Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
N A C
OT  LL  HILDREN IN 
 
F   C W W
OSTER  ARE  HO  ERE 
 
E  M
NROLLED IN  EDICAID 
 
R R H
ECEIVED  EQUIRED  EALTH 
S  
CREENINGS 
 
Daniel R. Levinson   
Inspector General  
 
March 2015  
OEI-07-13-00460     
EXECUTIVE SUMMARY:  NOT ALL CHILDREN IN FOSTER CARE WHO WERE 
ENROLLED IN MEDICAID RECEIVED REQUIRED HEALTH SCREENINGS 
OEI-07-13-00460 
 
WHY WE DID THIS STUDY 
 
Children in foster care often experience chronic medical, developmental, and mental health 
issues. States ability to ensure that foster children receive needed health services is critical to 
these childrens well-being.  The Social Security Act requires each State to develop a plan for 
ongoing oversight and coordination of health services for children in foster care, which includes 
establishing a schedule for initial and periodic screenings.  Screenings may include medical, 
dental, hearing, vision, mental health, and other (e.g., developmental) assessments.  Furthermore, 
the Administration for Children and Families (ACF) is responsible for monitoring States foster 
care programs, including States oversight and coordination of health services for children.  One 
method by which ACF monitors States is periodic reviews of States child welfare systems, 
known as Child and Family Services Reviews.  This report describes whether children in foster 
care receive required initial and periodic health screenings according to their States schedules. 
 
HOW WE DID THIS STUDY  
 
We selected four States with large foster care populations (California, Illinois, New York, and 
Texas) to determine whether children in foster care received initial and periodic health 
screenings as established in each States plan.  Nearly all children in foster care are eligible for 
Medicaid; therefore, Medicaid pays for many of the health care services that these children 
receive. Therefore, from each of the 4 States, we selected a simple random sample of 
100 children who were in foster care and were enrolled in Medicaid between July 1, 2011, and 
June 30, 2012. We also conducted a structured interview with staff from ACF to determine 
whether ACF ensures that children in foster care receive the required screenings. 
 
WHAT WE FOUND 
 
Nearly a third of children in foster care who were enrolled in Medicaid did not receive at least 
one required health screening. Furthermore, just over a quarter of children in foster care who 
were enrolled in Medicaid received at least one required screening late.  Moreover, ACFs 
reviews do not ensure that children in foster care receive the required screenings according to 
State schedules. 
 
WHAT WE RECOMMEND  
 
We recommend that ACF expand the scope of its Child and Family Services Reviews to 
determine whether children in foster care receive required screenings according to the 
timeframes specified in States plans.  ACF stated that it would consider this recommendation.   
We also recommend that ACF identify and disseminate State strategies to ensure that all children 
in foster care receive required screenings.  We  encourage ACF to work with States to (1) identify 
the barriers that prevent children in foster care from receiving required screenings and 
(2) identify, disseminate, and implement strategies for overcoming those barriers.   
     
Such strategies might include developing educational materials for foster parents that discuss the 
benefits of screenings and providing incentives to families and children in foster care to 
encourage participation in required screenings.  ACF concurred with this recommendation. 
     
TABLE OF CONTENTS 
 
Objectives ....................................................................................................1 

Background..................................................................................................1 

Methodology................................................................................................5 

Findings........................................................................................................7 

Nearly a third of children in foster care who were enrolled in 

Medicaid did not receive at least one required health screening .....7 

Over a quarter of children in foster care who were enrolled in 

Medicaid received at least one required health screening late .........7 

ACFs reviews do not ensure that children in foster care receive 

required health screenings according to State schedules .................8 

Conclusion and Recommendations ..............................................................9 

Agency Comments and Office of Inspector General Response .....11 
 
Appendixes ................................................................................................12 

A: Required Elements for Health Services Oversight and 

Coordination Plans.........................................................................12 

B: Four Selected States Schedules for Periodic Health  

Screenings......................................................................................13 

C: Detailed Methodology..............................................................16 

D: Point Estimates, Sample Sizes, and Confidence Intervals .......18 

E: Agency Comments  ...................................................................19 

Acknowledgments......................................................................................21 

     
OBJECTIVES 
1. 	  To determine for four selected States the extent to which children in 
foster care who were enrolled in Medicaid received required health 
screenings as established in States health services oversight and 
coordination plans. 
2. 	  To determine the extent to which the Administration for Children and 
Family Services (ACF) ensured that children in foster care receive 
required health screenings. 
BACKGROUND 
Foster Care 
Federal regulations define foster care as 24-hour substitute care for 
children placed away from  their parents or guardians...1  A child may be 
placed in foster care for reasons such as abuse, neglect, or abandonment.2   
Children in foster care are placed in a variety of settings that may include 
nonrelative foster homes, relative foster homes, group homes, and 
preadoptive homes.3  On September 30, 2013, there were approximately 
402,000 children in foster care nationwide.4  
Children in foster care experience a high rate of chronic medical, 
developmental, and mental health issues.5 The health care that children 
receive while in foster care is often affected by lack of access to and 
coordination of care.6  States ability to ensure that needed health services 
are received is critical to the well-being of children in foster care. 
 ____________________________________________________________ 
1 45 CFR   1355.20. 
2 American Academy of Child & Adolescent Psychiatry, Facts for Families:  Foster 

Care.  No. 64, May 2005. 

3 ACF,  The Adoption and Foster Care Analysis and Reporting System (AFCARS)  

FY [Fiscal Year]  2012 Data:  Preliminary FY 2012 Estimates as of November 2013. 

4 ACF,  Numbers of Children in Foster Care on September  30th, by State 

FY 2004-FY 2013. Accessed at 

http://www.acf.hhs.gov/sites/default/files/cb/children_in_care_2013.pdf on 
 
January 29, 2015. 
 
5 American Academy of Pediatrics.  Fostering Health:   Health Care for Children  and 

Adolescents in  Foster Care, 2nd Edition.  

6 American Academy of Pediatrics, Committee on Early Childhood, Adoption, and 

Dependent Care.  Health Care of  Young Children in  Foster Care, Pediatrics, Vol. 109, 

No. 3, March 2002, pp. 536541. 

Not All Children in Foster Care Received Required Health Screenings (OEI-07-13-00460)   1 
     
Health Services Oversight and Coordination Plans and 
Schedules for Required Health Screenings 
Pursuant to section 422(b)(15)(A) of the Social Security Act (the Act), 
each State must develop a plan for ongoing oversight and coordination of 
health services for children in foster care.7  Each States foster care agency 
must coordinate with its State Medicaid agency, health care experts 
(e.g., pediatricians, general practitioners, and specialists), and child 
welfare experts in developing the State plan.8 Each State is required to 
submit its plan to ACF every 5 years.9  Each State plan must include seven 
elements, one of which is a schedule for initial and periodic screenings 
that meets reasonable standards of medical practice.10  See Appendix A for 
a complete list of the seven required elements.11  
States must establish schedules for initial and periodic health screenings  
similar to existing standards of care. According to ACF guidance, State 
schedules for initial and periodic health screenings should mirror or 
incorporate elements of existing professional guidelines for physical, 
mental, and dental health screenings and standards of care.12  Examples 
of existing professional guidelines include, but are not limited to, the 
American Academy of Pediatrics  Recommendations for Preventative 
Pediatric Health and State Medicaid agencies Early and Periodic 
Screening, Diagnostic, and Treatment (EPSDT)13 schedules. 
____________________________________________________________ 
7 Section 422(b)(15)(A) of the Act  has been revised by three separate Public Laws:  the 

Fostering Connections to Success and  Increasing Adoptions Act of 2008 (P.L. No. 

110-351   205, enacted on  October 7, 2008); the Patient Protection and Affordable Care 

Act (P.L. No. 111-148,   2955, enacted on  March  23, 2010); and the Child and  Family  

Services Improvement  and Innovation Act  (P.L.  No. 112-34  101(b), enacted 

September 30,  2011).  The Patient Protection and Affordable Care Act was amended by 
 
the Health Care and Education Reconciliation  Act of 2010 (P.L. No. 111-152, enacted on 
 
March 30, 2010).  Together, these laws are referred to as the Affordable Care  Act. 

8 Section 422(b)(15)(A) of the Act. 

9 Each State is required to submit the health  services oversight  and coordination plan as 

part of its Child and Family Services Plan (CFSP) to ACF every 5 years (45 CFR 

  1357.15).  States were required to submit their CFSPs for FYs 2010 to  2014  by 
 
June 30, 2009. 

10 Section 422(b)(15)(A) of the Act.  Screenings may include medical, dental, hearing, 

vision, mental health, and other (e.g., developmental) assessments. 

11 This evaluation focuses on receipt of required  health screenings according to schedules 

established in States plans. 

12 ACF,  Program Instruction:  Guidance on  Fostering Connections to Success and 
 
Increasing Adoptions Act of  2008, July 2010.  Section  422(b)(15)(A)  of the Act does not 
 
stipulate how States must define their schedules for initial and periodic health screenings.  

Thus, States have  flexibility in establishing their schedules for such screenings.   

13 EPSDT is a Medicaid benefit that provides comprehensive and preventive health care 

services for children  under age 21.  EPSDT screenings must be provided at intervals that 

meet reasonable standards of medical practice. 

Not All Children in Foster Care Received Required Health Screenings (OEI-07-13-00460)   2 
     
ACF guidance does not stipulate which professional guidelines State 
foster care agencies should adopt or incorporate into the plans for their 
States.  
Selected States Health Screening Schedules 
Four States with large foster care populations were selected for inclusion 
in this evaluation:  California, Illinois, New York, and Texas.  These four 
States constitute 31 percent of the national population of children in foster 
care.14  
Each of the four States has a schedule for initial and periodic health 
screenings in its plan. Each of the four States requires that children 
entering foster care receive an initial health screening within a specific 
timeframe.  The States timeframes vary from within 24 hours of foster 
care placement to within 30 days of placement.  See Table 1 for each 
States timeframe.  
Table 1: State Timeframes for Initial Health Screenings  
Timeframe Within Which Initial Health  
State  
Screening Must Be Received  
California  24 hours  
24 hours; a second comprehensive medical 
Illinois  
screening within 21 days  
New York   24 hours  
Texas   30 days  
Source:  OIG analysis of State plans and survey responses, 2014.  
Each of the four States requires that children in foster care receive periodic 
screenings at specified intervals throughout their foster care placement.  
All four States intervals are based on the age of the child, and these 
intervals vary from State to State.  Generally, the four States require more 
frequent periodic screenings for children under age 3 than for those 3 and 
older. The screenings for children under age 3 are required at specified 
monthly intervals (e.g., every 2 months, every 6 months).  Once children 
reach age 3, the States require less frequent periodic screenings (e.g., 
annually or biennially). See Appendix B for the four States schedules. 
Each of the four States has incorporated elements of its EPSDT schedule 
into its schedule for health screenings for children in foster care. 
____________________________________________________________ 
14 These four  States constitute 31  percent of the national population  of children in  foster 
care. ACF, Foster Care FY20032012 Entries, Exits, and  In Care on the Last Day of  
Each Federal Fiscal Year. Accessed at 
www.acf.hhs.gov/sites/default/files/cb/entryexit2012.xlsx on May 28, 2014. 
Not All Children in Foster Care Received Required Health Screenings (OEI-07-13-00460)   3 
     
For Texas, the two are the same; Texas adopted the State EPSDT schedule 
as its schedule for screenings for children in foster care.  For the other 
three States, the schedules are similar to the EPSDT schedules, but require 
more frequent screenings. 
Medicaid for Children in Foster Care 
In all States, nearly all children in foster care are eligible for Medicaid 
services.15  Medicaid pays for many of the health care services that 
children in foster care receive.  In FY 2011, Medicaid paid over 
$5.3 billion for more than 865,000 children in foster care nationwide.16  
ACF Oversight 
Within ACF, the Childrens Bureau is responsible for providing Federal 
funding to States foster care programs and for overseeing those programs.  
As part of its oversight responsibilities, the Childrens Bureau reviews and 
approves States Child and Family Services Plans (CFSPs), which include 
the health services oversight and coordination plans and Annual Progress 
and Services Reports. The Childrens Bureau issues annual program  
instructions outlining the information that States must report to receive 
annual Federal funding, including information pertaining to the health 
services oversight and coordination plans.  The Childrens Bureau also 
conducts periodic reviews of each States child welfare system, known as 
Child and Family Services Reviews. 
Related Reports 
A 2010 Office of Inspector General (OIG) report found that for children 
enrolled in Medicaid in nine States, three out of four children did not 
receive all required medical, vision, and hearing screenings.17 The report 
also found that nearly 60 percent of children who received EPSDT 
medical screenings lacked at least one component of a complete medical 
screening.18 
 ____________________________________________________________ 
15 According to section 1902(a)(10)(A)(i)(I)  of  the Act, children in foster care covered 
under Title IV-E of the Act are eligible for Medicaid.  Children in foster care who are not 
eligible under Title IV-E might qualify for Medicaid through other eligibility categories 
established by each State. 
16 This information represents 46 States and is the most complete and  current data 
available.  Medicaid Statistical Information System Data Mart 2011  Quarterly Cube, 
filtered  for basis of eligibility value Foster Care Children.  Accessed at 
http://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-
Systems/MedicaidDataSourcesGenInfo/MSIS-Mart-Home.html on June  4, 2014.  
17 OIG,  Most Medicaid Children in Nine States Are Not Receiving All Required  
Preventive Screening Services, OEI-05-08-00520, May 2010. 
18 Ibid. 
Not All Children in Foster Care Received Required Health Screenings (OEI-07-13-00460)   4 
     
From 2003 through 2005, OIG published a series of reports on the use of 
Medicaid services by children in foster care in eight selected States.19   
Those reports found a variety of issues, including that foster care providers 
and caregivers were not receiving medical histories for children in their 
care and that not all children in foster care were receiving appropriate 
health care services.20  
A 2009 Government Accountability Office (GAO) report described how 
10 States identified health care needs  for children in foster care, ensured 
delivery of health services for these children, and documented and 
monitored their care.21  GAO found that the 10 States generally adopted 
policies specifying the timing and scope of childrens health assessments 
and that most States adopted practices  to facilitate access, coordinate care, 
and review medications for children in foster care.  GAO also found that 
several States shared data across State programs and employed quality 
assurance measures to track receipt of services.22  
METHODOLOGY 
From each of the 4 States, we selected a simple random sample of 
100 children in foster care enrolled in Medicaid between July 1, 2011, and 
June 30, 2012.23  Because of inaccuracies in the population data that States 
provided, a total of seven children who were not in foster care during the 
review period were selected; these children were not eligible to be in the 
sample.  Eliminating the 7 ineligible children brought the total sample size 
to 393 eligible children. See Table 2 below regarding the population and 
sample size for the four States. 
 ____________________________________________________________ 
19 OIG,  Foster Care Childrens  Use of Medicaid  Services in New Jersey, 
OEI-02-00-00360, July 2003;  OIG,  Childrens Use of  Health Care Services While in 
Foster Care:   Kansas, OEI-07-00-00640, August 2003;  OIG,  Childrens Use of  Health 
Care Services While in Foster Care:  Texas, OEI-07-00-00641, February  2004;   OIG,  
Childrens Use of  Health Care Services While in Foster Care:  Illinois, 
OEI-07-00-00642, February  2004;   OIG, Foster Care Childrens Use of Medicaid 
Services in Oregon, OEI-02-00-00363, June 2004;  OIG, Childrens Use of Health Care 
Services While in Foster Care:  North Dakota, OEI-07-00-00643, August 2004;  OIG,  
Childrens Use of  Health Care Services While in Foster Care:  Georgia, 
OEI-07-00-00644, January 2005; and OIG,  Childrens Use of  Health Care Services 
While in Foster Care:  New York, OEI-02-00-00362, June  2005. 
20 Ibid. 
21 GAO,  Foster Care:  State Practices for Assessing  Health Needs, Facilitating Service 
Delivery, and Monitoring  Childrens Care (GAO-09-26),  February 2009.  GAOs review  
included the following States:  California, Delaware, Florida, Illinois, Massachusetts, 

New York, Oklahoma, Texas, Utah, and  Washington. 
 
22 Ibid. 

23 This timeframe was the most recent complete year of Medicaid claims data available at 

the start of our data collection.  
Not All Children in Foster Care Received Required Health Screenings (OEI-07-13-00460)   5 
     
Table 2: Population of Children in Foster Care Enrolled in Medicaid at 

Any Time Between July 1, 2011, and June 30, 2012 and Sample Sizes  

Eligible Sampled 
State   Population Size   Sample Size  
Children  
Texas  46,353   100  100 
New York   35,874   100  96 
California  26,397   100  100 
Illinois   9,438   100  97 
     Total  118,062   400  393 
Source:  OIG analysis of State-submitted foster  care enrollment and Medicaid claims data, 2013. 
We requested case file documentation and Medicaid claims data 
representing health care services received by the sampled children in the 
review period. The States were unable to locate the requested case file 
documents for five sampled children, which brought the overall weighted 
response rate to 99 percent (388 sampled cases). We received Medicaid  
claims data for all of the 388 sampled cases.  The results of this review are 
projected to only the four selected States at the 95-percent confidence 
level.  
We interviewed Childrens Bureau staff regarding the extent to which ACF 
ensures that children in foster care receive required health screenings 
consistent with State schedules.  See Appendix C for a detailed description 
of our methodology. 
Limitations 
Although Medicaid is the primary source of health care coverage for most  
children in foster care, it is also possible for children in foster care to 
receive health care from other sources, such as schools, free health clinics, 
or a parents private insurance coverage.  It is possible that some children 
in our sample received health care services that were not paid for by 
Medicaid; therefore, these childrens receipt of required health screenings 
may be underestimated.  
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency.   
Not All Children in Foster Care Received Required Health Screenings (OEI-07-13-00460)   6 
     
FINDINGS 
Nearly a third of children in foster care who were 
enrolled in Medicaid did not receive at least one 
required health screening 
Twenty-nine percent of children in foster care who were enrolled in 
Medicaid who were required to receive at least one health screening 
during the review period did not receive one or more of those screenings.24   
Of the children who did not receive at least one required screening, 
12 percent did not receive their initial screening and 17 percent did not 
receive one or more periodic screenings.  Table 3 below shows the 
percentages of children who did not receive initial and periodic 
screenings. See Appendix D for all estimates and 95-percent confidence 
intervals for projections. 
Table 3: Percentages of  Children in Foster Care Who Did Not 
Receive at Least One Required Health Screening  
Percentage of Children in Foster  
Type of Missing Screening   Care Who Did Not Receive the 
Screening 
Initial screening   12%  
At least one required periodic screening   17% 
     Total missing the initial screening or at least one 
required periodic  screening   29%  
Source:  OIG analysis of State case files and Medicaid  claims for children in  foster care, 2014. 
Over a quarter of children in foster care who were 
enrolled in Medicaid received at least one required 
health screening late 
Twenty-eight percent of children in foster care who were required to 
receive at least one health screening received some screenings late.25 Of  
the children who received at least one required screening late, 17 percent 
received their initial screenings late and 10 percent received at least one 
periodic screening late. Table 4 below shows the percentages of children 
who received initial and periodic screenings late. 
 ____________________________________________________________ 
24 In the four States, 69 percent of all children in foster care should have received at least 
one screening  between July 1, 2011, and June 30, 2012.  The remaining children were  not  
required to have a screening during the review  period.  The sampled children were  
required to receive between  one and six screenings  during the review  period.   
25  We cannot  provide projections of  how many days late the late screenings  occurred.   
The number of children with at least one late screening  was too low in some States to  
produce a statistically valid estimate.  
Not All Children in Foster Care Received Required Health Screenings (OEI-07-13-00460)   7 
     
Table 4: Percentages of  Children in Foster Care Who Received 
Required Screenings Late 
Percentage of Children in Foster  
Type of Late Screening   Care Who Received Required 
Screening Late  
Initial screening   17%  
At least one required periodic screening   10% 
     Total receiving initial screening late or at least 
one required periodic screening late*   28%  
Source:  OIG analysis of State case files and Medicaid  claims for children in  foster care, 2014. 
* Because of rounding, the percentages for late initial and  periodic screenings do not total 28 percent. 
ACFs reviews do not ensure that children in foster 
care receive required health screenings according to 
State schedules 
Childrens Bureau staff reported that they review a sample of childrens 
case records in each State as part of the Child and Family Services 
Reviews. These reviews determine whether the State has appropriately 
assessed a childs health (i.e., physical and dental health) and mental 
health needs and whether the State identified and managed those needs by 
providing necessary services. These determinations are based on 
information collected from the childs case record and through interviews  
with individuals participating in the childs case, such as the child, 
biological parents, foster parents, and case workers.  
Childrens Bureau staff reported that the case record reviews performed as  
part of the Child and Family Services Reviews assess whether each child  
received initial and periodic screenings.  Specifically, staff reported that 
they assess whether the State is providing screenings when the child first 
enters foster care and on an ongoing basis while the child is in foster care.  
However, their reviews do not determine whether children in foster care 
received required screenings according to the time intervals specified in 
each States schedule.  
   
Not All Children in Foster Care Received Required Health Screenings (OEI-07-13-00460)   8 
     
CONCLUSION AND RECOMMENDATIONS 
Nearly a third of children in foster care who were enrolled in Medicaid in 
four States did not receive at least one health screening as required by 
their respective States plans for health services oversight and  
coordination, and 28 percent of children in foster care received a required 
screening late. 
Previous OIG work regarding all children enrolled in Medicaid in nine 
States revealed issues with childrens receipt of required preventive health 
screenings. OIG found that three out of four children enrolled in Medicaid 
did not receive all required medical, vision, and hearing screenings.  OIG 
also found that nearly 60 percent of children who received medical 
screenings lacked at least one component of a complete medical screening.  
That report recommended that the Centers for Medicare & Medicaid 
Services collaborate with States and providers to develop effective 
strategies to encourage childrens participation in preventive health 
screenings and identify and disseminate promising State practices for 
increasing childrens participation in screenings and providers delivery of 
complete medical screenings.  
Our findings and previous OIG work suggest that issues with childrens 
receipt of required screenings remain.  Missing or late screenings may 
prevent childrens mental health needs, physical health needs, and 
developmental needs from being identified and treated. 
ACF and States should do more to ensure that children in foster care 
receive required screenings.  Therefore, we recommend that ACF:  
Expand the scope of the Child and Family Services Reviews to 
determine whether children in foster care receive required 
health screenings according to the timeframes specified in 
States plans 
Although ACF assesses through the Child and Family Services Reviews 
whether States are providing health screenings when a child first enters 
foster care and on an ongoing basis, the reviews do not assess whether the 
screenings were received according to the timeframes specified in State 
plans. ACF should expand its Child and Family Services Reviews to 
ensure that children in foster care receive screenings according to the 
timeframes specified in States plans.   
Identify and disseminate State strategies to ensure that all 
children in foster care receive required health screenings 
We encourage ACF to work with States to identify the barriers that prevent 
children in foster care from receiving required screenings.  Once those 
Not All Children in Foster Care Received Required Health Screenings (OEI-07-13-00460)   9 
     
barriers are identified, ACF should work with States to identify, 
disseminate, and implement strategies for overcoming those barriers.  
Possible strategies include developing educational materials for foster 
parents that discuss the benefits of health screenings and providing 
incentives to families and children in foster care to encourage participation  
in required screenings. ACF could develop technical assistance and 
resources for States to assist them  with implementing identified strategies.  
   
Not All Children in Foster Care Received Required Health Screenings (OEI-07-13-00460)   10 
     
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
ACF stated that it would consider the first recommendation and concurred 
with the second. 
In responding to our first recommendation, ACF stated that it would 
consider implementing the recommendation in future Child and Family 
Service Reviews.  ACF stated that the initial round of Child and Family 
Service Reviews did determine whether children in foster care received 
health screenings according to the timeframes specified in States plans.  
However,  ACF reported challenges with making these determinations, 
such as obtaining documentation needed to support that children in foster 
care received required screenings according to States timeframes.  As a 
result, ACF chose to focus on whether childrens individual health needs 
were met in subsequent reviews.  ACF will assess whether reviewing 
receipt of required screenings according to State timeframes can be 
included in future reviews. 
In responding to our second recommendation, ACF stated that it currently 
provides training and technical assistance to States that is intended to 
facilitate implementation of Federal requirements and support program  
improvement.  ACF will work with its technical assistance providers to 
assist States with identifying strategies that ensure that all children in 
foster care receive required health screenings.  
We support ACFs efforts to address these issues and encourage continued 
progress, including expanding the Child and Family Services reviews to 
determine whether children in foster care receive required health 
screenings according to timeframes specified in States plans.  For the full 
text of ACFs comments, see Appendix E. 
   
Not All Children in Foster Care Received Required Health Screenings (OEI-07-13-00460)   11 
     
APPENIDX A 
Required Elements for Health Services Oversight and 
Coordination Plans 
Section 422(b)(15)(A) of the Act requires that each State plan include the 
following elements, which are quoted verbatim: 
 	  a schedule for initial and followup health screenings that meet 
reasonable standards of medical practice; 
 	  a description of how health needs identified through screenings 
will be monitored and treated, including emotional trauma  
associated with a childs maltreatment and removal from home; 
 	  a description of how medical information for children in care will 
be updated and appropriately shared, which may include the 
development and implementation of an electronic health record; 
 	  steps to ensure continuity of health care services, which may 
include the establishment of a medical home for every child in 
care;26  
 	  oversight of prescription medicines, including protocols for the 
appropriate use and monitoring of psychotropic medications; 
 	  how the State actively consults and involves health care experts 
and other professionals in assessing the health and well-being of 
children in foster care and in determining appropriate medical 
treatment for the children; and  
 	  for children aging out of foster care, steps to ensure that the 
components of the transition plan development process required 
under section 475(5)(H) of the Act related to health care needs, 
including the requirements to include options for health insurance; 
to include information about a health care power of attorney, health 
care proxy, or other similar document recognized under State law; 
and to provide the child with the option to execute such a 
document, are followed. 
   
____________________________________________________________ 
26 A medical home is an approach to providing comprehensive primary care, in which a  
primary care provider  works in  partnership  with a child and  family to ensure that all of 
the medical and nonmedical needs of the patient are met.  American Academy of 
Pediatrics, National Center for Medical  Home Implementation. What is a 
Family-Centered Medical Home?   Accessed at http://www.medicalhomeinfo.org on  
December 15, 2014. 
Not All Children in Foster Care Received Required Health Screenings (OEI-07-13-00460)   12 
     
APPENDIX B 
Four Selected States Schedules for Periodic Health 
Screenings  
Californias schedule for periodic health screenings is as follows: 
   for newborns, a screening by 1 month old; 
   for children aged 16 months, a screening every 2 months; 
   for children aged 715 months, a screening every 3 months; 
   for children aged 1623 months, a screening every 6 months; 
   for children aged 2 and 3 years old, an annual screening; 
   for children aged 45 years old, a screening every 2 years; 
   for children aged 68 years old, a screening every 3 years; and 
   for children aged 919 years old, a screening every 4 years. 
Illinois schedule for periodic health screenings is as follows: 
   For children aged 01 year, a screening occurs: 
o   at birth, 
o   between 35 days old, 
o   at 1 month old, 
o   at 2 months old, 
o   at 4 months old, 
o   at 6 months old, and 
o   at 9 months old. 

   For children aged 13 years, a screening occurs: 

o   at 12 months old,  
o   at 15 months old, 
o   at 18 months old,  
o   at 24 months old, and 
o   at 30 months old. 
   For children aged 3 years and older, a screening occurs annually. 
   
Not All Children in Foster Care Received Required Health Screenings (OEI-07-13-00460)   13 
     
New Yorks schedule for periodic health screenings is as follows: 
   For children aged 01 year, a screening occurs: 
o   between 24 weeks old, 
o   between 23 months old, 
o   between 45 months old, 
o   between 67 months old, and 
o   between 910 months old. 

   For children aged 16 years, a screening occurs: 

o   between 1213 months old, 
o   between 1415 months old, 
o   between 1619 months old, 
o   between 2325 months old, and 
o   annually for ages 35. 

   For children aged 621 years, a screening occurs: 

o   at 6 years old, 
o   between 89 years old, 
o   between 1011 years old, 
o   between 1213 years old, 
o   between 1415 years old, 
o   between 1617 years old, 
o   between 1819 years old, and 
o   at 20 years old. 
Texass schedule for periodic health screenings is as follows: 
   For children aged 01 year, a screening occurs: 
o   at birth, 
o   between 35 days old, 
o   at 2 weeks old, 
o   at 2 months old, 
o   at 4 months old, 
o   at 6 months old, and 
Not All Children in Foster Care Received Required Health Screenings (OEI-07-13-00460)   14 
     
o   at 9 months old. 
   For children aged 13 years, a screening occurs: 
o   at 12 months old,  
o   at 15 months old, 
o   at 18 months old,  
o   at 24 months old, and 
o   at 30 months old. 
   For children aged 3 years and older, a screening occurs annually.  
   
Not All Children in Foster Care Received Required Health Screenings (OEI-07-13-00460)   15 
     
APPENDIX C 
Detailed Methodology 
State Selection. As shown in Table C-1, children from the four States 
constituted approximately 31 percent of the total population of children in 
foster care as of September 30, 2012.27  
Table C-1: Selected States for Data Collection  
Number of Children in  Percentage of Children 
State   Foster Care as of  in Foster Care in the  
September 30, 2012  United States  
California  54,288   13.7%  
Texas   29,613   7.5%  
New York   23,924   6.0%  
Illinois   16,637   4.2%  
     Total:  124,462   31.4%  
Source:  OIG analysis of  child welfare outcomes report data for children in foster care, 2014. 
Response Rates.   Table C-2 below provides detailed information regarding 
the population, sample size, and response rates for the four States. 
Table C-2: Population of Children in Foster Care Enrolled in Medicaid at 
Any Time Between July 1, 2011, and July 30, 2012, Sample Sizes, and 
Response Rates by State* 
Estimated 
Estimated  Total   Eligible  Weighted  
Eligible  Responses 
State   Population   Eligible  Sampled  Sampled  Response 
Respondent   Received  
Population  Children   Children   Rates  
Population  
Texas   46,353   46,353   46,353  100  100  100  100%  
New York   35,874   34,439   34,439   100  96  96  100%  
California  26,397   26,397   25,869  100  100  98  98%  
Illinois   9,438   9,249   8,972   100  97  94  97%  
     Total   118,062   116,438   115,633  400  393  388  99%  
Source:  OIG analysis of State-submitted foster  care enrollment and Medicaid claims data, 2014. 
* The differences in the State populations between tables  C-1 and C-2 are due to  the nature of the data on which the numbers are 
based.  Table C-1 is based on child welfare data collected by ACF; it reflects the number of  children who were in foster  care on a  
single day, September 30, 2012.  Table C-2 is based on  foster  care enrollment data that the selected States provided to us  and 
reflects all children in foster care enrolled in Medicaid at any time between July 1, 2011, and June 30, 2012. 
Case File Documentation and Medicaid Claims Data Review.   We  
reviewed the foster care case file documentation provided by the four 
States to determine whether it supported the sampled childs receipt of 
____________________________________________________________ 
27 ACF,  Foster Care FY20032012 Entries, Exits, and In Care on the Last Day of Each 
Federal Fiscal Year. Accessed at 
www.acf.hhs.gov/sites/default/files/cb/entryexit2012.xlsx on May 28, 2014. 
Not All Children in Foster Care Received Required Health Screenings (OEI-07-13-00460)   16 
     
initial and periodic health screenings according to State schedules.28   To  
identify support for the receipt of a required initial or periodic screening, 
we looked for at least the date of the screening and a brief description of 
the screening. 
We reviewed Medicaid claims data for all health care services that each 
sampled child received between July 1, 2011, and June 30, 2012.  We  
identified the health care services received by each child that fell within 
the timeframes for the childs respective States required initial and 
periodic screenings and determined whether any of those services 
represented a required screening. 
Analysis of Results. Using the foster care case file documentation and 
Medicaid claims data, we assessed each childs receipt of health 
screenings according to the appropriate States schedule.  For example, if a 
child in our sample entered foster care on May 1, 2012, and his State 
required an initial screening within 72 hours of foster care placement, his 
initial screening must have occurred between May 1, 2012, and 
May 4, 2012, to satisfy the requirement. If either the foster care case file 
documentation or the Medicaid claims data supported receipt of the 
required screenings for a sampled child, we counted those screenings as 
received. If neither the foster care case file documentation nor the 
Medicaid claims supported receipt of a particular required screening by a 
sampled child, that screening was counted as not received. 
 
We assessed whether each child received health screenings timely. If 
either the foster care case file documentation or Medicaid claims data 
supported receipt of the required screenings for a sampled child, but 
showed that the screening was received after the specified timeframe or 
time interval, we counted that screening as late.29  
We followed up with foster care program officials in the four States 
regarding every child for whom we determined one or more screenings 
were missing.  State officials either provided additional documentation 
showing that the child did receive the screening(s) in question, or 
confirmed that the screening(s) were not received.  If additional 
____________________________________________________________ 
28 Some children in  our sample were not required to have a periodic screening  within the 
review period, on  the basis of their ages and  the relevant  States screening schedule.   
Additionally, some children in  our sample were not  required to have an initial screening  
within the review period.  These children entered foster care before the beginning of the 
review period  and their initial screenings should  have  occurred before the beginning of 
the review period.  
29  We cannot  provide projections of  how many days late the late screenings  occurred.   
The number of children with at least one late screening  was too low in some States to  
produce a statistically valid estimate.  
Not All Children in Foster Care Received Required Health Screenings (OEI-07-13-00460)   17 
     
documentation was provided showing that the screenings were received, 
we did not count those screenings as not received. 
APPENDIX D 
Table D-1:  Point Estimates, Sample Sizes, and Confidence 
Intervals 
   
95-Percent 
Sample  Point 
Estimate Description   Confidence 
Size  Estimate  
Interval  
Percentage of children in foster care who did not 
receive one or more required health screenings in  284  29.3%   23.6%35.7%  
the review period  
Percentage of children in foster care who should 
have received at least one screening in the review   388  68.8%   64.8%72.5%  
period  
Percentage of children in foster care who did not 
284  12.1%   8.5%16.9%  
receive an initial screening 
Percentage of children in foster care who did not 
284  17.2%   12.6%23.0%  
receive at least one periodic screening 
Percentage of children in foster care who received 
284  27.7%   22.8%33.1%  
at least one required screening late  
Percentage of children in foster care who received 
284  17.4%   14.2%21.3%  
their initial screening late 
Percentage of children in foster care who received 
284  10.2%   6.7%15.2%  
at least one of their periodic screenings late 
Source:  OIG analysis of State case files and Medicaid  claims for children in  foster care, 2014. 
Not All Children in Foster Care Received Required Health Screenings (OEI-07-13-00460)   18 
     
APPENDIX E 
Agency Comments 
Not All Children in Foster Care Received Required Health Screenings (OEI-07-13-00460)  19 
  Page2 
appropriate screening timeframes in its policies and/or a successful approach to 
implementing them in light of child outcomes. 
During the initial round of the Child and Family Services Reviews, we employed the 
approach that the OIG recommends. TI1at approach presented a number of challenges 
with locating documentation as well as assessing the adequacy of states' responsiveness 
to children's health care needs.  We, therefore, abandoned that approach in favor of the 
one described above for second round and now third rotmd.  Notwithstanding some ofthe 
challenges with comparing OIG's data with the second round results, we note that OIG's 
findings are very similar to those from the second round. 
As the Children's Bureau has already begun implementation of the CFSRs for the third 
round, we are unable to modify our approach at this time.  We will specifically monitor 
state perfom1ance in this area in order to assess whether returning to our earlier approach, 
and the OIG's recommendation, of monitoring state timeframes in conjtmction with our 
approach to ensuring states are individualizing its attention to a child's health issues is 
appropriate for fourth round. 
Recommendation:  Identify and disseminate State strategies to ensure that all children in 
foster care receive required health screenings. 
Response:  ACF concurs with this recommendation. 
The Children's Bureau currently provides training and technical assistance to states that 
is intended to facilitate implementation of federal policies and requirements and support 
progrant improvement.  We will work with our newly awarded technical assistance 
providers in fiscal year 2015 to plan and develop strategies for communicating health 
screening standards to states and create resources to assist them with implementation. 
ACF appreciates the opportunity to provide comments on the draft report and welcomes 
any further questions that the OIG may have regarding these issues.  Please direct any 
follow-up inquiries to our Office of Legislative Affairs and Budget OIG liaison, Scott 
Logan, at (202) 401-4529. 
Sincerely, 
Mark H. Greanber.g 
Acting Assistant Secretary 
for Children and Fantilies 
Not All Children in Foster Care Received Required Health Screenings (OEI-07-13-00460)  20     
ACKNOWLEDGMENTS 
This report was prepared under the direction of Brian T.  Whitley, Regional 
Inspector General for Evaluation and Inspections in the Kansas City 
regional office. 
Rae Hutchison served as the lead analyst for this study.  Other Office of 
Evaluation and Inspections staff from the Kansas City regional office who 
conducted the study include Jordan R. Clementi, Dennis Tharp, and 
Michala Walker.  Central office staff who provided support include 
Kevin Farber, Christine Moritz, and Sherri Weinstein. 
Not All Children in Foster Care Received Required Health Screenings (OEI-07-13-00460)   21 
   
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: 
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The Office  of  Audit Services  (OAS) provides auditing services  for HHS, either by  conducting  
audits  with its own audit resources or by  overseeing  audit work done by others.  Audits  
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out their respective responsibilities and are intended  to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and  
mismanagement and promote economy and efficiency  throughout  HHS. 
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The Office  of  Evaluation and Inspections (OEI)  conducts national evaluations to  provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud,  waste, or abuse  and promoting  
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reports also present practical recommendations for improving program operations.  
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The Office of Investigations (OI) conducts criminal, civil, and administrative investigations  
of  fraud and misconduct  related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI  utilizes its resources 
by actively  coordinating with the Department  of Justice  and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to  criminal 
convictions, administrative sanctions,  and/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 for OIGs  internal operations.  OCIG represents  OIG in all civil and 
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opinions, issues compliance program  guidance, publishes fraud alerts, and provides other  
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enforcement authorities.