Department of Health and Human Services 


OFFICE OF 

INSPECTOR GENERAL 

CHILDREN’S USE OF HEALTH 


CARE SERVICES WHILE IN 


FOSTER CARE: NEW YORK


Inspector General 

June 2005 

OEI-02-00-00362 
Office of Inspector General 
 http://oig.hhs.gov 

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, 

as amended, is to protect the integrity of the Department of Health and Human Services 

(HHS) programs, as well as the health and welfare of beneficiaries served by those 

programs. This statutory mission is carried out through a nationwide network of audits, 

investigations, and inspections conducted by the following operating components: 

Office of Audit Services 

The OIG's Office of Audit Services provides all auditing services for HHS, either by 

conducting audits with its own audit resources or by overseeing audit work done by others. 

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

in carrying out their respective responsibilities and are intended to provide independent 

assessments of HHS programs and operations in order to reduce waste, abuse, and 

mismanagement and to promote economy and efficiency throughout the department. 

Office of Evaluation and Inspections 

The OIG's Office of Evaluation and Inspections (OEI) conducts short-term management 

and program evaluations (called inspections) that focus on issues of concern to the 

department, the Congress, and the public. The findings and recommendations contained 

in the inspections reports generate rapid, accurate, and up-to-date information on the 

efficiency, vulnerability, and effectiveness of departmental programs. The OEI also 

oversees State Medicaid fraud control units, which investigate and prosecute fraud and 

patient abuse in the Medicaid program. 

Office of Investiga ions t

The OIG's Office of Investigations (OI) conducts criminal, civil, and administrative 

investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries 

and of unjust enrichment by providers. The investigative efforts of OI lead to criminal 

convictions, administrative sanctions, or civil monetary penalties. 

Office of Counsel to the Inspector General 

The Office of Counsel to the Inspector General (OCIG) provides general legal services to 

OIG, rendering advice and opinions on HHS programs and operations and providing all 

legal support in OIG's internal operations. The OCIG imposes program exclusions and 

civil monetary penalties on health care providers and litigates those actions within the 

department. The OCIG also represents OIG in the global settlement of cases arising 

under the Civil False Claims Act, develops and monitors corporate integrity agreements, 

develops compliance program guidances, renders advisory opinions on OIG sanctions to 

the health care community, and issues fraud alerts and other industry guidance. 
∆ EXECUTIVE SUMMARY 

OBJECTIVE 

To determine whether children in New York foster care have Medicaid 

coverage and are receiving health care services. 

BACKGROUND 

It is estimated that 532,000 children are in foster care nationwide, and 

many of them are reportedly in poor health. Compared with children 

from the same socioeconomic background, children in foster care suffer 

much higher rates of serious emotional and behavioral problems, 

chronic physical disabilities, birth defects, developmental delays, and 

educational difficulties. 

Almost all children in foster care are eligible for Medicaid services and 

for Medicaid’s Early and Periodic Screening, Diagnosis, and Treatment 

(EPSDT) program. Among other things, the EPSDT requires each State 

to make preventive health care and follow-up services available to 

Medicaid-eligible individuals under the age of 21. 

This inspection focuses on the State of New York and is part of a larger 

body of work in which eight States are being evaluated. The analysis is 

based on a review of Medicaid claims and case file records relating to 

50 children in New York foster care over a 26-month period, as well as 

interviews with foster care agency staff and caregivers. 

FINDINGS 

All children in the sample we reviewed have Medicaid coverage and 

are receiving health care services. All 50 children have a Medicaid 

identification number and all had at least 1 Medicaid claim between 

September 2000 and October 2002. 

One reason supporting this finding is that 43 of the 50 sample children 

benefit from New York’s Medicaid payment system called the per diem. 

In this system, participating agencies receive periodic (usually monthly) 

fixed payments per child from Medicaid to cover a variety of physician 

and dental services for the children in the agency’s care. This system 

provides flexibility in that it allows foster care agencies to employ 

health care providers onsite or to contract with them. 

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EXECUTIVE SUMMARY

Many caregivers are not informed about the Medicaid program and 

the EPSDT, and they often do not receive their children’s medical 

histories. Many caregivers say they are not taught how to navigate the 

Medicaid system. For example, 32 say they did not receive an 

explanation as to which services are covered by Medicaid and 23 say 

they did not get a schedule of doctor appointments children need. 

Twenty-one caregivers have not heard of the EPSDT program. Twentyfour say they have heard of it but only one of them reports that her child 

receives services under the program. 

Further, 20 caregivers say they did not receive any of their children’s 

medical histories. Eight more say they did receive some history, but not 

all of the important information. Three of these caregivers believe that 

their children’s health care was adversely affected because the 

information was missing. 

RECOMMENDATIONS 

The children in our sample are receiving needed services, especially 

preventive care. We believe that New York’s Medicaid payment system 

likely facilitates the children’s access to health care services. 

Nevertheless, we recommend that the Administration for Children and 

Families (ACF) and the Centers for Medicare & Medicaid Services 

(CMS) work with the New York State Office of Children and Family 

Services and Office of Medicaid Management to further promote access 

to services by addressing potential obstacles, including caregivers’ 

limited knowledge about the EPSDT and how to navigate the Medicaid 

system. We also recommend that ACF help the State ensure that the 

most complete medical histories are shared with the children’s 

caregivers. 

Agency Comments 

We received comments from ACF and CMS. The full text of the 

comments is included in Appendix D. ACF reports that it is working 

with New York on our recommendation to promote the importance of 

obtaining medical histories for children in foster care. ACF notes that a 

Program Improvement Plan was developed in response to the New York 

Child and Family Service Review conducted by ACF. This plan contains 

action steps that address the gathering of medical information and the 

physical and mental health needs of children served by New York’s child 

welfare system. ACF says that it monitors progress of the plan with 

quarterly reports. 

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EXECUTIVE SUMMARY 

CMS concurs with the recommendation that CMS work with New York 

to further promote access to services. CMS states that regional staff 

will work with the New York Office of Children and Family Services and 

Office of Medicaid Management to ensure that New York’s foster care 

staff is educated on Medicaid and the EPSDT program services. CMS 

also mentions that it is working with ACF to develop interagency multistate meetings. According to CMS, these meetings will focus on access 

to Medicaid services for children in foster care and facilitate 

communication between State Medicaid directors and Child Welfare 

directors. 

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∆ T A B L E O F C O N T E N T S 

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

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

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

All sampled children have Medicaid coverage and access to services . . . 8 

Caregivers are not informed about the Medicaid system and often 

 do not receive their children’s medical information................ 11

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

APPENDIXES .................................................. 14 

Appendix A: Services Inside and Outside the Per Diem Rate ........ 14

Appendix B: Children’s Demographic and Health Characteristics .... 15

Appendix C: Comparison of Children in Sample to Population....... 17

Appendix D: Agency Comments ............................... 18

ACKNOWLEDGMENTS ......................................... 23
∆ I N T R O D U C T I O N 

OBJECTIVE 

To determine whether children in New York foster care have Medicaid 

coverage and are receiving health care services. 

BACKGROUND 

It is estimated that 532,000 children are in foster care nationwide,1 and 

many of them are reportedly in poor health. Compared with children 

from the same socioeconomic background, children in foster care suffer 

much higher rates of serious emotional and behavioral problems, 

chronic physical disabilities, birth defects, developmental delays, and 

educational difficulties.2 According to the New York State Judicial 

Commission on Justice for Children, half of all children in the child 

welfare system nationwide suffer from developmental delays or mental 

health problems that are serious enough to need clinical intervention.3 

In addition to the needs they share with other children, such as 

immunizations, routine well-child examinations, and treatment of 

childhood diseases, children in foster care clearly have a greater need 

for specialized health care services. 

Despite their need, it appears that many children in foster care are not 

receiving adequate health care. It is estimated that 60 percent of all 

children in out-of-home care have moderate to severe mental health 

problems, yet less than one-third of those children receive mental health 

services.4 A Government Accountability Office (GAO) report issued in 

May 1995, entitled “Health Needs of Many Young Children are 

Unknown and Unmet,” found that a significant proportion of young 

children in foster care did not receive critical health-related services in 

the three locations studied (Los Angeles County, New York City, and 

1 Retrieved on June 23, 2004, from: 

http://www.acf.hhs.gov/programs/cb/dis/afcars/publications/afcars.htm. 

2 Health Care of You g Ch n ildren in Foster Care, Committee on Early Childhood, Adoption 

and Dependent Care, American Academy of Pediatrics, Policy Statement, Volume 109, 

Number 3, March 2002, pp. 536-541. 

3 Pamphlet on “Ensuring the Healthy Development of Foster Care Children,” New York 

State Permanent Judicial Commission on Justice for Children, 1999, page 4. 

4 Fact Sheet: The Health of Children in Out-Of-Home Care, Child Welfare League of 

America, retrieved March 14, 2003, from: 

http://www.cwla.org/programs/health/healthcarecwfact.htm. 

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INTROD UCTION

Philadelphia County).5 In fact, GAO estimated that only 1 percent of 

these children received Early and Periodic Screening, Diagnostic, and 

Treatment (EPSDT) services. 

Medicaid for Children in Foster Care 

The Medicaid program provides health care to specified groups of needy 

individuals. It is administered by the Centers for Medicare & Medicaid 

Services (CMS) and jointly funded by the Federal and State 

governments. Within broad national guidelines, each State establishes 

its own Medicaid eligibility standards; determines the type, amount, 

duration, and scope of services; sets the rate of payment for services; 

and administers its own State Medicaid program.6 

Almost all children in foster care are eligible for Medicaid services. 

Pursuant to section 1902 (a)(10)(A)(i)(I) of the Social Security Act (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 for 

Title IV-E services usually qualify for Medicaid through other eligibility 

categories set forth by each State. In fiscal year 2000, Medicaid 

payments for children in foster care nationwide were over $3.3 billion.7 

Early and Periodic Screening, Diagnosis, and Treatment 

The EPSDT is a Federal entitlement to comprehensive medical services 

for Medicaid-eligible children under the age of 21. While States have 

the flexibility to design their own Medicaid programs, the EPSDT 

program requires each State to provide coverage for comprehensive and 

preventive child health services to Medicaid-eligible individuals under 

the age of 21. In general, the EPSDT treatment services include 

periodic screening, vision, dental, and hearing services and all other 

services available under the Medicaid program. Treatment or medical 

care must be provided for any physical or mental conditions discovered 

by the screening services. 

y N s of Man ild n are Unkn n an e 5 Health eed y Young Ch re ow d Unm t, General Accounting 

6 Retrieved from CMS Web site on March 14, 2003: 

Office, GAO/HEHS-95-114, 1995, pp. 2 and 5. 

http://www.cms.hhs.gov/medicaid/mover.asp. 

x nditures for Federal Fiscal Ye n 7 Medicaid E pe ar 2000, By Type of Service for Mai tenance 

Assistan s an ce Statu d Basis of Eligibility All States; Medicaid Statistical Information 

System Report for Federal fiscal year 2000. National Total for Foster Care children, 

page 3, retrieved from CMS Web site on March 13, 2003: 

http://www.cms.gov/medicaid/msis/00total.pdf. 

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INTROD UCTION 

Under EPSDT, States must set distinct periodicity schedules for 

screening, dental, vision, and hearing services. Services must be 

provided at intervals that meet reasonable standards of medical 

practice. States must consult with recognized medical organizations 

involved in child health care, such as the American Academy of 

Pediatrics, in developing reasonable standards.8

New York 

Child Welfare. The New York State Office of Children and Family 

Services (OCFS) in the Department of Family Assistance is responsible 

for the State’s children in foster care. At the time of this inspection, 

New York had approximately 57,000 children in foster care. New York’s 

foster care system is decentralized so child welfare programs are Statesupervised and county-administered. New York State is divided into 

58 local social services districts. One of these districts includes the five 

boroughs of New York City. Almost one-third of the State’s children in 

foster care reside in New York City. Outside of New York City, each 

district corresponds to 1 of the 57 counties that make up the remainder 

of the State. 

In each district, children are placed either under the direct care of the 

local district or under the care of a contracted foster care agency, 

commonly referred to as a voluntary agency. These agencies provide 

services under contract with a local district. Nearly 80 percent of the 

children in foster care are under the care of voluntary agencies 

statewide. OCFS is responsible for licensing, inspecting, supervising, 

and monitoring them. In 2002, there were 153 such foster care agencies 

in New York. 

Pursuant to OCFS, each child in foster care has a case planner and a 

case manager. The case planner has the primary responsibility of 

providing, arranging, coordinating, and evaluating the provision of 

services to the child and family. When a child is placed with a 

voluntary agency, the case planner is a member of the agency’s staff. 

Case managers, on the other hand, are employees of the local social 

services district. They are responsible for authorizing the provision of 

services, approving the client eligibility determination, and approving 

service plans. When the child is placed in the care of the local district, 

the case manager is also the case planner. 

8 Retrieved from CMS Web site March 28, 2003: http://www.cms.gov/medicaid/epsdt/. 

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INTROD UCTION 

Medicaid Program. The New York State Department of Health is 

responsible for the State’s Medicaid program. Within this Department, 

the Office of Medicaid Management manages the Medicaid program, 

which is administered by local social services office. 

As in all States, children in New York foster care who meet Title IV-E 

requirements are eligible for Medicaid coverage. For children in New 

York foster care who do not meet IV-E requirements, Medicaid 

eligibility is determined by State standards and based, in part, on the 

child’s income. Medicaid must be authorized for 12-month periods in all 

foster care cases that are Medicaid eligible.9 

In fiscal year 2001, Medicaid expenditures for children in New York 

foster care were approximately $395 million. 

Managed Care. Children placed in the care of voluntary agencies are 

excluded from participating in managed care.10 Children under direct 

care, however, may be eligible for enrollment in a Medicaid managed 

care plan at the option of each local district. Districts may opt not to 

enroll children in managed care for a number of reasons, such as 

distance from providers or the special medical needs of the child. Of the 

58 social service districts, 5 enroll children in managed care. The New 

York City district is not one of the five. 

New York’s Medicaid Payment System. Voluntary agencies have the option 

of receiving a Medicaid payment per child, commonly referred to as the 

per diem, to pay for their children’s health care or having the children 

receive care through Medicaid fee-for-service. 

These payments cover many physician and dental services. They also 

cover most prescription and non-prescription drugs, home health, 

medical supplies, eye care, and mental health/behavioral health 

services. Agencies may have medical professionals on staff or contract 

with local providers to care for the children. In 2002, 96 of the 

153 voluntary agencies in New York State chose to receive the per diem. 

Agencies use the per diem to pay health care providers directly for 

rendered services.11 See Appendix A for services included and not 

included in the per diem rate. If a child needs services not included

9 NYS OCFS Eligibility Manual for Child Welfare Programs, June 2003, pp.4-4, 4-5. 

10New York Social Services Law, Title 11, section 364-j 3(d)(xi). 

11 NYS OCFS Eligibility Manual for Child Welfare Programs, June 2003, p. 4-2. 

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INTROD UCTION 

under the payment system, the child may go to a Medicaid provider. 

The provider would then bill Medicaid directly for these services. 

The per diem rate paid to the agency varies by agency and by the types 

of programs within the agency. The rate is based on the agency’s 

historic costs of providing medical care, subject to certain ceilings. Each 

agency receiving a per diem is required to submit a medical services 

expenditure distribution sheet to the Department of Health annually. It 

is a summary of all medical costs incurred by the foster care agency. 

The annual cost is the basis for determining rates for subsequent years. 

Per diem payments totaled $221,000 for the children in our sample from 

September 2000 through October 2002. In general, per diem payments 

were made to agencies monthly for each child in their care. The average 

per diem payment for the children in the sample was $263 per month. 

New York has formed a workgroup to look at standards of care, cost of 

care, and what services should and should not be included in the per 

diem rate. The workgroup includes representatives from OCFS, the 

Division of Budget, the Office of Mental Health, the Office of Alcohol 

and Substance Abuse Services, the Department of Health, Office of 

Mental Retardation and Developmental Disabilities, and the Council on 

Children and Families. 

METHODOLOGY 

This inspection is based on information gathered from multiple sources: 

a review of Medicaid claims and case file records relating to 50 children 

in New York foster care over a 26-month period; a review of Federal and 

State laws, regulations, and policies; and interviews with Federal and 

State agency officials, foster care agency staff, and caregivers. 

Reasons for State Selection 

This inspection focuses on the State of New York and is part of a larger 

body of work in which eight States are being evaluated. New York was 

selected because of its size, decentralized child welfare system, and 

geographic location. 

Sample 

The 50 children in the sample were randomly selected from a population 

of 41,232 children in continuous foster care placement for at least 

6 months prior to September 30, 2002. See Appendixes B and C for a 

more detailed description of children in the sample and a comparison of 

the children in the sample to the population. 

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INTRODUCTION 

It should be noted that, because of our sample size, we do not project our 

estimates to the universe of all children in New York foster care. Our 

purpose was to gain an understanding of how children in foster care 

receive medical care. 

Review of Medicaid Claims Data, Case File Information, and Federal and 

State Laws and Policies 

Medicaid Claims Data. New York’s Office of Medicaid Management 

provided a Medicaid claims history of 26 months for each of the 

50 children in our sample. The data include claims with service dates 

from September 2000 through October 2002. None of the children were 

enrolled in managed care at the time of the sample selection, so the 

Medicaid histories contain no managed care encounter data. All claims 

discussed in this report are fee-for-service. 

In reviewing the Medicaid claims, we paid particular attention to the 

types of service, claims coded as EPSDT, dates of service, and settings, 

where available. Medicaid claims data were organized into broad 

categories for analysis, such as preventive care, office visits, dental, and 

mental health. We excluded claims that were not health care related, 

such as those for transportation. We determined the periods of time the 

child was in foster care based on information given by the OCFS and the 

child’s foster care agency. Claims for services provided when the child 

was not in foster care were excluded. 

Case File Information. Forty-five of the fifty sampled children were placed 

in the care of voluntary agencies. These children, unlike the five in the 

direct care of a local district, could receive medical services paid by the 

per diem. Services provided under the per diem, along with any other 

services the child receives, are recorded in the child’s case file by the 

voluntary agency. The children in direct care receive health care 

services through Medicaid fee-for-service. We did not collect their case 

files because the services they received are evident from their Medicaid 

claims histories. 

We collected the medical portion of the case file from September 2000 

through October 2002 for each of the 45 children placed in the care of a 

voluntary agency. The case files did not distinguish between Medicaid 

services and those that are paid for by the State or other non-Medicaid 

sources, such as Head Start. Therefore, our analysis includes services 

that may not have been paid by Medicaid. 

In the case file review, just as in the Medicaid claims review, we 

excluded services that were not health care related or were provided 

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INTRODUCTION 

while the child was not in foster care. For each child, the health care 

services found in the case files were compared to the child’s Medicaid 

claims history. To prevent counting a service more than once, if the 

same service was found in the claims and the case file, that service was 

counted in the claims data and not counted in the case file review data. 

Law and Policy Reviews. We reviewed Federal and State laws, 

regulations, and policies pertaining to the provision of health care to 

children in foster care. 

Interviews 

Foster Care Agency Interviews. We conducted interviews, either in person 

or by telephone, with foster care agency staff responsible for each of the 

50 children in our sample. We interviewed each child’s case planner, 

who, as previously noted, has the primary responsibility of providing, 

arranging, coordinating, and evaluating the provision of services to the 

child and family. In some interviews with voluntary agencies, a member 

of the agency’s health care staff joined the case planner. We use the 

term “agency” to refer to the case planner and health care staff 

representing the child. 

The interviews focused on agency staff ’s understanding of Medicaid and 

experiences accessing health care services for the child in our sample. 

We also discussed any barriers to health care faced by the child and by 

children in foster care in general. 

Caregiver Interviews. We interviewed the caregivers for 49 of the children 

in our sample. We were unable to reach one caregiver. We use the term 

“caregiver” to refer to a foster parent or residential facility staff member 

who is responsible for the child. Forty of the children were in family 

care and nine were in residential care. Like the caseworker interviews, 

our interviews with caregivers focused on training, Medicaid, and 

procuring health care services for the child in our sample. 

Federal and State Agency Officials. We held several meetings, both in 

person and by telephone, with officials from CMS, the Administration 

for Children and Families (ACF), New York’s OCFS, and New York’s 

Office of Medicaid Management. Our discussions covered a wide 

spectrum of information to help us understand how the State’s foster 

care and Medicaid systems are organized and administered. 

This inspection was conducted in accordance with the Quality 

Standar s for Inspecti d ons issued by the President’s Council on Integrity 

and Efficiency. 

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∆ FINDINGS 


All the children in the sample have 

Medicaid coverage. All 50 children 

All children in the sample have Medicaid 

coverage and are receiving health care services 

have a Medicaid identification 

number, and all had at least 1 Medicaid claim filed for a service 

provided between September 2000 and October 2002. 

Forty-seven children in the sample received preventive care services. 

The EPSDT program requires each State to provide coverage for 

comprehensive and preventive child health services. Forty-seven of the 

fifty sampled children received at least one preventive health care 

service during the study period, according to the Medicaid claims and 

the case file documentation. The number of preventive care services per 

child ranged from 1 to 15. 

The sampled children received a variety of services in addition to 

preventive care. Forty-two children received office visit services. These 

services typically included treatment of an illness or injury. Forty-two 

children received diagnostic services, such as lab tests. Thirty-six 

children received all three of these services: preventive, office, and 

diagnostic. The number of total health care services per child ranged 

from 5 to 786 over the study period. Table 1 (shown on next page) lists 

the services received by the children in the sample. 

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FINDINGS 

i 164 

ice Visit 201 

/Di ic 216 

l 36 153 

36 

i 422 

V i 30 74 

i 112 

i 19 82 

9 

i / i l 7 756 

6 

l 5 

3 8 

S ervice T yp e 

N u m b er of C h ildren W ith at 

L east O n e S ervice T otal N um ber of S ervices 

Prevent ve 47 

Off 42 

Lab W ork agnost 42 

Denta

Mental Health 1,835 

Hear ng/Speech 32 

sion 

Im m unizat ons 27 

Emergency Serv ces 

Other 25 

Phys cal Occupat ona Therapy 

Case Management 30 

Hospita Services 15 

Supplies 

T able 1: N u m b er and T yp e of H ealth C are Services 

Source: Office of Evaluation and Inspections Medicaid Claim s Data and Case File Review. 

Caregivers and foster care agencies report their children have access to the 

health care they seek. 

Forty-six of forty-nine caregivers and 46 of 50 agencies interviewed 

report that the children in foster care receive the health care services 

they seek. Caregivers also say that finding providers for the children in 

the sample is not difficult. Forty-five caregivers report no problems 

finding doctors, dentists, or any other type of health care professionals. 

Of the four caregivers who report problems, two say finding a dentist 

who accepts Medicaid is difficult, one reports problems finding a dentist 

and a doctor, and the fourth reports problems finding a therapist. 

In total, caregivers and agencies describe five instances where they 

could not eventually get the care they sought for their children. In two 

of these instances, a provider was available but the child refused 

treatment. In another instance, the provider’s waiting list was 

reportedly too long. The remaining instances involve disagreement over 

treatment plans or difficulty getting prescription drugs. 

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FINDING S 

Caregivers and agencies report that eight children in the sample receive 

non-Medicaid health care services in addition to Medicaid services. 

Caregivers say that they pay for medications, medical care, or mental 

health care themselves. A few agencies say children in foster care 

receive counseling at a boys’ club, while another agency says the child in 

its program receives counseling and therapy through school. Several 

agencies point out that, in general, when a child needs health care 

services not covered by Medicaid, the foster care agency will pay for the 

services. 

According to caregivers and agencies, nine children in the sample are 

enrolled in some type of program that improves their access to health 

care. These programs include early intervention and specialized day 

care centers, which provide mental health care, speech therapy, or 

physical or occupational therapy. 

Most caregivers and agencies report that they have received training about 

health problems that often affect children in foster care. 

According to the Foster Care Program Placement Agreement, OCFS has 

the responsibility to provide training opportunities for foster parents 

and foster parents are responsible for attending training sessions. 

Thirty-nine of the forty-nine caregivers say they have received training 

about health issues relevant to children in foster care. This training 

covers topics such as mental/behavioral health, obtaining certain 

medical services, HIV/AIDS, and asthma. Thirty-three of the fifty 

agencies say they have received similar training. Forty-four children in 

the sample have either a caregiver or agency reporting that they 

received this training. Twenty-eight children have both a caregiver and 

an agency reporting that they received training. 

According to caregivers and agencies, 36 of the 50 sampled children 

have a variety of ongoing medical or mental health problems. These 

problems include asthma, attention deficit disorder, post-traumatic 

stress disorder, and depression. 

Forty-three children in the sample are covered by New York’s Medicaid 

payment system, called the per diem. 

As explained in the background section of this report, the per diem is 

paid to voluntary agencies in New York State for medical services 

necessary to meet the needs of the children in their care. Forty-three of 

the fifty children in the sample were covered by the per diem during the 

study period. Of the remaining seven children, five were in direct care 

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F INDINGS 

and therefore excluded from the per diem, and two were placed out-ofState for a time during the study. 

New York’s Office of Medicaid Management reports that the per diem 

gives localities the flexibility to provide services within the community. 

The agencies can have onsite medical staff or contract out, therefore 

ensuring a sufficient number of providers. All the voluntary agencies 

representing the children in the sample report that their agency has 

health professionals on staff. These professionals include nurses, 

mental health professionals, and physicians who often provide for the 

children or act as a resource for caregivers. Fifteen agencies and eight 

caregivers say that having a medical department or doctors onsite 

improves access to health care services. 

Thirty-four of the forty-three children covered by the per diem also had 

Medicaid fee-for-service health care claims. The remaining nine 

children covered by the per diem appear to have had all their health 

care services paid for by the per diem. A child could have fee-for-service 

claims while under the per diem for a variety of reasons. In addition to 

the routine care generally paid for by the per diem, the child may need 

care from a specialist or certain type of facility that is outside the per 

diem. These services are paid under Medicaid fee-for-service. (See 

Appendix A for a list of services that are inside or outside the per diem.) 

Many caregivers are not informed about the Medicaid Caregivers say they are not taught 

how to navigate the Medicaid program or the EPSDT, and they often do not receive system. their children’s medical information 

Caregivers report that they do not get information about Medicaid that 

could help them access Medicaid services for their children. For 

example: 

o Thirty-three caregivers say they did not receive telephone 

numbers to call if they had questions about Medicaid. 

o Thirty-two caregivers say they did not receive an explanation as to 

which services are covered under Medicaid. 

o Thirty caregivers say they did not receive a list of doctors who 

accept Medicaid. 

o Twenty-three caregivers say they did not receive a schedule of the 

doctor appointments children need. 

 O E I - 0 2 - 0 0 - 0 0 3 6 2 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE IN F OSTER CARE : NEW Y ORK 11 
F INDINGS 

o Fourteen caregivers say they did not receive any of this 

information. Five caregivers say they received all of this 

information. 

Not all caregivers and agencies know about the EPSDT. 

Twenty-one caregivers have not heard of the EPSDT or any of the 

program’s other names in New York, such as Child/Teen Health Plan or 

Child Health Assurance Program. Twenty-four caregivers say they 

have heard of the EPSDT (or one of its other names), but only one of 

them reports that her child receives services under the program. 

Twenty-seven agencies have not heard of the EPSDT. Twenty-two 

agencies say they have heard of the program but only six of them report 

that their children receive services under the program. 

Caregivers often do not receive their child’s medical history. 

Twenty caregivers say they did not receive any of their children’s 

medical histories. Eight more say they did receive some history but not 

all of the important information. In contrast, one agency reports that it 

did not receive a medical history. Five agencies say they did not receive 

all the important information about their children’s medical history. 

According to the Foster Care Program Placement Agreement, OCFS has 

the responsibility to provide foster parents with all pertinent 

information concerning youth placed in their home. 

Three caregivers believe the missing information adversely affected the 

health care of their children. One caregiver says that she had no record 

of her child’s immunizations so the child “had to start from scratch.” 

Another caregiver says she would have been better able to care for her 

child had she known the child came from an abusive home. The third 

caregiver says it would have been helpful to know that her child was 

born prematurely. 

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∆ R E C O M M E N D A T I O N S 


The children in our sample are receiving needed services, especially 

preventive care. We believe that New York’s Medicaid payment system, 

the per diem, likely facilitates the children’s access to health care 

services. Nevertheless, we recommend that ACF and CMS work with 

the New York State OCFS and Office of Medicaid Management to 

further promote access to services by addressing potential obstacles, 

including caregivers’ limited knowledge about the EPSDT and how to 

navigate the Medicaid system. We also recommend that ACF help the 

State ensure that the most complete medical histories are shared with 

the children’s caregivers. 

Agency Comments 

We received comments from ACF and CMS. The full text of the 

comments is included in Appendix D. ACF reports that it is working 

with New York on our recommendation to promote the importance of 

obtaining medical histories for children in foster care. ACF notes that a 

Program Improvement Plan was developed in response to the New York 

Child and Family Service Review conducted by ACF. This plan contains 

action steps that address the gathering of medical information and the 

physical and mental health needs of children served by the New York 

State child welfare system. ACF says that it monitors progress of the 

plan with quarterly reports. 

CMS concurs with the recommendation that CMS work with New York 

to further promote access to services. CMS states that regional staff 

will work with the New York OCFS and Office of Medicaid Management 

to ensure that the New York foster care staff is educated on Medicaid 

and the EPSDT program services. CMS also mentions that it is 

working with ACF to develop interagency multistate meetings. 

Pursuant to CMS, these meetings will address access to Medicaid 

services for children in foster care and facilitate communication between 

State Medicaid directors and Child Welfare directors. 

 O E I - 0 2 - 0 0 - 0 0 3 6 2 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE IN F OSTER CARE : NEW Y ORK 13 
∆ APPENDIX ~ A 

Services Inside and Outside the Medicaid Per Diem Rate 

Service 

Physician Administrative In the Rate 

Nurses In the Rate 

Physician Specialists In the Rate 

Physicians In the Rate 

Article 28 Freestanding Clinics In the Rate 

Psychiatrists In the Rate 

Psychologists In the Rate 

Certified Social Workers In the Rate 

OMH Licensed Vol Clinics In the Rate 

OMRDD Licensed Vol Clinics In the Rate 

OASAS Licensed Clinics In the Rate 

Dentists In the Rate 

Dental Freestanding Clinics In the Rate 

Prescription Drugs* In the Rate 

Non-Prescription Drugs* In the Rate 

Medical Supplies In the Rate 

Durable Medical Equipment In the Rate 

Home Health PCA/HHA/LPN/RN In the Rate 

Laboratory In the Rate 

X-ray In the Rate 

Transportation In the Rate 

Eye Care In the Rate 

OT/PT Speech and Audiology In the Rate 

Service 

Article 28 Outpatient Departments Out of Rate 

Emergency Room Out of Rate 

School-Based Health Clinics Out of Rate 

Family Planning Clinics Out of Rate 

OMH Partial Hospital Out of Rate 

OMH Day Treatment Out of Rate 

OMH State Clinics Out of Rate 

OMR/OASAS State Operated Clinics Out of Rate 

General Inpatient Out of Rate 

OMH Inpatient Out of Rate 

OMRDD Inpatient Out of Rate 

OASAS Inpatient Out of Rate 

Dental Outpatient Departments Out of Rate 

Early Intervention Out of Rate 

School Supportive Health Services Out of Rate 

Case Management Out of Rate 

*The per diem covers most prescription and non-prescription drugs. 

OEI-02-00-00362 NEW Y ORK F OSTER CARE CHILDREN ’ S USE OF HEALTH CARE S ERVICES 14 
∆ APPENDIX ~ B 

Children's Demographic and Health Characteristics 

The table below illustrates the demographic and health characteristics of the 50 children in the 

sample, including the number of months they were in foster care from September 2000 through 

October 2002. Placement setting refers to the type of foster care placement at the time of the 

interviews. 

ID Sex 

Age 

(years) 

Placement 

Setting 

Agency or Caregiver 

Reports Child has 

Medical Problem(s) 

Agency or Caregiver Reports 

Child has Mental Health 

Problem(s) 

Months in Care 

During Study 

Period 

1 Male 16 Residential Y Y 26 

2 Female 16 Family Y Y 26 

3 Male 17 Residential N Y 26 

4 Male 11 Family Y Y 18 

5 Female 14 Family Y N 12 

6 Male 5 Family N Y 24 

7 Female 4 Family Y Y 26 

8 Male 7 Family N N 26 

9 Female 6 Family N Y 26 

10 Male 8 Family Y Y 26 

11 Male 15 Residential N Y 13 

12 Female 5 Family N Y 26 

13 Male 18 Residential N Y 26 

14 Male 13 Kinship N N 26 

15 Female 2 Family Y N 23 

16 Male 15 Family Y Y 26 

17 Male 16 Family Y Y 10 

18 Male 1 Kinship N N 10 

19 Female 6 Kinship Y N 26 

20 Male 17 Trial Discharge Y Y 26 

21 Male 17 Kinship Y Y 19 

22 Male 6 Family N Y 26 

23 Male 10 Residential Y Y 26 

24 Male 8 Residential Y Y 10 

25 Female 10 Family N N 26 

OEI-02-00-00362 NEW Y ORK F OSTER CARE CHILDREN ’ S USE OF HEALTH CARE S ERVICES 15 
APPENDIX~B 

Children's Demographic and Health Characteristics (continued) 

Agency or Caregiver Agency or Caregiver Reports Months in Care 

Age Placement Reports Child has Child has Mental Health During Study 

ID Sex (years) Setting Medical Problem(s) Problem(s) Period 

26 Female 17 Family N N 26 

27 Female 9 Family N N 13 

28 Male 2 Family Y N 26 

29 Female 2 Family Y N 8 

30 Male 19 Residential N N 26 

31 Female 11 Family N Y 26 

32 Male 7 Kinship Y N 26 

33 Female 11 Family N N 23 

34 Female 4 Family N N 26 

35 Female 5 Trial Discharge N N 12 

36 Male 1 Family Y N 12 

37 Male 8 Kinship N N 25 

38 Female 4 Kinship Y N 26 

39 Female 4 Family Y N 26 

40 Female 20 Family Y N 26 

41 Male 7 Kinship Y Y 26 

42 Male 9 Family Y Y 26 

43 Female 11 Family N N 10 

44 Male 9 Family Y Y 26 

45 Male 15 Family N N 8 

46 Female 18 Kinship N Y 25 

47 Male 13 Residential N Y 8 

48 Female 12 Kinship N N 26 

49 Male 14 Residential N Y 10 

50 Female 6 Kinship Y N 26 

Source: New York State Office of Medicaid Management, January 2003 

OEI-02-00-00362 NEW Y ORK F OSTER CARE CHILDREN ’ S USE OF HEALTH CARE S ERVICES 16 
∆ APPENDIX ~ C 

Comparison of Children in Sample to Population 

The table shows characteristics of children in the sample and of the population of 

children in New York foster care for at least 6 continuous months. 

Comparison of Children in Sample to Population 

Sample 

Count 

Percent of 

Total 

GENDER 

Male 28 56% 

Female 22 44% 

Total 50 100% 

AGE 

0-2 5 10% 

3-5 7 14% 

6-9 13 26% 

10-13 9 18% 

14-17 12 24% 

18+ 4 8% 

Total 50 100% 

Population 

Count 

Percent of 

Total 

21,665 53% 

19,567 47% 

41,232 100% 

4,730 11% 

5,679 14% 

7,394 18% 

8,343 20% 

11,343 28% 

3,743 9% 

41,232 100% 

Source: New York State OCFS, 2002 

OEI-02-00-00362 NEW Y ORK F OSTER CARE CHILDREN ’ S USE OF HEALTH CARE S ERVICES 17 
∆ APPENDIX ~ D 

OEI-02-00-00362 NEW Y ORK F OSTER CARE CHILDREN ’ S USE OF HEALTH CARE S ERVICES 18 
APPENDIX~D 

OEI-02-00-00362 NEW Y ORK F OSTER CARE CHILDREN ’ S USE OF HEALTH CARE S ERVICES 19 
APPENDIX~D 

OEI-02-00-00362 NEW Y ORK F OSTER CARE CHILDREN ’ S USE OF HEALTH CARE S ERVICES 20 
APPENDIX~D 

OEI-02-00-00362 NEW Y ORK F OSTER CARE CHILDREN ’ S USE OF HEALTH CARE S ERVICES 21 
APPENDIX~D 

OEI-02-00-00362 NEW Y ORK F OSTER CARE CHILDREN ’ S USE OF HEALTH CARE S ERVICES 22 
∆ ACKNOWLEDGMENTS 


This report was prepared under the direction of Jodi Nudelman, Acting 

Regional Inspector General for Evaluation and Inspections in the New 

York regional office. Other principal Office of Evaluation and 

Inspections staff who contributed include: 

Nancy T. Harrison, Tea e m L ader 

Nicole Gillette, Lead Analyst 

Laura Torres, Program Analyst 

Thomas Zimmermann, Program Analyst 

Linda Hall, Program Specialist 

Elise Stein, Director, Public Health and Human Services Branch 

Technical Assistance 

Barbara Tedesco, Mathematical Statistician 

OEI-02-00-00362 NEW Y ORK F OSTER CARE CHILDREN ’ S USE OF HEALTH CARE S ERVICES 23