Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

NOT ALL CHILDREN IN 

FOSTER CARE WHO WERE 

ENROLLED IN MEDICAID 

RECEIVED REQUIRED HEALTH 

SCREENINGS 

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 children’s 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 State’s 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, ACF’s 

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 

ACF’s 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. 536–541. 

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 State’s 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 

State’s timeframe. 

Table 1: State Timeframes for Initial Health Screenings 

State Timeframe Within Which Initial Health 

Screening Must Be Received 

California 

Illinois 

New York 

Texas 

24 hours 

24 hours; a second comprehensive medical 

screening within 21 days 

24 hours 

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 FY2003–2012 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 Children’s Bureau is responsible for providing Federal 

funding to States’ foster care programs and for overseeing those programs. 

As part of its oversight responsibilities, the Children’s 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 Children’s 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 Children’s Bureau also 

conducts periodic reviews of each State’s 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-andSystems/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 children’s 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 Children’s Use of Medicaid Services in New Jersey, 

OEI-02-00-00360, July 2003; OIG, Children’s Use of Health Care Services While in 

Foster Care: Kansas, OEI-07-00-00640, August 2003; OIG, Children’s Use of Health 

Care Services While in Foster Care: Texas, OEI-07-00-00641, February 2004; OIG, 

Children’s Use of Health Care Services While in Foster Care: Illinois, 

OEI-07-00-00642, February 2004; OIG, Foster Care Children’s Use of Medicaid 

Services in Oregon, OEI-02-00-00363, June 2004; OIG, Children’s Use of Health Care 

Services While in Foster Care: North Dakota, OEI-07-00-00643, August 2004; OIG, 

Children’s Use of Health Care Services While in Foster Care: Georgia, 

OEI-07-00-00644, January 2005; and OIG, Children’s 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 Children’s Care (GAO-09-26), February 2009. GAO’s 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
 

State Population Size Sample Size Eligible Sampled 

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 Children’s 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 parent’s 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 children’s 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 

Type of Missing Screening 

Percentage of Children in Foster 

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 

Type of Late Screening 

Percentage of Children in Foster 

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. 

ACF’s reviews do not ensure that children in foster 

care receive required health screenings according to 

State schedules 

Children’s Bureau staff reported that they review a sample of children’s 

case records in each State as part of the Child and Family Services 

Reviews. These reviews determine whether the State has appropriately 

assessed a child’s 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 child’s case record and through interviews 

with individuals participating in the child’s case, such as the child, 

biological parents, foster parents, and case workers. 

Children’s 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 State’s 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 children’s 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 children’s participation in preventive health 

screenings and identify and disseminate promising State practices for 

increasing children’s participation in screenings and providers’ delivery of 

complete medical screenings. 

Our findings and previous OIG work suggest that issues with children’s 

receipt of required screenings remain. Missing or late screenings may 

prevent children’s 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 children’s 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 ACF’s 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 ACF’s comments, see Appendix E. 

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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 child’s 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 

California’s schedule for periodic health screenings is as follows: 

 for newborns, a screening by 1 month old; 

 for children aged 1–6 months, a screening every 2 months; 

 for children aged 7–15 months, a screening every 3 months; 

 for children aged 16–23 months, a screening every 6 months; 

 for children aged 2 and 3 years old, an annual screening; 

 for children aged 4–5 years old, a screening every 2 years; 

 for children aged 6–8 years old, a screening every 3 years; and 

 for children aged 9–19 years old, a screening every 4 years. 

Illinois’ schedule for periodic health screenings is as follows: 

 For children aged 0–1 year, a screening occurs: 

o at birth, 

o between 3–5 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 1–3 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 York’s schedule for periodic health screenings is as follows: 

 For children aged 0–1 year, a screening occurs: 

o between 2–4 weeks old, 

o between 2–3 months old, 

o between 4–5 months old, 

o between 6–7 months old, and 

o between 9–10 months old. 

 For children aged 1–6 years, a screening occurs: 

o between 12–13 months old, 

o between 14–15 months old, 

o between 16–19 months old, 

o between 23–25 months old, and 

o annually for ages 3–5. 

 For children aged 6–21 years, a screening occurs: 

o at 6 years old, 

o between 8–9 years old, 

o between 10–11 years old, 

o between 12–13 years old, 

o between 14–15 years old, 

o between 16–17 years old, 

o between 18–19 years old, and 

o at 20 years old. 

Texas’s schedule for periodic health screenings is as follows: 

 For children aged 0–1 year, a screening occurs: 

o at birth, 

o between 3–5 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 1–3 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 

State 

Number of Children in 

Foster Care as of 

Percentage of Children 

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* 

State Population 

Estimated 

Eligible 

Population 

Estimated 

Eligible 

Respondent 

Population 

Total 

Sampled 

Children 

Eligible 

Sampled 

Children 

Responses 

Received 

Weighted 

Response 

Rates 

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 child’s receipt of 

____________________________________________________________ 

27 ACF, Foster Care FY2003–2012 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 child’s respective State’s 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 child’s receipt of health 

screenings according to the appropriate State’s 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 State’s 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 

Estimate Description Sample 

Size 

Point 

Estimate 

95-Percent 

Confidence 

Interval 

Percentage of children in foster care who did not 

receive one or more required health screenings in 

the review period 

284 29.3% 23.6%–35.7% 

Percentage of children in foster care who should 

have received at least one screening in the review 

period 

388 68.8% 64.8%–72.5% 

Percentage of children in foster care who did not 

receive an initial screening 284 12.1% 8.5%–16.9% 

Percentage of children in foster care who did not 

receive at least one periodic screening 284 17.2% 12.6%–23.0% 

Percentage of children in foster care who received 

at least one required screening late 284 27.7% 22.8%–33.1% 

Percentage of children in foster care who received 

their initial screening late 284 17.4% 14.2%–21.3% 

Percentage of children in foster care who received 

at least one of their periodic screenings late 284 10.2% 6.7%–15.2% 

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: 

Office of Audit Services 

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 

examine the performance of HHS programs and/or its grantees and contractors in carrying 

out their respective responsibilities and are intended to provide independent assessments of 

HHS programs and operations. These assessments help reduce waste, abuse, and 

mismanagement and promote economy and efficiency throughout HHS. 

Office of Evaluation and Inspections 

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 

economy, efficiency, and effectiveness of departmental programs. To promote impact, OEI 

reports also present practical recommendations for improving program operations. 

Office of Investigations 

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 OIG’s internal operations. OCIG represents OIG in all civil and 

administrative fraud and abuse cases involving HHS programs, including False Claims Act, 

program exclusion, and civil monetary penalty cases. In connection with these cases, OCIG 

also negotiates and monitors corporate integrity agreements. OCIG renders advisory 

opinions, issues compliance program guidance, publishes fraud alerts, and provides other 

guidance to the health care industry concerning the anti-kickback statute and other OIG 

enforcement authorities.