""'CES.

:it'''4JO

TO:

FROM:

DEPARTMENT OF HEALTH &. HUMAN SERVICES Office of Inspector General

Washington , D.C. 20201

JUL - 8 2005

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

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
Children’s 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 State’s 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 

State 

Initial Medical Examinations Initial Dental Examinations 

Requirement(s) % Received 

Timely Requirement % Received 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 physician’s 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 

child’s 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 physician’s 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 child’s 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 child’s 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 child’s 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: Fos

In

ter Care Providers Who Reported Never R

formation for the Sampled Child in Their

State 

Number of Foster Care Providers Percentage of 

Foster Care 

Providers Who 

Reported Not 

Receiving Medical 

Information 

eceiving Medical 

Care 

Interviewed 

Reported Not 

Receiving Medical 

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 

Studied 384 165 43% 

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 child’s 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 child’s health care history and needs, as well as the services and 

supports required to meet those needs. 

As such, the report’s 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 child’s 

foster care provider and follows the child through subsequent foster care 

placements. A copy was required to be kept in the child’s case file. 

• In Kansas, the child welfare agency worked with a local State university to 

develop a medical report that contains the child’s 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 

EPSDT Service 

Evidence Reviewed 

Case-File 

Documentation 

Medicaid Claims 

Data 

Case-File 

Documentation 

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 

State’s 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 child’s 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
caseworker’s 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 child’s 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 State’s 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 child’s 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 child’s 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 

child’s medical history, the child’s case plan, verification of the duration of the child’s 

stay in foster care, and information regarding the child’s 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 child’s 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 child’s 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