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 :  G
OSTER  ARE EORGIA

Inspector General 
January 2005 
OEI-07-00-00644  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 OIGs internal operations.  The OCIG imposes program exclusions and 
civil monetary penalties on health care providers and litigates those actions within the 
department.  The OCIG also represents OIG in the global settlement of cases arising 
under the Civil False Claims Act, develops and monitors corporate integrity agreements, 
develops compliance program guidances, renders advisory opinions on OIG sanctions to 
the health care community, and issues fraud alerts and other industry guidance.    E X E C U T I V E   S U M M A R Y   
OBJECTIVE 
To determine whether sampled children in the Georgia foster care 
program receive health care services.  
BACKGROUND 
Section 471(a)(22) of the Social Security Act (the Act) requires States to 
provide children in foster care with quality services that protect their 
health and safety. Section 472(h)(1) of the Act deems children in foster 
care eligible for Medicaid health care services. Georgia is the focus of 
this inspection and is one of a series of eight States chosen to represent 
a diverse cross section of foster care nationwide.  All Title IV-E children 
in the Georgia foster care program are eligible for Medicaid. 
Federal Early and Periodic Screening, Diagnosis, and Treatment 
(EPSDT) guidelines require each State to make preventive health care 
services available to Medicaid-eligible individuals under the age of 21. 
The guidelines also require States to establish intervals for providing 
EPSDT examinations that meet reasonable standards of medical and 
dental practice as outlined in sections 1902(a)(43) and 1905(r) of the 
Act.  A unique aspect of the Georgia foster care program is its First 
Placement, Best Placement (FP/BP) Comprehensive Child and Family 
Assessment policy, which requires that all children entering foster care 
receive initial medical and dental examinations and a developmental 
assessment or psychological evaluation. 
This inspection is based on information gathered from multiple 
sources. We reviewed Federal and State policies; analyzed 
child-specific Medicaid claims data and case file documentation for 
50 randomly sampled children in the Georgia foster care program; and 
interviewed foster care providers (i.e., foster parents or residential care 
facility staff), caseworkers for the children in our sample, and relevant 
Georgia State staff.  Our analysis focused on a 3-year claims period for 
children in foster care ending on March 26, 2003.   
FINDINGS 
All 50 sampled children had Medicaid coverage, and 49 children had 
claims for health care services.  The 49 children with Medicaid claims 
had a total of 3,574 claims during our review period. 
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Thirty of forty-three sampled children required to receive an EPSDT 
medical examination received their most recent EPSDT medical 
examination within State-established frequency guidelines. 
According to State guidelines, 43 sampled children should have received 
EPSDT services based on their age and length of time in foster care. 
However, 13 of the 43 children did not receive an EPSDT medical 
examination within State-established guidelines. Seven of the fifty 
sampled children had been in foster care less than the time period that 
would have required an EPSDT examination based on the EPSDT 
guidelines established by the State. 
Twenty-one of thirty-five sampled children required to receive an 
EPSDT dental examination received their most recent EPSDT dental 
service within State-established frequency guidelines.  The EPSDT 
frequency guidelines adopted by Georgia required that children 3 years 
of age or older receive dental services every 6 months.  Thirty-five of the 
sampled children were 3 years of age or older and, therefore, should 
have received dental services. 
Many of the sampled children did not receive First Placement, Best 
Placement assessments within the State-required timeframe. 
Georgia State guidelines required that 39 of the 50 sampled children 
receive FP/BP services upon entry into foster care during the period 
covered by our Medicaid claims.  Fourteen children did not receive 
required FP/BP medical examinations within the required timeframe.  
Thirteen of the twenty-four children required to have an FP/BP dental 
examination did not receive it timely, and 4 of the 16 children required 
to receive a developmental assessment and 8 of 23 children required to 
receive a psychological evaluation did not receive it within the required 
timeframe. 
Four sampled children did not receive services to address 
documented mental health needs, and mental health needs were 
not documented for five children who received such services.  
Federal law requires that case plans be developed, and the Georgia 
Division of Family and Children Services requires that these plans 
include information regarding the childs current emotional and 
psychological status.  Case plans or State-required FP/BP assessments 
for four sampled children clearly indicated a need for mental health 
services.  However, no Medicaid claims for mental health services 
existed, and the caseworkers and foster care providers for these children 
stated they were not receiving mental health services.  Medicaid claims, 
caseworkers, and foster care providers for five other sampled children 
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indicated the children received mental health services, but the need for 
mental health services was not documented in the case plans for these 
children. 
Twenty-four of the fifty foster care providers reported never 
receiving medical information for the children in their care. 
Section 475(5)(D) of the Act requires that the health records of children 
in foster care be reviewed, updated, and supplied to the foster care 
providers at the time of placement. Caseworkers for 21 of the 
24 children whose foster care providers reported they did not receive 
medical information stated they had received or compiled some medical 
information for the sampled children.  
RECOMMENDATIONS 
The Administration for Children and Families (ACF) and the Centers 
for Medicare & Medicaid Services (CMS) should work with the Georgia 
Department of Community Health to ensure that:  
(cid:137) 	 The EPSDT medical examinations and dental services are received 
timely. 
ACF should work with the Georgia Department of Human Resources, 
Division of Family and Children Services (DFCS) to ensure that: 
(cid:137)  Assessments are completed within the required timeframe. 
(cid:137)  Foster care providers receive initial and updated medical 
information for children placed in their care. 
In addition, ACF should work with DFCS to ensure that case files 
contain required documentation, including mental health needs.  
Further, during the course of this study, we noted that some of the 
components of the FP/BP Comprehensive Child and Family 
Assessments mirrored the components required as part of EPSDT.  
We encourage ACF, CMS, DFCS, and the Georgia Department of 
Community Health to consider allowing services provided under either 
program to count for meeting the requirements of both programs, as 
appropriate. 
AGENCY COMMENTS  
ACF described actions it is taking that will address our 
recommendations.  The ACF is monitoring the State of Georgias actions 
through quarterly reports relative to the States efforts to ensure that 
EPSDT medical examinations and dental services are received timely 
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and to ensure that foster care providers receive appropriate medical 
information for children placed in their care. 
CMS concurred with the Office of Inspector General (OIG) 
recommendation and will have CMS regional office staff work with the 
Georgia Department of Community Health to ensure that EPSDT 
services are provided according to the State-established EPSDT 
frequency guidelines.  CMS also notes that its staff are available to the 
State and to ACF to provide any necessary technical assistance.  
Additionally, in response to an OIG suggestion, CMS will not prohibit 
FP/BP assessments from serving as EPSDT screenings if the screenings 
are provided in accordance with the State-established EPSDT frequency 
guidelines and meet the definition of an EPSDT screening, with all age 
appropriate screens and services being provided. 
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EXECUTIVE SUMMARY ......................................... i 

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

FINDINGS ...................................................... 10 

Medicaid coverage for children in foster care................... 10 

Receipt of EPSDT medical examinations ...................... 11 

Receipt of EPSDT dental services ............................ 11 

Timeliness of First Placement, Best Placement services ........ 12 

Documentation and receipt of mental health services  .......... 15 

Medical information for foster care providers .................. 16 

RECOMMENDATIONS ......................................... 17 

AGENCY COMMENTS ......................................... 18

APPENDIXES 
A: 	EPSDT and First Placement, Best Placement   

   Required Components ................................... 19 

B: 	Demographic Characteristics of Sampled Children .......... 20 

C: 	Medicaid Claims for Sampled Children .................... 22 

D: 	EPSDT Services for Sampled Children..................... 24 

E:	  First Placement, Best Placement Assessments.............. 26 

F: 	Agency Comments ....................................... 28 

ACKNOWLEDGMENTS ......................................... 32 
   I N T R O D U C  T  I O N  
OBJECTIVE 
To determine whether sampled children in the Georgia foster care 
program receive health care services. 
BACKGROUND 
At the time of our review, an estimated 542,000 children were in foster 
care nationwide,1 many of whom were 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.  Georgia 
was selected for its medium population size based on Bureau of the 
Census data when compared to other States.3   It was also chosen for its 
southern geographic location, largely rural setting, county-administered 
child welfare system, and fee-for-service provision of Medicaid services. 
Georgia had 13,149 children in foster care at the end of fiscal year 
(FY) 2002, based on the most recent Federal data available at the time 
of this study.4  The Administration for Children and Families (ACF) 
has regulatory oversight of the Title IV-E foster care program, including 
approval of State plans to ensure State foster care programs are 
operating within Federal guidelines.  Within Georgia, the Department 
of Human Resources, Division of Family and Children Services (DFCS), 
manages the Title IV-E foster care program. 
Compared with other children from the same socioeconomic 
backgrounds, children in foster care suffer much higher rates of serious 
physical and psychological problems.5   Vision, hearing, and dental 
problems are prevalent in the foster care population, and physical 
health problems (e.g., delayed growth and development, malnutrition, 
1 Department of Health and Human Services, Administration for Children and Families, Adoption and 
Foster Care Analysis and Reporting System Report for the period ending September 30, 2001. 
Retrieved July 6, 2004 from http://www.acf.hhs.gov/programs/cb/publications/afcars/report8.htm. 
2 Other States selected for review are Illinois, Kansas, New Jersey, New York, North Dakota, 
Oregon, and Texas. 
3 Bureau of the Census, retrieved January 21, 2004, from http://www.factfinder.census.gov/. 
4 Department of Health and Human Services, Administration for Children and Families, Foster Care: 
Entries, Exits, and In Care on the Last Day.  Retrieved on January 13, 2004, from 
http://www.acf.hhs.gov/programs/cb/dis/tables/entryexit2002.htm. 
5 Casey Family Programs, National Center for Resource Family Support, Health Care Issues for Children 
in Foster Care, March 25, 2002. 
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and asthma) affect 30 to 40 percent of children in the child welfare 

system.6

Children in foster care have greater health care needs, yet many foster 
care providers reported having difficulty finding health care 
professionals who were willing to care for these children (we use the 
term foster care provider to refer to a foster parent or a residential 
care facility who is responsible for a child in foster care).7  The health 
care available for children in foster care is often characterized by lack of 
access; lack of information sharing among health care professionals; and 
long delays in obtaining services.8  Furthermore, studies have shown 
that low percentages of children in foster care are actually receiving 
services.9  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 the age of 21 that 
might otherwise go undetected or untreated. However, a Government 
Accountability Office report released in July 2001 stated that available 
data from short-range studies showed that the percentage of children in 
the general population receiving EPSDT services is very low.10 
Periodic dental care (i.e., oral screenings and examinations) is included 
as part of EPSDT and must be performed by a dentist.  Georgia 
requirements for EPSDT services require that every child receive dental 
services in accordance with the frequency guidelines developed by the 
State and at other intervals as medically necessary.  The EPSDT dental 
frequency guidelines must be established after consultation with 
recognized dental organizations involved in child health care.   
6   Fact Sheet: The Health of Children in Out-of-Home Care.  Child Welfare League of America. 
Retrieved October 17, 2002, from http://www.cwla.org/programs/health/healthcarewfact.htm. 
7  Chernoff, R. et. al., (1994) Assessing the Health Status of Children Entering Foster Care, 
Pediatrics, 93:2, 594-601. 
8 Health Care of Young Children in Foster Care, Pediatrics, 109:3, 2002. 
Retrieved January 14, 2004, from http://www.aap.org/policy/re0054.html. 
9 Ensuring the Healthy Development of Foster Children, New York State Permanent Judicial 
Commission on Justice for Children, 1999 and Medicaid: Stronger Efforts Needed to Ensure 
Childrens Access to Health Screening Services, Government Accountability Office, GAO-01-749, 
July 2001. 
10 Medicaid: Stronger Efforts Needed to Ensure Childrens Access to Health Screening Services. 
Government Accountability Office, GAO-01-749, July 2001. 
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Medicaid for Children in Foster Care 
All children in the Georgia Title IV-E foster care program are eligible 
for Medicaid. Section 472(h)(1) of the Social Security Act (the Act) 
deems children eligible for Medicaid health care services and 
section 1902(a)(10)(A)(i)(I) of the Act requires that Medicaid services be 
made available to them.  Federal EPSDT guidelines require each State 
to make comprehensive and preventive child health services available to 
Medicaid-eligible individuals under the age of 21, as outlined in 
sections 1902(a)(43) and 1905(r) of the Act.  Within a broad framework, 
each State establishes its own Medicaid eligibility standards; 
determines the types, amount, duration, and scope of Medicaid services; 
sets the rate of payment for services to Medicaid patients; and 
administers its own Medicaid program.11 
In FY 2000, Medicaid payments for children in foster care nationwide 
totaled over $3.3 billion.12   Georgia Medicaid expenditures for this 
population totaled approximately $36 million in 2000.13  The Centers 
for Medicare & Medicaid Services (CMS) is responsible for the Federal 
oversight of individual State Medicaid programs.  The Georgia 
Department of Community Health manages the State Medicaid 
program. 
Georgia Health Check 
In accordance with Federal law, participation in the Medicaid program 
requires States to establish EPSDT guidelines for all Medicaid-eligible 
individuals under 21 years of age.14  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.15  Georgia has established the 
Health Check program to meet Federal EPSDT requirements. 
11  Retrieved September 12, 2002, from http://cms.hhs.gov/medicaid/eligibility/criteria.asp. 
12  Department of Health and Human Services, Medicaid Statistical Information System (MSIS) Report 
Fiscal Year 2000:  All States. Retrieved January 14, 2004, from 
http://www.cms.gov/medicaid/msis/00ga.pdf. 
13  Department of Health and Human Services, Medicaid Statistical Information System (MSIS) Report 
Fiscal Year 2000: Georgia.  Retrieved January 14, 2004, from 
http://www.cms.gov/medicaid/msis/00ga.pdf. 
14  Section 1905(a) of the Social Security Act. 
15 Section 1905(r) of the Social Security Act. 
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The current frequency schedule established for the Health 
Check EPSDT program requires a complete physical examination at 
birth; 1, 2, 4, 6, 9, 12, 15, and 18 months of age; annually from 2 to 
5 years of age; and every other year between 6 and 21 years of age.  
The frequency schedule requires that vision and hearing screenings be 
included as part of every Health Check physical screening for all 
children regardless of their age, if determined necessary based on their 
medical history. Health Check also requires dental services, separate 
from the medical examinations, and that all children 3 years of age and 
older receive dental services every 6 months.16 
Georgia requires that caseworkers refer all children entering foster care 
to the Medicaid eligibility office and that caseworkers coordinate with 
Medicaid-eligibility workers to determine the Title IV-E foster care and 
Medicaid program eligibility for the children they refer.  All children 
determined eligible for Title IV-E foster care funds in Georgia are 
automatically eligible for Medicaid health care services.17 
Further, Georgia requires State child welfare staff (e.g., eligibility 
specialists and caseworkers) to inform all foster care providers caring 
for Medicaid-eligible children of the availability of EPSDT services and 
to document that such services were offered.  The foster care caseworker 
is also responsible for arranging appropriate and timely medical care for 
children in foster care, obtaining health-related documents for the case 
record, and making arrangements for the children to receive initial 
health examinations as soon as possible after placement.18 
First Placement, Best Placement 
Georgia designed the First Placement, Best Placement (FP/BP) program 
in response to the Adoption and Safe Families Act, Public Law 105-89.19 
This Act requires States to develop case plans for children entering 
foster care to ensure reasonable efforts are made to reunite them with 
their families, ensure their health and safety while they are in foster 
care, and ensure appropriate decisions are made regarding permanency 
(e.g., reunification with the childs family or adoption).   
16 Georgia Multihealthnet System, Department of Community Health, Report Specification, 
Health Notification Letter-Dental Screening, May 30, 2002. 
17 Georgia Department of Community Health Manual, Section 2801-1, April 1, 2003. 
18 Georgia Department of Human Resources, Social Services Manual, Chapter 1000, 
Section 1007.3, May 2000. 
19 The Adoption and Safe Families Act, Administration for Children and Families, Program Instruction, 
ACYF-CB-PI-98-02, January 8, 1998. 
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The FP/BP program policy requires that all children entering foster care 
after July 1999 receive a Comprehensive Child and Family Assessment, 
which includes (1) the completion of a family assessment detailing the 
childs family history, a summary of the childs strengths, needs, and 
functional level,20 (2) a medical examination, (3) a dental examination, 
and (4) a developmental assessment for children 3 years of age or 
younger or a psychological evaluation for children 4 to 21 years of  
age. 21  Information obtained through the Comprehensive Child and 
Family Assessments aid child welfare agency staff, juvenile courts, 
families, and foster care providers in making decisions that will assure 
the safety and well-being of children in foster care.22 
All children entering foster care in Georgia must be referred for 
FP/BP services within 5 working days of the 72-hour detention 
hearing.23   The FP/BP caseworkers then have 30 days from the date of 
the referral to complete the Comprehensive Child and Family 
Assessment. At the time of our review, DFCS was contracting with 
80 private entities to provide FP/BP services, which included the 
development of a case plan and determination of needed interventions 
and services for all children entering foster care in Georgia.  
Medical and dental examinations to rule out conditions that may impact 
the childs overall well-being are required each time a child enters foster 
care.24   Some of the components required as part of the Comprehensive 
Child and Family Assessment (e.g., medical and dental examinations 
and developmental assessments and psychological evaluations) are also 
required as part of an EPSDT screening, as shown in Appendix A.  
However, FP/BP examinations and assessments are not used by the 
State to satisfy the EPSDT frequency guideline requirements. 
20  First Placement, Best Placement Manual, Section VI, June 2002 requires that a childs functional 
level be based on the Child and Adolescent Functional Scale, or Preschool and Early Childhood 
Functional Scale. 
21  First Placement, Best Placement Manual, Introduction Section, June 2002.

22  Ibid., p. 1.

23  The 72-hour detention hearing is used to determine if the State should retain custody of the child 

and maintain them in foster care. 
24  First Placement, Best Placement Manual, Sections III and IV, June 2002. 
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Initial Case Plan 
To meet Federal requirements,25 Georgia child welfare policy stipulates 
that caseworkers must develop an initial case plan for each child 
entering foster care within 30 days of entering State custody.26 Each 
childs case plan must include information obtained from his/her 
FP/BP assessment, information regarding family strengths and 
resources, and goals established for the child and his/her family.  To the 
extent available, information regarding each childs health (e.g., medical 
history, known medical problems, medications, immunizations, current 
health status, and dental status), the names and addresses of the childs 
health care professionals, and the childs emotional and psychological 
status are included in the initial case plan.  State policy requires that 
all case plans be reviewed and updated every 6 months.   
Section 475(1)(B) of the Act requires States to develop a plan for each 
child entering foster care to ensure their needs are addressed. Pursuant 
to section 475(1)(C) of the Act, available and accessible health 
information about a child is required to be included in the plan.  Section 
471(a)(15)(A) of the Act provides that the health and safety of children 
in foster care be considered of paramount concern.  Section 475(5)(D) of 
the Act requires that a childs health record be updated and supplied to 
the foster care provider with whom the child is placed.  Medical 
information plays a role in ensuring children receive required health 
care services.  In response, Georgia requires caseworkers to discuss with 
foster care providers the health status and health care needs of each 
child in their care, and to give foster care providers medical health 
information about each child placed in their care.  Caseworkers are also 
required to document that the foster care provider received the health 
information on each child.  The information provided to foster care 
providers should include, at a minimum and where available and 
accessible, the names and addresses of the childs current health care 
professionals, a record of the childs immunizations, known medical 
problems, medications, and any other relevant health information 
determined appropriate to share with the foster care provider.27 If any 
of this information is unknown or unavailable at the time the child is 
25 45 CFR  1356.21(g)(2) states that case plans must be developed no later that 60 days from the childs 
removal from the home. 
26  Georgia Department of Human Resources, Social Services Manual, Chapter 1007.2, p.8, May 2000. 
27 Georgia Department of Human Resources, Social Services Manual, Chapter 1007.2, p. 4, May 2000. 
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placed with a foster care provider, the caseworker is to provide an 
explanation regarding the missing information in the initial case plan.  
Caseworkers are instructed not to leave the medical portion of the case 
plan blank.28 
METHODOLOGY 
This inspection focused on the receipt of health care and dental services 
that meet EPSDT guidelines; the receipt of mental health services; and 
the provision of medical information to foster care providers. This study 
did not focus on 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: review of Federal 
and State policies; child-specific Medicaid claims data and case file 
documentation for 50 sampled children; interviews with caseworkers 
and foster care providers for the 50 sampled children; and interviews 
with Georgia State agency officials.  
Reasons for State Selection 
Georgia was selected for its medium population size based on 
Bureau of the Census data when compared to other States.  It was also 
chosen for its southern geographic location, largely rural setting, 
county-administered child welfare system, and fee-for-service provision 
of Medicaid services. 
Sample 
Children who met the following criteria were included in the study 
population: (1) were in foster care on March 26, 2003; (2) resided in 
Georgia; (3) were eligible for Title IV-E foster care program 
maintenance funds; and (4) had been in continuous foster care 
placements for at least 6 months. DFCS provided us with a list of the 
9,711 children who met these criteria.29  Appendix B provides 
information on the 50 children included in our study. 
28 Georgia Department of Human Resources, Social Services Manual, Chapter 1011.2 (7), p. 4, 
November 2000. 
29 Based on the Adoption and Foster Care Analysis and Reporting System information regarding children 
in foster care in Georgia, the Atlanta metropolitan area is underrepresented in the universe of 
children in IV-E foster care.  The percentage of children in foster care in the Atlanta region eligible 
for IV-E foster care maintenance is significantly lower than the remainder of the State. 
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Review of Law, Regulations, Policies, Medicaid Data, and Case File 

Documentation 

Law, Regulation, and Policy ReviewWe reviewed Federal laws and 
regulations and Georgia State foster care, Medicaid, and EPSDT 
program policies. The Georgia Health Check program meets the 
Federal EPSDT requirements. Therefore, we used State-established 
Health Check frequency guidelines to determine whether children in 
foster care were receiving required EPSDT medical examinations and 
dental services timely. 
Medicaid Claims ReviewDFCS provided us with up to 3 years of 
Medicaid claims data for each of the children in our sample. The 
data included Medicaid claims for physician, dental, pharmaceutical, 
and mental health services paid between March 26, 2000, and 
March 26, 2003. For children entering foster care on or after 
March 26, 2000, we analyzed Medicaid claims data from the date they 
entered foster care through March 26, 2003. Appendix C provides the 
number of Medicaid claims for each child in the sample who received 
services during the period covered by our review. 
Case File DocumentationWe requested case file documentation from 
Georgia DFCS local offices for all of the children in our sample, 
including documentation of medical, dental and mental health services 
provided, the childs medical history, the childs case plan, the FP/BP 
Comprehensive Child and Family Assessment, verification of the 
duration of the childs stay in foster care, and information regarding the 
childs health and general well-being. We received case file 
documentation for all 50 children. 
We reviewed case file documentation to determine if each sampled child 
had been referred for, scheduled for, or had actually received medical, 
dental, or mental health services (e.g., EPSDT form signed by a 
physician or other health care professional). Appendix D provides 
information regarding each sampled childs EPSDT services. 
We also reviewed the case file documentation and Medicaid claims data 
provided to determine if sampled children received FP/BP family 
assessments, medical and dental examinations, and developmental 
assessments or psychological evaluations, within the required 
timeframes. To determine the timeliness of these assessments, we used 
the dates listed on the copies of the assessment or evaluation reports. 
Therefore, all children should have received a Comprehensive Child and 
Family Assessment within 38 days of entering care. The 38 days 
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included completion of the court hearing required within 72 hours of 
entering care, 5 days to complete a referral for a FP/BP assessment, and 
30 days to complete the FP/BP assessment.  We also reviewed Medicaid 
claims data to identify initial medical examinations provided in 
outpatient and emergency room settings.  Appendix E identifies those 
children who received FP/BP services and the types of services they 
received.  
Interviews 
Foster Care Provider InterviewsWe conducted structured interviews with 
50 foster care providers responsible for the children in our sample (16 in 
person and 34 by telephone).  The interviews with foster care providers 
(i.e., foster parent or residential care facility staff) focused on the 
Medicaid program and the services available, the training they received 
related to the health and well-being of children, and their experiences 
procuring health care services for the children in our sample.   
Caseworker InterviewsWe conducted structured telephone interviews 
with the caseworkers assigned to all 50 sampled children.  Each of these 
interviews focused on the caseworkers understanding of the Medicaid 
program and the health and mental health services available, the 
training they received related to the health and well-being of children, 
their experiences accessing health care services, and any barriers to 
obtaining needed health care.  Each caseworker spoke specifically about 
the sampled childs case, and generally about his or her own experiences 
working in foster care. We analyzed the caseworkers responses and 
compared them to those of the foster care providers, noting any 
consensus or disagreement within and between the two groups. 
State Agency OfficialsTo enhance our understanding of the States 
foster care and Medicaid programs, we consulted, both in person and by 
telephone, with DFCS and the Georgia Department of Community 
Health staff. 
This inspection was conducted in accordance with the Quality 
Standards for Inspectionsissued by the Presidents Council on Integrity 
and Efficiency. 
OEI-07-00-00644  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  GEORGIA  9  
 F I N D I N G S
All 50 sampled children had Medicaid coverage,  Federal law requires that all 
and 49 had claims for health care services  children eligible for the 
Title IV-E foster care program be 
provided Medicaid services.30   In Georgia, all children in Title IV-E 
foster care are automatically eligible for Medicaid, including EPSDT 
services.31   Forty-nine of the fifty sampled children had Medicaid claims 
for health care services during the 3-year period covered by our study.  
One of the fifty sampled children, in foster care for over a year, had no 
Medicaid claims for health care services during the period covered by 
this study.  Table 1 details the various types of Medicaid-covered 
services and the number of claims by type of service provided for the 
49 sampled children with claims for health care services. 
Table 1:  Number and Type of Medicaid Claims for 
49 Sampled Children 
Number of 
Total Number of 
Claim Type  Children with at 
Claims 
Least One Claim 
Case Management*  45  839 
Dental  31  121 
Diagnostic 14  28 
Hospital/Emergency Care  18  43 
Laboratory 23  80 
Mental Health  37  494 
Miscellaneous**  38  121 
Optometry/Audiology 19  65 
Physical/Occupational 
3  15 
Therapy 
Physician Office  44  326 
Prescription Drug  46  1,335 
Skilled/Residential Care  5  49 
Surgical Procedures  4  10 
Transportation/Supplies  7  8 
Vaccines  22  40 
Total  3,574 
*	   Case management includes four Medicaid claims for Targeted Case Management.  
The remaining Case Management claims are for child protective services and residential 
care services case management. 
** Paid claims for which no diagnosis or procedure codes were given.
     See Appendix C for the number and type of Medicaid claims for the sampled children. 
Source: Office of Inspector General, 2004. 
30 Section 1902(a)(10)(A)(i)(I) of the Social Security Act. 

31 Georgia Department of Community Health Manual, Part II-Chapter 700, April 2003.

OEI-07-00-00644  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  GEORGIA  10  F I N D I N G S  

Thirty of forty-three sampled children  The EPSDT medical 
required to receive an EPSDT medical  examinations are intended to 
screen for and identify health 
examination received their most recent 
needs that may not be detected 
EPSDT medical examination within 
during a medical examination 
State-established frequency guidelines 
for a specific condition. All 
age-appropriate EPSDT examinations must be completed in accordance 
with the State-established EPSDT frequency guidelines. If a child 
entering foster care has not received the required age-appropriate 
EPSDT examinations in accordance with the frequency guidelines, the 
child should receive the needed services at the earliest possible time.32 
The Georgia DFCS is responsible for arranging appropriate and timely 
medical care for all children in foster care and arranging for an initial 
health examination as soon as the child is placed in foster care.  Seven 
of the fifty sampled children had been in foster care less than the time 
period specified by the EPSDT frequency guidelines for their age group 
and were not required to receive EPSDT examinations during that time.  
Of the remaining 43 sampled children, 30 received their most recent 
required EPSDT medical examinations within State-established 
guidelines. However, 13 of the 43 sampled children who should have 
received EPSDT medical examinations did not receive them within the 
required timeframe.  Caseworkers for 9 of these 13 children stated they 
were familiar with the Health Check program and indicated they had 
received training regarding EPSDT screenings or understood the 
required health examination policies for children in foster care. 
The EPSDT frequency guidelines 
Twenty-one of thirty-five sampled 
adopted by Georgia require that all 
children required to receive EPSDT 
children 3 years of age or older 
dental services received their most 
receive dental services every 
recent EPSDT dental service within 
6 months and allow for all children 
State-established frequency guidelines    to be referred for dental services at 
any time. Thirty-nine of the 
sampled children were 3 years of age or older.  However, we could 
evaluate receipt of required dental services only for the 35 sampled 
children with a full 6 months of Medicaid claims during our study 
period. 
32 Georgia Department of Community Health Manual, Part II, Chapter 900, Section 902, April 2003. 
OEI-07-00-00644  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  GEORGIA  11  F I N D I N G S  
Only 21 of the 35 children required to receive dental services received 
their most recent required dental service, in accordance with the 
State-established EPSDT frequency guidelines. We were unable to 
determine why the remaining 14 children did not receive their most 
recent required dental services within the required timeframe. Only 
1 foster care provider for the 14 children reported experiencing 
problems finding a dentist that would accept Medicaid and treat the 
sampled child in his/her care. 
Many of the sampled children did not receive  Section 471(a)(22) of the Act 
First Placement, Best Placement assessments  required States to develop and 
implement standards to 
within the State-required timeframe 
ensure the health and safety 
of children in foster care by January 1, 1999.  In response to this 
statute, Georgia DFCS established the FP/BP program in 1998 
beginning with five demonstration counties.  They implemented the 
program statewide in July 1999.33  Policies governing the 
FP/BP program require that children entering foster care after 
July 1999 receive all services required as part of a Comprehensive Child 
and Family Assessment (i.e., family assessment, medical and dental 
examinations, and developmental assessment or psychological 
evaluation) within 30 days from the date the DFCS caseworker makes 
the referral to the FP/BP agency.  In most respects, FP/BP components 
mirrored those required as part of EPSDT examinations.  See 
Appendix A for a comparison of EPSDT and FP/BP required 
components. 
Forty of the fifty sampled children entered foster care after 
July 1999 and, therefore, were required to receive a Comprehensive 
Child and Family Assessment.  However, we could determine 
FP/BP compliance for only 39 of the sampled children because 1 child 
entered foster care during the period covered by FP/BP policy, but 
before the beginning of our Medicaid claims window.  Not all children 
received all of the required assessment services, and some services were 
not received timely. 
33 Georgia Department of Human Resources, Division of Family and Children Services, First 
Placement/Best Placement Fact Sheet dated February 2003. 
OEI-07-00-00644  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  GEORGIA  12  FF II NN DD II NN GG SS  
Family Assessments are not completed timely. 
The goal of a family assessment is to gather information about the child 
and his/her family. The family assessment includes information about the 
childs history and aids in identifying services relating to the health and 
safety of the child and his/her needs while in foster care. Caseworkers 
provided us with family assessments for 26 of the 39 sampled children 
covered by FP/BP. Fifteen of the twenty-six assessments were dated, but 
only 2 of the 15 were completed within the required 30-day timeframe. 
Eleven of the twenty-six assessments were not dated, and we were unable 
to determine if they were completed within the required 30-day 
timeframe. We did not receive family assessments for the remaining 
13 sampled children and, therefore, were unable to determine if family 
assessments for these children were completed or completed timely. 
Fourteen of thirty-nine sampled children did not receive FP/BP medical 
examinations within the State-required timeframe. 
The initial medical examination documents the childs medical history 
upon entering foster care. This information is used by DFCS to assure 
that the medical needs of children in foster care are addressed. Some of 
the FP/BP initial medical examination components mirrored those 
components required as part of EPSDT medical examinations. 
Twenty-five of the thirty-nine sampled children required to receive FP/BP 
services received their initial medical examinations timely. Twelve of 
these thirty-nine children did not, waiting 46 to 435 days after entering 
foster care to receive an initial medical examination. Two of the thirty-
nine sampled children did not have case file information or Medicaid 
claims data to indicate they received the required medical examination 
even though one child had been in foster care 242 days and the other had 
been in foster care 398 days at the end of the period covered by our 
Medicaid claims window. 
Thirteen of twenty-four sampled children did not receive FP/BP dental 
examinations within the State-required timeframe. 
The initial dental examination, required for children age 3 and older, 
documents the childs dental history upon coming into foster care. DFCS 
uses this information to ensure that the dental needs of children in foster 
care are addressed. Like the initial FP/BP medical examinations, 
FP/BP dental examination components mirrored those required as part 
of EPSDT dental services. 
Twenty-four of the thirty-nine sampled children were age 3 or older on the 
date they entered foster care, and were required to have a dental 
OEI-07-00-00644  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  GEORGIA  13  F I N D I N G S  
examination completed within 30 days from the date of referral to FP/BP. 
However, only 7 of these 24 sampled children received their initial dental 
examination timely. Thirteen children waited from 43 to 371 days after 
entering foster care to receive their initial dental examinations, and four 
children had no Medicaid claims for dental examinations.   
Some sampled children did not receive developmental assessments or 
psychological evaluations within the State-required timeframe. 
Developmental AssessmentsThe initial developmental assessment screens 
and assesses developmental milestones and characteristics for children 3 
years of age or younger when they enter foster care.  The information 
from these assessments is critical in making placement decisions, 
developing case plans, assuring the safety and well-being of the child, and 
obtaining services for children who have developmental delays.  The 
EPSDT guidelines do not require that children receive an initial 
developmental assessment but some of the aspects of the initial 
assessment meet the EPSDT developmental/behavioral component 
requirements.  
Sixteen of the thirty-nine sampled children referred to FP/BP were 
3 years of age or younger when they entered foster care.  Two of these 
sixteen sampled children received their developmental assessment timely.  
Ten of the sixteen sampled children received their developmental 
assessments 40 to 885 days after entering foster care.  We were unable to 
document the receipt of the required initial developmental assessment for 
4 of the 16 children because there was no Medicaid claim to indicate an 
assessment had been completed and no developmental assessment report 
was included in the case file. 
Psychological EvaluationsInitial psychological evaluations differ 
from developmental assessments and are only required for children age 
4 and older.  These evaluations should include, but are not limited to, the 
psychological status of the child or adolescent at the time they enter foster 
care.  If a psychological evaluation yields any mental health concerns, the 
psychological summary and report must provide detailed 
recommendations and actions to be taken.34  DFCS uses this information 
to identify the childs mental health service needs and to assure his/her 
safety and well-being. The initial psychological evaluation is not required 
34 First Placement, Best Placement Manual, Section IV, June 2002. 
OEI-07-00-00644  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  GEORGIA  14  F I N D I N G S  
by the EPSDT frequency guidelines, but meets some of the EPSDT 
developmental/behavioral component requirements.  
Twenty-three of the thirty-nine sampled children referred to FP/BP were 
4 to 21 years of age when they entered foster care.  Fifteen of the twenty-
three sampled children received their psychological evaluations within 
required timeframes.  Eight of the twenty-three sampled children who 
received a psychological evaluation did not receive it within the required 
30-day timeframe, with receipt ranging from 41 to 461 days after referral.   
Section 475(1)(B) of the Act 
Four sampled children did not receive services to 
requires a case plan to be 
address documented mental health needs, and 
developed for each child entering 
mental health needs were not documented for five 
foster care, and that the plan 
children who received such services 
should include steps for assuring 
that the child receives safe and proper care.  Section 475(1)(C) of the Act 
requires the health records of the child including names and addresses 
of providers, a record of immunizations, any known medical problems, 
medications, and any other relevant health information also be included 
in the plan.  The Georgia DFCS further requires that case plans contain 
information regarding the childs current emotional and psychological 
status.35  The Georgia DFCS requires caseworkers to complete case 
plans within 30 days from the date a child enters foster care, and to 
update the plans every 6 months. 
Discrepancies existed in the documentation and receipt of mental health 
services for 9 of the 50 sampled children.  Four of the nine sampled 
children had an assessment indicating a need for mental health 
services.  However, these four children received no additional mental 
health services.  The remaining five children had Medicaid claims 
indicating they received mental health services, and caseworkers and 
foster care providers for these children acknowledged the children were 
getting their mental health services needs met, but the need for mental 
health services was not documented.  Documentation is essential to 
ensure the continuation of needed services. 
35 Georgia Department of Human Resources, Social Services Manual, Chapter 1007.8, p. 19, May 2000. 
OEI-07-00-00644  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  GEORGIA  15  FF II NN DD II NN GG SS
  
Section 471(a)(15)(A) of the Act
Twenty-four of the fifty foster care providers 
provides that the health and 
reported never receiving medical information 
safety of children in foster care be 
for the children in their care  considered of paramount concern. 
Medical information supplies 
foster care providers with information necessary to ensure that the child 
in their care receives proper care and that the childs needs are met. 
Section 475(5)(D) of the Act requires that a childs health records be 
reviewed and updated and supplied to the foster care provider with 
whom the child is placed at the time of each placement. Georgia 
requires all caseworkers to supply the foster care provider with a copy of 
the health information on the child, and to document that the foster 
care provider received the health information.36 
Of the 50 foster care providers we interviewed, 24 stated they received 
no medical information for the sampled children in their care. However, 
caseworkers for 21 of these 24 children reported they had received or 
compiled some medical information for the sampled children. While we 
were unable to determine the reasons that available medical 
information was not given to these 21 foster care providers, failure to 
share this information indicates a problem in the communication of 
medical information from caseworkers to foster care providers and could 
result in childrens needs not being met. 
36 Georgia Department of Human Resources, Social Services Manual, Chapter 1000, 
Sections 1011.2, p.4, November 2000. 
OEI-07-00-00644  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  GEORGIA  16  
 R E C O M M E N  D A T  I O N S  
States are required to ensure that all children in foster care are 
provided quality health care services that protect their health.  States 
are also required to develop a plan for each child that includes their 
health care needs and medical information and to supply foster care 
providers with a childs health record at the time the child is placed 
with them. Medical information plays a role in ensuring that children 
receive required health care services.  The EPSDT program is intended 
to detect various health needs.  The Georgia FP/BP program requires 
that each child who enters foster care receive a Comprehensive Child 
and Family Assessment. However, if children do not receive the 
required EPSDT services or FP/BP assessments, or do not receive those 
services timely, their health needs may go undetected and untreated. 
ACF and CMS should work with the Georgia Department of Community 
Health to ensure that:  
o 	 The EPSDT medical examinations and dental services are 
received timely. 
ACF should work with the Georgia Department of Human Resources, 
DFCS to ensure that: 
o 	 Assessments are completed within the required timeframe. 
o 	 Foster care providers receive initial and updated medical 
information for children placed in their care. 
In addition, ACF should work with DFCS to ensure that case files 
contain required documentation, including mental health needs.  
Further, during the course of this study, we noted that some of the 
components of the FP/BP Comprehensive Child and Family 
Assessments mirrored the components required as part of EPSDT.  
We encourage ACF, CMS, DFCS, and the Georgia Department of 
Community Health to consider allowing services provided under either 
program to count for meeting the requirements of both programs, as 
appropriate. 
OEI-07-00-00644  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  GEORGIA  17  
 A G E N C Y   C O M M E N T S
ACF described actions it is taking that will address our 
recommendations.  It is monitoring the State of Georgia through 
quarterly reports relative to the States efforts to ensure that EPSDT 
medical examinations and dental services are received timely and to 
ensure that foster care providers receive appropriate medical 
information for children placed in their care. 
CMS concurred with the OIG recommendation and will have CMS 
regional office staff work with the Georgia Department of Community 
Health to ensure that EPSDT services are provided according to the 
State-established EPSDT frequency guidelines. CMS also notes that its 
staff is available to the State and to ACF to provide any necessary 
technical assistance.  Additionally, in response to an OIG suggestion, 
CMS will not prohibit FP/BP assessments to serve as EPSDT screenings 
if the screenings are provided in accordance with the State-established 
EPSDT frequency guidelines and meet the definition of an EPSDT 
screening, with all age appropriate screens and services being provided. 
OEI-07-00-00644  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  GEORGIA  18    A P P E N D I X   ~   A
EPSDT and First Placement, Best Placement Required Components 
The table below provides a comparison of EPSDT and FP/BP 
components. 
FP/BP
Screening/Examination  EPSDT Required 
Required 
Components  Component 
Component 
INITIAL/INTERVAL  Y  Y 
MEASUREMENTS 
Height and Weight  Y  Y 
Head Circumference  Y  Y 
Blood Pressure  Y  Y 
SENSORY SCREENING 
Vision  Y  Y 
Hearing  Y  Y 
MENTAL HEALTH  Y*     Y** 
PHYSICAL EXAMINATION  Y  Y 
PROCEDURES  Y  Y 
Hereditary/Metabolic  Y  Y 
Screening (newborn)  Y  Y 
Immunization  Y  Y 
Tuberculin Test  Y  Y 
Hematocrit or Hemoglobin  Y  Y 
Urine  Y  Y 
Lead Screening  Y  N 
ANTICIPATORY GUIDANCE  Y  Y 
DENTAL EXAMINATION  Y  Y 
*The EPSDT mental health component requires developmental/behavioral assessments 
be performed by the physician who conducts the EPSDT medical examination. 
**The FP/BP mental health component requires developmental assessments and 
psychological evaluations be performed by trained professionals who specialize in the 
field of mental health, and are more extensive than those required as part of an EPSDT 
medical examination. 
OEI-07-00-00644  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  GEORGIA  19    A P P E N D I X   ~   B
Demographic Charactertics of Sampled Children 
The table below provides the demographic characteristics of each of 
the 50 sampled children and his or her foster care placement history 
as of June 1, 2003. 
Entries 
Months Since Placements  Months Since Caseworkers  Months 
OIG  Age in  Placement  into 
Sex  Foster Care  Since Last  Last  Since Last  Caseworker 
ID  Years  Setting  Foster 
Entry (2)  Entry (3)  Placement (4)  Entry (5)  with Case (6) 
Care (1) 
1  3  M  Family  1  33  1  33  3  24 
2  14  F  Family  1  26  2  20  *  7 
3  15  M  Residential  2  13  5  4  1  13 
4  1  M  Family  1  21  1  21  2  17 
5  11  F  Family  1  28  6  18  3  5 
6  2  F  Family  *  18  1  18  1  18 
7  11  M  Family  1  14  1  14  1  14 
8  7  M  Family  1  13  1  13  *  5 
9  16  F  Residential  1  40  7  30  4  22 
10  3  F  Family  1  21  1  21  2  4 
11  5  F  Family  1  25  2  12  3  12 
12  2  M  Family  1  12  2  9  1  12 
13  13  F  Family  2  14  1  14  4  1 
14  17  F  Kinship  1  91  1  91  2  12 
15  10  F  Kinship  2  19  4  12  4  1 
16  16  F  Family  *  44  3  16  *  24 
17  12  F  Family  1  19  2  15  2  12 
18  3  M  Family  1  9  1  9  1  9 
19  16  F  Residential  2  35  8  7  3  24 
20  17  F  Family  1  52  2  9  3  1 
21  7  M  Therapeutic  1  29  *  19  5  1 
22  3  M  Family  1  22  3  1  1  22 
23  12  M  Family  2  11  1  11  *  6 
24  8  M  Family  1  20  1  20  3  16 
25  16  F  Family  3  20  2  18  3  4 
26  9  M  Therapeutic  1  116  6  1  5  12 
27  1  M  Family  1  15  2  1  4  12 
28  2  F  Family  1  31  1  31  3  2 
29  9  F  Family  1  75  3  13  2  12 
30  15  M  Residential  1  22  10  2  3  3 
31  7  F  Family  1  56  2  6  8  6 
OEI-07-00-00644  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  GEORGIA  20  A P P E N D I X ~ B  

Entries 
Months Since Placements  Months Since Caseworkers  Months 
OIG  Age in  Placement  into 
Sex  Foster Care  Since Last  Last  Since Last  Caseworker 
ID  Years  Setting  Foster 
Entry (2)  Entry (3)  Placement (4)  Entry (5)  with Case (6) 
Care (1) 
32  1  F  Family  1  10  1  10  2  6 
33  11  M  Kinship  2  131  *  120  3  5 
34  11  `F  Family  2  10  2  8  1  10 
35  17  F  Institution  1  102  3  32  5  18 
36  8  F  Family  1  26  1  26  *  24 
37  3  F  Family  2  36  2  14  3  5 
38  1  F  Family  1  10  1  10  1  10 
39  2  F  Family  1  24  2  2  3  11 
40  2  F  Family  1  30  1  30  2  29 
41  17  F  Residential  1  19  1  19  1  19 
42  9  F  Kinship  1  37  1  37  2  3 
43  1  F  Family  1  9  1  9  1  9 
44  17  M  Institution  1  28  5  13  *  27 
45  10  M  Family  1  21  3  1  *  13 
46  1  M  Family  1  14  2  5  2  12 
47  17  M  Therapeutic  1  48  1  48  3  2 
48  8  F  Kinship  2  12  2  7  *  10 
49  13  F  Family  1  54  *  10  6  16 
50  15  M  Residential  1  21  10  3  3  3 
KEY 
(1)  Entries into Foster Carenumber of times a child has entered State custody. 
(2)  Months Since Foster Care Entrylength of time from the date of the childs 
most recent entry into foster care until June 1, 2003, when interviews were 
conducted with caseworkers and foster care providers, or the date the child left 
care if that date precedes June 1, 2003.   
(3)  Placements Since Last Entrytotal number of placements, in all settings 
(e.g., Foster Home, Residential Care Facility), the child experienced during their 
most recent entry into foster care.  
(4)  Months Since Last Placementlength of time from the date of the most 
recent foster care placement to the date the foster care provider was interviewed.   
(5)  Caseworkers Since Last Entrynumber of caseworkers assigned 
responsibility for the child since his/her last entry into foster care.  
(6)  Months Caseworker with Casenumber of months the most recent 
caseworker has been assigned responsibility for the child. 
(*)  Indicates an unknown value. 
OEI-07-00-00644  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  GEORGIA  21    A P P E N D I X   ~   C
Medicaid Claims for Sampled Children 
The table below indicates each of the 50 childrens paid Medicaid 
claims for physician visits, dental services, prescription medications, 
and mental health services from March 26, 2000, to March 26, 2003.   
Number of Medicaid Claims* 
OIG ID  Medical and  Dental  Prescription  Mental Health 
Physician's Visits  Services  Medications  Services 
1  36  0  54  0 
2  2  1  11  21 
3  2  0  16  11 
4  13  0  10  0 
5  8  3  80  25 
6  10  0  50  1 
7  2  2  27  28 
8  1  3  12  1 
9  6  0  11  62 
10  0  0  6  0 
11  1  0  8  1 
12  0  0  25  0 
13  1  3  0  0 
14  15  5  30  7 
15  2  0  10  4 
16  12  10  22  5 
17  3  4  34  14 
18  6  0  16  1 
19  14  3  19  12 
20  5  5  4  7 
21  8  4  47  26 
22  9  0  27  0 
23  2  1  27  2 
24  4  2  24  8 
25  0  5  0  19 
26  17  3  54  30 
27  0  0  0  0 
28  35  1  19  0 
29  6  4  19  84 
30  4  3  40  10 
31  1  1  0  1 
32  11  0  5  1 
33  1  3  2  18 
34  0  2  7  1 
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Number of Medicaid Claims* 
Medical and  Dental  Prescription  Mental Health 
OIG ID 
Physician's Visits  Services  Medications  Services 
35  7  4  5  28 
36  9  6  22  10 
37  10  0  9  1 
38  5  0  15  0 
39  1  0  1  0 
40  14  0  27  0 
41  1  5  137  1 
42  3  13  4  1 
43  2  0  1  1 
44  13  8  108  1 
45  3  7  22  22 
46  7  0  13  0 
47  7  4  187  0 
48  5  1  20  2 
49  0  1  31  24 
50  2  4  17  3 
TOTAL  326  121  1335  494 
KEY 
* 	Includes only services for which a Medicaid claim was paid.  Services 
documented in the case file for which no Medicaid claims were paid are 
not included.   
OEI-07-00-00644  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  GEORGIA  23    A P P E N D I X   ~   D
EPSDT Services for Sampled Children 
The table below reflects EPSDT services received by each of the 
50 sampled children from March 26, 2000, to March 26, 2003, or from 
entry into foster care to March 26, 2003, whichever is shorter. 
Medical  Case Plan  EPSDT Services Current (3) 
History In  Completed In 
OIG ID 
Case File  30 Days Medical  Dental 
(1)  (2) 
1  Y  Y  A  D 
2  Y  Y  C  A 
3  Y  Y  B  D 
4  Y  Y  A  D 
5  Y  N  B  A 
6  Y  Y  A  D 
7  Y  Y  B  C 
8  Y  N  B  C 
9  Y  NP  D  C 
10  Y  Y  C  D 
11  Y  Y  C  C 
12  Y  NP  C  D 
13  Y  Y  B  C 
14  Y  NP  B  A 
15  Y  Y  B  C 
16  Y  Y  B  A 
17  Y  NP  D  A 
18  Y  N  B  D 
19  Y  Y  B  C 
20  Y  Y  B  A 
21  Y  NP  C  A 
22  Y  Y  A  D 
23  Y  Y  C  A 
24  Y  Y  B  A 
25  Y  Y  B  A 
26  Y  NP  D  C 
27  Y  NP  C  D 
28  Y  NP  A  B 
29  Y  Y  C  C 
30  Y  NP  A  C 
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Medical  Case Plan  EPSDT Services Current (3) 
History In  Completed In 
OIG ID 
Case File  30 Days Medical  Dental 
(1)  (2) 
31  Y  NP  A  A 
32  Y  Y  A  D 
33  Y  Y  B  A 
34  Y  N  C  C 
35  Y  NP  D  C 
36  Y  Y  A  A 
37  Y  NP  C  C 
38  Y  NP  C  D 
39  Y  NP  C  D 
40  Y  Y  A  D 
41  Y  Y  A  A 
42  Y  Y  D  A 
43  Y  N  A  D 
44  Y  Y  A  A 
45  Y  NP  D  A 
46  Y  Y  A  D 
47  Y  Y  B  C 
48  Y  Y  A  A 
49  Y  NP  C  B 
50  Y  NP  D  B 
KEY 
(1) 	 Medical History in Case Filecase file documentation provided by the 
sampled childs caseworker included a medical history 
(2)  Case Plan Completed in 30 Dayscase plan was completed within 30 days 
after the child entered foster care or was not provided to us. 

Y - Case plan completed within 30 days. 

N - Case plan not completed within 30 days. 

NP - Case plan not provided to us. 

(3)  EPSDT Services CurrentMedical and Dental  
A - Most recent required service was received. 
B - One or more services were received, but the sampled child would not 
have been considered out of compliance if the service had not been 
received based on his/her age or the length of time the child had been in 
foster care at the time of our review. 

C - Most recent required service was not received. 

D - No services were received, but none were required during our 
claims window (i.e., the length of time the child had been in foster 
care and the period covered by our claims window did not extend 
the full length of time covered by the EPSDT frequency guidelines 
for the childs age, or the child was under 3 years of age and not 
required to receive dental services). 
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First Placement, Best Placement Assessments 
The table below reflects the number of days from the date of entry into 
foster care to the date child received initial assessment services from a 
First Placement, Best Placement professional. 
Child Entered  FP/BP Initial 
Initial Required Services 
Care During the  Services 
OIG 
Medicaid  Required  Developmental  Psychological  Medical  Dental 
ID 
Claims Window  Assessment  Evaluation  Examination     Examination  
(1)  (2)  (3)  (3)  (4)  (4) 
1  Y  Y  X   9   
2  Y  Y    27  4  4 
3  Y  Y   26  3  X 
4  Y  Y  42   2   
5  Y  Y    33  25  371 
6  Y  Y  335   46   
7  Y  Y    55  19  145 
8  Y  Y   84  61  21 
9  N  Y 
10  Y  Y  X   8   
11  Y  Y    461  1  X 
12  Y  Y  X   243   
13  Y  Y    37  34  34 
14  N  N 
15  Y  Y   28  435  X 
16  N  N 
17  Y  Y   **  49  1 
18  Y  Y  21   26   
19  Y  Y    35  20  43 
20  N  N 
21  Y  Y   41  38  216 
22  Y  Y  85   17   
23  Y  Y    98  148  168 
24  Y  Y   23  1  123 
25  Y  Y   15  9  290 
26  N  N 
27  Y  Y  90   X   
28  Y  Y  58   294   
29  N  N 
30  Y  Y    33  2  23 
OEI-07-00-00644  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  GEORGIA  26  A P P E N D I X ~ E  

Child Entered  FP/BP Initial 
Initial Required Services 
Care During the  Services 
OIG 
Medicaid Claims  Required  Developmental  Psychological  Medical  Dental 
ID 
Window  Assessment  Evaluation  Examination  Examination   
(1)  (2)  (3)  (3)  (4)  (4) 
31  N  N 
32  Y  Y  40   5   
33  N  N 
34  Y  Y    17  X  15 
35  N  N 
36  Y  Y   25  204  156 
37  Y  Y  885   158  X 
38  Y  Y  X   21   
39  Y  Y  54   2   
40  Y  Y  150   7   
41  Y  Y    16  1  13 
42  Y  Y   73  121  128 
43  Y  Y  26   9   
44  Y  Y    13  356  213 
45  Y  Y   41  1  125 
46  Y  Y  140   4   
47  N  N 
48  Y  Y    13  6  130 
49  N  N 
50  Y  Y   102  340  349 
KEY 
(1) Child Entered Care During the Medicaid Claims Windowchild entered foster care 
between March 26, 2000, and March 26, 2003. 
(2) FP/BP Initial Services Requiredchild entered foster care after July 1999, and, 
therefore, was required to receive FP/BP initial services. 
(3) Developmental Assessment or Psychological Evaluationnumber of days from the date 
the sampled child entered foster care and receipt of a developmental assessment or 
psychological evaluation.  We used either the date of the psychological report from the childs 
case file or the Medicaid claims data date, whichever was closest to the childs foster care 
entry date. 
(4) Medical Examination or Dental Examinationnumber of days from the date the sampled 
child entered foster care and receipt of a medical examination or dental services.  We used 
the Medicaid claims data date or medical documentation from the case file, whichever was 
closest to the childs foster care entry date, to determine when the child received his/her first 
outpatient, emergency room, or EPSDT medical examination.   
X Indicates service not received. 
 Indicates that the service was not required based on the sampled childs age at the time of 
our review.   
**  Child received a psychological evaluation 125 days before coming into foster care. 
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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 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 that 
contributed include: 
Deborah Walden, Team Leader

Zula Crutchfield, Project Leade
r 
Elander Phillips, Program Analyst 
Linda Paddock, Program Analyst
Brian Whitley, Program Analyst
Steve Milas, Program Analyst 
Michala Walker, Program Analyst
Linda Hall, Program Specialist 
Barbara Tedesco, Mathematical Statistician 
OEI-07-00-00644  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE:  GEORGIA  32