Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

Inspector General 

AUGUST 2003 

OEI -07-00-00640 

CHILDREN’S USE OF HEALTH 

CARE SERVICES WHILE IN 

FOSTER CARE: KANSAS 
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 Evalu ation 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. 

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. The OI also oversees State Medic aid 

fraud control units, which investigate and prosecute fraud and patient abuse in the Medicaid 

program. 

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. 
EXECUTIVE SUMMARY

OBJECTIVE 

To determine whether sampled children in the Kansas foster care 

program receive health care services. 

BACKGROUND 

Compared with children from the same socioeconomic background, 

children in foster care suffer much higher rates of serious emotional 

and behavioral problems, chronic physical disabilities, birth defects, 

and developmental delays. Kansas had 6,569 children in foster 

care at the end of the Federal fiscal year 2000, and utilized a 

statewide public-private partnership for the delivery of child 

welfare services. Kansas is one of a series of States chosen to 

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

Administration for Children and Families (ACF) has regulatory 

oversight of the Title IV-E foster care programs. The Centers for 

Medicare & Medicaid Services (CMS) is responsible for oversight of 

individual State Medicaid programs. 

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

eligible for Medicaid. Federal Early and Periodic Screening, 

Diagnosis, and Treatment (EPSDT) guidelines require each State to 

provide coverage for preventive health care services to Medicaideligible individuals under the age of 21, as outlined in 

Section 1905(r) of the Social Security Act (the Act). In addition, 

Sections 472(h) and 1902(a)(10)(A)(i)(I) of the Act require States to 

provide Medicaid, or equivalent health insurance coverage, to 

children eligible to receive Title IV-E foster care program 

maintenance funds. 

This inspection is based on information gathered from multiple 

sources: reviews of Federal and State policies; analysis of childspecific Medicaid claims data and case file documentation for 

50 randomly-sampled children; interviews with foster care 

providers (e.g., foster parents and residential care facility staff) and 

caseworkers for the children in our sample; interviews with Kansas 

State agency officials; and telephone calls to dental office staff to 

validate foster care providers’ concerns regarding the lack of 

available Medicaid dental providers. This study did not address 

follow-up care or the appropriateness of ongoing health care in 

meeting the needs of foster children. 

OEI - 07 - 00 - 00640 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : KANSAS i 
EXECUTIVE SUMMARY 

FINDINGS 

All sampled children have Medicaid coverage and claims for 

services 

In accordance with Federal law and State regulations, all of the 

sampled children have Medicaid coverage. All 50 children had at 

least one claim for services through Medicaid. 

Ninety percent of sampled children received EPSDT 

Medicaid examinations, and 82 percent received EPSDT 

dental examinations, in accordance with State guidelines 

Ninety percent (45/50) of the sampled children were receiving 

medical services that met the current EPSDT periodicity time 

frames. Eighty-two percent (32/39) of children required to receive 

dental services received a dental examination within established 

EPSDT guidelines, although foster care providers expressed 

difficulties locating dentists willing to accept Medicaid patients. 

Eighty-two percent of sampled children received initial 

medical examinations within required timeframes 

Of the 39 children in our sample who had initial placements during 

our study time period, 82 percent (32) had a Medicaid paid claim or 

case file documentation indicating a medical examination took 

place within 30 days of placement. 

All sampled children received mental health services 

The Kansas IV-E foster care program State plan requires that an 

individual case plan, including an assessment of the child’s mental 

health needs, be developed for each child in foster care within 

30 days of their entry into State custody. All children in our sample 

had a completed case plan and Medicaid claims for mental health 

services. 

OEI - 07 - 00 - 00640 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : KANSAS ii 
EXECUTIVE SUMMARY 

Forty-three percent of foster care providers in our sample 

reported never receiving a medical history for the child in 

their care 

Sections 422(b)(10)(B)(ii) and 475(5)(D) of the Act provide for a case 

review system and procedures for ensuring that a child’s health 

record is reviewed, updated, and supplied to the foster care 

provider. Forty-three percent (20/46) of foster care providers 

interviewed reported never receiving a medical history for the 

sample child in their care. However, 12 out of 20 caseworkers for 

these children reported compiling or receiving a medical history. 

RECOMMENDATIONS 

To ensure that children in foster care have access to and receive the 

most appropriate health care services, we recommend that: 

ACF work with the Kansas Department of Social and 

Rehabilitation Services to promote the importance of obtaining 

medical histories for children in foster care and providing this 

information to foster parents. 

CMS work with the Kansas Department of Social and 

Rehabilitation Services to increase the number of Medicaid health 

care providers willing to provide services to children in foster care, 

and provide case workers and foster care providers with current 

lists of Medicaid providers willing to treat children in foster care. 

AGENCY COMMENTS 

ACF indicated the background provided in this report was useful. 

ACF also notes that they are working with the Kansas Department 

of Social and Rehabilitation Services to promote the importance of 

obtaining medical histories for children in foster care, and have 

included steps necessary to gather medical information and provide 

the information to foster parents. We incorporated suggested 

terminology changes into this document. The full text of ACF’s 

comments to the draft report is located in Appendix D. 

CMS concurs, in part, with our recommendations and points out 

that the Medicaid program is State-administered within broad 

Federal guidelines. As such, CMS does not have the ability to 

directly impact the numbers of providers participating in the 

OEI - 07 - 00 - 00640 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : KANSAS iii 
Kansas Medicaid program or the collection, maintenance, and 

distribution of lists of participating providers. However, CMS 

indicates they are available to provide technical assistance to the 

State to promote these processes. The full text of CMS’s comments 

to the draft report is located in Appendix E. 

OEI - 07 - 00 - 00640 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : KANSAS iv 
TABLE OF CONTENTS

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

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

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

All sampled children have Medicaid coverage and claims for 

services ............................................................................................... 8

High percentages of sampled children received EPSDT medical 

and dental examinations.................................................................... 8

Eighty-two percent of sampled children received initial medical 

examinations within required timeframes ...................................... 11

All sampled children received mental health services .................... 11

Forty-three percent of sampled foster care providers never 

received a medical history for the child in their care ...................... 12

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

APPENDICES .............................................................................................. 15

Appendix A: Kansas Foster Care and Medicaid Programs ............. 15

Appendix B: Detailed Demographic Data ........................................ 16

Appendix C: Detailed Claims Data .................................................. 18

Appendix D: Agency Comments - ACF ............................................ 20

Appendix E: Agency Comments - CMS............................................ 24

ACKNOWLEDGMENTS................................................................................ 26

OEI - 07 - 00 - 00640 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : KANSAS v
INTRODUCTION

OBJECTIVE 

To determine whether sampled children in the Kansas foster care 

program receive health care services. 

BACKGROUND 

Currently, there are an estimated 565,000 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 a series of States for review.2 The States 

were chosen to represent a diverse cross-section of foster care 

nationwide. Kansas was selected because of its child welfare 

population size, State location, Medicaid fee-for -service coverage for 

children in foster care, and statewide public-private partnership for 

child welfare service delivery. Kansas had 6,569 children in foster 

care at the end of the Federal fiscal year 2000, based on the most 

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

Administration for Children and Families (ACF) has regulatory 

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

plans to ensure State foster care programs are operating within 

Federal guidelines. 

Compared with children from similar socioeconomic backgrounds, 

children in foster care suffer much higher rates of serious physical 

and psychological problems.4 Dental problems are prevalent in the 

foster care population and physical health problems (e.g., delayed 

growth and development, malnutrition, and asthma) affect 30 to 

40 percent of children in the child welfare system.5 

1 Retrieved November 1, 2002, from 

http://www.acf.dhhs.gov/programs/cb/dis/afcars/cwstats.html 

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

North Dakota, Oregon, and Texas. 

3 FY 2000 Foster Care Entries, Exits, and In Care on the Last Day. Retrieved 

May 20, 2003, from http://www.acf.hhs.gov/programs/cb/dis/talbes/entryexit.htm. 

4 Health Care Issues for Children in Foster Care, March 25, 2002. Retrieved 

May 20, 2002, from http://www.casey.org/cnc/documents/health_care_issues.pdf. 

5 Fact sheet: The Health of Children in Out-of-Home Care. Child Welfare League of 

America. Retrieved May 17, 2003, from 

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

OEI - 07 - 00 - 00640 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : KANSAS 1 
INTRODUCTION 

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

foster care providers (e.g., foster parents and residential care 

facility staff) report having difficulty finding health care 

professionals who are 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 providers; and long delays in obtaining services.7 

Furthermore, studies have shown low percentages of children in 

foster care are actually receiving services. One report states that 

less than one-third of children in the child protective system 

nationwide received mental health services in 1995. 8 A General 

Accounting Office (GAO) report released in July 2001 states that 

available data from short-range studies show that the percentage of 

children in the general population receiving Early Periodic 

Screening, Diagnosis, and Treatment (EPSDT) services is very low.9 

The EPSDT program is designed to screen for, diagnose, and treat 

medical conditions that might otherwise go undetected or 

untreated. Preventive services for the early detection of disease 

have been associated with substantial reductions in morbidity and 

mortality. The benefits of incorporating preventive health care into 

medical practice have become apparent in recent years, as cases of 

previously common and debilitating medical conditions have 

declined in number following the introduction of effective 

preventive health care services. 10 Preventive dental care is also 

included as part of EPSDT. A journal article concludes that 

adherence to American Dental Association recommendations for 

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 Ensuring the Healthy Development of Foster Children, New York State Permanent 

Judicial Commission on Justice for Children, 1999. 

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

Screening Services. General Accounting Office, GAO-01-749, July 2001. 

10 Guide to Clinical Preventive Services, 2nd edition, U.S. Preventive Services Task 

Force, 1996. Retrieved March 12, 2003 from 

http://hstat.nlm.nih.gov/hq/Hquest/db/local.gcps.cps/screen/Browse/s/44098/cmd/H 

F/action/GetText?IHR=CHI. 

OEI - 07 - 00 - 00640 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : KANSAS 2 
INTRODUCTION 

preventive behaviors over the long-term yields greater benefits 

than doing so over the short term.11 

Medicaid for Children in Foster Care 

Kansas provides Medicaid coverage to all children in Title IV-E 

foster care, as well as other eligible children. 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 

for children eligible to receive Title IV-E foster care maintenance 

funds. Federal EPSDT guidelines require each State to provide 

coverage for comprehensive and preventive child health services to 

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

Section 1905(r) of the Act. Within broad national guidelines, each 

State establishes its own eligibility standards for the Medicaid 

program; 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. 12 In 2000, 

Medicaid payments for children in foster care totaled $3.3 billion 

nationally.13 Kansas Medicaid expenditures to provide health care 

services to children in foster care totaled $10.8 million in 1999. The 

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

Federal oversight of individual State Medicaid programs. 

States design their own Medicaid programs and establish EPSDT 

guidelines in accordance with Federal requirements to provide 

coverage for preventive child health services to all Medicaid-eligible 

individuals under the age of 21. 14 State EPSDT programs must 

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

necessary health care and treatment at intervals established by the 

State that meet reasonable standards of practice published by 

recognized health care organizations. Kansas established the Kan 

Be Healthy program to meet Federal EPSDT requirements. The 

current EPSDT periodicity schedule, established in August 2001, 

for the Kan Be Healthy program, requires that medical screenings 

occur at: birth; 1, 2, 4, 6, 9, 12, 15 and 18 months of age; 2, 3, 4, 5, 6, 

11 Journal of Dental Research, March 2003; 82 (3): 223-7

12 Retrieved May 20, 2003 fromhttp://cms.hhs.gov/Medicaid/eligibility/criteria.asp.

13 Medicaid Statistical Information System (MSIS) Report Fiscal 2000: Illinois. 

Retrieved May 20, 2003 from http://www.cms.gov/medicaid/msis/00tx.pdf

14 Section 1905(r) of the Social Security Act.

OEI - 07 - 00 - 00640 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : KANSAS 3 
INTRODUCTION 

8, and 10 years of age; and annually between the ages of 10 and 21. 

After age 3, children receiving EPSDT services are required to 

receive a vision screening every 2 years and a hearing screening 

every 3 years. Vision and hearing screenings are conducted as part 

of EPSDT medical screenings. Dental screenings are conducted 

separately. Under the public-private partnership, foster care 

contractors are responsible for ensuring that all children in foster 

care receive EPSDT screenings. Section 6141.02 of the Kansas 

Medical Services Manual specifies that information provided to 

program beneficiaries must include information about how Kan Be 

Healthy services can be obtained. 

In addition, Section 471(a)(22) of the Act requires States to develop 

a State plan that includes standards to ensure that all children in 

foster care placements are provided quality services that protect 

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

the Act require procedures to ensure that a child’s health record is 

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 providers, 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. The Kansas foster care program policies require that each 

child receive a medical examination within 30 days of entering 

State custody and that a case plan be developed for each child 

within this same 30 days. The case plan must include an 

assessment of the child’s mental health needs and the services 

required to meet those needs. 

METHODOLOGY 

This study focused on the receipt of medical and dental health care 

services within EPSDT guidelines; requirements for initial and 

comprehensive health screenings upon entry into foster care; case 

plan assessments of mental health needs and 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. 

OEI - 07 - 00 - 00640 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : KANSAS 4 
INTRODUCTION 

This inspection is based on information gathered from multiple 

sources: reviews of Federal and State policies; analysis of childspecific Medicaid claims data and case file documentation for 

50 randomly-sampled children in foster care; interviews with 

caseworkers and foster care providers for each of the 50 children in 

our sample; interviews with Kansas State agency officials; and 

telephone calls to dental office staff to validate foster care providers’ 

concerns regarding the lack of available Medicaid dental providers. 

Reasons for State Selection 

Kansas was selected due to its small size, centralized child welfare 

system, geographic location, fee-for -service payment of Medicaid 

health care services (Kansas does not utilize managed care for 

children in foster care), and its statewide public-private partnership 

for provision of child welfare services. The Kansas Department of 

Social and Rehabilitation Services (SRS) is responsible for the 

welfare of children in State custody. However, instead of State, 

county, or local offices providing direct service delivery in child 

welfare cases, private contractors provide foster care and adoption 

services. An overview of the Kansas public-private partnership is 

provided in Appendix A. 

Sample 

Children who met the following criteria were included in the study 

population: (1) were in foster care on June 14, 2002; (2) resided in 

Kansas; and (3) had been in continuous out-of-home foster care 

placements for at least 6 months. SRS provided us with a list of the 

3,766 children (of the 6,569 children in foster care at the end of 

Federal fiscal year 2000) who met these criteria. We selected a 

simple random sample of 50 children in foster care in Kansas, 

based on this defined population, which allowed us to formulate an 

overview of their use of health care services. Appendices B and C 

provide information on the children included in our sample. 

Review of State Policy, Medicaid Data, and Case File Documentation 

Policy Review - We reviewed Federal and Kansas foster care and 

Medicaid policies. All children in foster care in Kansas are eligible 

for Medicaid services, regardless of their Title IV-E foster care or 

other eligibility status (e.g., Temporary Assistance for Needy 

Families). Federal law relating to EPSDT requires that States 

meet reasonable standards of medical and dental practice, as 

OEI - 07 - 00 - 00640 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : KANSAS 5 
INTRODUCTION 

determined by the State after consultation with recognized medical 

and dental organizations. Kansas’s Kan Be Healthy program 

satisfies the Federal ESPDT requirement. We used Kan Be 

Healthy policy guidelines to determine whether children in foster 

care received health care services within required time frames. 

Medicaid Claims Data Review - SRS provided us with 3 years of 

Medicaid claims histories for each of the children in our sample. 

The data included claims for physician, dental, pharmaceutical, and 

mental health services paid between June 1, 1999, and 

May 31, 2002. We paid particular attention to the types of health 

and mental health services, dates of service, settings where the 

services were provided, and diagnoses, where available. We 

included only those Medicaid claims after the child’s most recent 

entry into foster care and any claims prior to entry that were 

pertinent in establishing periodicity for services (i.e., Kan Be 

Healthy). 

Case File Documentation Review - We requested and reviewed case 

file documentation from local offices for all the children in our 

sample. Information requested included documentation of medical 

and mental health services provided, duration of the child’s stay in 

foster care, and information regarding the child’s general wellbeing. 

Interviews 

Foster Care Provider Interviews - We use the term “foster care 

provider” to refer to a foster parent or a staff member of a 

residential facility who is responsible for the child. We conducted 

structured interviews with 46 of the 50 foster care providers (20 in 

person and 26 by telephone) responsible for the children in our 

sample between July 31 and August 28, 2002. After repeated 

attempts, we were unable to interview four foster care providers. 

The four children, whose foster care providers we were unable to 

interview, were not included in certain comparative analyses, but 

were included in our Medicaid claims data analysis. Our 

interviews with foster care providers focused on Medicaid programs 

and services available, training related to the health and wellbeing of children, and procuring health care services for the 

children included in our sample. 

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INTRODUCTION 

Caseworker Interivews - We conducted structured interviews with 

each child’s caseworker either in person (22) or by telephone (26) 

between July 29 and September 6, 2002. Two caseworkers were 

responsible for more than one child, giving us a total of 

48 caseworkers for the 50 children in our sample. Each of these 

interviews focused on the caseworker’s understanding of the 

Medicaid programs and services available, training related to the 

health and well-being of children, their experience accessing 

services for the sampled child, and any barriers to health care faced 

by the child. 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. 

Discussions with State Agency Officials - To enhance our 

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

consulted, both in person and by telephone, with SRS officials who 

are responsible for the administration of both programs in the State 

of Kansas. Our discussions covered a wide spectrum of 

information, including the overall provision of Medicaid services for 

children in foster care, the Kan Be Healthy (EPSDT) program, 

Kansas’ public-private partnership, and Medicaid claims for 

children in foster care. 

Dental Provider Contacts - During our interviews with foster care 

providers, they reported difficulty scheduling dental appointments 

for children in their care. To validate these difficulties, we 

contacted the offices of dental care providers. At our request, SRS 

provided us with a list of 26 dental providers whom they believed 

accepted Medicaid patients in 2 areas of the State where foster care 

providers and caseworkers reported the most difficulty scheduling 

dental appointments for children in their care. We called the offices 

of all 26 dental providers and asked them whether they were 

accepting new Medicaid patients and, if so, when their first 

available appointment was for a routine dental examination. 

This inspection was conducted in accordance with the Quality 

Standards for Inspections issued by the President’s Council on 

Integrity and Efficiency. 

OEI - 07 - 00 - 00640 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : KANSAS 7 
FINDINGS 

All sampled children have Medicaid 

coverage and claims for services 

Federal law requires States to 

provide Medicaid or equivalent 

health insurance coverage to 

children eligible to receive Title IV-E foster care program 

maintenance funds. Within broad national guidelines, each State 

establishes its own Medicaid-eligibility standards. Children in 

foster care in Kansas are eligible for all health care services 

provided through the Medicaid program, including EPSDT. 

Our review of Medicaid claims and interview data indicates that all 

50 children in our sample had Medicaid coverage. Our analysis of 

the Medicaid claims data revealed that each sampled child had paid 

health care claims since entering foster care. Overall, foster care 

providers were aware of the availability of Medicaid services for 

children in their care and were receiving monthly Medicaid cards 

for them. The 50 children in our sample had received a total of 

5,853 Medicaid health care services while in foster care since 

June 1, 1999, as outlined in the following chart. 

Table 1: Number and Type of Medicaid Claims 

for 50 Children in the Sample 

Claim type Number of children 

with at least one claim 

Total number of 

claims* 

Physician office 50 2,126 

Mental Health 50 1,916 

Prescriptions 49 1,129 

Dental 37 675 

Hospitalization 5 7 

Total 5,853 

*A detailed list of services for each child is located in Appendix C. 

Source: OIG analysis of Kansas Medicaid claims data 

Ninety percent of children in the sample Federal EPSDT guidelines 

received routine physical examinations, require each State to provide 

and 82 percent received EPSDT dental physical, mental, vision, hearing, 

examinations, in accordance with State and dental screenings, and other 

necessary health care and guidelines treatment, as needed, at 

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FINDINGS 

intervals established by the State. These services must meet 

reasonable standards of practice published by recognized health 

care organizations and are designed to prevent, diagnose, and treat 

medical conditions that might otherwise go undetected or 

untreated. Kansas’ Kan Be Healthy program fulfills the Federal 

EPSDT requirements. 

Physical Examinations 

A review of 3 years of Medicaid claims data and case file 

documentation showed that 90 percent (45/50) of the children in 

this study were receiving EPSDT services within the time frames 

established by Kansas at the time of our review. For the five 

children in foster care who did not have current EPSDT services, 

either the caseworker, foster care provider, or both stated that the 

child did, in fact, receive EPSDT services; however, we were not 

provided with medical documentation to support receipt of those 

services. 

While it is difficult to pinpoint specific practices that enabled 

Kansas to meet established guidelines for providing required 

EPSDT services to many of the sampled children in foster care, 

evidence collected suggests two factors may be instrumental. First, 

the Kansas Medicaid program distributes monthly Medicaid cards 

to each Medicaid client; these cards are printed with the due date of 

the next required Kan Be Healthy (EPSDT) screen. Foster care 

providers indicated the information printed on the Medicaid card 

was helpful. Also, caseworkers conduct monthly visits to each 

foster child’s placement, during which they monitor the child’s 

health care and receipt of required services. Caseworkers must 

complete the form (CFS 3050C) every 6 months that includes a 

section verifying that the child’s most recent Kan Be Healthy 

screening is correct (i.e., received within periodicity guidelines). 

Dental Examinations 

Kansas EPSDT guidelines require every child in foster care over 

3 years of age to have an annual dental examination. Of the 

40 children in our sample 3 years of age and older, 98 percent 

(39/40) had at least 1 oral evaluation since their entry into foster 

care, and 82 percent (32/39) received an evaluation within the past 

year. Six children who were overdue for required services had 

received previous dental services, such as resins and sealants. The 

OEI - 07 - 00 - 00640 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : KANSAS 9 
FINDINGS 

one child with no Medicaid claim for an oral evaluation had no 

other dental claims, and the child’s foster care provider was one of 

the four non-respondents whom we were unable to interview. 

One possible reason that the percentage of children receiving 

EPSDT dental services is lower than the percentage receiving other 

EPSDT services is because, according to interview data, foster care 

providers experience difficulty locating dentists willing to accept 

Medicaid patients. Foster care providers also reported difficulty 

scheduling appointments with dental providers participating in the 

Medicaid program. Of the 31 foster care providers interviewed who 

had attempted to schedule a dental appointment for the foster child 

in their care, 12 reported having difficulty locating a dentist who 

would accept Medicaid patients. Of the 19 foster care pr oviders 

who indicated they did not have a problem locating a dentist, 6 

foster care providers reported having difficulty scheduling an 

appointment. 

Foster care providers reported that participating dentist’s offices 

are often geographically far from the foster care provider’s 

residence and that very few dentists were accepting new Medicaid 

patients. They reported that the lack of dental providers willing to 

accept Medicaid patients was acute in two geographic areas of the 

State - one large and one small community. At our request, the 

SRS created a list of dental providers that it believed accepted 

Medicaid patients in these two communities. The list provided by 

SRS contained the names of 24 dentists in the large community 

(out of 105 total dentists) and 2 dentists in the small community 

(out of 7 total dentists). 

To validate the problems that foster care providers reported, we 

called the offices of the 26 dentists listed and asked if the dentist 

was accepting new Medicaid patients, and if so, when the first 

available appointment could be scheduled. These contacts revealed 

that only 6 of the 24 dental providers in the large community were 

accepting new Medicaid patients. Both listed dentists in the small 

community were accepting new Medicaid patients. An appointment 

for a routine dental examination with any of the eight dentists 

accepting new Medicaid patients could be scheduled within 3 days 

to 2 months, depending on the provider. Given that only 8 of the 

dentists who accepted Medicaid (out of 112 dentists total in the 

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FINDINGS 

2 communities) were accepting new Medicaid patients, finding a 

dentist willing to treat a child on Medicaid is problematic. 

Eighty-two percent of sampled children Federal law requires States to 

develop a State plan that includes 

received initial medical examinations standards to ensure that children in 

foster care placements are provided within required timeframes quality services that protect their 

safety and health. The Kansas foster care program, as outlined in 

the Kansas IV-E foster care program State plan, requires that 

children in foster care receive a medical examination within 30 

days of entering State custody. Thirty-nine children in our sample 

had initial placements between June 1999 and November 2001 (the 

time period covered by our claims data less six months, due to the 

time it takes to submit and process some claims). Eighty-two 

percent (32/39) of these children had a Medicaid paid claim or case 

file documentation indicating a medical examination took place 

within 30 days of placement. 

All sampled children received While there are no requirements in 

Title IV-E of the Act that address 

mental health services the provision of mental health 

services to children in foster care specifically, Section 471(a)(22) of 

the Act requires States to develop and implement standards to 

ensure that all children in foster care placements are provided 

quality services that protect their safety and health. The Kansas 

foster care program policies require that a case plan be developed 

for each foster child within 30 days of a child entering State 

custody. The case plan requires an assessment of the child’s mental 

health needs and the services required to meet those needs. 

Assessments for mental health needs are important because 

children in foster care are more likely to suffer from mental health 

problems than other children.15 

15 Health Care Issues for Children in Foster Care, March 25, 2002. 

RetrievedOctober 17, 2002, from 

http://www.casey.org/cnc/documents/health_care_issues.pdf. 

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FINDINGS 

All children in our sample had a completed case plan that 

addressed the child’s mental health needs, and all children in our 

sample had at least one Medicaid claim for some type of mental 

health service. We did not evaluate the adequacy of the mental 

health assessments or services provided. 

Federal law requires that a

Forty-three percent of foster care providers child’s health record is 

reported never receiving a medical history for the reviewed, updated, and 

sampled child in their care supplied to the foster care 

provider when they are 

placed in foster care. Twenty of the 46 foster care providers 

interviewed reported never receiving a medical history for the 

sampled child in their care. However, caseworkers for 12 out of 

these 20 foster care providers reported compiling or receiving a 

medical history. Two out of the 12 foster care providers who did not 

receive the medical history available to the caseworker reported 

being unaware of documented mental health problems facing the 

foster child in their care. A child’s health may be compromised if 

the foster care provider is unaware of the child’s family medical 

history, chronic physical health pr oblems, mental health problems, 

or other medical needs. 

In exploring why medical histories were not shared with foster care 

providers, several reasons were identified. 

o The caseworker was a student intern. 

o The child’s case changed from foster care to adoption status, 

and the adoption caseworker had assumed that the foster care 

caseworker provided a medical history to the foster care 

providers. 

o The caseworker lost the medical record. 

The failure to provide a medical history is particularly problematic 

because the foster care providers whom we questioned indicated 

that caseworkers are the most important source of information for 

them regarding the health care needs of children in their care. 

Fifty-nine percent (27/46) of foster care providers interviewed 

indicated that when they have questions about accessing medical 

services for the foster child, they would ask the child’s caseworker 

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first. Less common cited sources included the child’s primary care 

physician or staff at an SRS or Medicaid office. 

RECOMMENDATIONS 

To ensure children in foster care have access to and receive the 

most appropriate health care services, we recommend that: 

ACF work with the Kansas Department of Social and 

Rehabilitation Services to: 

o Promote the importance of obtaining medical histories for 

children in foster care and providing this information to foster 

parents 

CMS work with the Kansas Department of Social and 

Rehabilitation Services to: 

o Increase the number of Medicaid health care providers willing 

to provide services to children in foster care 

o Develop and maintain current and accurate lists of Kansas 

health care providers participating in the Medicaid program by 

area or community 

o Provide case workers and foster care providers with current 

lists of Medicaid providers willing to treat children in foster 

care 

AGENCY COMMENTS 

ACF indicated the background provided in this report was useful. 

ACF notes it found that only 78 percent of the children included in 

the Kansas Children and Family Services Review, conducted in 

August 2001, received medical services, but that differences in its 

review and Office of Inspector General findings may be explained 

by the use of different methodologies. ACF also notes four 

conclusions resulting from its review. The first two, related to an 

insufficient number of dental care providers that accept Medicaid 

and foster parents not always being provided with timely medical 

information for the children in their care, were similar to our 

findings. ACF is working with the Kansas Department of Social 

and Rehabilitation Services to promote the importance of obtaining 

medical histories for children in foster care and have included steps 

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CONCLUSION/RECOMMEND ATIONS 

necessary to gather medical information and provide the 

information to foster parents as part of a Program Improvement 

Plan. The latter two conclusions, related to foster parent 

reimbursement to transport children for medical care and the need 

for improvements in the provision of mental health services, 

focused on issues outside the scope of our study. The full text of 

ACF’s comments to the draft report is located in Appendix D. 

The CMS concurs, in part, with our recommendations and points 

out that the Medicaid program is State-administered within broad 

Federal guidelines. As such, CMS does not have the ability to 

directly impact the numbers of providers participating in the 

Kansas Medicaid program or the collection, maintenance, and 

distribution of lists of participating providers. However, CMS 

indicates they are available to provide technical assistance to the 

Kansas Department of Social and Rehabilitation Services, the State 

agency responsible for both the Medicaid and Title IV-E foster care 

programs, to promote efforts to ensure children in foster care have 

adequate access to health care services. The full text of CMS’s 

comments to the draft report is located in Appendix E. 

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APPENDIX~A

Kansas Foster Care and Medicaid Programs 

The Kansas Department of Social and Rehabilitation Services is 

responsible for all children in State custody in Kansas. Within that 

Department, the Division of Children and Family Policy is 

specifically responsible for providing child protective services. The 

child welfare system is administered through a public-private 

partnership, in which the State is ultimately responsible for the 

well-being of children in State custody, but private contractors 

provide direct services, instead of State or county offices. Kansas 

has five contracted agencies, one in each region of the State, who in 

turn subcontract with other agencies to provide services at the 

community level. Each agency is paid a flat fee, plus an additional 

amount for each child whom it serves. State contracts with 

participating agencies are awarded every 4 years and renewed 

annually. 

Health care for Kansas children in foster care is provided primarily 

through Medicaid, and all Kansas children in foster care are statuseligible for Medicaid. There are no special health guidelines or 

coverage exceptions for children in foster care; they follow the same 

rules as the general Medicaid population. Although Medicaid 

managed care is available in Kansas, managed care programs are 

not used to provide benefits to children in foster care. Each child in 

foster care is issued a monthly Medicaid card that must be shown to 

access benefits, and these cards are printed with the date of the 

child’s most recent Kan Be Healthy screening and the date that the 

child’s next screening is due. Other sources of health care funding 

for children in foster care in Kansas include Head Start, public 

health clinics, and any private health insurance a child’s biological 

parents might have. 

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Detailed Demographic Data

The table below is merely descriptive in nature and describes the 

demographic characteristics of each sampled child and his or her 

foster care placement history (the first 6 columns) at the end of 

May 2002.

ID Sex Age 

(years)

Placement 

Setting

Entries 

into foster 

care (1)

Months 

since last 

entry (2)

Placements 

since last 

entry (3)

Months 

since last

placement 

(2)

Caseworkers 

since last 

entry

Months 

caseworker 

with case 

(2)

1 F 1 Family 1 7 1 10 1 10

2 F 4 Family 1 23 1 25 1 3

3 M 14 Family 1 7 1 9 2 4

4 F 17 Kinship 1 37 1 37 2 2

5 F 6 Family 1 44 1 46 2 3

6 F 4 Kinship 1 8 1 11 2 7

7 F 1 Family 1 15 1 17 3 8

8 F 8 Family 1 13 2 8 1 14

9 M 9 Family 1 8 2 9 1 11

10 M 2 Family 1 15 2 7 1 18

11 F 10 Family 1 27 2 26 1 28

12 F 16 Family 1 12 2 13 1 14

13 F 15 Kinship 1 14 2 5 2 16

14 M 3 Family 1 21 2 14 2 4

15 M 4 Family 1 34 2 36 2 13

16 F 2 Family 1 23 2 25 2 5

17 M 1 Residential 1 13 2 13 2 7

18 F 9 Family 2 20 2 10 3 10

19 M 9 Family 1 33 2 36 3 15

20 F 1 Family 1 17 2 3 3 12

21 F 6 Family 1 21 2 24 4 11

22 M 3 Kinship 1 30 2 21 4 21

23 F 11 Family 1 28 3 25 2 25

24 F 3 Family 1 20 3 9 4 18

25 F 17 Kinship 1 15 3 13 5 9

26 F 13 Secure Care 1 7 4 3 1 9

27 M 4 Kinship 1 18 4 18 2 3

28 F 1 Family 1 15 4 15 2 7

29 M 18 Independent 1 16 4 5 3 10

30 M 12 Family 1 56 4 18 3 24

31 M 11 Family 2 13 4 6 3 2

32 F 18 Family 1 29 4 13 3 22

33 M 12 Family 1 20 4 2 4 5

34 M 5 Adoptive 1 50 4 52 8 6

35 F 14 Family 1 38 5 13 1 13

36 M 14 Family 1 29 5 10 2 4

37 F 15 Family 1 22 5 6 5 15

APPENDIX~B
APPENDIX~B 

ID Sex Age 

(years) 

Placement 

Setting 

Entries 

into foster 

care (1) 

Months 

since last 

entry (2) 

Placements 

since last 

entry (3) 

Months 

since last 

placement 

(2) 

Caseworkers 

since last 

entry 

Months 

caseworker 

with case 

(2) 

38 F 14 Kinship 1 15 6 5 2 5 

39 M 12 Family 1 28 6 3 3 3 

40 M 17 Residential 1 11 6 5 3 1 

41 F 5 Family 2 55 6 42 3 8 

42 F 17 Family 1 18 7 1 5 20 

43 M 15 Family 2 36 9 2 2 9 

44 M 6 Adoptive 1 39 9 2 4 20 

45 M 7 Family 2 44 10 9 3 6 

46 F 17 Family 1 11 11 11 1 15 

47 F 11 Residential 1 62 11 23 5 14 

48 M 19 

Group 

Home 1 65 14 3 8 16 

49 F 14 Family 1 16 16 5 2 3 

50 M 15 Residential 1 30 18 8 4 1 

(1) “Entries into foster care” refers to the number of times a child has entered State custody (i.e., number of foster 

care “episodes”).

(2) “Months since last entry” is the length of time from the date of the child’s most recent entry into State custody 

until 05/31/02, which coincides with the last date of our claims record. “Months since last placement” is the 

length of time from the date of the most recent placement to the date the foster care provider was interviewed, and 

may be up to 4 months greater than “months since last entry” due to rounding. “Months caseworker with case” is 

the length of time from the date the caseworker initially took over the case until the date the caseworker was 

interviewed and may be up to 4 months greater than “months since last entry” due to rounding. 

(3) “Placements since last entry” refers to the number of placement settings (e.g., Foster Home A, Foster Home B, 

Metro Residential Facility) a child has experienced during each “episode” in foster care.

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Detailed Claims Data

The table below describes whether the child received required 

services, including a tally of services during his or her time in foster 

care from a period June 1, 1999, to May 30, 2000, or entry to 

May 30, 2002, whichever is shorter.

ID

EPSDT 

current 

(1)

Dental 

current 

(1,2)

30-day 

physical 

assessment

Medical 

history 

provided 

to care 

provider

Office visit 

claims

Mental 

healthrelated 

claims

Prescription 

claims

Dental 

claims

Hospital 

claims

1 YES N/A YES YES 25 20 18 0 0

2 YES NO YES YES 43 25 8 18 0

3 YES YES YES NO 12 8 2 4 0

4 NO NO N/A YES 16 33 5 13 0

5 YES YES N/A YES 8 40 8 53 0

6 YES YES YES NO 13 12 6 12 0

7 YES N/A YES YES 33 24 14 0 1

8 YES YES YES NO 16 51 5 9 0

9 YES N/A YES NO 75 7 29 0 0

10 YES N/A YES NO 50 19 29 0 0

11 YES YES YES NO 101 78 41 22 0

12 YES YES YES YES 15 20 3 2 0

13 YES YES YES YES 9 19 5 17 0

14 YES N/A YES YES 21 24 21 0 0

15 YES YES NO NO 59 32 18 4 0

16 YES N/A NO YES 18 17 4 0 0

17 YES N/A YES NO 25 14 16 0 0

18 YES YES YES YES 14 22 3 22 0

19 YES YES YES NO 22 41 6 20 0

20 YES N/A YES YES 40 20 16 0 0

21 YES YES NO NO 7 37 3 11 0

22 YES N/A YES NO 23 30 15 0 0

23 YES NO YES NO 17 82 5 24 0

24 YES N/A YES YES 30 19 20 3 0

25 NO* NO YES No 

Interview 22 12 9 0 0

26 YES NO YES NO 27 15 54 0 1

27 YES YES YES YES 15 114 4 23 0

APPENDIX~C
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APPENDIX~C

ID

EPSDT 

current 

(1)

Dental 

current 

(1,2)

30-day 

physical 

assessment

Medical 

history 

provided 

to care 

provider

Office visit 

claims

Mental 

healthrelated 

claims

Prescription 

claims

Dental 

claims

Hospital 

claims

28 YES N/A YES NO 16 15 3 0 0

29 YES YES YES NO 56 37 2 17 0

30 YES NO N/A YES 62 43 16 17 0

31 YES YES YES YES 8 49 0 5 0

32 NO YES YES YES 179 127 92 39 1

33 YES YES YES YES 6 29 2 7 0

34 YES NO* N/A No 

Interview 57 32 45 0 0

35 NO YES N/A YES 15 47 2 24 0

36 YES YES YES YES 290 38 45 9 1

37 NO YES NO NO 9 43 11 13 0

38 YES YES YES YES 12 45 22 25 0

39 YES YES NO No 

Interview 60 60 101 10 3

40 YES YES YES NO 29 10 6 8 0

41 YES YES N/A NO 24 48 13 10 0

42 YES YES YES YES 70 25 54 24 0

43 YES YES N/A YES 60 94 5 52 0

44 YES YES N/A YES 55 73 16 13 0

45 YES YES N/A NO 30 32 13 33 0

46 YES YES NO No 

Interview 14 12 3 2 0

47 YES YES N/A YES 98 47 147 9 0

48 YES YES N/A NO 20 54 15 14 0

49 YES YES YES YES 72 51 57 31 0

50 YES YES NO YES 128 70 92 56 0

(1) * = No record of screening ever performed 

(2) N/A = Under the age of 3 years or child was placed before June 1, 1999
APPENDIX~D

Agency Comments - ACF 

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APPENDIX~D 

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APPENDIX~D 

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APPENDIX~D 

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APPENDIX~E

Agency Comments - CMS 

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APPENDIX~E 

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ACKNOWLEDGMENTS

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

Regional Inspector General for Evaluation and Inspections and 

Gina Maree, Assistant Regional Inspector General for Evaluation 

and Inspections in Kansas City. Other principal Office of 

Evaluation and Inspections staff who contributed include:

Deborah Walden, Team Leader

Steve Milas, Program Analyst 

Michala Walker, Program Analyst

Brian T. Whitley, Program Analyst

Linda Paddock, Program Analyst

Linda Hall, Program Specialist (Washington, D.C.)

Barbara Tedesco, Mathematical Statistician (Baltimore)

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