Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

Inspector General 

June 2004 

OEI-02-00-00363 

FOSTER CARE CHILDREN’S USE 

OF MEDICAID SERVICES IN 

OREGON 
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 (OAS) 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 Investigations 

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 model compliance plans, renders advisory opinions on OIG sanctions to the 

health care community, and issues fraud alerts and other industry guidance. 
,t"'C'S. 

DEPARTMENT OF HEALTH &, HUMAN SERVICES Office of Inspector General 

.l.""JO Washington , D. C. 20201 

JUN - 8 2004 

TO:	 Wade F. Horn, Ph. 

Assistant Secretary for Children and Families 

FROM: 

SUBJECT:	 OIG Final Report: "Foster Care Children s Use of Medicaid Services in 

Oregon " OEI-02-00-00363 

Attached for your review is a final report that assesses whether sampled Oregon foster 

care children are receiving Medicaid health care services. We conducted this inspection 

in response to concerns about the health care that foster care children are receiving. 

Oregon is one of eight States being evaluated. 

Our analysis of2 years of Medicaid claims for a random sample of 50 Oregon foster care 

children and interviews with their caseworkers and caregivers reveal that the children in 

the sample have Medicaid coverage and access to services. Targeted case management is 

the most common and most costly Medicaid claim for children in our sample. Yet, we found that recipients do not receive any extra, or even ordinary, health care as a result of 

targeted case management. Twenty of the 50 sampled foster care children do not have 

. preventive care claims during the study period. This lack of preventive care may be due 

in part, to the belief of some Oregon offcials that Oregon is not bound by any Early and 

Periodic Screening, Diagnosis, and Treatment (EPSDT) requirements. In fact, Oregon is bound by EPSDT requirements and is relieved only from its obligation to pay for services 

required to treat a condition identified during an EPSDT screening that are beyond the 

scope of the benefits package available to an individual receiving Medicaid. For some 

foster care children in the sample, caregivers have diffculty obtaining medical records 

and accessing dental and mental health services. In addition, sampled children placed 

out-of-State experience problems obtaining medical coverage. 

We believe that the Administration for Children and Families (ACF) and the Centers for 

Medicare & Medicaid Services (CMS) should work with the State of Oregon to ensure 

that all eligible foster care children receive appropriate health care services. Accordingly, 

we recommend that CMS review the use of targeted case management for foster care 
Page 2 - Wade F. Horn, Ph.D. and Mark B. McClellan, M. , Ph. 

children in Oregon to ensure that it is consistent with State plan provisions and current 

CMS requirements for this service. CMS may want to review the use of targeted case 

management for foster care children in other States to determine the nature and cost of 

this service. Also , CMS should work with Oregon to clarify the intent of Oregon s lll5 

waiver and the State s obligations under EPSDT. ACF and CMS should work with 

Oregon to promote preventive health care that is consistent with EPSDT guidelines. 

Finally, ACF should work with Oregon and involved paries, such as the State child 

welfare administrators and the administrators of the Interstate Compact on the Placement 

of Children, to address the health care needs of foster care children placed across State 

lines. 

In response to our recommendations, CMS is completing a policy letter to the State 

Medicaid Directors that wil define targeted case management activities that can be 

claimed for Federal financial paricipation from the Medicaid program; adding two 

authorities to Oregon s waiver list that wil clarify the intent; and working with the State 

to promote preventive health care that is consistent with EPSDT guidelines. ACF reports 

that it is actively working with Oregon in the areas of managed care, training, and followup care. ACF plans to form a panel of State child welfare administrators, State foster 

care managers, State adoption managers, and Interstate Compact on the Placement of 

Children administrators to address the issues of placing foster care children across State 

lines. We also received comments from the State of Oregon. Oregon stated that they 

plan to continue to work with ACF and CMS to clarfy current policies and practices and 

to improve future program delivery. 

Please send us your final management decision, including any action plan, as appropriate 

within 60 days. If you have any questions or comments about this report, please do not 

hesitate to call me or one of your staff may contact Elise Stein, Director, Public Health 

and Human Services Branch, at (202) 619-2686 or through e-mail 

Elise.Stein(loig.hhs. gov). To facilitate identification, please refer to report number 

OEI-02-00-00363 in all correspondence. 

Attachment 
� ABSTRACT 

We reviewed a random sample of 50 children in foster care and 

found that they have Medicaid coverage and access to services. 

Targeted case management is the most common and most costly 

Medicaid claim for children in our sample. Yet, we found that 

recipients do not receive any extra, or even ordinary, health care 

as a result of receiving targeted case management. Twenty of 

the 50 sampled foster care children did not have preventive care 

claims during the study period. This lack of preventive care 

may be due, in part, to the belief of some Oregon officials that 

Oregon is not bound by any Early and Periodic Screening, 

Diagnosis, and Treatment (EPSDT) requirements. In fact, 

Oregon must comply with EPSDT requirements and pay for 

preventive care unless the EPSDT screening identifies a 

condition that is beyond the scope of the benefits package 

available to an individual. For some foster care children in the 

sample, caregivers have difficulty obtaining medical records and 

accessing dental and mental health services. In addition, 

sampled children placed out-of-State experience problems 

obtaining medical coverage. The Centers for Medicare & 

Medicaid Services (CMS) and the Administration for Children 

and Families (ACF) concurred with OIG recommendations that: 

CMS review the use of targeted case management; CMS clarify 

the intent of the EPSDT portion of Oregon’s 1115 waiver; ACF 

and CMS remind Oregon to cover and pay for preventive health 

care consistent with EPSDT; and ACF address the health care 

needs of foster care children placed across State lines. 

OEI - 02 - 00 - 00363 F OSTER C ARE C HILDREN’ S USE OF MEDICAID SERVICES IN O REGON i 
EXECUTIVE SUMMARY 
 

OBJECTIVE 

To determine whether Oregon’s foster care children are 

receiving Medicaid health care services. 

BACKGROUND 

Currently, there are an estimated 534,000 children in foster care 

nationwide, and many of them are reportedly in poor health. 

Compared with children from the same socioeconomic 

background, foster care children suffer much higher rates of 

serious emotional and behavioral problems, chronic physical 

disabilities, birth defects, and developmental delays. Despite 

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

receiving adequate health care. 

This inspection focuses on the State of Oregon and is part of a 

larger body of work in which eight States are being evaluated. 

The analysis includes 2 years of Medicaid claims for 50 Oregon 

foster care children and interviews with their caseworkers and 

caregivers. 

FINDINGS 

Forty-nine of 50 foster care children in the sample have 

Medicaid coverage and access to services 

The foster care children in the sample in Oregon have medical 

coverage and are accessing health care services. During the 2-

year inspection period, the vast majority of children in the 

sample (49 out of 50) have at least 1 Medicaid claim for the time 

they were in foster care. Overall, the number of Medicaid claims 

per child in the sample ranges from 0 to 472. The majority of 

caseworkers and caregivers report that their foster care children 

have access to needed medical care. 

Targeted case management is the most common and most 

costly Medicaid claim for Oregon foster care children in the 

sample 

Representatives of Oregon Medicaid define targeted case 

management services as assisting an individual in gaining 

access to additional services. Targeted case management claims 

account for 75 percent of all Medicaid health care payments for 

OEI - 02 - 00 - 00363 F OSTER C ARE C HILDREN’ S USE OF MEDICAID SERVICES IN O REGON ii 
EXECUTIVE SUMMARY EXECUTIVE SUMMARY 

the sample Oregon foster care children. Over the study period, 

Oregon's State Office for Services to Children and Families 

collected approximately $604 to $800 per month, per foster care 

child from Medicaid for targeted case management. These 

payments total $710,420 for our sample. We estimate the total 

payments for targeted case management for our sample 

universe to be approximately $71 million over the study period. 

It appears that recipients do not receive any extra, or even 

ordinary, health care as a result of receiving targeted case 

management. 

Twenty of the 50 foster care children in the sample do not 

have preventive care claims 

Twenty children in the sample show no preventive claims at all 

over 2 years. Eighteen of these 20 have been in continuous 

foster care for a year or more. None of the 50 children have 

Early and Periodic Screening, Diagnosis, and Treatment 

(EPSDT) claims. The lack of preventive care claims may be due 

to Oregon's lack of a clear periodicity schedule for preventive 

care and the belief of some State officials that Oregon is not 

bound by any EPSDT requirements. In addition, we found that 

confusion exists regarding the EPSDT portion of the State’s 

Section 1115 waiver, which relieves Oregon only from its 

obligation to pay for services required to treat a condition 

identified during an EPSDT screening that are beyond the scope 

of the benefits package available to an individual receiving 

Medicaid. 

Some children face problems due to incomplete medical 

records, access to certain health care services, and out-ofState medical coverage 

Medical records for children in the sample are often incomplete, 

and it appears that caseworkers may not be transferring the 

medical history to caregivers. Foster care children also face 

difficulties accessing dental and mental health services, 

although most children are able to get needed care eventually. 

Problems include wait time for appointments, lack of Medicaid 

providers, dissatisfaction with quality of care, and trouble 

determining which dentists in the area are Medicaid providers. 

In addition, foster care children placed out-of-State have 

difficulty obtaining medical coverage in their new State. 

OEI - 02 - 00 - 00363 F OSTER C ARE C HILDREN’ S USE OF MEDICAID SERVICES IN O REGON iii 
EXECUTIVE SUMMARY EXECUTIVE SUMMARY 

RECOMMENDATIONS 

We believe that the Administration for Children and Families 

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

should work with the State of Oregon to ensure that all eligible 

foster care children receive appropriate health care services. 

Accordingly, we recommend that: 

o	 CMS review the use of targeted case management for foster 

care children in Oregon to ensure that it is consistent with 

State plan provisions and current CMS requirements for this 

service. CMS may also want to consider reviewing the use of 

targeted case management for foster care children in other 

States to determine the nature and the cost of this service. 

o	 CMS work with Oregon to clarify the State’s waiver and the 

State’s obligations under EPSDT. CMS should also revise 

the incorrect citation in the EPSDT portion of Oregon’s 1115 

waiver. 

o	 ACF and CMS work with Oregon to promote preventive 

health care that is consistent with EPSDT guidelines. 

o	 ACF work with Oregon and involved parties, such as the 

State child welfare administrators and the administrators of 

the Interstate Compact on the Placement of Children 

(ICPC), to address the health care needs of foster care 

children placed across State lines. 

Agency Comments 

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

comments are included in Appendix G. CMS concurs with our 

recommendations. In regard to targeted case management 

(TCM), CMS notes that it is “completing a major policy letter to 

the State Medicaid Directors that will define TCM activities that 

can be claimed for Federal financial participation from the 

Medicaid program.” We encourage CMS to issue this policy 

letter as soon as possible and to share it with all State child 

welfare agencies as well as the State Medicaid Directors. 

We are pleased that CMS is adding two authorities to the list of 

waived statutory provisions for Oregon that will clarify the 

terms of the waiver. CMS will also work with Oregon to ensure 

OEI - 02 - 00 - 00363 F OSTER C ARE C HILDREN’ S USE OF MEDICAID SERVICES IN O REGON iv 
EXECUTIVE SUMMARY 

the State understands that Oregon has obligations under the 

EPSDT program. 

CMS agrees to work with the State to promote preventive health 

care that is consistent with EPSDT guidelines. It is our hope 

that these efforts will include the formulation of a clear 

periodicity schedule, as required by the EPSDT program. 

In its comments, ACF notes that it is actively working with 

Oregon in the areas of managed care, training, and follow-up 

care. We encourage ACF to continue its current efforts. We also 

encourage ACF to address actively the issue of preventive care 

for foster care children, possibly through the Oregon Program 

Improvement Plan. The Oregon Program Improvement Plan 

was developed as a result of an ACF Child and Family Services 

Review, which measures individual States’ performance related 

to the health and well being of children in the child welfare 

system. Action Step 23.2.3 in the Oregon Program Improvement 

Plan calls for a clear policy for children receiving adequate, 

timely, necessary and culturally-competent mental health, 

medical and dental services. We believe preventive care should 

be thoroughly addressed in this policy. 

ACF plans to form a panel of State child welfare administrators, 

State foster care managers, State adoption managers, and ICPC 

administrators. This panel will “identify barriers, issues and 

suggested resolutions related to placing children across State 

lines.” We encourage the timely formation of this panel and 

look forward to receiving the panel’s findings. 

We also received comments from the State of Oregon. The full 

text of these comments can be found in Appendix G. The State 

responded that a medical chart review would have given a more 

accurate assessment of the services provided. The State believes 

that the text of the EPSDT portion of the 1115 waiver is correct 

and that the State carefully administers the targeted case 

management program. Oregon commented that the medical 

service problem in interstate placements needs to be addressed 

at the national level. Oregon plans to continue to work with 

ACF and CMS to clarify current policies and practices and to 

improve future program delivery. 

OEI - 02 - 00 - 00363 F OSTER C ARE C HILDREN’ S USE OF MEDICAID SERVICES IN O REGON v 
TABLE OF CONTENTS 
 

ABSTRACT ................................ ......... i
 

EXECUTIVE SUMMARY ........................... ii 
 

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

FINDI NGS ................................ .......... 7
 

Foster children have Medicaid coverage and access to services........ 7
 

Targeted case management is the most common and costly claim...9
 

Many children do not have preventive care claims ......................... 11
 

Some children face problems............................................................ 13
 

RECOMMENDATIONS ............................ 16 
 

APPENDICES ................................ ..... 18 
 

Appendix A: Oregon Administrative Rules...................................... 18
 

Appendix B: Comparison of Sample to Universe ............................. 22
 

Appendix C: Demographics ............................................................. 23
 

Appendix D: Description of 50 Foster Children in Sample ............ 25
 

Appendix E: Medicaid Claims for Sample ....................................... 26
 

Appendix F: Oregon Waiver, Excerpts from Social Security Act .... 27
 

Appendix G: Comments ................................................................... 28
 

ACKNOWLEDGMENTS ........................... 46 
 

OEI - 02 - 00 - 003 63 F OSTER C ARE C HILDREN’ S USE OF MEDICAID SERVICES IN O REGON VI
 
INTRODUCTION 
 

OBJECTIVE 

To determine whether Oregon’s foster care children are 

receiving Medicaid health care services. 

BACKGROUND 

Currently, there are an estimated 534,000 children in foster care 

nationwide,1 and many of them are reportedly in poor health. 

Compared with children from the same socioeconomic 

background, foster care children suffer much higher rates of 

serious emotional and behavioral problems, chronic physical 

disabilities, birth defects, developmental delays, and educational 

difficulties. 2 According to one source, half of all children in the 

child welfare system 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, foster care 

children clearly have a greater need for specialized health care 

services. 

Despite their need, it appears that many foster care children are 

not receiving adequate health care. Many foster parents report 

difficulty in finding health care professionals who are willing to 

care for their children. 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 General Accounting 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 foster care children did not 

receive critical health-related services in the three locations 

1 Retrieved from http://www.acf.dhhs.gov/programs/cb/dis/afcars/cwstats.htmlon 

1/27/04 

2 Health Care of Young Children in Foster Care, Committee on Early Childhood, 

Adoption and Dependent Care, American Academy of Pediatrics, Pediatrics, 

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 Factsheet: The Health Of Children In Out-Of-Home Care. Child Welfare League of 

America. Retrieved 3/14/2003 from: 

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

OEI - 02 - 00 - 00363 F OSTER C ARE C HILDREN’ S USE OF MEDICAID SERVICES IN O REGON 1 
INTRODUCTION INTRODUCTION 

studied (Los Angeles County, New York City, and Philadelphia 

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

children received Early and Periodic Screening, Diagnosis, and 

Treatment (EPSDT) services. 

Medicaid for Foster Care Children 

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 of the States does the following: 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 foster care children are eligible for Medicaid services. 

According to section 1902 (a)(10)(A)(i)(I) of the Social Security 

Act, foster care children covered under Title IV-E of the Social 

Security Act are eligible for Medicaid. Foster care children who 

are not eligible for Title IV-E usually qualify for Medicaid 

through other eligibility categories set forth by each State. In 

fiscal year 2000, Medicaid payments for foster care children 

nationwide were over $3.3 billion.7 

Early and Periodic Screening, Diagnosis, and Treatment (EPSDT). 

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, 

EPSDT treatment services include all mandatory and optional 

services available under the Medicaid program. Diagnostic 

services are covered whenever there is a medical need to conduct 

further examination. Treatment or medical care must be 

5 Healthy Needs of Many Young Children are Unknown and Unmet, General Accounting Office , 

GAO/HEHS-95-114, 1995, pages 2 and 5 

6 Retrieved 3/14/2003 from: http://www.cms.hhs.gov/medicaid/mover.asp 

7 Medicaid Expenditures for Federal Fiscal Year 2000, By Type of Service for 

Maintenance Assistance Status and Basis of Eligibility All States; MSIS Report for 

Federal fiscal year 2000. National Total for Foster Care children, page 3. Retrieved 

from CMS website on 3/13/03: http://www.cms.gov/medicaid/msis/00total.pdf 

OEI - 02 - 00 - 00363 F OSTER C ARE C HILDREN’ S USE OF MEDICAID SERVICES IN O REGON 2 
INTRODUCTION INTRODUCTION 

provided for any physical or mental conditions discovered by the 

screening services. 

Under EPSDT, States must set distinct periodicity schedules for 

screening, dental, vision and hearing services, and 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 

Oregon 

Child Welfare - Oregon's foster care system is centrally managed. 

At the time of this inspection, the State had just fewer than 

7,400 children in foster care.9 Also, at that time, the Oregon 

State Office for Services to Children and Families was 

responsible for administering child welfare programs, including 

foster care and adoptions. Since the inspection was conducted, 

Oregon has reorganized its social service system. The Children, 

Adults and Families group within the Department of Human 

Services is currently responsible for administering child welfare 

programs. During our study period, Oregon had 16 districts 

with 42 child welfare offices and employed about 949 child 

welfare caseworkers. Caseworkers in child welfare offices are 

responsible for the placement, monitoring, and coordination of 

services for foster care children. 

Oregon Medicaid - The Office of Medical Assistance Programs 

(OMAP) is also within the Department of Human Services. 

OMAP administers the Medicaid program in Oregon and is 

responsible for the Medicaid claims data. 

In Oregon, Medicaid is administered through the Oregon Health 

Plan (OHP). OHP offers three types of basic medical coverage: a 

fee-for-service plan; a managed care plan; and a primary care 

case management plan. 

Oregon Administrative Rules state that foster care children 

have the right to "ordinary medical, dental, psychiatric, 

psychological, and hygienic care and treatment when the child's 

8 Retrieved from CMS Website 3/28/03: http://www.cms.gov/medicaid/epsdt/ 

9 Child Welfare Outcomes 1999: Annual Report, Section IV-C, State data pages, 

Oregon (from AFCARS database, FY 99) 

http://www.acf.dhhs.gov/programs/cb/publications/cwo99/statedata/or.htm 

OEI - 02 - 00 - 00363 F OSTER C ARE C HILDREN’ S USE OF MEDICAID SERVICES IN O REGON 3 
INTRODUCTION 

condition requires it."10 Also under Oregon Administrative 

Rules, all foster care children in the care and custody of the 

Department of Human Services receive the State's medical plan 

benefits. A small number of these children have too much 

income, such as survivor benefits, to be eligible for Medicaid 

under Title XIX. In these cases, health benefits are paid with 

State funds.11 

Waivers - Under section 1115 of the Social Security Act, which 

provides the Secretary of the Department of Health and Human 

Services (HHS) with authority to authorize experimental, pilot, 

or demonstration projects that are likely to assist in promoting 

the objectives of the Medicaid statute, HHS approved waivers 

for the OHP Demonstration Project. 

HHS granted Oregon a partial waiver of the EPSDT 

requirement in 1995. The Section 1115 waiver allows Oregon to 

eliminate certain health care services in order to extend 

Medicaid coverage to more people. The text of the waiver states 

that Oregon is no longer obligated to pay for services required to 

treat a condition identified during an EPSDT screening that are 

beyond the scope of the benefit package available to an 

individual receiving Medicaid. 

Oregon now offers a benefits package under the OHP that is 

based on a list of primary and acute medical and mental illness 

conditions and services ranked by the Health Services 

Commission in Oregon.12 It is called the prioritized list of 

services and is approved by CMS. 

METHODOLOGY 

This inspection is based on information gathered from multiple 

sources: Medicaid claims data; a review of Federal and State 

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

officials, caseworkers, and caregivers. 

10 See Appendix A, Oregon Administrative Rules (OAR): 413-010-0180 

11 See Appendix A, OAR 416-610-0140 

12 From Centers for Medicare & Medicaid Services website, retrieved 3/18/2003: 

http://www.cms.gov/medicaid/1115/default.asp; 

http://www.cms.gov/medicaid/1115/orfact.asp 

OEI - 02 - 00 - 00363 F OSTER C ARE C HILDREN’ S USE OF MEDICAID SERVICES IN O REGON 4 
INTRODUCTION 

Reasons for State Selection 

This inspection focuses on the State of Oregon and is part of a 

larger body of work in which eight States are being evaluated. 

Oregon was selected because of its size, centralized child welfare 

system, and geographic location. 

Sample 

Our population consisted of 5,004 Oregon children in continuous 

foster care placement for at least 6 months prior to July 2002. 

From this population, a simple random sample of 50 children 

was selected. See Appendices B through D for a comparison of 

the children in the sample to the population and a more detailed 

description of children in the sample. 

The size of the sample limits our ability to estimate the 

population from the sample. However, in the case of the amount 

spent for targeted case management claims, the variability of 

these amounts was relatively small (either $674 or $800, 

depending on what month the claim was submitted). Since the 

variability was small, we were able to produce an estimate of 

the amount spent on targeted case management claims in the 

population using standard statistical formulas for a simple 

random sample. 

Review of Medicaid Claims Data and State Laws and Policy 

Medicaid Claims Data - Oregon Medicaid provided a claims 

history for 2 years for all of the children in our sample. The 

data include claims with service dates between July 2000 and 

July 2002. Encounter data for children in managed care are 

also included in these data. We refer to all fee-for-service claims 

and managed care encounters as "claims," unless otherwise 

specified. 

In reviewing the Medicaid claims, we paid particular attention 

to the types of services, dates of service, and settings, where 

available. Medicaid claims data are organized into broad 

categories for analysis. We excluded claims that were not health 

care related, such as those for transportation and photocopying 

of medical records. We determined the periods of time the child 

was in foster care, based on information given by the State 

Medicaid office and caseworkers. We excluded claims with a 

service date for a time our data clearly show that the child was 

not in foster care. If it was not clear that the child was in foster 

OEI - 02 - 00 - 00363 F OSTER C ARE C HILDREN’ S USE OF MEDICAID SERVICES IN O REGON 5 
INTRODUCTION I NTRODUCTION 

care during a certain period of time, we included Medicaid 

claims corresponding to that time in our analysis. 

Law and Policy Reviews - We reviewed Federal and State laws 

and policies pertaining to the health care of foster care children. 

Interviews 

Caseworker Interviews - We interviewed caseworkers for the 

children in the sample either in person or by telephone. We 

spoke with 45 caseworkers, representing 47 children. (Two 

caseworkers were responsible for more than one child in the 

sample). Three caseworkers refused to cooperate, despite our 

repeated attempts to interview them and our repeated attempts 

to enlist the State's help in encouraging caseworker cooperation. 

The caseworkers we spoke with were the ones responsible for 

the children at the time the sample was pulled. Each interview 

focused on the caseworker's understanding of Medicaid, his or 

her experience accessing services for the sampled foster care 

children, and any barriers faced by foster care children in 

general for the time period of our inspection. Caseworkers also 

provided a written placement history for each child. 

Caregiver Interviews - We interviewed caregivers for 44 of the 50 

children in our sample. We were unable to reach and gain the 

cooperation of six caregivers. We use the term "caregiver" to 

refer to a foster parent or staff member of a residential facility 

who is responsible for the child. The caregivers we spoke with 

were the ones responsible for the children at the time the 

sample was pulled. Like the caseworker interviews, our 

interviews with caregivers focused on training, Medicaid, and 

procuring health services for the child for the time period of our 

inspection. 

State Agency Officials - We held several meetings, both in person 

and by telephone, with officials from the Oregon State 

Department of Human Services, State Office for Children and 

Family Services (now Children, Adults and Families group). 

Our discussions covered a wide spectrum of information to help 

us understand how the State's foster care and Medicaid systems 

are organized. 

This inspection was conducted in accordance with the Quality 

Standards for Inspections issued by the President's Council on 

Integrity and Efficiency. 

OEI - 02 - 00 - 00363 F OSTER C ARE C HILDREN’ S USE OF MEDICAID SERVICES IN O REGON 6 
FINDINGS 
 

Forty-nine of 50 foster care children in the sample The children in the sample in 

have Medicaid coverage and access to services	 Oregon have medical coverage, 

which is required by Federal 

and State laws. Forty-nine out of 50 foster care children in the 

sample have at least 1 Medicaid claim between July 2000 and 

July 2002. Caseworkers and/or caregivers reported that 47 of 

the children in the sample had Medicaid coverage in Oregon at 

the time of the interview. The caseworkers and caregivers for 

the remaining children could not confirm Medicaid coverage. 

Most children in the sample have access to Medicaid services 

An analysis of Medicaid claims shows that the children in the 

sample are accessing health care services. As seen in Table 1, 

the majority of children in the sample (44 out of 50) have at 

least 1 office visit claim in a 2-year period while they were in 

foster care. The children in the sample with an office visit claim 

have an average of over six office visits each. In addition, 80 

percent of the children in the sample have a labwork or 

diagnostic claim. 

Overall, the number of Medicaid claims per child in the sample 

ranges from 0 to 472. The majority of caseworkers and 

caregivers believe that their foster care children have access to 

needed medical care. Eighty-seven percent of the caseworkers 

and 82 percent of the caregivers interviewed report that their 

child receives needed medical care. 

Further, despite reported barriers to access that will be 

discussed later, foster care children seem to be accessing mental 

health services in addition to other medical services. Thirtythree children in the sample (66 percent) have 2,079 mental 

health claims over the 2-year inspection period. 

OEI - 02 - 00 - 00363 F OSTER C ARE C HILDREN’ S USE OF MEDICAID SERVICES IN O REGON 7 
FINDINGS 

Table 1: Number and Type of Medicaid Claims for 50 Children 

in Sample 

Claim Type 

Number of Children 

with at Least One 

Claim 

Total Number of 

Claims 

Targeted case management 49 962 

Office visit 44 295 

Labwork/Diagnostic 40 374 

Mental health 33 2079 

Prescription drug 31 683 

Immunization 30 199 

Preventive 30 59 

Dental 28 314 

Emergency Room 23 59 

Supplies 22 86 

School-based services 19 54 

Vision 18 99 

Physical/Occupational therapy 8 138 

Hospital 7 29 

Clinic 7 24 

Hearing/Speech 6 27 

Other 4 10 

Home visit 3 5 

Total 5,496 

Source: OIG Analysis of Oregon Medicaid Claims Data 

The foster care children in the sample have a variety of reported 

conditions. According to caseworkers and caregivers, 82 percent 

(41 out of 50) of the children in our sample have a medical or 

mental health problem. These problems include asthma, 

seizures, depression, anxiety, developmental delays, and abuse. 

See Appendix D for a description of reported medical and mental 

health problems of children in the sample. 

OEI - 02 - 00 - 00363 F OSTER C ARE C HILDREN’ S USE OF MEDICAID SERVICES IN O REGON 8 
FINDINGS 

Foster care children in Oregon sometimes receive health care services 

outside of Medicaid 

According to caregivers and caseworkers, 19 children receive 

health care services paid for by a source other than Medicaid. 

These other services are paid for by foster parents, branch 

funds, or by schools or non-profit organizations. Branch offices 

have State funds available to them to be used for services not 

covered by Medicaid. Most of the additional services received 

were related to mental health treatments or prescription drugs. 

Targeted case management is the most common Case management is allowable 

and most costly Medicaid claim for Oregon under Medicaid (section 

1905(a)(19) of the Social Security foster care children in our sample Act), and defined in section 

1915(g)(2) as services which will assist an individual eligible 

under the State plan in gaining access to needed medical, social, 

educational and other services. Representatives of Oregon 

Medicaid define targeted case management services as assisting 

an individual in gaining access to additional services. 

Targeted case management claims account for the majority of 

Medicaid payments for Oregon foster care children. Forty-nine 

out of 50 foster care children in our sample have a Medicaid 

claim for targeted case management services paid to Oregon's 

State Office for Services to Children and Families. These 

targeted case management payments occur virtually every 

month the children are in care during the 2-year study period. 

This includes children in fee-for-service and managed care 

plans. 

Oregon’s State Office for Services to Children and Families 

collected approximately $604 to $800 per month per foster child 

for targeted case management over the study period. By way of 

comparison, Medicaid pays $101 for Medicaid managed care per 

month per foster child in Oregon. In total, the State collected 

$710,420 from Medicaid for targeted case management for the 

50 children over the 2-year study period. (See Appendix E.) 

This amount represents an estimated 75 percent of all Medicaid 

health care payments for these children over this period. 

We estimate targeted case management payments for our 

sample population to be $71 million over the study period (plus 

OEI - 02 - 00 - 00363 F OSTER C ARE C HILDREN’ S USE OF MEDICAID SERVICES IN O REGON 9 
FINDINGS 

or minus $7 million at the 95 percent confidence level). Our 

population is a subgroup of all Oregon children in foster care 

(5,004 out of 7,400). 

The State collects the same amount for each child each month 

the child is in foster care. For instance, all targeted case 

management claims in November 2000 are $800 each. All 

targeted case management claims in December 2001 are $674 

each. The type and degree of physical and mental health 

impairments among children showing these targeted case 

management claims vary widely. While some children appear to 

have complex medical and emotional problems, others appear to 

have none. In fact, six children have no reported physical or 

mental health impairments at all; yet, they each have a targeted 

case management claim every month along with the rest of the 

sample. 

It appears that recipients do not receive any extra, or even 

ordinary, health care as a result of receiving targeted case 

management. As noted earlier, Oregon Medicaid 

representatives define targeted case management services as 

assisting an individual in gaining access to additional services. 

Yet, some children show repeated targeted case management 

claims during long stretches of time without any other Medicaid 

services. For example, 1 child has a targeted case management 

claim every month for 21 consecutive months with only 1 other 

Medicaid claim for that entire time period. This child's 

caseworker and caregiver report that the child does not receive 

other health care services outside of Medicaid. In addition, 17 

children in the sample show no preventive care claims but have 

targeted case management claims for virtually every month that 

they were in foster care. 

OEI - 02 - 00 - 00363 F OSTER C ARE C HILDREN’ S USE OF MEDICAID SERVICES IN O REGON 10 
FINDINGS 

Twenty of the 50 foster care children in the sample Sampled children lack EPSDT 

do not have preventive care claims claims andpreventive care 

The children in the sample 

may not be receiving an appropriate level of preventive care 

even though preventive care is covered under the Oregon Health 

Plan. The Medicaid data show no claims at all for EPSDT 

services for the children in our sample. Twenty children also 

show no preventive care claims over the 2-year study period. 

Eighteen of these children have been in continuous foster care 

for a year or more. Table 2 provides the ages for these 18 

children. 

Table 2: 

Continuous Foster Care for 

At Least One Year with No 

Preventive Claims 

Age 

Number of Children 

Without Preventive 

Claims 

4 2 

6 3 

7 2 

10 1 

12 2 

13 1 

15 1 

16 4 

17 2 

Total 18 

Number of Children in 

Source: OIG Analysis of Oregon Medicaid Data 

The EPSDT program requires that each State establish a 

periodicity schedule at intervals that meet reasonable standards 

of medical practice. Oregon's prioritized list of Medicaid services 

includes preventive care, but it does not provide a specific 

schedule for these services, nor does it provide recipients or 

providers with a clear periodicity schedule for preventive care. 

OEI - 02 - 00 - 00363 F OSTER C ARE C HILDREN’ S USE OF MEDICAID SERVICES IN O REGON 11 
FINDINGS FINDINGS 

Confusion exists regarding the EPSDT portion of the State's waiver 

and implementation 

There appears to be confusion regarding the breadth of the 

EPSDT portion of the 1115 waiver. We learned during 

interviews that some State representatives are under the 

impression that Oregon is waived from all EPSDT requirements, 

which, in fact, it is not. Since EPSDT requires periodic health 

screenings of children, the belief that Oregon is not bound by 

EPSDT may contribute to the lack of preventive care we see in 

the sample children. 

The EPSDT portion of Oregon’s Section 1115 waiver eliminates 

the requirement that the State must pay for services to treat a 

condition identified during an EPSDT screening that are beyond 

the scope of the benefit package available to the individual. 

(The benefit package is Oregon’s Health Services Commission 

Prioritized List of Health Services.) However, the waiver 

approval incorrectly cites the section of the Social Security Act 

that is being waived as section 1902(a)(43)(A). Section 

1902(a)(43)(A) is the requirement that States must inform 

Medicaid-eligible children of the EPSDT benefits available to 

them. (Appendix F includes the full text of the EPSDT portion 

of the waiver and the Social Security Act citation.) 

Oregon’s Department of Human Services has recently 

commented that the “State believes that the text of the waiver is 

correct and that the State is waived from payments of conditions 

identified during an EPSDT screening.” The State’s comments 

do not address other EPSDT requirements. CMS, also in recent 

comments, explains Oregon’s responsibilities. CMS states that 

the intent of the waiver was that “Oregon would not pay for 

treatment of conditions identified as part of an EPSDT 

screening if the treatment of that condition was not covered on 

the Prioritized List of Health Care Services. When granting this 

waiver, CMS intended that Oregon would be required to comply 

with all other requirements of the entire EPSDT program.” 

OEI - 02 - 00 - 00363 F OSTER C ARE C HILDREN’ S USE OF MEDICAID SERVICES IN O REGON 12 
FINDINGS 

Medical records are often incomplete

Some children face problems due to incomplete Caregivers may not be able to 

medical records, access to certain health care meet their legal obligation if 

services, and out-of-State medical coverage they do not receive available 

medical records. Oregon 

requires caregivers to maintain a health care record for the 

child, including medical history and immunization records for a 

period of 3 years. If a child moves, records must be transferred 

to the child's new home. (See Appendix A, OAR 309-046-0190 

(11).) 

Caseworkers may not be transferring medical histories to 

caregivers. Nineteen of the 44 caregivers interviewed say they 

did not receive any of their foster child's medical history at all. 

Yet, 46 out of the 47 caseworkers interviewed indicate that they 

had received at least some medical history on the foster child in 

the sample. 

Some children encounter problems accessing dental and mental 

health services 

Difficulties accessing dental and mental health services are 

reported, although most children are able to get needed care 

eventually. Caregivers for 16 children report a problem 

accessing needed dental care. Problems include wait time for 

appointments, lack of Medicaid providers, dissatisfaction with 

quality of care, and trouble determining which dentists in the 

area were Medicaid providers. Twelve of the 16 children who 

experienced a problem report eventually being able to get the 

care they needed. For example, some caseworkers find 

alternative sources of funding in the community for braces or 

other cosmetic dental procedures. When asked about all foster 

care children, not just children in our sample, nearly half the 

caseworkers interviewed mention that foster care children in 

general have problems accessing dental care. 

Of the 35 children in the sample with a reported mental health 

problem, caregivers of 14 complain about mental health services. 

Specifically, the caregivers of seven of these children feel that 

the treatment that their child receives is inadequate. The 

caregivers of the remaining children encounter problems or 

barriers accessing mental health services, such as wait time for 

appointments, lack of Medicaid providers, lack of 

services/coverage, and difficulty finding good quality of care. 

OEI - 02 - 00 - 00363 F OSTER C ARE C HILDREN’ S USE OF MEDICAID SERVICES IN O REGON 13 
FINDINGS 

Caseworkers, too, cite problems with mental health services. 

Caseworkers for 16 children feel that foster care children in 

general, not just those in the sample, experience barriers 

accessing mental health services. 

Caregivers and caseworkers also report problems accessing 

prescription medications. Nine children in the sample 

experience problems getting needed prescriptions. Eight of the 

nine children are eventually able to get the prescriptions they 

need. 

Foster care children placed out-of-State experience problems 

accessing care 

Our data show that five children in the sample were placed outof-State for at least some portion of the 2-year inspection period. 

One of the 5 was out of State for 22 months of the inspection 

period. The other four were out of State for less than 1 year. 

It appears from the claims data that all five out-of-State 

children had Medicaid coverage in Oregon while they were 

living in Oregon. Yet, only one of them seems to have Medicaid 

coverage in the other State in which they were placed. Three of 

the five caregivers cite problems getting a Medicaid card as a 

barrier to the child's access to health care. 

All 50 States, including Oregon, are members of the Interstate 

Compact on the Placement of Children (ICPC), which requires 

that a foster child placed over State lines receive adequate 

protections and support services. It establishes procedures for 

placement and compels the placing agency, sometimes called the 

“sending agency,” to maintain responsibility for the child. The 

language of the ICPC, however, does not specifically require that 

a foster child placed over State lines receive a Medicaid card in 

his/her new State. According to Oregon’s Department of Human 

Services Client Services Manual, the sending agency is 

responsible for arranging for medical coverage for the child 

before the child is placed in another State. 

Caseworker involvement with the five out-of-State children in 

our sample varies. Two caseworkers say that they do not know 

if their child has a Medicaid card. The caregivers for these 

children report that their Oregon caseworker is not involved in 

their child’s health care. Two other caseworkers are more 

involved. For example, one caseworker says she knows that the 

OEI - 02 - 00 - 00363 F OSTER C ARE C HILDREN’ S USE OF MEDICAID SERVICES IN O REGON 14 
FINDINGS 

child does not have Medicaid coverage, and it is her 

responsibility to get it, but she has not been successful yet. The 

child has been without coverage for over a year, and the 

caregiver is paying for all of the child's medical care out-ofpocket. A second caseworker reports difficulties in getting a 

Medicaid card in the new State and directing the child to the 

right place to get care. The caseworker for the remaining child, 

according to the caregiver, is involved in the child’s health care, 

although the child does not yet have a Medicaid card in the new 

State. 

Despite a lack of medical coverage, all five caregivers of the outof-State children say that their foster care child has received a 

well-child exam while in their care. In some cases, the caregiver 

pays out-of-pocket for this care. These services are not captured 

in Medicaid claims data. 

OEI - 02 - 00 - 00363 F OSTER C ARE C HILDREN’ S USE OF MEDICAID SERVICES IN O REGON 15 
RECOMMENDATIONS 
 

We believe that the Administration for Children and Families 

(ACF) and CMS should work with the State of Oregon to ensure 

that all eligible foster care children receive appropriate health 

care services. Accordingly, we recommend that: 

o	 CMS review the use of targeted case management for foster 

care children in Oregon to ensure that it is consistent with 

State plan provisions and current CMS requirements for this 

service. CMS may also want to consider reviewing the use of 

targeted case management for foster care children in other 

States to determine the nature and the cost of this service. 

o	 CMS work with Oregon to clarify the State’s waiver and the 

State’s obligations under EPSDT. CMS should also revise 

the incorrect citation in the EPSDT portion of Oregon’s 1115 

waiver. 

o	 ACF and CMS work with Oregon to promote preventive 

health care that is consistent with EPSDT guidelines. 

o	 ACF work with Oregon and involved parties, such as the 

State child welfare administrators and the administrators of 

ICPC, to address the health care needs of foster care 

children placed across State lines. 

Agency Comments 

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

comments are included in Appendix G. CMS concurs with our 

recommendations. In regard to targeted case management 

(TCM), CMS notes that it is “completing a major policy letter to 

the State Medicaid Directors that will define TCM activities that 

can be claimed for Federal financial participation from the 

Medicaid program which are integral and inseparable functions 

of the foster care and child welfare programs, and the social 

service block grant (Social Security Act (the Act) titles IVB, IVE 

and XX).” We encourage CMS to issue this policy letter as soon 

as possible and to share it with all State child welfare agencies 

as well as the State Medicaid Directors. 

We are pleased that CMS is adding two authorities to the list of 

waived statutory provisions for Oregon that will clarify the 

terms of the waiver. CMS will also “work with Oregon to ensure 

the State recognizes that the current waiver...is not a waiver of 

the requirements of the entire EPSDT program, but rather for 

OEI - 02 - 00 - 00363 F OSTER C ARE C HILDREN’ S USE OF MEDICAID SERVICES IN O REGON 16 
RECOMMENDATIONS 

the payment of treatment for conditions identified as part of an 

EPSDT screening, if such conditions are not covered by the 

Prioritized List.” 

CMS agrees to work with the State to promote preventive health 

care that is consistent with EPSDT guidelines. It is our hope 

that these efforts will include the formulation of a clear 

periodicity schedule, as required by the EPSDT program. 

In its comments, ACF notes that it is actively working with 

Oregon in the areas of managed care, training, and follow-up 

services. The action steps for these efforts are included in the 

Oregon Program Improvement Plan, developed in response to an 

ACF Child and Family Services Review. These reviews measure 

individual States’ performance related to the health and wellbeing of children in the child welfare system. We encourage 

ACF to continue its current efforts. We also encourage ACF to 

address actively the issue of preventive care for foster care 

children. Action Step 23.2.3 in the Oregon Program 

Improvement Plan calls for a clear policy for children receiving 

adequate, timely, necessary and culturally competent mental 

health, medical and dental services. We believe preventive care 

should be thoroughly addressed in this policy. 

ACF plans to form a panel of State child welfare administrators, 

State foster care managers, State adoption managers, and ICPC 

administrators. This panel will “identify barriers, issues and 

suggested resolutions related to placing children across State 

lines.” We encourage the timely formation of this panel and 

look forward to receiving the panel’s findings. 

We also received comments from the State of Oregon. The full 

text of these comments is included in Appendix G. Oregon 

states that a file review would give a more accurate assessment 

of services provided. Oregon believes that the text of the EPSDT 

portion of the 1115 waiver is correct and that the State carefully 

administers the targeted case management program. Oregon 

commented that the medical service problem in interstate 

placements needs to be addressed at the national level. Oregon 

plans to continue to work with ACF and CMS to clarify current 

policies and practices and to improve future program delivery. 

OEI - 02 - 00 - 00363 F OSTER C ARE C HILDREN’ S USE OF MEDICAID SERVICES IN O REGON 17 
APPENDIX~A 
 

Oregon Administrative Rules (OAR) 

413-010-0180 Ba sic Rights of Children in the State Office for Services 

to Children and Families’s (SOSCF's) Custody. 

Each child placed in the legal custody of SOSCF has the 

following rights: 

(1) To be physically placed in the least restrictive environment 

that can appropriately meet the child's needs; 

(2) To be provided basic needs such as adequate food, clothing, 

and shelter; 

(3) To receive care, supervision, and discipline, and to be taught 

to act responsibly and respect the rights of others; 

(4) To be provided ordinary medical, dental, psychiatric, 

psychological, and hygienic care and treatment when the child's 

condition requires it; 

(5) To be provided with free and appropriate education; 

(6) To be protected from physical and sexual abuse, emotional 

abuse and exploitation; 

(7) To be provided services which will reunite the child with his 

or her own family except when there is clear evidence that the 

family will not protect the child's welfare; 

(8) To be provided services to develop a safe, permanent 

alternative to the child's own family, when suitable family 

resources are not available; 

(9) To be accorded the least restrictive legal status that is 

consistent with the child's need for protection or the protection 

of the community, and to receive advocacy and/or legal 

representation, when needed, to assure that the child's best 

interests are presented to the court; 

(10) To receive respect and be nurtured in accordance with his or 

her background, religious heritage, race and culture; 

(11) To visit and communicate with members of his or her family 

within reasonable guidelines as set by the service plan and by 

the court; 

(12) To be involved, in accordance with his or her age and ability 

and with the law, in making major decisions that affect his or 

her life; 

OEI - 02 - 00 - 00363 F OSTER C ARE C HILDREN’ S USE OF MEDICAID SERVICES IN O REGON 18 
APPENDIX~A 

(13) To receive encouragement and be afforded reasonable 

opportunities to participate in sports, youth activities in school 

and neighborhood, and other enrichment programs; 

(14) To earn and keep his or her own money and to receive 

guidance in managing resources to prepare him or her for 

independence. 

416-610-0140 GA Medical Policy 

All children in paid substitute care who do not meet the 

eligibility requirements for Title XIX, will be eligible for General 

Assistance (GA) medical through OMAP. 

309-046-0190 Standards and Practices for Care and Services: 

(11) Child Records. A record shall be developed, kept current 

and available on the premises for each child admitted to the 

foster home: 

(a) General Information. The provider shall maintain a record 

for each child in the home. The record must include: 

(A) The child's name, date of entry into the foster home, date of 

birth, gender, religious preference, and guardianship status; 

(B) The name, addresses, and telephone number of the child's 

guardian, family, advocate, or other significant person; 

(C) The name, address, and telephone number of the child's 

preferred primary health provider, designated back up health 

care provider and/or clinic, dentist, preferred hospital, medical 

card number and any private insurance information, and 

Oregon Health Plan choice; 

(D) The name, address, and telephone number of the child's 

school program; and 

(E) The name, address, and telephone number of the CMHP 

case manager and representatives of other agencies providing 

services to the child. 

(b) Child records shall be available to representatives of the 

Division and SOSCF conducting inspections or investigations, as 

well as to the child, if appropriate, and the guardian, or other 

legally authorized persons. 

OEI - 02 - 00 - 00363 F OSTER C ARE C HILDREN’ S USE OF MEDICAID SERVICES IN O REGON 19 
APPENDIX~A 

(c) Child records shall be kept for a period of three years. If a 

child moves or the foster home closes, copies of pertinent 

information shall be transferred to the child's new home. 

(d) Medical Information shall include: 

(A) History of physical, emotional and medical problems, 

accidents, illnesses or mental status that may be pertinent to 

current care; 

(B) Current orders for medications, treatments, therapies, use 

of restraints, special diets and any known food or medication 

allergies; 

(C) Completed Medication Administration Records (MAR) from 

previous months; 

(D) Pertinent medical information such as hospitalizations, 

accidents, immunization records including Hepatitis B status 

and previous TB tests, incidents or injuries affecting the health, 

safety or emotional well-being of the child; and 

(E) Documentation or other notation of guardian consent for 

medical treatment that is not routine, including surgery and 

anesthesia. 

(e) Individual Support Plan. The child's ISP is prepared by the 

ISP team, and addresses each child's behavior, medical and 

support needs. The ISP shall be developed within 60 days of 

placement and updated annually or whenever the child's needs 

change. The ISP shall describe the child's behavior, medical, 

support needs and capabilities, and will include by whom, when, 

and how often care and services will be provided. 

(f) Financial records: 

(A) A separate financial record must be maintained for each 

child if the provider manages or handles the child's money. 

(B) Each child's financial record shall document the receipt of 

the room and board fee that is paid to the provider at the 

beginning of each month. 

(C) Any single item over $50 purchased with the child's 

personal funds, unless otherwise indicated in the child's ISP, 

will be documented including receipts, in the child's financial 

record. 

OEI - 02 - 00 - 00363 F OSTER C ARE C HILDREN’ S USE OF MEDICAID SERVICES IN O REGON 20 
APPENDIX~A 

(D) The child's ISP team will address how the child's personal 

spending money will be managed and documented. 

(E) If the child has a separate commercial bank account, records 

from that account must be maintained with the financial record. 

OEI - 02 - 00 - 00363 F OSTER C ARE C HILDREN’ S USE OF MEDICAID SERVICES IN O REGON 21 
APPENDIX~B 
 

Comparison of Children in Sample to Universe of Oregon Foster Care 

Children in Continuous Care for 6 Months 

As shown in the table below, gender and ages of the children in 

the sample are similar to that of the universe of all Oregon 

foster care children in continuous care for 6 months prior to 

sample selection. Slightly more than half of the sample and 

universe are male. Thirty percent of both the sample and 

universe are age 5 or under, roughly 34 percent are between the 

ages of 6 and 12, about 36 percent are age 13 or over. 

Comparison of Children in Sample to Universe 

50 Children in Sample Universe 

GENDER 

Count % of Total Count % of Total 

Male 27 54% 2619 52% 

Female 23 46% 2385 48% 

Total 50 100% 5004* 100% 

AGE 

0-2 10 20% 647 13% 

3-5 5 10% 859 17% 

6-9 10 20% 981 20% 

10-12 7 14% 861 17% 

13-17 18 36% 1484 30% 

18+ 0 0% 172 3% 

Total 50 100% 5004* 100% 

Source: Oregon Medicaid Data 

* The universe of foster care children in continuous foster care for 6 

months prior to sample selection was 5,004 children. The total 

number of foster care children in care at the time of sample 

selection was approximately 7,400. 

OEI - 02 - 00 - 00363 F OSTER C ARE C HILDREN’ S USE OF MEDICAID SERVICES IN O REGON 22 
OEI - 02 - 00 - 00363 F OSTER C ARE C HILDREN’ S USE OF MEDICAID SERVICES IN O REGON 23

Demographics

The table below shows demographic and health characteristics 

of each of 50 sampled children, including the amount of time 

they were in foster care during our 2-year study period. 

Placement setting refers to the type of foster care placement the 

child was in at the time our sample was pulled in July 2002. 

ID Sex Age

(years)

Placement

Setting

Caseworker or 

Caregiver Reported 

Medical Problem(s)

Caseworker or 

Caregiver Reported 

Mental Health 

Problem(s)

Amount of Time in 

Care (Months)

1 M 15 Residential Y Y 24

2 M 12 Family N Y 19

3 M 15 Family Y Y 24

4 M 11 Family N Y 24

5 F 6 Family N N 23

6 M 16 No Information Y Y 24

7 M 13 Family Y Y 24

8 M 4 Kinship Y N 24

9 F 13 Kinship N Y 24

10 M 2 Family Y N 24

11 F 14 No Information N Y 24

12 M 17 Family Y Y 23

13 M 9 Kinship N Y 22

14 F 5 Family Y Y 24

15 F 12 Family N Y 24

16 F 5 Family N N 21

17 M 10 No Information Y Y 24

18 M 14 Residential N Y 24

19 M 16 Family Y Y 24

20 F 17 Family Y Y 24

21 M 10 Family N Y 24

22 M 17 Family N Y 24

23 M 2 Family N N 24

24 M 6 Family Y N 24

25 F 2 No Information N N 24

26 M 6 Kinship Y Y 10

27 F 7 Family Y Y 24

28 M 13 Residential Y Y 23

29 M 13 Residential N Y 10

APPENDIX~C
APPENDIX~C 

ID Sex Age 

(years) 

Placement 

Setting 

Caseworker or 

Caregiver Reported 

Medical Problem(s) 

Caseworker or 

Caregiver Reported 

Mental Health 

Problem(s) 

Amount of Time in 

Care (Months) 

30 F 7 Family Y Y 22 

31 M 16 Kinship Y Y 24 

32 F 6 Kinship N Y 22 

33 F 1 Kinship N Y 22 

34 F 7 Family N Y 24 

35 M 0 Family N N 9 

36 F 1 Family N N 10 

37 M 0 Family Y N 10 

38 F 1 Family Y Y 11 

39 F 7 Family N Y 24 

40 M 1 Kinship N N 16 

41 F 5 Kinship Y N 24 

42 F 2 Family Y Y 23 

43 F 4 No Information No Information No Information 24 

44 F 13 Family N Y 24 

45 M 9 Family Y Y 24 

46 M 11 Family Y Y 19 

47 F 16 Family Y N 24 

48 F 11 Kinship Y Y 17 

49 M 15 Family N Y 24 

50 F 15 Family N N 24 

Source: Oregon Medicaid Data, OIG analysis of interview data. 

OEI - 02 - 00 - 00363 F OSTER C ARE C HILDREN’ S USE OF MEDICAID SERVICES IN O REGON 24
 
APPENDIX~D 
 

Description of 50 Oregon Foster Care Children in 

Sample 

Medical problems 

Caseworkers or caregivers report that approximately 50 percent 

of the children in our sample have at least one medical problem. 

Medical problems included acne, asthma, cerebral palsy, drug 

affected, vision problems, obesity, seizures, allergies, heart 

problems, and genetic disorders. Caseworkers or caregivers also 

report that at least 70 percent of the children in our sample 

have a minimum of 1 mental health problem. The most common 

mental health problems are related to depression, anxiety, or 

emotional disorders. Caregivers, in particular, note many 

problems with anger or behavioral issues. A number of children 

also suffer from attention-deficit or attention-deficithyperactivity disorder and/or post-traumatic stress disorder. 

Still other children have developmental delays, learning 

disabilities, and suffer from some form of abuse or neglect. 

Types of Medicaid enrollment 

Foster care children sometimes have several different 

placements or go in and out of foster care, so they often 

participate in a few plans. Most children in our sample were 

enrolled in more than one type of plan under the Oregon Health 

Plan during our inspection period. Forty-two children were 

enrolled in a managed care plan for at least some portion of our 

study period. Thirty-three were enrolled in a fee-for-service 

plan, and three were enrolled in a primary care case 

management plan at some point. In addition, some children 

were enrolled in one type of plan for medical coverage and 

another type of plan for dental and/or mental health services. 

For example, a child might have a fee-for-service medical plan 

but be enrolled in a dental health maintenance organization 

plan. 

OEI - 02 - 00 - 00363 F OSTER C ARE C HILDREN’ S USE OF MEDICAID SERVICES IN O REGON 25 
APPENDIX~E 
 

FEE FOR SERVICE MANAGED CARE 

962 962 $710,420 0 ** 

295 109 $4,934 186 ** 

374 158 $3,693 216 ** 

2079 517 $57,136 1562 ** 

683 666 $55,711 17 ** 

199 74 $8,914 125 ** 

59 34 $2,108 25 ** 

314 19 $669 295 ** 

59 25 $1,751 34 ** 

86 18 $1,486 68 ** 

54 54 $5,386 0 ** 

99 22 $565 77 ** 

138 44 $2,500 94 ** 

29 7 $1,398 22 ** 

24 3 $433 21 ** 

27 10 $342 17 ** 

10 9 $1,886 1 ** 

5 0 0 5 ** 

Source: OIG Analysis of Oregon Medicaid Data 

** Medicaid pays an average capitated rate of $101.22 per child per month for managed care services.13 Children in the sample 

were in managed care a total of 731 out of 1101 months. 

Number and Amount of Fee-for-Service and Managed Care Claims 

for 50 Children in Sample During the 2-year Inspection Period: 

Claim Type 

Targeted case management 

Office visit 

Labwork/Diagnostic 

Mental health 

Prescription drug 

Immunization 

Preventive 

Dental 

Emergency Room 

Supplies 

School-based services 

Vision 

Physical/Occupational therapy 

Hospital 

Clinic 

Hearing/Speech 

Other 

Home visit 

TOTAL 

13 http://www.dh s.state.or.us/healthplan/data_pubs/archives/caprates01-02.pdf 

PricewaterhouseCoopers LLP report on Oregon Health Plan Medicaid 

Demonstration, Capitation Rate Development, Federal Fiscal Year 2002; 9/25/01, 

page 18, Exhibit 2, Statewide Capitation Rate for Fiscal Year 2002 

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APPENDIX~F 
 

EPSDT Portion of Oregon’s Section 1115 Waiver 

(Excerpt from October 15, 2002, Approval Letter from CMS) 

“Under the authority of section 1115(a)(1) of the Act, the 

following waivers of Medicaid and SCHIP State plan 

requirements contained in section 1902 and 2103 of the Act are 

granted to enable Oregon to carry out the Oregon Health Plan 2 

demonstration through this period: 

7. Early and Periodic Screening, Section 1902(a)(43)(A)
 

Diagnosis and Treatment 
 

(EPSDT)
 

To waive the requirement that States must pay for services 

required to treat a condition identified during an EPSDT 

screening that are beyond the scope of the benefit package 

available to the individual.” 

Excerpt from Social Security Act: Section 1902 (a)(43)(A) 

“SEC. 1902. [42 U.S.C. 1396a] (a) A State plan for medical 

assistance must-­

(43) provide for-­

(A) informing all persons in the State who are under the age of 

21 and who have been determined to be eligible for medical 

assistance including services described in section 1905(a)(4)(B), 

of the availability of early and periodic screening, diagnostic, 

and treatment services as described in section 1905(r) and the 

need for age-appropriate immunizations against vaccinepreventable diseases,” 

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� APPENDIX ~ G 
 

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ACKNOWLEDGMENTS 
 

This report was prepared under the direction of John I. Molnar, 
 

former Regional Inspector General for Evaluation and 
 

Inspections in the New York Regional Office, and Jodi 
 

Nudelman, Assistant Regional Inspector General. Other 
 

principal Office of Evaluation and Inspections staff who 
 

contributed include:
 

Nancy Harrison, Team Leader
 

Laura Torres, Lead Analyst
 

Natasha Besch, Program Analyst
 

Nicole Gillette, Program Analyst
 

Thomas Zimmermann, Program Analyst
 

Linda Hall, Program Specialist
 

Barbara Tedesco, Statistician
 

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