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DEPARTMENT OF HEALTH &. HUMAN SERVICES Office of Inspector General

Washington , D.C. 20201

AUG 2 4 2004

TO: Wade F. Horn, Ph.

Assistant Secretay for

Children and Families

FROM:

Mark B. McClellan, M.D., Ph.

Administrator

Centers for M dicar

;ticaid Services

Dara Corrga

Acting Principal Deputy Inspector General

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

Care: North Dakota " OEI-07-00-00643

Attched is a final report that assesses whether sampled children in the North Dakota

foster care program are receiving health care services that fulfill Federal and State

requirements. We conducted this inspection in response to concerns about the health care

that children in foster care are receiving. This report is one of a series of inspections that

focus on children s use of health care services while in foster care in eight States:

Georgia, Ilinois, Kansas, New Jersey, New York, North Dakota, Oregon, and Texas.

We determined that all 50 of the children in our sample had Medicaid coverage and

Medicaid claims for health care services. Thirty-five of the fifty sampled children

received their most recent required Early and Periodic Screening, Diagnosis, and

Treatment (EPSDT) examination, and 30 of 38 sampled children required to receive

EPSDT dental services had received their most recent EPSDT dental service. Some

sampled children waited months after entering foster care to receive an initial

comprehensive medical examination recommended by the State. We also found that

mental health needs were not documented for 12 of the 34 sampled children who received

mental health services as Federal law requires. Such documentation is importt to 

ensure children receive appropriate and necessary services timely. Finally, Federal law

and State policy require that foster care providers (i. , foster parents or residential care

facility staff receive medical information about the child in their care, yet 9 of the 48

foster care providers interviewed reported never receiving this information.

We recommend that the Administration for Children and Families (ACF) work with the

North Dakota Division of Children and Family Services to examine how initial

comprehensive medical examinations for children entering foster care are being provided;

ensure that case plans reflect required mental health needs; and promote the importance

of caseworkers obtaining medical information for children in foster care and giving the
Page 2 - Wade F. Horn, Ph.D. and Mark B. McClellan, M. , Ph.

medical information to foster care providers, in accordance with Federal requirements.

We recommend that the Centers for Medicare & Medicaid Services (CMS) work with the

North Dakota Division of Medical Services to develop a method for notifying foster care

providers of when required EPSDT services are due; and to increase the number of dental

providers accepting Medicaid in North Dakota. We also recommend that ACF and CMS

work with the North Dakota Department of Human Services to coordinate State agency

efforts to educate caseworkers and foster care providers regarding the importnce and

availability of EPSDT medical examinations; to ensure caseworkers and foster care

providers understad the difference between comprehensive EPSDT examinations and

medical examinations for specific health conditions; and to educate caseworkers and

foster care providers regarding State EPSDT frequency schedules for dental services.

In response to our recommendations, ACF noted that it is actively working with the

North Dakota Division of Medical Services to promote the importance of obtaining

medical histories and providing medical information to foster care providers and that

these issues are being addressed in the Program Improvement Plan developed in response

to a Child and Family Services Review. They also note that only 79 percent of the cases

reviewed during the on-site portion ofthe Child and Family Services Review

substantially achieved the outcome measure which determines if children receive

adequate services to meet their physical and mental health needs. CMS generally

concured with our recommendations but clarified that they should be carried out by joint

action of the North Dakota Divisions of Medical Services and Children and Family

Services. CMS stated that their regional office staff is available to provide techncal

assistance to both Divisions, as appropriate.

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 your staff may contact Elise Stein, Director, Public Health and

Human Services Branch, at (202) 619-2686 or through e-mail (Elise.Stein(goig.hhs. gov

To facilitate identification, pl se refer tOJepQrtm.1IIlb J QEI-Q'Z.. OO..Dit643 in all

correspondence.

Attchment
 Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

 

Inspector General 

AUGUST 2004 

OEI-07-00-00643 

 

CHILDREN’S USE OF HEALTH 

CARE SERVICES WHILE IN 

FOSTER CARE: NORTH DAKOTA 
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. 

 
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In response to concerns about the health care children in foster care are 

receiving, we conducted a series of studies in eight States to assess 

whether sampled children in foster care are receiving health care 

services that fulfill Federal and State requirements. This study 

determined that all 50 sampled children in the North Dakota foster care 

program had Medicaid coverage and claims. Thirty-five sampled 

children received their most recent required Early and Periodic 

Screening, Diagnosis, and Treatment (EPSDT) examinations and 30 of 

38 children required to receive dental services had their most recent 

EPSDT dental service. We also found that some children waited 

months after entering foster care to receive a comprehensive medical 

examination recommended by the State. In addition, 9 of 48 foster care 

providers (i.e., foster parents or residential care facility staff) reported 

never receiving a medical history for the sampled child in their care, 

and mental health needs were undocumented in the case plans for 12 of 

the 34 sampled children receiving mental health services, both of which 

are required to meet Federal requirements. 

We recommend that the Administration for Children and Families 

and the Centers for Medicare & Medicaid Services work with the 

North Dakota Department of Human Services to address shortcomings. 

 ABSTRACT 
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OBJECTIVE 

To determine whether sampled children in the North Dakota foster care 

program receive health care services. 

BACKGROUND 

Sections 472(h) and 1902(a)(10)(A)(i)(I) of the Social Security Act (the 

Act) require States to provide Medicaid or Medicaid-equivalent coverage 

to children eligible to receive Title IV-E funds. North Dakota is the 

focus of this inspection and is one of a series of eight States chosen to 

represent a diverse cross-section of foster care nationwide. All 

Title IV-E children in the North Dakota foster care program are eligible 

for Medicaid. Federal Early and Periodic Screening, Diagnosis, and 

Treatment (EPSDT) guidelines require each State to make preventive 

health care services available to Medicaid-eligible individuals under the 

age of 21 and establish State guidelines regarding the intervals for 

providing EPSDT examinations that meet reasonable standards of 

medical and dental practice, as outlined in Sections 1902(a)(43) and 

1905(r) of the Act. 

This inspection is based on information gathered from multiple sources. 

We reviewed Federal and State policies; analyzed child-specific 

Medicaid claims data and case file documentation for 50 randomly 

sampled children in the North Dakota foster care program; interviewed 

foster care providers (i.e., foster parents or residential care facility 

staff), caseworkers responsible for children in our sample, State child 

welfare and medical services staff, Child Welfare Program Directors 

representing 4 Native American Nations, and other State agency 

officials. Our analysis focused on a 3-year Medicaid claims history for 

the period November 1, 1999 to November 1, 2002. 

FINDINGS 

All 50 sampled children had Medicaid coverage and claims for 

health care services. 

Each of the 50 sampled children was enrolled in the Medicaid program, 

had a Medicaid card or number, and had at least 1 Medicaid claim 

during the period covered by our study. 

 EXECUTIVE SUMMARY 
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EXECUTIVE SUMMARY 

Thirty-five of the fifty sampled children received their most recent 

EPSDT medical examination, within State-established frequency 

guidelines. 

Overall, 35 sampled children received their most recent EPSDT medical 

examination, within State-established guidelines, based on their age 

and length of time in foster care. Six children who did not receive an 

EPSDT examination remained in compliance with the State guidelines 

based on their age or the date they entered foster care. However, eight 

children who should have received an EPSDT examination, did not. 

Some foster care providers stated that they did not believe EPSDT 

examinations were necessary because the child was receiving care for a 

specific condition. The only systematic notification foster care providers 

received regarding required EPSDT services was an annual letter from 

the Division of Medical Services reminding them that EPSDT services 

are available. 

Thirty of thirty-eight sampled children required to receive an EPSDT 

dental examination received their most recent EPSDT dental 

examination, within State-estabished frequency guidelines. 

The EPSDT frequency guidelines adopted by North Dakota require that 

all children over 3 years of age receive dental services every 6 months. 

Thirty-eight of the sampled children were over age 3 and, because they 

had been in foster care more than 6 months, were required to have 

received dental services. Thirty of these thirty-eight children received 

their most recent required dental service within State-established 

EPSDT frequency guidelines. Based on the State-established 

guidelines, the 38 children should have received at least 121 dental 

services. However, only 64 of these 121 dental services were received 

timely, and 57 were received outside the required timeframe or not 

received at all. Thirteen of the forty-nine caseworkers for children in 

our sample reported a severe shortage of dentists willing to treat 

Medicaid patients. 

Some sampled children waited months after entering foster care to 

receive a comprehensive medical examination recommended by the 

State. 

Federal law requires States to ensure that all children in foster care are 

provided quality services that protect their health. North Dakota’s 

foster care policy recommends that children receive an initial medical 

examination upon entry into foster care. We found that some sampled 

children waited months before receiving an EPSDT medical 
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EXECUTIVE SUMMARY 

examination. While 31 of 38 sampled children who entered foster care 

during the period covered by our study received an EPSDT medical 

examination, they waited 2 to 435 days from entry before their health 

needs were comprehensively assessed. The lack of a specific 

requirement for an initial medical examination may have contributed to 

the remaining seven children who entered foster care during the study 

period not having received an EPSDT medical examination, despite 

having been in foster care between 106 and 715 days. 

Mental health needs were not documented for 12 of 34 sampled 

children receiving mental health services, as required. 

In meeting Federal requirements to ensure that children in foster care 

placements are provided quality services that protect their health, 

North Dakota requires that individual case plans for children in foster 

care include their mental health needs. Our case file and claims data 

review indicated that 34 of the 50 sampled children received mental 

health services during the period covered by our study. However, the 

need for mental health services was not documented in the case plans 

for 12 of these 34 children. 

Nine of forty-eight foster care providers reported never receiving 

medical information for the sampled children in their care. 

Federal law requires that the health records of children in foster care be 

reviewed, updated, and supplied to the foster care provider at the time 

of placement. Of the 48 foster care providers we interviewed, 9 reported 

never receiving medical information for the sampled children in their 

care. However, caseworkers for eight of these nine children reported 

receiving or compiling medical information on the sampled children. 

RECOMMENDATIONS 

The Administration for Children and Families (ACF) should work with 

the North Dakota Division of Children and Family Services to: 

 Examine how initial comprehensive medical examinations 

for children entering foster care are being provided. 

 Ensure case plans reflect mental health needs, as required. 

 Promote the importance of caseworkers obtaining medical 

information for children in foster care, and supplying the 

foster care providers with the information, in accordance 

with Federal requirements. 
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EXECUTIVE SUMMARY 

The Centers for Medicare & Medicaid Services (CMS) should work with 

the North Dakota Division of Medical Services to: 

 Develop a method for notifying foster care providers when 

required EPSDT services are due. 

 Increase the number of dentists accepting Medicaid in 

North Dakota. 

ACF and CMS should work with the North Dakota Department of 

Human Services to coordinate State agency efforts to: 

 Educate caseworkers and foster care providers regarding the 

importance and availability of EPSDT medical 

examinations. 

 Ensure caseworkers and foster care providers understand 

the difference between comprehensive EPSDT examinations 

and medical examinations for specific health conditions. 

 Educate caseworkers and foster care providers on State 

EPSDT frequency guidelines for dental services. 

AGENCY COMMENTS 

ACF noted that it is working with the North Dakota Department of 

Human Services to promote the importance of obtaining medical 

histories and providing medical information to foster care providers and 

that these issues are being addressed in the Program Improvement Plan 

developed in response to a Child and Family Services Review. It also 

notes that only 79 percent of the cases reviewed during the on-site 

portion of the Child and Family Services Review substantially achieved 

the outcome measure which determines if children receive adequate 

services to meet their physical and mental health needs. 

CMS generally concurred with our recommendations, but clarified that 

the recommendations should be carried out by joint action of the 

North Dakota Divisions of Medical Services and Children and Family 

Services. CMS stated that its regional office staff is available to provide 

technical assistance to both Divisions, as appropriate. 
ABSTRACT ....................................................... i 

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

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

FINDINGS ....................................................... 9 

 Medicaid coverage for children in foster care .....................................9 

 Receipt of EPSDT medical examinations..........................................10 

 Receipt of EPSDT dental services .....................................................11 

 Comprehensive medical examinations ............................... 12 

 Documentation and receipt of mental health services .....................13 

 Medical information for foster care providers ..................................14 

RECOMMENDATIONS ......................................... 15 

APPENDICES .................................................. 17 

 A: Demographic Characteristics of Sampled Children....................17 

 B: Medicaid Claims for Sampled Children .......................... 19 

 C: EPSDT Services for Sampled Children ........................... 21 

 D: Agency Comments - ACF .......................................... 23 

 E: Agency Comments - CMS.......................................... 27 

ACKNOWLEDGMENTS......................................... 29 

 TABLE OF CONTENTS 
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OBJECTIVE 

To determine whether sampled children in the North Dakota foster care 

program receive health care services. 

BACKGROUND 

There are an estimated 542,000 children in foster care nationwide,1 

many of whom are reportedly in poor health. To determine if children 

in foster care are receiving mandated health care services, we selected 

eight States for review.2 The States were chosen to represent a diverse 

cross-section of foster care nationwide. North Dakota was chosen for its 

small population size, geographic location, rural setting, countyadministered child welfare system, Native American population, and 

fee-for-service provision of Medicaid services. North Dakota had 

1,129 children in foster care at the end of fiscal year (FY) 2000, based on 

the most recent Federal data available at the time of our study.3 The 

Administration for Children and Families (ACF) has regulatory 

oversight of the Title IV-E foster care program, including approval of 

State plans to ensure State foster care programs are operating within 

Federal guidelines. Within the North Dakota Department of Human 

Services, the Division of Children and Family Services manages the 

Title IV-E foster care program. 

Compared with other children from the same socioeconomic 

backgrounds, children in foster care suffer much higher rates of serious 

physical and psychological problems.4 Vision, hearing, and dental 

problems are prevalent in the foster care population, and physical 

1 Department of Health and Human Services, Administration for Children and Families, 

Adoption and Foster Care Analysis and Reporting System Report for the period ending 

September 30, 2001. Retrieved April 5, 2004 from 

http://www.acf.hhs.gov/programs/cb/publications/afcars/report8.htm. 

2 Other States selected for review are Georgia, Illinois, Kansas, New Jersey, New York, 

Oregon, and Texas. 

3 Department of Health and Human Services, Administration for Children and Families, 

Foster Care: Entries, Exits, and In Care on the Last Day. The 1,129 children in foster 

care include children in both the Title IV-E and non-Title IV-E foster care programs. 

Retrieved April 5, 2004 from http://www.acf.dhhs.gov/programs/cb/dis/tables/entryexit2002.htm. 

4 Casey Family Programs, National Center for Resource Family Support, Health Care 

Issues for Children in Foster Care, March 25, 2002. Retrieved October 17, 2002 from 

http://www.casey.org/cnc/documents/health care issues.pdf.

 INTRODUCTION 
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INTRODUCTION 

health problems (e.g., delayed growth and development, malnutrition, 

and asthma) affect 30 to 40 percent of children in the child welfare 

system.5 

Children in foster care have greater health care needs, yet many foster 

care providers (we use the term “foster care provider” to refer to foster 

parents or residential care facility staff) reported having difficulty 

finding health care professionals who were willing to care for these 

children.6 The health care available for children in foster care is often 

characterized by lack of access; lack of information sharing among 

health care professionals; and long delays in obtaining services.7 

Furthermore, studies have shown that low percentages of children in 

foster care are actually receiving services. Therefore, concern exists 

that children with the greatest health care needs may not be receiving 

needed services. 

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

program is designed to screen for, diagnose, and treat medical 

conditions in Medicaid-eligible individuals under age 21 that might 

otherwise go undetected or untreated. However, a General 

Accountability Office report released in July 2001 states that available 

data from short range studies show that the percentage of children in 

the general population receiving EPSDT services is very low.8 

Periodic dental care is also included as part of EPSDT, and must be 

performed by a dentist. North Dakota EPSDT dental examinations are 

required for every child in accordance with the frequency guidelines 

developed by the State. Dental frequency guidelines must be 

established by the State after consultation with recognized dental 

organizations involved in child health care. 

5 Factsheet: The Health of Children in Out of Home Care. Child Welfare League of 

America. Retrieved October 17, 2002 from 

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

6 Chernoff, R. et. al., Assessing the Health Status of Children Entering Foster Care, 

 Pediatrics, 93:2, 1994. 

7 Health Care of Young Children in Foster Care. Pediatrics, 109:3, 2002. Retrieved 

 May 12, 2003 from http://www.aap.org/policy/re0054.html. 

8 Medicaid: Stronger Efforts Needed to Ensure Children’s Access to Health Screening 

Services. General Accountability Office, GAO-01-749, July 2001. 
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INTRODUCTION 

Medicaid for Children in Foster Care 

All children in the North Dakota Title IV-E foster care program are 

eligible for Medicaid. Sections 472(h) and 1902(a)(10)(A)(i)(I) of the 

Social Security Act (the Act) require States to provide Medicaid or 

equivalent health insurance coverage to all children in foster care, 

including those eligible to receive Title IV-E foster care program 

maintenance funds. Federal EPSDT guidelines require each State to 

make comprehensive and preventive child health services available to 

Medicaid-eligible individuals under the age of 21, as outlined in 

Sections 1902(a)(43) and 1905(r) of the Act. Within a broad framework, 

each State establishes its own Medicaid eligibility standards; 

determines the type, amount, duration, and scope of Medicaid services; 

sets the rate of payment for services to Medicaid patients; and 

administers its own Medicaid program.9 

In FY 2000, Medicaid payments for children in foster care nationwide 

totalled over $3.3 billion.10 North Dakota Medicaid expenditures for 

this population totalled approximately $10.7 million in 2000.11 The 

Centers for Medicare & Medicaid Services (CMS) is responsible for the 

Federal oversight of individual State Medicaid programs. Within the 

North Dakota Department of Human Services, the Division of Medical 

Services manages the State Medicaid program. 

North Dakota Health Tracks 

In accordance with Federal law, participation in the Medicaid program 

requires States to establish EPSDT services for all Medicaid-eligible 

individuals under 21 years of age.12 State EPSDT programs must 

provide medical, hearing, vision, and dental screenings, and other 

necessary health care and treatment at intervals established by the 

State that meet reasonable standards of practice published by 

9 Retrieved September 12, 2002 from http://cms.hhs.gov/medicaid/mover.htm

 and http://cms.hhs.gov/medicaid/eligibility/criteria.asp.

10 Department of Health and Human Services, Medicaid Statistical Information System 

 (MSIS) Report Fiscal Year 2000: All States. Retrieved August 6, 2003, from 

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

11 Department of Health and Human Services, Medicaid Statistical Information System 

 (MSIS) Report Fiscal Year 2000: North Dakota. Retrieved April 5, 2004, from 

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

12 Section 1905(r) of the Social Security Act. 
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INTRODUCTION 

recognized health care organizations. North Dakota has established the 

Health Tracks program to meet Federal EPSDT requirements. 

The current frequency schedule established for the Health 

Tracks program requires a complete physical examination 

at 1, 2, 4, 6, 9, 12, 15, and 18 months of age; during each year that the 

child is 2, 3, 4, 5, 6, 8, and 10 years of age; and during each year of the 

child’s life thereafter through the age of 21. The Health Tracks program 

does not require EPSDT services for children 7 and 9 years of age. 

Health Tracks program guidelines require that vision and hearing 

screenings be included as part of every EPSDT physical examination for 

all children over 6 years of age. Health Tracks also requires a complete 

dental examination every 6 months, separate from the medical 

examination, for all children over 3 years of age. 

North Dakota requires State child welfare staff (e.g., eligibility 

specialists or caseworkers) to inform the guardians of all Medicaideligible children of the availability of health services and to document 

that such services were offered. Foster care providers are generally 

responsible for ensuring the children in their care receive these 

examinations. North Dakota recommends, but does not require, that 

children receive a medical examination upon entry into foster care in 

addition to the health care services provided in accordance with the 

Health Tracks frequency guidelines.13 

While Section 1905(r)(1)(B)(i) of the Social Security Act requires that 

mental health development be included in EPSDT screenings, 

North Dakota imposes no specific requirements for mental health 

screenings or the provision of mental health services for children in 

foster care beyond requiring that legal custodians provide for the 

physical, mental, and moral welfare of the children in their custody.14 

Case plans are required to address clinically diagnosed disabling 

conditions.15 

Section 471(a)(22) of the Act requires States to develop a State plan that 

includes standards to ensure that children in foster care placements in 

public and private agencies are provided quality services that protect 

13 North Dakota Department of Human Services (NDDHS), Service Chapter 623 05 05-60. 

14 NDDHS 624-05-05-11. 

15 NDDHS 624-05-05-20. 
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INTRODUCTION 

their safety and health. Sections 422(b)(10)(B)(ii) and 475(5)(D) of the 

Act require procedures to ensure that health records for children in 

foster care be reviewed, updated, and supplied to the foster care 

provider at the time of placement. According to Section 475(1)(C) of the 

Act, health records should include, to the extent available and 

accessible, the names and addresses of the child’s health care 

professionals, a record of the child’s immunizations, the child’s known 

medical problems, the child’s medications, and any other relevant 

health information concerning the child determined to be appropriate by 

the State agency. 

To meet Federal requirements, North Dakota requires that a 

permanency plan (case plan) addressing each child’s medical and 

mental health needs, and a record of the child’s immunizations and 

known medical problems, be developed within 30 days of a child’s entry 

into foster care. The case plans are required to be reviewed and 

updated quarterly and should include all available health records. The 

health information contained in the case plans is to be supplied to the 

foster care providers.16 

METHODOLOGY 

This inspection focused on the receipt of health care and dental services 

that meet EPSDT guidelines; the receipt of mental health services; and 

the provision of medical information to foster care providers. This study 

did not address follow-up care or the appropriateness of ongoing health 

care in meeting the needs of children in foster care. The inspection is 

based on information gathered from multiple sources: reviews of 

Federal and State policies; child-specific Medicaid claims data for 

50 randomly sampled children; case file documentation for 49 of the 

50 sampled children (case file information for 1 sampled child was not 

provided); interviews with caseworkers and foster care providers for the 

49 sampled children for which case files were received; and interviews 

with North Dakota State agency and Native American Nation officials. 

Reasons for State Selection

North Dakota was selected for its small population size, geographic 

location, rural setting, county-administered child welfare system, 

16 NDDHS 624-05-05-17. 
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INTRODUCTION 

Native American population, and fee-for-service provision of Medicaid 

services. 

Sample 

Children who met the following criteria were included in the study 

population: (1) were in foster care on January 22, 2003; (2) resided in 

North Dakota; (3) were eligible for Title IV-E foster care program 

maintenance funds; and (4) had been in continuous out-of-home foster 

care placements for at least 6 months. The Division of Children and 

Family Services provided us with a list of the 381 children who met 

these criteria. We selected a simple random sample of 50 children from 

this list. Appendices A, B, and C provide information on the children 

included in our study, and the services they received. 

Review of Policies, Medicaid Data, and Case File Documentation

Policy Review -- We reviewed Federal and State foster care, Medicaid, 

and EPSDT program policies. The North Dakota Health Tracks 

program meets Federal EPSDT requirements. Therefore, we used 

Health Tracks guidelines to determine whether children in foster care 

were receiving required EPSDT medical and dental services timely. 

Medicaid Claims Data Review -- The Division of Medical Services provided 

us with up to 3 years of Medicaid claims data for each of the children in 

our sample. The data included Medicaid claims for physician, dental, 

pharmaceutical, and mental health services paid between 

November 1, 1999 and November 1, 2002, the most recent 3-year period 

for which claims data was available. We paid particular attention to the 

types of services provided and service dates. We included only those 

Medicaid claims for services provided after the child’s most recent entry 

into foster care. For sampled children entering foster care on or after 

November 1, 1999, we analyzed Medicaid claims data from the date 

they entered foster care through November 1, 2002. All Medicaid 

services provided to sampled children were included in our analysis. 

However, sampled children who had been in foster care less than 

6 months during our claims window were not considered out of 

compliance if they had not received the EPSDT service. Appendix B 

provides information regarding the Medicaid services each sampled 

child received. 

Case File Documentation -- We requested case file documentation from 

the Division of Children and Family Services local offices for all of the 

children in our sample, including documentation of medical, dental, and 

mental health services provided, the child’s medical history, the child’s 
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INTRODUCTION 

initial and most recent case plan, duration of the child’s stay in foster 

care, and information regarding the child’s health and general wellbeing. We received and reviewed information for 49 children; despite 

repeated requests, we were not provided with the documentation for 

1 child. 

We also received and reviewed caseworker or residential treatment 

center notes for some of the sampled children indicating that the 

children had been referred for or scheduled to receive medical, dental, or 

mental health services or that they had actually received the services. 

However, in the absence of a Medicaid claim or other supporting 

documentation (e.g., an EPSDT form signed by a physician or other 

health care professional), we were unable to include the noted services 

in our analysis. 

Interviews 

Foster Care Provider Interviews -- We conducted structured interviews 

with 48 of the foster care providers (i.e., foster parents or residential 

care facility staff) responsible for the children in our sample (8 in person 

and 40 by telephone) between April 15, 2003 and May 29, 2003. We 

were unable to interview two foster care providers because we were 

unable to obtain the case file containing contact information for one 

sampled child and the caseworker failed to provide the foster parent 

contact information for another child within the timeframe of our study. 

The interviews with foster care providers focused on the Medicaid 

program and the services available, the training they received related to 

the health and well-being of children, and their experiences procuring 

health care services for the children in our sample. 

Caseworker Interviews -- We conducted structured telephone interviews 

with 49 of the caseworkers assigned to the children in our sample 

between March 27, 2003 and May 22, 2003. We did not receive the case 

file for one child and therefore lacked the information needed to contact 

the caseworker. Each of these interviews focused on the caseworker’s 

understanding of the Medicaid program and the services available, the 

training they received related to the health and well-being of children, 

their experiences accessing health care services, and any barriers to 

obtaining needed health care. Each caseworker spoke specifically about 

the sampled child’s case, and generally about his or her own experiences 

working in foster care. We analyzed the caseworkers’ responses and 

compared them to those of the foster care providers, noting any 

consensus or disagreement within and between the two groups. 
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INTRODUCTION 

State Agency and Native American Nation Officials -- To enhance our 

understanding of the State’s foster care and Medicaid programs, we 

consulted, both in person and by telephone, with State staff and Child 

Welfare Program Directors for the Spirit Lake Sioux, Standing Rock 

Sioux, Three Affiliated Tribes, and Turtle Mountain Chippewa Nations. 

This inspection was conducted in accordance with the Quality 

Standards for Inspections issued by the President’s Council on Integrity 

and Efficiency.
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Federal law requires that all 

children eligible for the 

Title IV-E foster care program be 

provided Medicaid or Medicaid-equivalent services.17 In North Dakota, 

all children in foster care are eligible for Medicaid, including Early and 

Periodic Screening, Diagnosis, and Treatment (EPSDT) services.18 

Each of the 50 sampled children had Medicaid coverage and at least 

1 Medicaid claim for health care services during the 3-year period 

covered by our study. Table 1 details the various types of Medicaidcovered services and the number of claims by type of service provided 

for the 50 sampled children. 

* Ambulatory Surgical Center which includes emergency room visits. 

** Includes respite care, speech and language, nursing, nutritional, and developmental services. 

***Includes 41 Medicaid claims for Targeted Case Management. The remaining Case Management claims are 

for child protective services and residential care services case management. 

 A detailed list of selected services for each of the 50 sampled children is located in Appendix B. 

17 Section 1902(a)(43) of the Social Security Act. 

18 NDDHS 623-05-05-63. 

All 50 sampled children had Medicaid coverage 

and claims for health care services. 

 FINDINGS 

Claim Type

Number of 

Children with at 

Least One Claim

Total Number of 

Claims

Physician Office 46 407

Prescription Drug 45 1001

Laboratory 30 139

Dental 33 346

Hospital/ASC* 30 443

Optometry/Audiology 30 157

Mental Health 34 617

Diagnostic 9 27

Physical/Occupational 

Therapy

8 133

Supplies 18 227

Transportation 13 60

Early Intervention** 2 21

Case Management*** 22 449

Medication Review 15 94

Total 4121

Table 1: Number and Type of Medicaid Claims for 50 

Sampled Children

Source: Office of Evaluation and Inspections, analysis of North Dakota Medicaid claims 

data 2003.
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FINDINGS 

EPSDT medical examinations are 

intended to screen for and identify 

health care needs that may not be 

detected during a medical 

examination for a specific condition. All age-appropriate EPSDT 

examinations must be completed in accordance with the State-established 

EPSDT frequency guidelines. Overall, 35 sampled children received their 

most recent EPSDT medical examination, within State-established 

guidelines. Six sampled children had been in foster care less than the time 

period specified by the State frequency guidelines for their age group and 

were not required to receive EPSDT services during the period covered by 

our study. However, based on their age and length of time in foster care, 

and the State EPSDT frequency guidelines, eight children who should have 

received an EPSDT medical examination did not. 

Based on their age and the length of time they were in foster care, 25 of the 

50 sampled children were required to receive at least 1 EPSDT medical 

examination during the period covered by our review. Collectively, these 

25 children were required to receive 49 EPSDT examinations. However, 

only 30 of these 49 required examinations were received. 

Caseworkers or foster care providers for sampled children indicated that 

some EPSDT examinations were not performed because they believed them 

to be unnecessary. Some reported that the children were receiving routine 

medical care through their primary care physicians or the residential 

treatment centers in which some children were placed. Other caseworkers 

and foster care providers reported the children had recently been treated 

for a specific health care problem. Some children missed required EPSDT 

screenings because their caseworkers or foster care providers believed no 

services were necessary during the required times. 

The lack of systematic reminders also may be critical in explaining why 

children did not receive required EPSDT examinations. In accordance with 

State foster care policy, all children entering foster care must be made 

aware of Health Tracks services. However, no systematic or standardized 

monitoring is done to ensure children actually receive the required Health 

Tracks services. Further, foster care providers are not systematically 

notified of services that are due or lacking. The only notification foster care 

providers received regarding EPSDT services was an annual letter from the 

Division of Medical Services reminding them that EPSDT services are 

available. 

Thirty-five of fifty sampled children received 

their most recent EPSDT medical examination, 

within State-established frequency guidelines. 
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FINDINGS 

The EPSDT frequency guidelines 

adopted by North Dakota require 

that all children over 3 years of age 

receive dental services at least every 

6 months. Thirty-eight of the 

sampled children had been in foster 

care at least 6 months during the period covered by our study. Thirty of 

these thirty-eight children received their most recent required dental 

service in accordance with the State-established EPSDT frequency 

guidelines.19 Two of the thirty-eight children had received a dental 

service at some time since entering foster care but did not receive their 

most recent service in accordance with the State-established frequency 

guidelines. Six children had received no EPSDT dental services. 

Overall, the 38 children should have received at least 121 dental 

services to meet the State-established EPSDT guidelines. Sixty-four of 

these one hundred twenty-one services were received timely, and 

57 were received outside the required timeframe or not received at all. 

EPSDT dental services were not required during our study period for 

the remaining 11 sampled children. Six of these eleven children were 

under age 3 at the end of the claims window and not required to receive 

EPSDT dental services based on the frequency guideline. Five of the 

eleven were in foster care less than 6 months during the period covered 

by our Medicaid claims (i.e., the child entered foster care between 

May 1, 2002 and July 22, 2002). 

There are a variety of reasons children in foster care may not have 

received required EPSDT dental services. Twenty-one of the 

forty-nine caseworkers and 23 of the 48 foster care providers were 

unfamiliar with the EPSDT program or unaware of the dental 

frequency guidelines. Thirteen of the forty-nine caseworkers 

interviewed reported a severe shortage of dentists willing to treat 

Medicaid patients, which may contribute to foster care providers’ 

difficulty in accessing dental services. In addition, 31 caseworkers and 

18 foster care providers reported that dentists willing to treat Medicaid 

patients had long waiting lists for appointments and that many dentists 

were not accepting new Medicaid patients. 

19 Recent dental services include dental services provided during the last 6 months of our 

Medicaid claims data or services provided in the last 6-month period based on the State 

EPSDT frequency guidelines. 

Thirty of thirty-eight sampled children 

required to receive an EPSDT dental 

examination received their most recent EPSDT 

dental examination, within State-established 

frequency guidelines. 
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FINDINGS 

Section 471(a)(22) of the Act 

requires that States ensure all 

children in foster care are 

provided quality services that 

protect their health. 

North Dakota State foster care policy recommends that children receive 

an initial medical examination upon entry into foster care.20 We found 

that some children wait months before their health needs are 

comprehensively assessed. Thirty-eight sampled children entered foster 

care during the period covered by our Medicaid claims 

(November 1, 1999 to November 1, 2002). Thirty-one of these children 

received an EPSDT examination, which we used as evidence of receipt 

of a comprehensive medical examination, with at least two children 

waiting over 430 days to receive their first examination (see Table 2). 

Initial medical examinations being recommended versus required may 

have contributed to the remaining seven children who entered foster 

care during the study period not having received an EPSDT medical 

examination, despite having been in foster care between 106 and 

715 days (see Table 3). 

20 NDDHS 623-05-05-63. 

Age

Num ber of 

Children in 

Age Group

Days to First 

Com prehensive 

M edical Exam 

(Range)

Days to First 

Com prehensive 

M edical Exam 

(M edian)

0 - 6 m onths 3 2 - 117 27

7 - 23 m onths 1 127 127

2 - 5 years 8 22 - 431 67.5

6 - 9 years 7 6 - 435 118

10 - 21 years 12 10 - 203 113

Total 31 2 - 435 109

Table 2: Days to First Com prehensive EPSDT M edical 

Exam ination

Source: Office of Evaluation and Inspections, analysis of Medicaid claims data and 

case file documentation.

Some sampled children waited months after 

entering foster care to receive the 

comprehensive medical examination 

recommended by the State. 
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FINDINGS 

Table 3: Days in Foster Care Without a Comprehensive EPSDT Medical Exam 

Age 

Number of 

Children in 

Age Group 

Days Without 

Comprehensive 

Medical Exam (Range) 

Days Without 

Comprehensive Medical 

Exam (Median) 

0 - 6 months 0 0 0 

7 - 23 months 0 0 0 

2 - 5 years 1 113 113 

6 - 9 years 2 155 - 444 299 

10 - 21 years 4 106 - 715 208 

Total 7 106 - 715 193 

Section 475(1)(B) of the Act 

requires that a case plan be 

developed for each child that 

enters foster care, and that the 

plan ensures that services address the child’s needs, including mental 

health, while the child is in foster care. North Dakota requires that 

individual case plans for children in foster care include their mental 

health needs.21 Further, case plans must address clinically diagnosed 

disabling conditions (e.g., attention deficit or hyperactive disorders, 

conduct disorders, emotional disturbances, and mental retardation).22 

Each child in foster care is to be provided with needed mental health 

services identified in his/her case plan. 

Thirty-four of the fifty sampled children received at least one mental 

health service during the time period covered by our review. The 

receipt of mental health services were documented by Medicaid claims 

for 33 of the sampled children and by case file documentation for 

1 child. However, the need for mental health services was not 

documented in the case plans for 12 of the 34 sampled children who 

received mental health services. A lack of documentation in the case 

21 NDDHS 624-05-05-20. 

22 NDDHS 624-05-05-20. 

Mental health needs were not documented for 

12 of 34 sampled children receiving mental 

health services, as required. 

Source: Office of Evaluation and Inspections, analysis of Medicaid claims data and case file 

documentation.
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FINDINGS 

plans could result in children not continuing to receive services. If the 

child is placed with another foster care provider or assigned a new 

caseworker unaware of his/her mental health needs, services may not be 

continued without documentation. 

Section 475(5)(D) of the Act 

requires the health records of 

children in foster care be 

reviewed, updated, and supplied 

to the foster care provider with whom the child is placed at the time of 

each placement in foster care. North Dakota requires that the health 

information contained in the case plans be supplied to foster care 

providers.23 However, of the 48 foster care providers we interviewed, 

9 reported never receiving medical information for the sampled children 

in their care. Caseworkers for eight of the nine children placed with 

these foster care providers indicated they had compiled or received some 

medical information for the sampled children. This indicates a problem 

in the communication of medical information from caseworkers to foster 

care providers. 

Some of the foster care providers who did not receive medical 

information when the child was placed with them were unaware that 

they should have it or could ask for it. While we do not know why 

medical information contained in these case files was not given to the 

foster care providers, failure to provide available medical information to 

foster care providers could result in children’s medical needs not being 

met. 

23 NDDHS 624-05-05-17. 

Nine of the forty-eight foster care providers 

reported never receiving medical information 

for the children in their care. 
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RECOMMENDATIONS 

States are required to ensure that all children in foster care are 

provided quality health care services that protect their health. The 

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

program is intended to detect various health needs. However, if 

children do not receive the required services or do not receive those 

services timely, their health needs may go undetected and untreated. 

The Administration for Children and Families (ACF) should work with 

the North Dakota Division of Children and Family Services to: 

 Examine how initial comprehensive medical examinations 

for children entering foster care are provided. 

 Ensure case plans reflect mental health needs, as required. 

 Promote the importance of caseworkers obtaining medical 

information for children in foster care and supplying foster 

care providers with the information, in accordance with 

Federal requirements. 

The Centers for Medicare & Medicaid Services (CMS) should work with 

the North Dakota Division of Medical Services to: 

 Develop a method for notifying foster care providers of when 

required EPSDT services are due. 

 Increase the number of dental providers accepting Medicaid 

in North Dakota. 

ACF and CMS should work with the North Dakota Department of 

Human Services to coordinate State agency efforts to: 

 Educate caseworkers and foster care providers regarding the 

importance and availability of EPSDT medical 

examinations. 

 Ensure caseworkers and foster care providers understand 

the difference between comprehensive EPSDT examinations 

and medical examinations for specific health conditions. 

 Educate caseworkers and foster care providers on State 

EPSDT frequency guidelines for dental services. 

 RECOMMENDATIONS 
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RECOMMENDATIONS 

AGENCY COMMENTS 

ACF noted that it is working with the Department of Human Services to 

promote the importance of obtaining medical histories and providing 

medical information to foster care providers and that these issues are 

being addressed in the Program Improvement Plan developed in 

response to a Child and Family Services Review. They also note that 

only 79 percent of the cases reviewed during the on-site portion of the 

Child and Family Services Review substantially achieved the outcome 

measure which determines if children receive adequate services to meet 

their physical and mental health needs. 

CMS generally concurred with our recommendations but clarified that 

the recommendations should be carried out by joint action of the 

North Dakota Divisions of Medical Services and Children and Family 

Services. CMS stated that its regional office staff is available to provide 

technical assistance to both Divisions, as appropriate. 
OEI-07-00-00643 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE IN F OSTER CARE : N ORTH DAKOTA 17 

Demographic Characteristics of Sampled Children 

The table below provides the demographic characteristics of each of the 50 sampled 

children and his or her foster care placement history as of May 2003. 

 APPENDIX ~ A 

ID Sex Age Placement 

Setting

Entries into 

Foster Care (1)

Months Since 

Foster Care Entry 

(2)

Placements 

Since Last 

Entry (3)

Months Since Last 

Placement (4)

Caseworkers 

Since Last Entry 

(5)

Months 

Caseworker With 

Case (6)

1 F 17 Therapeutic 1 15 2 4 1 18

2 M 17 Residential 2 89 29 6 4 43

3 F 17 Residential 2 14 2 10 4 14

4 M 16 Therapeutic 1 10 2 4 1 13

5 M 15 Kinship 3 26 10 12 4 6

6 M 15 Residential 2 12 2 8 1 12

7 M 15 Residential * 42 1 42 2 24

8 F 15 Residential 1 28 2 9 * 8

9 F 13 Family 1 9 1 9 1 10

10 M 14 Family 13 52 15 14 2 14

11 M 12 Therapeutic 1 29 6 3 2 14

12 M 12 Therapeutic 1 54 6 11 2 5

13 F 12 Kinship 2 52 4 4 1 48

14 F 14 Residential 5 67 7 15 6 24

15 F 12 Family 2 17 2 11 1 17

16 M 11 Family 1 29 2 25 2 9

17 F 11 Family 1 20 1 20 1 20

18 F 10 Therapeutic 1 92 1 92 2 120

19 F 12 Family 1 62 1 62 * 18

20 M 11 Family 3 26 12 6 4 6

21 M 10 Family 1 92 4 9 4 70

22 M 9 Family 2 20 1 20 1 20

23 M 8 Family 1 12 2 10 1 20

24 M 8 Family 1 22 2 17 3 90

25 F 11 Family 2 9 1 9 1 61

26 F 10 Family 1 26 4 18 2 8

27 F 7 Unknown 1 13 2 5 2 2

28 F 6 Kinship 1 35 3 17 3 21

29 M 12 Family 1 21 2 4 1 22

30 F 17 Residential 4 15 3 11 2 13

31 M 6 Family 1 14 3 13 1 14

32 F 5 Family * 35 * 24 2 24

33 M 5 Family 2 21 2 12 1 21

34 F 5 Family 1 57 4 45 2 42

35 M 16 Residential 2 18 4 6 3 7

36 F 4 Family 1 21 2 4 1 21

37 F 4 Family 2 9 1 9 1 9

38 M 3 Family 1 29 2 13 2 6

39 F 3 Family 2 12 1 12 2 9
OEI-07-00-00643 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE IN F OSTER CARE : N ORTH DAKOTA 18 

APPENDIX~A 

KEY 

(1) Entries into Foster Care -- number of times a child has entered State custody.

(2) Months Since Foster Care Entry -- length of time from the date of the child’s most recent entry into foster care 

until May 2003, when interviews were conducted with caseworkers and foster care providers, or the date the 

child left care if that date precedes May 2003. 

(3) Placements Since Last Entry -- number of placements, in all settings (e.g., Foster Home, Residential Care 

Facility), the child experienced during his/her most recent entry into foster care. 

(4) Months Since Last Placement -- length of time from the dae of the most recent placement to the date the foster 

care provider was interviewed. 

(5) Caseworkers Since Last Entry -- number of caseworkers assigned responsibility for the child since his/her last 

entry into foster care, including family caseworkers and child-specific caseworkers. 

(6) Months Caseworker With Case – number of months the most recent caseworker had been assigned 

responsibility for the child, which may be larger than the number of “Months Since Foster Care Entry,” 

because some caseworkers were working with the child before the child officially entered foster care 

(e.g., through the juvenile justice system, family preservation services). 

(*) Unknown. 

ID Sex Age Placement 

Setting

Entries Into 

Foster Care 

(1)

Months Since 

Foster Care 

Entry (2)

Placements 

Since Last 

Entry (3)

Months Since Last 

Placement (4)

Caseworkers 

Since Last 

Entry (5)

Months 

Caseworker 

With Case (6)

40 M 3 Family 2 11 4 5 1 11

41 F 5 Kinship 1 22 1 22 1 22

42 M 10 Family 4 11 2 4 1 11

43 F 2 Family 1 25 2 7 2 18

44 F 1 Family 1 19 1 19 1 19

45 M 1 Family 1 14 1 14 1 14

46 F 17 Family 1 90 16 8 5 6

47 M 17 Therapeutic 1 12 1 12 1 16

48 F 16 Residential 1 22 3 9 2 24

49 F 15 Family 2 46 6 16 2 16

50*
OEI-07-00-00643 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE IN F OSTER CARE : N ORTH DAKOTA 19 

Medicaid Claims for Sampled Children 

The table below indicates each of the 50 sampled children’s paid Medicaid claims for 

physician and office visits, dental services, prescription medications, and mental health 

services while they were in foster care from November 1, 1999 to November 1, 2002. 

OIG ID

EPSDT and 

Physician's 

Office Visits

Dental 

Services

Prescription 

Medications

Mental 

Health 

Services

1 5 11 4 0

2 5 3 50 64

3 2 1 11 3

40 0 40

5 5 19 4 1

62 0 21

7 3 4 0 22

8 5 11 6 8

91 4 44

10 11 25 2 38

11 4 9 19 3

12 12 28 142 88

13 21 12 7 25

14 9 11 62 51

15 1 9 11 15

16 7 15 44 24

17 7 0 2 6

18 12 15 185 0

19 2 7 2 0

20 10 11 18 28

21 1 0 3 4

22 4 6 4 21

23 7 4 9 2

24 3 0 2 0

25 0 0 3 5

26 8 11 11 44

27 1 0 0 0

28 14 14 8 0

29 0 10 0 11

30 7 0 4 10

31 7 9 1 7

32 2 13 2 0

33 8 3 3 0

34 19 0 57 0

35 5 8 25 20

Number of Medicaid Claims*

 APPENDIX ~ B 
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APPENDIX~B 

 

KEY 

* The Number of Medicaid Claims includes only services for which a Medicaid claim was paid. 

Services documented in the case file for which no Medicaid claims were paid are not included. 

OIG ID

EPSDT and 

Physician's 

Office Visits

Dental Services Prescription 

Medications

Mental Health 

Services

36 8 15 3 8

37 2 0 0 1

38 3 0 0 0

39 3 0 1 0

40 3 0 2 3

41 3 6 1 0

42 0 0 13 5

43 52 0 24 0

44 36 0 10 0

45 24 0 5 0

46 5 8 14 3

47 3 4 38 6

48 18 8 47 20

49 26 12 30 46

50 11 20 102 20

Total 407 346 1001 617

Number of Medicaid Claims*
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EPSDT Services for Sampled Children 

The table below reflects EPSDT services received by each of the 50 sampled children from 

November 1, 1999 to November 1, 2002 or from entry into care to November 1, 2002, 

whichever is shorter. 

EPSDT Medical Dental EPSDT 

Medical Dental

1 N Y 441 10 23 B A

2 Y N 2658 199 65 A C

3 N N 407 23 128 B A

4 N Y 295 56 X B D 

5 Y Y 776 117 112 A A

6 Y Y 347 X 36 D A

7 N Y 1265 156 152 A C

8 N N 853 203 128 A C

9 Y Y 272 48 92 B B

10 N Y 1571 261 322 A A

11 Y Y 862 X 607 C A

12 Y Y 1634 267 177 A A

13 N Y 1549 500 393 A A

14 Y Y 2017 196 169 C A

15 N N 504 182 105 B A

16 N Y 874 21 250 A A

17 N Y 602 X X D C

18 N N 2746 X 191 C A

19 N N 1863 329 337 A A

20 Y Y 776 118 112 B A

21 N N 2755 X X C C

22 N Y 610 435 69 A A

23 Y Y 360 150 13 B A

24 N Y 654 288 X B C

25 Y Y 264 X X D D

26 N Y 766 6 115 A A

27 N Y 383 109 X B C

28 Y Y 1060 134 134 B A

29 N Y 626 167 164 B A

30 N N 436 109 X B C

31 Y Y 427 41 55 B A

32 N Y 1037 61 257 A C

33 N Y 644 431 317 A A

34 Y Y 1707 378 X C C

35 N N 549 148 79 B A

36 Y Y 615 22 40 B A

37 N N 279 X X D D

38 Y Y 868 127 X A D

39 Y Y 369 66 66 B B

40 N Y 334 69 X B D

Days to First Service (4) Services Current (5)

OIG ID

Medical 

History in 

Casefile (1)

Case Plan 

Completed in 

30 Days (2)

Days Since 

Foster Care 

Entry (3)

 APPENDIX ~ C 
OEI-07-00-00643 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE IN F OSTER CARE : N ORTH DAKOTA 22 

APPENDIX~C 

 

KEY 

(1) Medical History in Casefile -- casefile documentation provided by the caseworker included a medical history. 

(2) Case Plan Completed in 30 Days -- case plan was completed within 30 days 

Y -- case plan completed within 30 days. 

N -- case plan not completed within 30 days. 

(3) Days Since Foster Care Entry -- number of days the sampled child had been in foster care at the time the 

foster care provider was interviewed. 

(4) Days to First Service: 

A number indicates the number of days between November 1, 1999 (the beginning date for Medicaid 

claims included in our study) or the date the child entered foster care (if the child entered foster care after 

November 1, 1999) and the date the child received his/her first EPSDT medical or dental service. 

X -- child did not receive this type of service within the period covered by our review. 

(5) Services Current: 

A - The most recent required service was received. 

B - One or more services were received, but had they not been provided the child would not have been out 

 of compliance based on age or length of time in foster care. 

C - A recent required service was not received. 

D - No services were received. but none were required during our claims window (i.e., the length of time 

the child had been in foster care and the period covered by our claims window did not extend the full 

length of time covered by the EPSDT frequency guideline for the child’s age, or the child was under 

3 years of age and not required to receive dental services). 

*Unknown.

EPSDT 

Medical Dental EPSDT 

Medical Dental

41 Y Y 653 429 478 B A

42 Y Y 319 X 103 D B

43 Y N 740 117 X C D

44 N Y 558 2 X C D

45 N Y 418 27 X C D

46 Y Y 2687 1044 33 A A

47 N Y 370 X 158 D A

48 N Y 661 57 45 A A

49 Y Y 1369 532 178 A C

 50*

Days to First Service (4) Services Current (5)

OIG ID

Medical 

History in 

Casefile (1)

Case Plan 

Completed in 

30 Days (2)

Days Since 

Foster Care 

Entry (3)
OEI-07-00-00643 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE IN F OSTER CARE : N ORTH DAKOTA 23 

Agency Comments - ACF

 APPENDIX ~ D 
OEI-07-00-00643 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE IN F OSTER CARE : N ORTH DAKOTA 24 

APPENDIX~D 
OEI-07-00-00643 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE IN F OSTER CARE : N ORTH DAKOTA 25 

APPENDIX~D 
OEI-07-00-00643 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE IN F OSTER CARE : N ORTH DAKOTA 26 

APPENDIX~D 
OEI-07-00-00643 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE IN F OSTER CARE : N ORTH DAKOTA 27 

Agency Comments - CMS

 APPENDIX ~ E 
OEI-07-00-00643 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE IN F OSTER CARE : N ORTH DAKOTA 28 

APPENDIX~E 
OEI-07-00-00643 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE IN F OSTER CARE : N ORTH DAKOTA 29 

This report was prepared under the direction of Brian T. Pattison, 

Regional Inspector General for Evaluation and Inspections in the 

Kansas City regional office, and Gina Maree, Assistant Regional Inspector 

General. Other principal Office of Evaluation and Inspections staff who 

contributed include: 

Deborah Walden, Team Leader

Linda Paddock, Project Leader

Michala Walker, Program Analyst

Brian Whitley, Program Analyst 

Steve Milas, Program Analyst 

Zula Crutchfield, Program Analyst 

Elander Phillips, Program Analyst 

Linda Hall, Program Specialist (Washington, DC)

Barbara Tedesco, Mathematical Statistician (Baltimore, Md.) 

 ACKNOWLEDGMENTS