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 : K
OSTER  ARE ANSAS 
Inspector General 
AUGUST 2003 
OEI -07-00-00640  Office of Inspector General

http://oig.hhs.gov 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department of Health and Human Services (HHS) 
programs, as well as the health and welfare of beneficiaries served by those programs. This 
statutory mission is carried out through a nationwide network of audits, investigations, and 
inspections conducted by the following operating components: 
Office of Audit Services 
The OIG's Office of Audit Services (OAS) provides all auditing services for HHS, either by 
conducting audits with its own audit resources or by overseeing audit work done by others. 
Audits examine the performance of HHS programs and/or its grantees and contractors in 
carrying out their respective responsibilities and are intended to provide independent 
assessments of HHS programs and operations in order to reduce waste, abuse, and 
mismanagement and to promote economy and efficiency throughout the department. 
Office of Evaluation and Inspections 
The OIG's Office of Evaluation and Inspections (OEI) conducts short-term management and 
program evaluations (called inspections) that focus on issues of concern to the department, 
the Congress, and the public. The findings and recommendations contained in the 
inspections reports generate rapid, accurate, and up-to-date information on the efficiency, 
vulnerability, and effectiveness of departmental programs. 
Office of Investigations 
The OIG's Office of Investigations (OI) conducts criminal, civil, and administrative 
investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries and of 
unjust enrichment by providers. The investigative efforts of OI lead to criminal convictions, 
administrative sanctions, or civil monetary penalties. The OI also oversees State Medicaid 
fraud control units, which investigate and prosecute fraud and patient abuse in the Medicaid 
program. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, 
rendering advice and opinions on HHS programs and operations and providing all legal 
support in OIG's internal operations. The OCIG imposes program exclusions and civil 
monetary penalties on health care providers and litigates those actions within the 
department. The OCIG also represents OIG in the global settlement of cases arising under 
the Civil False Claims Act, develops and monitors corporate integrity agreements, develops 
model compliance plans, renders advisory opinions on OIG sanctions to the health care 
community, and issues fraud alerts and other industry guidance.  E X E C U T I V E   S U M M A R Y

OBJECTIVE 
To determine whether sampled children in the Kansas foster care 
program receive health care services. 
BACKGROUND 
Compared with children from the same socioeconomic background, 
children in foster care suffer much higher rates of serious emotional 
and behavioral problems, chronic physical disabilities, birth defects, 
and developmental delays. Kansas had 6,569 children in foster 
care at the end of the Federal fiscal year 2000, and utilized a 
statewide public-private partnership for the delivery of child 
welfare services. Kansas is one of a series of States chosen to 
represent a diverse cross-section of foster care nationwide. The 
Administration for Children and Families (ACF) has regulatory 
oversight of the Title IV-E foster care programs. The Centers for 
Medicare & Medicaid Services (CMS) is responsible for oversight of 
individual State Medicaid programs. 
All Title IV-E children in the Kansas foster care program are 
eligible for Medicaid. Federal Early and Periodic Screening, 
Diagnosis, and Treatment (EPSDT) guidelines require each State to 
provide coverage for preventive health care services to Medicaid-
eligible individuals under the age of 21, as outlined in 
Section 1905(r) of the Social Security Act (the Act). In addition, 
Sections 472(h) and 1902(a)(10)(A)(i)(I) of the Act require States to 
provide Medicaid, or equivalent health insurance coverage, to 
children eligible to receive Title IV-E foster care program 
maintenance funds. 
This inspection is based on information gathered from multiple 
sources: reviews of Federal and State policies; analysis of child-
specific Medicaid claims data and case file documentation for 
50 randomly-sampled children; interviews with foster care 
providers (e.g., foster parents and residential care facility staff) and 
caseworkers for the children in our sample; interviews with Kansas 
State agency officials; and telephone calls to dental office staff to 
validate foster care providers concerns regarding the lack of 
available Medicaid dental providers. This study did not address 
follow-up care or the appropriateness of ongoing health care in 
meeting the needs of foster children. 
OEI-07-00-00640  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: KANSAS  i  E X E C U T I V E   S U M M A R Y  
FINDINGS 
All sampled children have Medicaid coverage and claims for 
services 
In accordance with Federal law and State regulations, all of the 
sampled children have Medicaid coverage. All 50 children had at 
least one claim for services through Medicaid. 
Ninety percent of sampled children received EPSDT 
Medicaid examinations, and 82 percent received EPSDT 
dental examinations, in accordance with State guidelines 
Ninety percent (45/50) of the sampled children were receiving 
medical services that met the current EPSDT periodicity time 
frames. Eighty-two percent (32/39) of children required to receive 
dental services received a dental examination within established 
EPSDT guidelines, although foster care providers expressed 
difficulties locating dentists willing to accept Medicaid patients. 
Eighty-two percent of sampled children received initial 
medical examinations within required timeframes 
Of the 39 children in our sample who had initial placements during 
our study time period, 82 percent (32) had a Medicaid paid claim or 
case file documentation indicating a medical examination took 
place within 30 days of placement. 
All sampled children received mental health services 
The Kansas IV-E foster care program State plan requires that an 
individual case plan, including an assessment of the childs mental 
health needs, be developed for each child in foster care within 
30 days of their entry into State custody. All children in our sample 
had a completed case plan and Medicaid claims for mental health 
services. 
OEI-07-00-00640  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: KANSAS  ii  E X E C U T I V E   S U M M A R Y  
Forty-three percent of foster care providers in our sample 
reported never receiving a medical history for the child in 
their care 
Sections 422(b)(10)(B)(ii) and 475(5)(D) of the Act provide for a case 
review system and procedures for ensuring that a childs health 
record is reviewed, updated, and supplied to the foster care 
provider. Forty-three percent (20/46) of foster care providers 
interviewed reported never receiving a medical history for the 
sample child in their care. However, 12 out of 20 caseworkers for 
these children reported compiling or receiving a medical history. 
RECOMMENDATIONS 
To ensure that children in foster care have access to and receive the 
most appropriate health care services, we recommend that: 
ACF work with the Kansas Department of Social and 
Rehabilitation Services to promote the importance of obtaining 
medical histories for children in foster care and providing this 
information to foster parents. 
CMS work with the Kansas Department of Social and 
Rehabilitation Services to increase the number of Medicaid health 
care providers willing to provide services to children in foster care, 
and provide case workers and foster care providers with current 
lists of Medicaid providers willing to treat children in foster care. 
AGENCY COMMENTS 
ACF indicated the background provided in this report was useful. 
ACF also notes that they are working with the Kansas Department 
of Social and Rehabilitation Services to promote the importance of 
obtaining medical histories for children in foster care, and have 
included steps necessary to gather medical information and provide 
the information to foster parents. We incorporated suggested 
terminology changes into this document. The full text of ACFs 
comments to the draft report is located in Appendix D. 
CMS concurs, in part, with our recommendations and points out 
that the Medicaid program is State-administered within broad 
Federal guidelines. As such, CMS does not have the ability to 
directly impact the numbers of providers participating in the 
OEI-07-00-00640  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: KANSAS  iii  Kansas Medicaid program or the collection, maintenance, and 
distribution of lists of participating providers. However, CMS 
indicates they are available to provide technical assistance to the 
State to promote these processes. The full text of CMSs comments 
to the draft report is located in Appendix E. 
OEI-07-00-00640  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: KANSAS  iv  T A B L E   O F   C O N T E N T S

EXECUTIVE SUMMARY .................................................................................i

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

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

All sampled children have Medicaid coverage and claims for 

services ............................................................................................... 8

High percentages of sampled children received EPSDT medical 

and dental examinations.................................................................... 8

Eighty-two percent of sampled children received initial medical 

examinations within required timeframes......................................11

All sampled children received mental health services .................... 11

Forty-three percent of sampled foster care providers never 

received a medical history for the child in their care ...................... 12

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

APPENDICES ..............................................................................................15

Appendix A: Kansas Foster Care and Medicaid Programs ............. 15

Appendix B: Detailed Demographic Data ........................................ 16

Appendix C: Detailed Claims Data .................................................. 18

Appendix D: Agency Comments - ACF ............................................ 20

Appendix E: Agency Comments - CMS............................................24

ACKNOWLEDGMENTS................................................................................26

OEI-07-00-00640  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: KANSAS  v
 I N T R O D U C T I O N

OBJECTIVE 
To determine whether sampled children in the Kansas foster care 
program receive health care services. 
BACKGROUND 
Currently, there are an estimated 565,000 children in foster care 
nationwide,1 many of whom are reportedly in poor health. To 
determine if children in foster care are receiving mandated health 
care services, we selected a series of States for review.2 The States 
were chosen to represent a diverse cross-section of foster care 
nationwide. Kansas was selected because of its child welfare 
population size, State location, Medicaid fee-for-service coverage for 
children in foster care, and statewide public-private partnership for 
child welfare service delivery.  Kansas had 6,569 children in foster 
care at the end of the Federal fiscal year 2000, based on the most 
recent Federal data available at the time of our review.3 The 
Administration for Children and Families (ACF) has regulatory 
oversight of the Title IV-E foster care program, including State 
plans to ensure State foster care programs are operating within 
Federal guidelines. 
Compared with children from similar socioeconomic backgrounds, 
children in foster care suffer much higher rates of serious physical 
and psychological problems.4 Dental problems are prevalent in the 
foster care population and physical health problems (e.g., delayed 
growth and development, malnutrition, and asthma) affect 30 to 
40 percent of children in the child welfare system.5 
1 Retrieved November 1, 2002, from 
http://www.acf.dhhs.gov/programs/cb/dis/afcars/cwstats.html 
2 Other States selected for review are: Georgia, Illinois, New Jersey, New York, 
North Dakota, Oregon, and Texas. 
3 FY 2000 Foster Care Entries, Exits, and In Care on the Last Day. Retrieved 
May 20, 2003, from http://www.acf.hhs.gov/programs/cb/dis/talbes/entryexit.htm. 
4 Health Care Issues for Children in Foster Care, March 25, 2002. Retrieved 
May 20, 2002, from http://www.casey.org/cnc/documents/health_care_issues.pdf. 
5 Fact sheet: The Health of Children in Out-of-Home Care. Child Welfare League of 
America. Retrieved May 17, 2003, from 
http://www.cwla.org/programs/health/healthcarecwfact.htm. 
OEI-07-00-00640  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: KANSAS  1  I N T R O D U C T I O N  
Children in foster care have greater health care needs, yet many 
foster care providers (e.g., foster parents and residential care 
facility staff) report having difficulty finding health care 
professionals who are willing to care for these children.6 The 
health care available for children in foster care is often 
characterized by lack of access; lack of information sharing among 
health care providers; and long delays in obtaining services.7 
Furthermore, studies have shown low percentages of children in 
foster care are actually receiving services. One report states that 
less than one-third of children in the child protective system 
nationwide received mental health services in 1995. 8 A General 
Accounting Office (GAO) report released in July 2001 states that 
available data from short-range studies show that the percentage of 
children in the general population receiving Early Periodic 
Screening, Diagnosis, and Treatment (EPSDT) services is very low.9 
The EPSDT program is designed to screen for, diagnose, and treat 
medical conditions that might otherwise go undetected or 
untreated.  Preventive services for the early detection of disease 
have been associated with substantial reductions in morbidity and 
mortality. The benefits of incorporating preventive health care into 
medical practice have become apparent in recent years, as cases of 
previously common and debilitating medical conditions have 
declined in number following the introduction of effective 
preventive health care services. 10 Preventive dental care is also 
included as part of EPSDT. A journal article concludes that 
adherence to American Dental Association recommendations for 
6 Chernoff, R. et. Al., Assessing the Health Status of Children Entering Foster Care, 
Pediatrics, 93:2, 1994. 
7 Health Care of Young Children in Foster Care. Pediatrics, 109:3, 2002. Retrieved 
May 12, 2003, from http://www.aap.org/policy/re0054.html. 
8 Ensuring the Healthy Development of Foster Children, New York State Permanent 
Judicial Commission on Justice for Children, 1999. 
9 Medicaid: Stronger Efforts Needed to Ensure Childrens Access to Health 
Screening Services. General Accounting Office, GAO-01-749, July 2001. 
10 Guide to Clinical Preventive Services, 2nd edition, U.S. Preventive Services Task 
Force, 1996. Retrieved March 12, 2003 from 
http://hstat.nlm.nih.gov/hq/Hquest/db/local.gcps.cps/screen/Browse/s/44098/cmd/H 
F/action/GetText?IHR=CHI. 
OEI-07-00-00640  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: KANSAS  2  I N T R O D U C T I O N  
preventive behaviors over the long-term yields greater benefits 
than doing so over the short term.11 
Medicaid for Children in Foster Care 
Kansas provides Medicaid coverage to all children in Title IV-E 
foster care, as well as other eligible children. Sections 472(h) and 
1902(a)(10)(A)(i)(I) of the Social Security Act (the Act) require 
States to provide Medicaid or equivalent health insurance coverage 
for children eligible to receive Title IV-E foster care maintenance 
funds. Federal EPSDT guidelines require each State to provide 
coverage for comprehensive and preventive child health services to 
Medicaid-eligible individuals under the age of 21, as outlined in 
Section 1905(r) of the Act. Within broad national guidelines, each 
State establishes its own eligibility standards for the Medicaid 
program; determines the type, amount, duration, and scope of 
Medicaid services; sets the rate of payment for services to Medicaid 
patients; and administers its own Medicaid program. 12 In 2000, 
Medicaid payments for children in foster care totaled $3.3 billion 
nationally.13 Kansas Medicaid expenditures to provide health care 
services to children in foster care totaled $10.8 million in 1999. The 
Centers for Medicare & Medicaid Services (CMS) is responsible for 
Federal oversight of individual State Medicaid programs. 
States design their own Medicaid programs and establish EPSDT 
guidelines in accordance with Federal requirements to provide 
coverage for preventive child health services to all Medicaid-eligible 
individuals under the age of 21. 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. Kansas established the Kan 
Be Healthy program to meet Federal EPSDT requirements.  The 
current EPSDT periodicity schedule, established in August 2001, 
for the Kan Be Healthy program, requires that medical screenings 
occur at: birth; 1, 2, 4, 6, 9, 12, 15 and 18 months of age; 2, 3, 4, 5, 6, 
11 Journal of Dental Research, March 2003; 82 (3): 223-7

12 Retrieved May 20, 2003 fromhttp://cms.hhs.gov/Medicaid/eligibility/criteria.asp.

13 Medicaid Statistical Information System (MSIS) Report Fiscal 2000: Illinois. 

Retrieved May 20, 2003 from http://www.cms.gov/medicaid/msis/00tx.pdf

14 Section 1905(r) of the Social Security Act.

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8, and 10 years of age; and annually between the ages of 10 and 21. 
After age 3, children receiving EPSDT services are required to 
receive a vision screening every 2 years and a hearing screening 
every 3 years. Vision and hearing screenings are conducted as part 
of EPSDT medical screenings. Dental screenings are conducted 
separately. Under the public-private partnership, foster care 
contractors are responsible for ensuring that all children in foster 
care receive EPSDT screenings. Section 6141.02 of the Kansas 
Medical Services Manual specifies that information provided to 
program beneficiaries must include information about how Kan Be 
Healthy services can be obtained. 
In addition, Section 471(a)(22) of the Act requires States to develop 
a State plan that includes standards to ensure that all children in 
foster care placements are provided quality services that protect 
their safety and health. Sections 422(b)(10)(B)(ii) and 475(5)(D) of 
the Act require procedures to ensure that a childs health record is 
reviewed, updated, and supplied to the foster care provider at the 
time of placement. According to Section 475(1)(C) of the Act, health 
records should include, to the extent available and accessible, the 
names and addresses of the childs health providers, a record of the 
childs immunizations, the childs known medical problems, the 
childs medications, and any other relevant health information 
concerning the child, determined to be appropriate by the State 
agency. The Kansas foster care program policies require that each 
child receive a medical examination within 30 days of entering 
State custody and that a case plan be developed for each child 
within this same 30 days. The case plan must include an 
assessment of the childs mental health needs and the services 
required to meet those needs. 
METHODOLOGY 
This study focused on the receipt of medical and dental health care 
services within EPSDT guidelines; requirements for initial and 
comprehensive health screenings upon entry into foster care; case 
plan assessments of mental health needs and services; and the 
provision of medical information to foster care providers. This 
study did not address follow-up care or the appropriateness of 
ongoing health care in meeting the needs of children in foster care. 
OEI-07-00-00640  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: KANSAS  4  I N T R O D U C T I O N  
This inspection is based on information gathered from multiple 
sources: reviews of Federal and State policies; analysis of child-
specific Medicaid claims data and case file documentation for 
50 randomly-sampled children in foster care; interviews with 
caseworkers and foster care providers for each of the 50 children in 
our sample; interviews with Kansas State agency officials; and 
telephone calls to dental office staff to validate foster care providers 
concerns regarding the lack of available Medicaid dental providers. 
Reasons for State Selection 
Kansas was selected due to its small size, centralized child welfare 
system, geographic location, fee-for-service payment of Medicaid 
health care services (Kansas does not utilize managed care for 
children in foster care), and its statewide public-private partnership 
for provision of child welfare services. The Kansas Department of 
Social and Rehabilitation Services (SRS) is responsible for the 
welfare of children in State custody. However, instead of State, 
county, or local offices providing direct service delivery in child 
welfare cases, private contractors provide foster care and adoption 
services. An overview of the Kansas public-private partnership is 
provided in Appendix A. 
Sample 
Children who met the following criteria were included in the study 
population: (1) were in foster care on June 14, 2002; (2) resided in 
Kansas; and (3) had been in continuous out-of-home foster care 
placements for at least 6 months. SRS provided us with a list of the 
3,766 children (of the 6,569 children in foster care at the end of 
Federal fiscal year 2000) who met these criteria. We selected a 
simple random sample of 50 children in foster care in Kansas, 
based on this defined population, which allowed us to formulate an 
overview of their use of health care services. Appendices B and C 
provide information on the children included in our sample. 
Review of State Policy, Medicaid Data, and Case File Documentation 
Policy Review -We reviewed Federal and Kansas foster care and 
Medicaid policies. All children in foster care in Kansas are eligible 
for Medicaid services, regardless of their Title IV-E foster care or 
other eligibility status (e.g., Temporary Assistance for Needy 
Families). Federal law relating to EPSDT requires that States 
meet reasonable standards of medical and dental practice, as 
OEI-07-00-00640  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: KANSAS  5  I N T R O D U C T I O N  
determined by the State after consultation with recognized medical 
and dental organizations. Kansass Kan Be Healthy program 
satisfies the Federal ESPDT requirement. We used Kan Be 
Healthy policy guidelines to determine whether children in foster 
care received health care services within required time frames. 
Medicaid Claims Data Review -SRS provided us with 3 years of 
Medicaid claims histories for each of the children in our sample. 
The data included claims for physician, dental, pharmaceutical, and 
mental health services paid between June 1, 1999, and 
May 31, 2002. We paid particular attention to the types of health 
and mental health services, dates of service, settings where the 
services were provided, and diagnoses, where available. We 
included only those Medicaid claims after the childs most recent 
entry into foster care and any claims prior to entry that were 
pertinent in establishing periodicity for services (i.e., Kan Be 
Healthy). 
Case File Documentation Review -We requested and reviewed case 
file documentation from local offices for all the children in our 
sample. Information requested included documentation of medical 
and mental health services provided, duration of the childs stay in 
foster care, and information regarding the childs general well-
being. 
Interviews 
Foster Care Provider Interviews -We use the term foster care 
provider to refer to a foster parent or a staff member of a 
residential facility who is responsible for the child. We conducted 
structured interviews with 46 of the 50 foster care providers (20 in 
person and 26 by telephone) responsible for the children in our 
sample between July 31 and August 28, 2002. After repeated 
attempts, we were unable to interview four foster care providers. 
The four children, whose foster care providers we were unable to 
interview, were not included in certain comparative analyses, but 
were included in our Medicaid claims data analysis. Our 
interviews with foster care providers focused on Medicaid programs 
and services available, training related to the health and well-
being of children, and procuring health care services for the 
children included in our sample. 
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Caseworker Interivews -We conducted structured interviews with 
each childs caseworker either in person (22) or by telephone (26) 
between July 29 and September 6, 2002. Two caseworkers were 
responsible for more than one child, giving us a total of 
48 caseworkers for the 50 children in our sample. Each of these 
interviews focused on the caseworkers understanding of the 
Medicaid programs and services available, training related to the 
health and well-being of children, their experience accessing 
services for the sampled child, and any barriers to health care faced 
by the child. Each caseworker spoke specifically about the sampled 
childs case, and generally about his or her own experiences 
working in foster care. We analyzed the caseworkers responses 
and compared them to those of the foster care providers, noting any 
consensus or disagreement within and between the two groups. 
Discussions with State Agency Officials -To enhance our 
understanding of the States foster care and Medicaid programs, we 
consulted, both in person and by telephone, with SRS officials who 
are responsible for the administration of both programs in the State 
of Kansas. Our discussions covered a wide spectrum of 
information, including the overall provision of Medicaid services for 
children in foster care, the Kan Be Healthy (EPSDT) program, 
Kansas public-private partnership, and Medicaid claims for 
children in foster care. 
Dental Provider Contacts -During our interviews with foster care 
providers, they reported difficulty scheduling dental appointments 
for children in their care. To validate these difficulties, we 
contacted the offices of dental care providers. At our request, SRS 
provided us with a list of 26 dental providers whom they believed 
accepted Medicaid patients in 2 areas of the State where foster care 
providers and caseworkers reported the most difficulty scheduling 
dental appointments for children in their care. We called the offices 
of all 26 dental providers and asked them whether they were 
accepting new Medicaid patients and, if so, when their first 
available appointment was for a routine dental examination. 
This inspection was conducted in accordance with the Quality 
Standards for Inspections issued by the Presidents Council on 
Integrity and Efficiency. 
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All sampled children have Medicaid  Federal law requires States to 
provide Medicaid or equivalent 
coverage and claims for services 
health insurance coverage to 
children eligible to receive Title IV-E foster care program 
maintenance funds. Within broad national guidelines, each State 
establishes its own Medicaid-eligibility standards. Children in 
foster care in Kansas are eligible for all health care services 
provided through the Medicaid program, including EPSDT. 
Our review of Medicaid claims and interview data indicates that all 
50 children in our sample had Medicaid coverage. Our analysis of 
the Medicaid claims data revealed that each sampled child had paid 
health care claims since entering foster care. Overall, foster care 
providers were aware of the availability of Medicaid services for 
children in their care and were receiving monthly Medicaid cards 
for them. The 50 children in our sample had received a total of 
5,853 Medicaid health care services while in foster care since 
June 1, 1999, as outlined in the following chart. 
Table 1: Number and Type of Medicaid Claims 
for 50 Children in the Sample 
Number of children  Total number of 
Claim type 
with at least one claim  claims* 
Physician office  50  2,126 
Mental Health  50  1,916 
Prescriptions  49  1,129 
Dental  37  675 
Hospitalization  5  7 
Total  5,853 
*A detailed list of services for each child is located in Appendix C. 
Source: OIG analysis of Kansas Medicaid claims data 
Ninety percent of children in the sample  Federal EPSDT guidelines 
received routine physical examinations,  require each State to provide 
physical, mental, vision, hearing, 
and 82 percent received EPSDT dental 
and dental screenings, and other 
examinations, in accordance with State 
necessary health care and
guidelines 
treatment, as needed, at 
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intervals established by the State. These services must meet 
reasonable standards of practice published by recognized health 
care organizations and are designed to prevent, diagnose, and treat 
medical conditions that might otherwise go undetected or 
untreated. Kansas Kan Be Healthy program fulfills the Federal 
EPSDT requirements. 
Physical Examinations 
A review of 3 years of Medicaid claims data and case file 
documentation showed that 90 percent (45/50) of the children in 
this study were receiving EPSDT services within the time frames 
established by Kansas at the time of our review. For the five 
children in foster care who did not have current EPSDT services, 
either the caseworker, foster care provider, or both stated that the 
child did, in fact, receive EPSDT services; however, we were not 
provided with medical documentation to support receipt of those 
services. 
While it is difficult to pinpoint specific practices that enabled 
Kansas to meet established guidelines for providing required 
EPSDT services to many of the sampled children in foster care, 
evidence collected suggests two factors may be instrumental. First, 
the Kansas Medicaid program distributes monthly Medicaid cards 
to each Medicaid client; these cards are printed with the due date of 
the next required Kan Be Healthy (EPSDT) screen. Foster care 
providers indicated the information printed on the Medicaid card 
was helpful. Also, caseworkers conduct monthly visits to each 
foster childs placement, during which they monitor the childs 
health care and receipt of required services. Caseworkers must 
complete the form (CFS 3050C) every 6 months that includes a 
section verifying that the childs most recent Kan Be Healthy 
screening is correct (i.e., received within periodicity guidelines). 
Dental Examinations 
Kansas EPSDT guidelines require every child in foster care over 
3 years of age to have an annual dental examination. Of the 
40 children in our sample 3 years of age and older, 98 percent 
(39/40) had at least 1 oral evaluation since their entry into foster 
care, and 82 percent (32/39) received an evaluation within the past 
year. Six children who were overdue for required services had 
received previous dental services, such as resins and sealants. The 
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one child with no Medicaid claim for an oral evaluation had no 
other dental claims, and the childs foster care provider was one of 
the four non-respondents whom we were unable to interview. 
One possible reason that the percentage of children receiving 
EPSDT dental services is lower than the percentage receiving other 
EPSDT services is because, according to interview data, foster care 
providers experience difficulty locating dentists willing to accept 
Medicaid patients. Foster care providers also reported difficulty 
scheduling appointments with dental providers participating in the 
Medicaid program. Of the 31 foster care providers interviewed who 
had attempted to schedule a dental appointment for the foster child 
in their care, 12 reported having difficulty locating a dentist who 
would accept Medicaid patients. Of the 19 foster care pr oviders 
who indicated they did not have a problem locating a dentist, 6 
foster care providers reported having difficulty scheduling an 
appointment. 
Foster care providers reported that participating dentists offices 
are often geographically far from the foster care providers 
residence and that very few dentists were accepting new Medicaid 
patients. They reported that the lack of dental providers willing to 
accept Medicaid patients was acute in two geographic areas of the 
State -one large and one small community. At our request, the 
SRS created a list of dental providers that it believed accepted 
Medicaid patients in these two communities. The list provided by 
SRS contained the names of 24 dentists in the large community 
(out of 105 total dentists) and 2 dentists in the small community 
(out of 7 total dentists). 
To validate the problems that foster care providers reported, we 
called the offices of the 26 dentists listed and asked if the dentist 
was accepting new Medicaid patients, and if so, when the first 
available appointment could be scheduled. These contacts revealed 
that only 6 of the 24 dental providers in the large community were 
accepting new Medicaid patients. Both listed dentists in the small 
community were accepting new Medicaid patients. An appointment 
for a routine dental examination with any of the eight dentists 
accepting new Medicaid patients could be scheduled within 3 days 
to 2 months, depending on the provider. Given that only 8 of the 
dentists who accepted Medicaid (out of 112 dentists total in the 
OEI-07-00-00640  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: KANSAS  10  F I N D I N G S  
2 communities) were accepting new Medicaid patients, finding a 
dentist willing to treat a child on Medicaid is problematic. 
Federal law requires States to 
Eighty-two percent of sampled children 
develop a State plan that includes 
received initial medical examinations  standards to ensure that children in 
foster care placements are provided
within required timeframes 
quality services that protect their 
safety and health. The Kansas foster care program, as outlined in 
the Kansas IV-E foster care program State plan, requires that 
children in foster care receive a medical examination within 30 
days of entering State custody. Thirty-nine children in our sample 
had initial placements between June 1999 and November 2001 (the 
time period covered by our claims data less six months, due to the 
time it takes to submit and process some claims). Eighty-two 
percent (32/39) of these children had a Medicaid paid claim or case 
file documentation indicating a medical examination took place 
within 30 days of placement. 
All sampled children received  While there are no requirements in 
Title IV-E of the Act that address 
mental health services 
the provision of mental health 
services to children in foster care specifically, Section 471(a)(22) of 
the Act requires States to develop and implement standards to 
ensure that all children in foster care placements are provided 
quality services that protect their safety and health.  The Kansas 
foster care program policies require that a case plan be developed 
for each foster child within 30 days of a child entering State 
custody. The case plan requires an assessment of the childs mental 
health needs and the services required to meet those needs. 
Assessments for mental health needs are important because 
children in foster care are more likely to suffer from mental health 
problems than other children.15 
15 Health Care Issues for Children in Foster Care, March 25, 2002. 
RetrievedOctober 17, 2002, from 
http://www.casey.org/cnc/documents/health_care_issues.pdf. 
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All children in our sample had a completed case plan that 
addressed the childs mental health needs, and all children in our 
sample had at least one Medicaid claim for some type of mental 
health service. We did not evaluate the adequacy of the mental 
health assessments or services provided. 
Federal law requires that a
Forty-three percent of foster care providers 
childs health record is 
reported never receiving a medical history for the 
reviewed, updated, and 
sampled child in their care  supplied to the foster care 
provider when they are 
placed in foster care. Twenty of the 46 foster care providers 
interviewed reported never receiving a medical history for the 
sampled child in their care. However, caseworkers for 12 out of 
these 20 foster care providers reported compiling or receiving a 
medical history. Two out of the 12 foster care providers who did not 
receive the medical history available to the caseworker reported 
being unaware of documented mental health problems facing the 
foster child in their care.  A childs health may be compromised if 
the foster care provider is unaware of the childs family medical 
history, chronic physical health pr oblems, mental health problems, 
or other medical needs. 
In exploring why medical histories were not shared with foster care 
providers, several reasons were identified. 
o  The caseworker was a student intern. 
o	 The childs case changed from foster care to adoption status, 
and the adoption caseworker had assumed that the foster care 
caseworker provided a medical history to the foster care 
providers. 
o  The caseworker lost the medical record. 
The failure to provide a medical history is particularly problematic 
because the foster care providers whom we questioned indicated 
that caseworkers are the most important source of information for 
them regarding the health care needs of children in their care. 
Fifty-nine percent (27/46) of foster care providers interviewed 
indicated that when they have questions about accessing medical 
services for the foster child, they would ask the childs caseworker 
OEI-07-00-00640  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: KANSAS  12  first. Less common cited sources included the childs primary care 
physician or staff at an SRS or Medicaid office. 
RECOMMENDATIONS 
To ensure children in foster care have access to and receive the 
most appropriate health care services, we recommend that: 
ACF work with the Kansas Department of Social and 
Rehabilitation Services to: 
o	 Promote the importance of obtaining medical histories for 
children in foster care and providing this information to foster 
parents 
CMS work with the Kansas Department of Social and 
Rehabilitation Services to: 
o	 Increase the number of Medicaid health care providers willing 
to provide services to children in foster care 
o	 Develop and maintain current and accurate lists of Kansas 
health care providers participating in the Medicaid program by 
area or community 
o	 Provide case workers and foster care providers with current 
lists of Medicaid providers willing to treat children in foster 
care 
AGENCY COMMENTS 
ACF indicated the background provided in this report was useful. 
ACF notes it found that only 78 percent of the children included in 
the Kansas Children and Family Services Review, conducted in 
August 2001, received medical services, but that differences in its 
review and Office of Inspector General findings may be explained 
by the use of different methodologies. ACF also notes four 
conclusions resulting from its review. The first two, related to an 
insufficient number of dental care providers that accept Medicaid 
and foster parents not always being provided with timely medical 
information for the children in their care, were similar to our 
findings.  ACF is working with the Kansas Department of Social 
and Rehabilitation Services to promote the importance of obtaining 
medical histories for children in foster care and have included steps 
OEI-07-00-00640  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: KANSAS  13  C O N C L U S I O N / R E C O M M E N D A T I O N S  
necessary to gather medical information and provide the 
information to foster parents as part of a Program Improvement 
Plan. The latter two conclusions, related to foster parent 
reimbursement to transport children for medical care and the need 
for improvements in the provision of mental health services, 
focused on issues outside the scope of our study. The full text of 
ACFs comments to the draft report is located in Appendix D. 
The CMS concurs, in part, with our recommendations and points 
out that the Medicaid program is State-administered within broad 
Federal guidelines. As such, CMS does not have the ability to 
directly impact the numbers of providers participating in the 
Kansas Medicaid program or the collection, maintenance, and 
distribution of lists of participating providers. However, CMS 
indicates they are available to provide technical assistance to the 
Kansas Department of Social and Rehabilitation Services, the State 
agency responsible for both the Medicaid and Title IV-E foster care 
programs, to promote efforts to ensure children in foster care have 
adequate access to health care services. The full text of CMSs 
comments to the draft report is located in Appendix E. 
OEI-07-00-00640  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: KANSAS  14  AA PP PP EE NN DD II XX ~~ AA

Kansas Foster Care and Medicaid Programs 
The Kansas Department of Social and Rehabilitation Services is 
responsible for all children in State custody in Kansas. Within that 
Department, the Division of Children and Family Policy is 
specifically responsible for providing child protective services. The 
child welfare system is administered through a public-private 
partnership, in which the State is ultimately responsible for the 
well-being of children in State custody, but private contractors 
provide direct services, instead of State or county offices. Kansas 
has five contracted agencies, one in each region of the State, who in 
turn subcontract with other agencies to provide services at the 
community level. Each agency is paid a flat fee, plus an additional 
amount for each child whom it serves. State contracts with 
participating agencies are awarded every 4 years and renewed 
annually. 
Health care for Kansas children in foster care is provided primarily 
through Medicaid, and all Kansas children in foster care are status-
eligible for Medicaid. There are no special health guidelines or 
coverage exceptions for children in foster care; they follow the same 
rules as the general Medicaid population. Although Medicaid 
managed care is available in Kansas, managed care programs are 
not used to provide benefits to children in foster care. Each child in 
foster care is issued a monthly Medicaid card that must be shown to 
access benefits, and these cards are printed with the date of the 
childs most recent Kan Be Healthy screening and the date that the 
childs next screening is due. Other sources of health care funding 
for children in foster care in Kansas include Head Start, public 
health clinics, and any private health insurance a childs biological 
parents might have. 
OEI-07-00-00640  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: KANSAS  15  A P P E N D I X ~ B  
Detailed Demographic Data 
The table below is merely descriptive in nature and describes the 
demographic characteristics of each sampled child and his or her 
foster care placement history (the first 6 columns) at the end of 
May 2002. 
   
 
Months  Months 
Entries  Months  Placements  Caseworkers 
Age   Placement  since last  caseworker 
ID Sex  into foster since last  since last  since last 
(years)  Setting  placement  with case 
care (1)  entry (2)  entry (3)  entry 
(2)  (2) 
1  F  1  Family  1  7  1  10  1  10 
2  F  4  Family  1  23  1  25  1  3 
3  M  14  Family  1  7  1  9  2  4 
4  F  17  Kinship  1  37  1  37  2  2 
5  F  6  Family  1  44  1  46  2  3 
6  F  4  Kinship  1  8  1  11  2  7 
7  F  1  Family  1  15  1  17  3  8 
8  F  8  Family  1  13  2  8  1  14 
9  M  9  Family  1  8  2  9  1  11 
10  M  2  Family  1  15  2  7  1  18 
11  F  10  Family  1  27  2  26  1  28 
12  F  16  Family  1  12  2  13  1  14 
13  F  15  Kinship  1  14  2  5  2  16 
14  M  3  Family  1  21  2  14  2  4 
15  M  4  Family  1  34  2  36  2  13 
16  F  2  Family  1  23  2  25  2  5 
17  M  1  Residential  1  13  2  13  2  7 
18  F  9  Family  2  20  2  10  3  10 
19  M  9  Family  1  33  2  36  3  15 
20  F  1  Family  1  17  2  3  3  12 
21  F  6  Family  1  21  2  24  4  11 
22  M  3  Kinship  1  30  2  21  4  21 
23  F  11  Family  1  28  3  25  2  25 
24  F  3  Family  1  20  3  9  4  18 
25  F  17  Kinship  1  15  3  13  5  9 
26  F  13  Secure Care  1  7  4  3  1  9 
27  M  4  Kinship  1  18  4  18  2  3 
28  F  1  Family  1  15  4  15  2  7 
29  M  18  Independent 1  16  4  5  3  10 
30  M  12  Family  1  56  4  18  3  24 
31  M  11  Family  2  13  4  6  3  2 
32  F  18  Family  1  29  4  13  3  22 
33  M  12  Family  1  20  4  2  4  5 
34  M  5  Adoptive  1  50  4  52  8  6 
35  F  14  Family  1  38  5  13  1  13 
36  M  14  Family  1  29  5  10  2  4 
37  F  15  Family  1  22  5  6  5  15 
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  A P P E N D I X ~ B  
Months  Months 
Entries  Months  Placements  Caseworkers 
Age  Placement  since last  caseworker 
ID Sex  into foster since last  since last  since last 
(years)  Setting  placement  with case 
care (1)  entry (2)  entry (3)  entry 
(2)  (2) 
38  F  14  Kinship  1  15  6  5  2  5 
39  M  12  Family  1  28  6  3  3  3 
40  M  17  Residential  1  11  6  5  3  1 
41  F  5  Family  2  55  6  42  3  8 
42  F  17  Family  1  18  7  1  5  20 
43  M  15  Family  2  36  9  2  2  9 
44  M  6  Adoptive  1  39  9  2  4  20 
45  M  7  Family  2  44  10  9  3  6 
46  F  17  Family  1  11  11  11  1  15 
47  F  11  Residential  1  62  11  23  5  14 
Group 
48  M  19  Home  1  65  14  3  8  16 
49  F  14  Family  1  16  16  5  2  3 
50  M  15  Residential  1  30  18  8  4  1 
(1) Entries into foster care refers to the number of times a child has entered State custody (i.e., number of foster 

care episodes).

(2) Months since last entry is the length of time from the date of the childs most recent entry into State custody 

until 05/31/02, which coincides with the last date of our claims record. Months since last placement is the 

length of time from the date of the most recent placement to the date the foster care provider was interviewed, and 

may be up to 4 months greater than months since last entry due to rounding. Months caseworker with case is 

the length of time from the date the caseworker initially took over the case until the date the caseworker was 

interviewed and may be up to 4 months greater than months since last entry due to rounding. 

(3) Placements since last entry refers to the number of placement settings (e.g., Foster Home A, Foster Home B, 

Metro Residential Facility) a child has experienced during each episode in foster care.

OEI-07-00-00640  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: KANSAS  17  A P P E N D I X ~ C  
Detailed Claims Data 
The table below describes whether the child received required 
services, including a tally of services during his or her time in foster 
care from a period June 1, 1999, to May 30, 2000, or entry to 
May 30, 2002, whichever is shorter. 
 
 
   
Medical 
Mental 
EPSDT  Dental  30-day  history 
Office visit  health- Prescription  Dental  Hospital 
ID  current  current  physical  provided 
claims  related  claims  claims  claims 
(1)  (1,2)  assessment  to care 
claims 
provider 
1  YES  N/A  YES  YES  25  20  18  0  0 
2  YES  NO  YES  YES  43  25  8  18  0 
3  YES  YES  YES  NO  12  8  2  4  0 
4  NO  NO  N/A  YES  16  33  5  13  0 
5  YES  YES  N/A  YES  8  40  8  53  0 
6  YES  YES  YES  NO  13  12  6  12  0 
7  YES  N/A  YES  YES  33  24  14  0  1 
8  YES  YES  YES  NO  16  51  5  9  0 
9  YES  N/A  YES  NO  75  7  29  0  0 
10  YES  N/A  YES  NO  50  19  29  0  0 
11  YES  YES  YES  NO  101  78  41  22  0 
12  YES  YES  YES  YES  15  20  3  2  0 
13  YES  YES  YES  YES  9  19  5  17  0 
14  YES  N/A  YES  YES  21  24  21  0  0 
15  YES  YES  NO  NO  59  32  18  4  0 
16  YES  N/A  NO  YES  18  17  4  0  0 
17  YES  N/A  YES  NO  25  14  16  0  0 
18  YES  YES  YES  YES  14  22  3  22  0 
19  YES  YES  YES  NO  22  41  6  20  0 
20  YES  N/A  YES  YES  40  20  16  0  0 
21  YES  YES  NO  NO  7  37  3  11  0 
22  YES  N/A  YES  NO  23  30  15  0  0 
23  YES  NO  YES  NO  17  82  5  24  0 
24  YES  N/A  YES  YES  30  19  20  3  0 
No 
25  NO*  NO  YES  22  12  9  0  0 
Interview 
26  YES  NO  YES  NO  27  15  54  0  1 
27  YES  YES  YES  YES  15  114  4  23  0 
  OEI-07-00-00640  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE: KANSAS  18 
   
  A P P E N D I X ~ C 
Medical 
Mental 
EPSDT  Dental  30-day  history 
Office visit  health- Prescription  Dental  Hospital 
ID  current  current  physical  provided 
claims  related  claims  claims  claims 
(1)  (1,2)  assessment  to care 
claims 
provider 
28  YES  N/A  YES  NO  16  15  3  0  0 
29  YES  YES  YES  NO  56  37  2  17  0 
30  YES  NO  N/A  YES  62  43  16  17  0 
31  YES  YES  YES  YES  8  49  0  5  0 
32  NO  YES  YES  YES  179  127  92  39  1 
33  YES  YES  YES  YES  6  29  2  7  0 
No 
34  YES  NO*  N/A  57  32  45  0  0 
Interview 
35  NO  YES  N/A  YES  15  47  2  24  0 
36  YES  YES  YES  YES  290  38  45  9  1 
37  NO  YES  NO  NO  9  43  11  13  0 
38  YES  YES  YES  YES  12  45  22  25  0 
No 
39  YES  YES  NO  60  60  101  10  3 
Interview 
40  YES  YES  YES  NO  29  10  6  8  0 
41  YES  YES  N/A  NO  24  48  13  10  0 
42  YES  YES  YES  YES  70  25  54  24  0 
43  YES  YES  N/A  YES  60  94  5  52  0 
44  YES  YES  N/A  YES  55  73  16  13  0 
45  YES  YES  N/A  NO  30  32  13  33  0 
No 
46  YES  YES  NO  14  12  3  2  0 
Interview 
47  YES  YES  N/A  YES  98  47  147  9  0 
48  YES  YES  N/A  NO  20  54  15  14  0 
49  YES  YES  YES  YES  72  51  57  31  0 
50  YES  YES  NO  YES  128  70  92  56  0 
 
 
 
 
 
 
 
(1)  * = No record of screening ever performed         
(2) N/A = Under the age of 3 years or child was placed before June 1, 1999 
  OEI-07-00-00640  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN FOSTER CARE: KANSAS  19 
   
  A P P E N D I X ~ D

Agency Comments - ACF 
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 A P P E N D I X ~ D  
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 A P P E N D I X ~ D  
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 A P P E N D I X ~ D  
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 A P P E N D I X ~ E

Agency Comments - CMS 
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 A P P E N D I X ~ E  
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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 T. Pattison, 

Regional Inspector General for Evaluation and Inspections and 

Gina Maree, Assistant Regional Inspector General for Evaluation 

and Inspections in Kansas City. Other principal Office of 

Evaluation and Inspections staff who contributed include:

Deborah Walden, Team Leader

Steve Milas, Program Analyst 

Michala Walker, Program Analyst

Brian T. Whitley, Program Analyst

Linda Paddock, Program Analyst

Linda Hall, Program Specialist (Washington, D.C.)

Barbara Tedesco, Mathematical Statistician (Baltimore)

OEI-07-00-00640  CHILDRENS USE OF HEALTH CARE SERVICES WHILE IN F OSTER CARE: KANSAS  26