'" 
""'CES.
DEPARTMENT OF HEALTH &. HUMAN  SERVICES Office of Inspector General
:it'''4JO Washington, D.C. 20201
JUL - 8 2005
TO: Susan OlT
Associate Commissioner for the Children s Bureau
Administration for Children and Families
Dennis G. Smith
Director, Center for Medicaid State Operations
Centers for Medicare & Medicaid Services
FROM:
Brian Ritchie 
Acting Deputy Inspector General
for Evaluation and Inspections
SUBJECT: "Children s Use of Health Care Services While in Foster Care:
Common Themes " OEI-07-00-00645
The Offce of Inspector General (OIG) would like to take this opportunity to share the attached
document, which provides information regarding access to health care services for children in
foster care. The document is based on eight studies that our offce conducted
, the last of which
was recently released. Upon completion of the studies
, we reviewed the experiences of all eight
States and have identified common themes and additional information we believe noteworthy
and of importance to you and to all States in your continuing efforts to ensure access to health
care services and favorable outcomes for children in foster care
, especially with respect to:
Ensuring the identification of health and mental health needs of children entering foster
care
Increasing the number of Early Periodic Screening, Diagnosis, and Treatment and other
required examinations received within required timeframes
Emphasizing the importnce of case workers' obtaining medical information for children
in foster care and foster care providers' receipt of health information for the children in
their care
Documenting, updating, and managing health and mental health information for children
in foster care Page 2 - Susan OlT and Dennis G. Smith
Enhancing communication between the State agencies responsible for administering the
foster care and Medicaid programs, and
Using multiple sources of information to identify the services children in foster care have
received or may be lacking.
OIG offered recommendations for improvement in each of the individual State reports. The
attched document does not contain any additional recommendations and requires no formal
comment from you. However, we would welcome any comments you might wish to share.
If you have any questions regarding this information, or if we can be of any fuher assistace
please do not hesitate to call me or your staff may contact Elise Stein, Director, Public Health
and Human Services Branch, at (202) 619-2686 or through e-mail (Elise.Stein(ioig.hhs.gov).
To facilitate identification, please refer to report number OEI-07-00-00645 in all
cOlTespondence.
Attachment Childrens Use of Health Care Services While in Foster Care: 

Common Themes 

OEI-07-00-00645 

July 2005 

Summary 
The Office of Inspector General, Office of Evaluation and Inspections, conducted a series 
of inspections in eight States1 to determine whether children in foster care in those States 
were receiving Medicaid and other health care services.  Here we offer a summary of the 
reports of these inspections in hope that this information and the information presented in 
each of the individual State reports will be useful in all States efforts to identify the 
health and mental health services children in foster care are receiving or lacking, and that 
it will be used to ensure that children in foster care receive the health and mental health 
services they need. 
Our field work varied to address each States provision of health care services to children 
in foster care. The field work consisted of a review of State policies, analysis of 
child-specific Medicaid claims data and case-file documentation for sampled children in 
foster care, interviews with caseworkers and foster care providers (i.e., foster parents and 
residential facility staff) for children in our sample, and interviews with staff in the State 
agencies responsible for administering the foster care and Title XIX Medicaid programs.  
This mixed-method approach to our data collection allowed us to identify the receipt of 
more health screenings and examinations than would have been identified using a single 
data source. 
We found that, even though sampled States utilized differing approaches 
(i.e., fee-for-service or per diem rates) to provide Medicaid services to children in 
foster care, all of the 400 sampled children included in these studies were covered by 
their States Medicaid program and most had made Medicaid claims for health care 
services. Through our use of mixed methods, in which we reviewed both Medicaid 
claims and case-file documentation in five of the eight States,2 we found that the 
experiences of sampled children varied in the receipt of required services.  Mental health 
screening requirements also varied, ranging from generally requiring that legal custodians 
provide for the mental health of children in their custody to specifically requiring that a 
developmental or psychological evaluation be completed within specific timeframes.  
Many foster care providers (i.e., foster parent or residential care facility staff) interviewed 
1 The eight States (Georgia, Kansas, Illinois, New Jersey, New York, North Dakota, Oregon, and Texas) 
represented 24 percent of the total foster care population nationwide and a diverse cross section of foster 
care. 
2 We followed somewhat different methodologies in three of the eight States.  We analyzed Medicaid 
claims data, but not case-file documentation, in New Jersey and Oregon. We analyzed both Medicaid 
claims data and case-file documentation in New York, but because New York used a per diem approach 
to pay for Medicaid services that children in foster care received, these sampled children could not be 
compared to children in the other States.  In all three States, we determined the receipt of services beyond 
those required. 
1
 reported not receiving medical histories or other medical information about children in 
their care. 
Not all sampled children received Early and Periodic Screening, Diagnosis, 
and Treatment examinations or initial examinations required upon entering 
State custody 
The number of sampled children who received required Early and Periodic Screening, 
Diagnosis, and Treatment (EPSDT) examinations or required initial medical and dental 
examinations upon entering State custody varied by State.  Some services were not 
received by any of the sampled children.  In five States, we analyzed both fee-for-service 
Medicaid claims data and case-file documentation to determine if sampled children had 
received required health care services.  Thus, we were able to make comparisons for 
these five States.  We did so based primarily on whether they had received their most 
recent required EPSDT examinations in accordance with State-established frequency 
guidelines, and whether they had received an initial examination upon entering State 
custody in the States where initial examinations were required.   
EPSDT Examinations. EPSDT examinations are designed to screen for, diagnose, and 
treat conditions of Medicaid-eligible children that might go otherwise undetected or 
untreated.  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.  The percentage of sampled children in the five States who had received 
their most recent required EPSDT medical and dental examinations in accordance with 
State-established frequency guidelines ranged from 60 to 100 percent,3 as detailed in 
Table 1. 
Table 1: Percentage of Sampled Children Receiving EPSDT 
Examinations Timely 
State  Medical Examinations  Dental Examinations 
Georgia  60%  60% 
Illinois  100%  76% 
Kansas*  90%  82% 
North Dakota  70%  79% 
Texas  94%  92% 
*Kansas is the only sample State that printed notification of upcoming 
required EPSDT medical and dental examinations on monthly Medicaid 
cards mailed to foster care providers. 
Source: Office of Inspector General, review of case files for sampled children 
in five States, 2005 
3 Based on their age, the length of time they had been in foster care, individual State-established EPSDT 
frequency guidelines, and the periods covered by the individual State studies, 233 of the 250 sampled 
children in the five States were required to receive an EPSDT medical examination and 201 were required 
to receive a dental examination during the periods covered by these studies.  
2  Initial Examinations. Initial health examinations provide an early assessment of children 
and their health care needs as they enter the foster care system.  Four States where we 
examined both Medicaid claims and case-file documentation required that children 
entering foster care receive an initial medical examination within State-established 
timeframes.  (One State recommended but did not require an initial medical 
examination.)  Two States required that children entering foster care receive an initial 
dental examination within State-established timeframes; three States did not.  The 
percentage of sampled children who received State-required initial medical examinations 
within established timeframes ranged from 42 to 97 percent.  The percentages of children 
entering foster care who received required dental examinations in the two States where 
they are required were 29 and 66 percent.  The percentages of sampled children in the 
four States who received the medical and dental examinations required by their State 
upon entering foster care are detailed in Table 2. 
Table 2: Medical and Dental Examinations Required Upon Entering Foster Care 
and Percentage of Sampled Children Who Received These Examinations Timely 
Initial Medical Examinations  Initial Dental Examinations 
State 
% Received  % Received 
Requirement(s)  Requirement 
Timely  Timely 
Georgia  38 Days  64%  38 Days  29% 
Illinois*  24 hrs & 21 Days  97% & 42%  N/A  N/A 
Kansas  30 Days  82%  N/A  N/A 
Texas  30 Days  75%  90 Days  66% 
*Illinois required that children receive an Initial Health Screening within 24 hours of entering State 
Custody and a separate Comprehensive Health Evaluation within 21 days of entering State 
custody. 
Source: Office of Inspector General, review of case files for sampled children in four States, 2005 
  Requirements for initial examinations in the four States were as follows:  
 	 The Georgia First Placement, Best Placement (FP/BP) program required that all 
children entering foster care receive a Comprehensive Child and Family 
Assessment, which includes a complete medical examination, a dental 
examination, and a developmental assessment or psychological evaluation within 
38 days of entering State custody. The components of these assessments mirrored 
those required as part of EPSDT examinations.  Because children are required to 
receive Comprehensive Child and Family Assessments separately from the 
EPSDT examinations, we believe some children may have received one 
examination and not the other (e.g., FP/BP versus EPSDT), and children receiving 
both required examinations may have received some duplicated services. 
 	 Illinois required that all children entering foster care receive an Initial Health 
Screening within 24 hours of entering State custody to identify and document 
acute medical problems and evidence of abuse, and to provide the caseworker 
with appropriate medical information to place the child.  The Initial Health 
3
 Screening is scheduled by the caseworker and can be performed at a hospital, 
clinic, or physicians office, meaning that screenings can be performed 24 hours a 
day, 7 days a week. The State also required that children receive a 
Comprehensive Health Evaluation, which includes an in-depth physical 
examination and comprehensive medical and psychosocial history, within 21 days 
of entering State custody. Illinois did not require an initial dental examination 
upon entering State custody. 
 	 Kansas required that all children entering foster care receive an initial medical 
examination within 30 days of entering State custody.  Kansas did not require an 
initial dental examination. 
 	 Texas required that all children entering foster care receive an initial medical 
examination within 30 days of entering State custody and an initial dental 
examination within 90 days. 
Required mental health screenings were not received and mental health needs were 
undocumented for some sampled children 
Research has shown that children often enter foster care after experiencing traumatic life 
events and suffer much higher rates of serious psychological problems than other children 
from similar socioeconomic backgrounds.4  Therefore screening for the mental health 
needs of children in foster care is essential.  States establish their own policies regarding 
the identification of mental health needs.  Mental health screening requirements for 
children in foster care in the eight States we reviewed ranged from simply requiring that a 
childs guardian be informed of the availability of mental health services and that legal 
custodians provide for the mental health of children in custody, to requiring that all 
children in foster care receive a psychological evaluation or developmental assessment 
within 38 days of entering State custody. Two of the States reviewed had implemented 
specific guidelines regarding the provision of mental health services to children in foster 
care. These required that a licensed therapist, psychologist, or psychiatrist perform a 
comprehensive psychological examination of children entering foster care.  Specifically, 
 	 Georgia required children in foster care to receive a developmental assessment 
(ages 3 years or younger) or psychological evaluation (ages 4 years and older) 
within 38 days of entering foster care to assess their mental health needs.  
However, 22 of the 39 sampled children who entered foster care during the period 
covered by our study did not receive the required assessments/evaluations within 
the required timeframes, and four children were not receiving ongoing services 
for assessed and documented mental health needs.   
4 Casey Family Programs, National Center for Resource Family Support, Health Care Issues for Children in
   Foster Care, March 25, 2002.  
4
  	 Illinois required that children in foster care ages 5 and older receive a mental 
health screening, but only 1 in 14 of the sampled children ages 5 years and older 
received the screening. 
We found that the only mental health screening some sampled children received was 
provided as part of an EPSDT examination, the results of which were recorded in the 
physical health assessment forms completed by the screening physicians.  These 
notations were often simply a reflection of the physicians review of reported behavior 
regarding developmental and emotional observations (i.e., exercise, sleep habits, 
discipline, school grades and attendance, emotions, and peer interaction).  Federal 
EPSDT guidelines require that Medicaid-eligible children under the age of 21 receive 
screening services that meet reasonable standards of medical and dental practice, as 
determined by the State after consultation with recognized medical and dental 
organizations. However, Federal EPSDT guidelines do not specifically address standards 
required for mental health screenings.  Federal EPSDT guidelines address mental health 
screenings as part of overall medical screenings and do not require consultation with 
recognized mental health organizations.   
We also found that the identification of a childs mental health needs did not necessarily 
ensure that foster care providers were aware of those needs, or that the need for or receipt 
of services received were documented in the case files for the sampled children.  For 
example, in Georgia, the foster care providers for four children were unaware of the 
identified need for mental health services even though it was noted in the case file, and 
mental health needs were not documented in the case files for 5 sampled children 
receiving mental health services in Georgia and for 12 of the 34 sampled children who 
had received mental health services in North Dakota.  In evaluating whether children are 
receiving adequate services to meet their mental health needs, the Administration for 
Children and Families (ACF) noted in the Children and Family Services Reviews (CFSR) 
for seven of the eight States we studied that mental health services were an area needing 
improvement.   
Forty-three percent of foster care providers reported never receiving medical 
information for the sampled children in their care 
Of the foster care providers we interviewed in the eight States, 43 percent (165/384) 
indicated that they had received no medical history for the sampled child placed in their 
care. Section 475(5)(D) of the Social Security Act requires that a childs health records 
be reviewed, updated, and supplied to the foster care provider at the time of each 
placement.   
Foster care providers offered the following examples of negative consequences resulting 
from the absence of medical information for children in their care: 
 	 They were unaware of severe medical problems the child had suffered in the past 
(e.g., collapsed lungs, malnutrition) that could affect the childs ongoing health 
care needs. 
5
  	 The lack of medical information had subjected the child to repeated 

immunizations. 

 	 They were unable to provide medical information to physicians treating the 
sampled children in their care. 
Our findings regarding foster care providers who reported not receiving medical 
information for the sampled children in their care echo the findings of ACF, in that all 
eight States failed to achieve substantial conformity with the portion of the CFSR 
addressing the sharing of medical information.  Through the CFSRs, ACF explores how 
State child welfare agencies track the medical needs of and services provided to children 
in foster care and the provision of medical information to foster care providers.  More 
specifically, whether health records are given to foster care providers is part of the CFSR 
measure used to determine State performance and substantial conformity with the child 
and family well-being outcome, which assesses if children in the child welfare system are 
receiving adequate services to meet their physical and mental health needs.5  ACF must 
be able to determine that a State has substantially achieved the outcome in 90 percent of 
the sample cases selected by ACF for review, and 95 percent of the sample cases selected 
in all subsequent reviews. 
Table 3: Foster Care Providers Who Reported Never Receiving Medical 
Information for the Sampled Child in TheirCare 
Percentage of 
Number of Foster Care Providers 
Foster Care 
Providers Who 
State  Reported Not 
Reported Not 
Interviewed  Receiving Medical 
Receiving Medical 
Information 
Information 
Georgia  50  24  48% 
Illinois  46  12  26% 
Kansas  46  20  43% 
New Jersey  50  18  68% 
New York  49  20  48% 
North Dakota  48  9  19% 
Oregon  44  19  43% 
Texas  50  23  46% 
All States 
384  165  43% 
Studied 
Source: Office of Inspector General, review of case files for sampled children in eight States, 2005 
The Georgetown University Child Development Center identified the need for exchange 
of health care information in a 3-year study between 1997 and 2000.  The report stressed 
that 
5 45 CFR  1355.34 (b)(1)(iii)(C). 
6  to ensure a childs safety and well-being, and to enhance his/her 
opportunity for a permanent placement, parents, caregivers, agencies, 
courts, schools, and health care providers must have a clear understanding 
of the childs health care history and needs, as well as the services and 
supports required to meet those needs. 
As such, the reports authors recommended that State child welfare agencies 
establish a system for gathering and recording needed health care information on 
children and their families and for sharing it with all involved persons.6 
To alleviate some of the problems associated with the communication of health 
information to foster care providers, some States have implemented procedures to collect 
the information, ensure that foster care providers receive it, and ensure that it is kept up to 
date.  Examples of procedures designed to collect and document medical information 
included the following: 
 	 In Illinois, physicians were paid a $15 incentive fee to initiate a Health Passport in 
conjunction with performing the Comprehensive Health Evaluations each child is 
required to receive within 21 days of entering foster care.  The Health Passport is 
a booklet containing pertinent medical information that is provided to the childs 
foster care provider and follows the child through subsequent foster care 
placements.  A copy was required to be kept in the childs case file. 
 	 In Kansas, the child welfare agency worked with a local State university to 
develop a medical report that contains the childs medical history.  This report 
was to be updated on an ongoing basis to reflect all medical examinations and 
immunizations the child received and was to be given to each foster care provider 
who cared for the child.   
Conclusion 
It is our hope that this information and the information presented in each of the individual 
State reports will be useful in efforts in all States to identify the health and mental health 
services children in foster care are receiving or lacking.  We hope that this information 
will be used to ensure that children in foster care receive the health and mental health 
services they need, especially as related to: 
 	 Ensuring the identification of health and mental health needs of children entering 
foster care; 
 	 Increasing the number of EPSDT and other required examinations received within 
required timeframes; 
6 Georgetown University, Child Development Center (2000), Meeting the Health Care Needs of 
Children in the Foster Care System, Summary of State and Community Efforts:  Key Findings.  
7
  	 Promoting the importance of obtaining medical information for children in foster 
care and furnishing it to foster care providers;  
 	 Documenting, updating, and managing health and mental health information for 
children in foster care; 
 	 Enhancing communication between the State agencies responsible for 
administering the foster care and Medicaid programs; and 
 	 Using multiple sources of information to identify the services children in foster 
care have received or may be lacking. 
Additionally, based on our review of prior related studies, we embarked upon this 
series of foster care studies expecting to find that many children in foster care were 
not receiving required or needed health care services.  Had we followed common 
existing research approaches and relied solely on Medicaid claims data or case-file 
documentation, that would have proven to be true (see Appendix A).  However, 
through our use of mixed methods, in which we reviewed both Medicaid claims data 
and case-file documentation, we found that most sampled children had received 
Medicaid health care services. Appendix B offers a detailed description of methods 
used in our studies for those who might wish to similarly determine receipt of health 
care services by children in foster care. 
8
 Appendix A 
Use of Case-File Documentation and Medicaid Claims 
to Assess EPSDT Participation 
Using the mixed methods outlined in Appendix B, we reviewed both Medicaid claims 
data and case-file documentation.  This use of mixed methods revealed that sampled 
children received more EPSDT health care screenings than a review of either the case 
files or Medicaid claims histories alone would have shown. The disparity between the 
receipt of services based solely on case-file documentation or Medicaid claims data was 
even more striking in our review of EPSDT dental services.  We believe possible causes 
as to why either data source is not complete could include the following:  health care 
providers may not be submitting Medicaid claims for some services, children in foster 
care may receive some health and dental services from providers who do not participate 
in the Medicaid program, caseworkers may not be documenting some EPSDT services, 
communication between caseworkers and foster care providers regarding health care and 
dental services may be lacking, or difficulty may arise in transferring records from 
physicians to caseworkers. 
In the five States where we assessed the receipt of EPSDT services, each of the 
250 sampled children was eligible to receive EPSDT health care and dental examinations.  
Based on their age, length of time in foster care, and State-established EPSDT guidelines, 
233 of the 250 sampled children should have received an EPSDT medical examination 
and 201 should have received a dental examination during the periods covered by these 
studies. The table below details the number of children in our sample in five States who 
were eligible to receive EPSDT medical and dental health care examinations, and the 
number that would have been counted as having received their most recent EPSDT 
examinations in accordance with State-established EPSDT frequency guidelines. 
Evidence Supporting Receipt of EPSDT Services 
Evidence Reviewed 
Case-File 
EPSDT Service 
Case-File  Medicaid Claims  Documentation 
Documentation  Data  and/or Medicaid 
Claims Data 
Medical  129 (55.4%)  169 (72.5%)  207 (88.8%) 
Dental  64 (32.3%)  141 (70.1%)  159 (79.1%) 
Source: Office of Inspector General, review of case files for sampled children in five States, 2005 
EPSDT Medical Examinations.  A review of the case files alone would produce results 
demonstrating that only 129 of the 233 eligible sampled children received an EPSDT 
medical examination in accordance with State-established guidelines.  A review of claims 
data alone would demonstrate that 169 of the 233 eligible sampled children received 
these EPSDT medical examinations timely.  However, a review of both case-file 
9  documentation and Medicaid claims data indicated that 207 of the 233 eligible sampled 
children received their most recent EPSDT medical examination within the 
State-established timeframes.   
EPSDT Dental Examinations.  A review of case-file documentation alone would show 
that only 64 of 201 eligible sampled children received dental services in accordance with 
State guidelines. A review of Medicaid claims data alone would show that 141 of the 
201 eligible sampled children received dental services timely.  However, a review of both 
case-file documentation and Medicaid claims data indicated that 159 of the 201 sampled 
children received dental services within required timeframes. 
10
 Appendix B 
Methods Used in Five States to Determine the Health Care Services

Sampled Children Received 

In five of the eight States, we limited our reviews to the receipt of health and dental 
services that met State-established EPSDT frequency guidelines, the receipt of 
State-required initial medical examinations, the receipt and documentation of mental 
health services required by the States, and the provision of medical information to foster 
care providers.7  We did not focus on follow-up care or the appropriateness of ongoing 
health care in meeting the needs of sampled children.  These five inspections were based 
on information gathered from multiple sources:  review of Federal and State policies, 
child-specific Medicaid claims data and case-file documentation for the sampled 
children, interviews with caseworkers and foster care providers for sampled children, and 
interviews with State child welfare and Medicaid agency officials.   
Law, Regulations, and Policy Review.  We reviewed Federal laws and regulations and 
State foster care, Medicaid, and EPSDT program policies.  We used State-established 
EPSDT frequency guidelines to determine whether sampled children had received 
required EPSDT medical examinations and dental services timely.  We used 
State-established guidelines regarding initial examinations required upon entry into foster 
care. We consulted with State agency officials to enhance our understanding of each 
States foster care and Medicaid programs and of individual State policies and 
requirements developed with regard to Federal EPSDT and child welfare requirements.   
Sample Selection.  States were selected based on population size, geographic 
location, rural or metropolitan setting, child welfare program administration 
(i.e., county-administered or State-administered), and fee-for-service or managed 
care provision of Medicaid services. 
Children who met selected criteria were included in the study populations in each of the 
five States. The criteria were that the child: 
  Was in foster care at the time the study was being conducted, 
  Resided within the sample State, 
  Was eligible for Title IV-E foster care program maintenance funds, and  
  Had been in continuous foster care placements for at least 6 months. 
At our request, the child welfare agencies in each of these five States provided us with a 
list of children who met these criteria.  The information provided for each child included 
the childs name, date of birth, sex, county of residence, foster care entry date, 
7 We followed somewhat different methodologies in three of the eight States.  We analyzed Medicaid 
claims data, but not case-file documentation, in New Jersey and Oregon. We analyzed both Medicaid 
claims data and case-file documentation in New York, but because New York used a per diem approach 
to pay for Medicaid services that children in foster care received, these sampled children could not be 
compared to children in other States.  In all three States, we determined the receipt of services beyond 
those required. 
11
 caseworkers name and contact information, child welfare case number, Medicaid 
number, current placement setting (e.g., family, kinship, therapeutic, or residential foster 
care), the number of times the child had entered foster care, the number of months since 
the childs most recent entry into foster care, the number of placements the child had 
experienced during the most recent entry, and the number of months the child had resided 
in the most recent placement.   
We randomly selected 50 children from the list provided by each State for inclusion in 
our studies. 
Medicaid Claims Review.  At our request, the State Medicaid agencies in each of the 
five States provided us with up to 3 years of Medicaid claims data for 50 sampled 
children. The 3-year Medicaid claims period was identified based on each States ability 
to provide detailed Medicaid claims information (i.e., the 36-month period prior to the 
most recent date for which the State was able to provide the information). 
General Medicaid claims information provided for the sampled children in each State 
included: 
  The childs name, Medicaid identification number, and date of birth; 
  Dates Medicaid eligibility and/or Title IV-E eligibility began; and 
  Other identified health insurance. 
Specific claims data for each Medicaid service provided to the sampled children 
included: 
  Date of service, 
  Type of service (procedure code and description), 
  Diagnosis code, 
  Place of service, 
  Provider type, 
  Unit of service, 
  Amount billed to Medicaid, 
  Whether the claim was paid or denied (and reason for denial), and 
  Payment amount. 
We analyzed the Medicaid claims information provided to determine if the sampled 
children had received Medicaid services since entering foster care, what Medicaid 
services they had received, and if the services they received met State-established EPSDT 
frequency guidelines and State requirements for the receipt of initial medical and dental 
examinations and mental health care evaluations or assessments.  Medicaid claims for the 
entire 3-year claims period were reviewed for sampled children who entered foster care 
prior to the beginning of the period.  For children who entered foster care after the 
beginning of the selected Medicaid claims period, we analyzed Medicaid claims data 
from the date they entered foster care through the end of the Medicaid claims period.  
Each sampled childs age and length of time in foster care was considered with regard to 
12
 State-established EPSDT frequency guidelines and requirements for initial medical, 
dental, and mental health services in determining whether the child had received the most 
recent required EPSDT medical and dental examinations and required initial 
examinations.   
Case-File Documentation Review.  We worked with child welfare agency staff in each 
of the five States to determine what case-file documentation was needed to verify the 
receipt of EPSDT and other required health care services in their State.  We then 
requested that documentation from local child welfare offices.  The information requested 
included supporting documentation of medical, dental, and mental health services 
provided to the child (e.g., physician notes, medical forms signed by a physician), the 
childs medical history, the childs case plan, verification of the duration of the childs 
stay in foster care, and information regarding the childs health and general well-being.   
We reviewed the case-file documentation provided as evidence that each sampled child 
had received medical, dental, or mental health services (e.g., EPSDT form signed by a 
physician or other health care professional). As in our review of Medicaid claims, we 
compared each childs age and length of time in foster care to State-established EPSDT 
frequency guidelines to determine whether sampled children had received their most 
recent required EPSDT medical and dental examinations and whether they received 
required initial medical, dental, or mental health services.   
Foster Care Provider and Caseworker Interviews.  We conducted structured 
interviews, in person or by telephone, with the foster care providers and caseworkers 
responsible for most children included in each State sample.  These interviews provided 
us with valuable insights regarding why sampled children had received, or may not have 
received, required health or mental health care services.  The interviews with foster care 
providers (i.e., foster parent or residential care facility staff) focused on the Medicaid 
program and the services available, the training they had received related to the health 
and well-being of children, and their experiences procuring health care services for the 
sampled children.  Interviews with caseworkers focused on their understanding of the 
Medicaid program and the health and mental health services available, the training they 
received related to the health and well-being of children, their experiences accessing 
health care services, and any barriers to obtaining needed health care.  Each caseworker 
spoke specifically about the sampled childs case, and generally about his or her own 
experiences working in foster care. We compared the caseworkers responses with the 
responses of the foster care providers, noting any consensus or disagreement within and 
between the two groups. 
13