  F  13  Kinship  N  Y  24 
10  M  2  Family  Y  N  24 
11  F  14  No Information  N  Y  24 
12  M  17  Family  Y  Y  23 
13  M  9  Kinship  N  Y  22 
14  F  5  Family  Y  Y  24 
15  F  12  Family  N  Y  24 
16  F  5  Family  N  N  21 
17  M  10  No Information  Y  Y  24 
18  M  14  Residential  N  Y  24 
19  M  16  Family  Y  Y  24 
20  F  17  Family  Y  Y  24 
21  M  10  Family  N  Y  24 
22  M  17  Family  N  Y  24 
23  M  2  Family  N  N  24 
24  M  6  Family  Y  N  24 
25  F  2  No Information  N  N  24 
26  M  6  Kinship  Y  Y  10 
27  F  7  Family  Y  Y  24 
28  M  13  Residential  Y  Y  23 
29  M  13  Residential  N  Y  10 
 
 
  
  OEI-02-00-00363  FOSTER CARE CHILDRENS USE OF MEDICAID SERVICES IN OREGON  23 
  A P P E N D I X ~ C  
Caseworker or 
Caseworker or 
Age  Placement  Caregiver Reported  Amount of Time in 
ID  Sex  Caregiver Reported 
(years)  Setting  Mental Health  Care (Months) 
Medical Problem(s) 
Problem(s) 
30  F  7  Family  Y  Y  22 
31  M  16  Kinship  Y  Y  24 
32  F  6  Kinship  N  Y  22 
33  F  1  Kinship  N  Y  22 
34  F  7  Family  N  Y  24 
35  M  0  Family  N  N  9 
36  F  1  Family  N  N  10 
37  M  0  Family  Y  N  10 
38  F  1  Family  Y  Y  11 
39  F  7  Family  N  Y  24 
40  M  1  Kinship  N  N  16 
41  F  5  Kinship  Y  N  24 
42  F  2  Family  Y  Y  23 
43  F  4  No Information  No Information  No Information  24 
44  F  13  Family  N  Y  24 
45  M  9  Family  Y  Y  24 
46  M  11  Family  Y  Y  19 
47  F  16  Family  Y  N  24 
48  F  11  Kinship  Y  Y  17 
49  M  15  Family  N  Y  24 
50  F  15  Family  N  N  24 
Source: Oregon Medicaid Data, OIG analysis of interview data. 
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  A P P E N D I X ~ D
 
Description of 50 Oregon Foster Care Children in 
Sample 
Medical problems 
Caseworkers or caregivers report that approximately 50 percent 
of the children in our sample have at least one medical problem. 
Medical problems included acne, asthma, cerebral palsy, drug 
affected, vision problems, obesity, seizures, allergies, heart 
problems, and genetic disorders. Caseworkers or caregivers also 
report that at least 70 percent of the children in our sample 
have a minimum of 1 mental health problem. The most common 
mental health problems are related to depression, anxiety, or 
emotional disorders. Caregivers, in particular, note many 
problems with anger or behavioral issues. A number of children 
also suffer from attention-deficit or attention-deficit-
hyperactivity disorder and/or post-traumatic stress disorder. 
Still other children have developmental delays, learning 
disabilities, and suffer from some form of abuse or neglect. 
Types of Medicaid enrollment 
Foster care children sometimes have several different 
placements or go in and out of foster care, so they often 
participate in a few plans. Most children in our sample were 
enrolled in more than one type of plan under the Oregon Health 
Plan during our inspection period. Forty-two children were 
enrolled in a managed care plan for at least some portion of our 
study period. Thirty-three were enrolled in a fee-for-service 
plan, and three were enrolled in a primary care case 
management plan at some point. In addition, some children 
were enrolled in one type of plan for medical coverage and 
another type of plan for dental and/or mental health services. 
For example, a child might have a fee-for-service medical plan 
but be enrolled in a dental health maintenance organization 
plan. 
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Number and Amount of Fee-for-Service and Managed Care Claims 
for 50 Children in Sample During the 2-year Inspection Period: 
FEE FOR SERVICE  MANAGED CARE 
Claim Type 
Targeted case management  962  962  $710,420  0  ** 
Office visit  295  109  $4,934  186  ** 
Labwork/Diagnostic  374  158  $3,693  216  ** 
Mental health  2079  517  $57,136  1562  ** 
Prescription drug  683  666  $55,711  17  ** 
Immunization  199  74  $8,914  125  ** 
Preventive  59  34  $2,108  25  ** 
Dental  314  19  $669  295  ** 
Emergency Room  59  25  $1,751  34  ** 
Supplies  86  18  $1,486  68  ** 
School-based services  54  54  $5,386  0  ** 
Vision  99  22  $565  77  ** 
Physical/Occupational therapy  138  44  $2,500  94  ** 
Hospital  29  7  $1,398  22  ** 
Clinic  24  3  $433  21  ** 
Hearing/Speech  27  10  $342  17  ** 
Other  10  9  $1,886  1  ** 
Home visit  5  0  0  5  ** 
T O T A L  
Source: OIG Analysis of Oregon Medicaid Data 
** Medicaid pays an average capitated rate of $101.22 per child per month for managed care services.13  Children in the sample 
were in managed care a total of 731 out of 1101 months. 
13 http://www.dh s.state.or.us/healthplan/data_pubs/archives/caprates01-02.pdf 
PricewaterhouseCoopers LLP report on Oregon Health Plan Medicaid 
Demonstration, Capitation Rate Development, Federal Fiscal Year 2002; 9/25/01, 
page 18, Exhibit 2, Statewide Capitation Rate for Fiscal Year 2002 
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EPSDT Portion of Oregons Section 1115 Waiver 
(Excerpt from October 15, 2002, Approval Letter from CMS) 
Under the authority of section 1115(a)(1) of the Act, the 
following waivers of Medicaid and SCHIP State plan 
requirements contained in section 1902 and 2103 of the Act are 
granted to enable Oregon to carry out the Oregon Health Plan 2 
demonstration through this period: 
7. Early and Periodic Screening,  Section 1902(a)(43)(A)
 
Diagnosis and Treatment 
 
(EPSDT)
 
To waive the requirement that States must pay for services 
required to treat a condition identified during an EPSDT 
screening that are beyond the scope of the benefit package 
available to the individual. 
Excerpt from Social Security Act: Section 1902 (a)(43)(A) 
SEC. 1902. [42 U.S.C. 1396a] (a) A State plan for medical 
assistance must-
(43) provide for-
(A) informing all persons in the State who are under the age of 
21 and who have been determined to be eligible for medical 
assistance including services described in section 1905(a)(4)(B), 
of the availability of early and periodic screening, diagnostic, 
and treatment services as described in section 1905(r) and the 
need for age-appropriate immunizations against vaccine-
preventable diseases, 
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  A C K N O W L E D G M E N T S
 
This report was prepared under the direction of John I. Molnar, 
 
former Regional Inspector General for Evaluation and 
 
Inspections in the New York Regional Office, and Jodi 
 
Nudelman, Assistant Regional Inspector General. Other 
 
principal Office of Evaluation and Inspections staff who 
 
contributed include:
 
Nancy Harrison, Team Leader
 
Laura Torres, Lead Analyst
 
Natasha Besch, Program Analyst
 
Nicole Gillette, Program Analyst
 
Thomas Zimmermann, Program Analyst
 
Linda Hall, Program Specialist
 
Barbara Tedesco, Statistician
 
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