Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

Inspector General 

FEBRUARY 2004 

OEI-07-00-00641 

CHILDREN’S USE OF HEALTH 

CARE SERVICES WHILE IN 

FOSTER CARE: TEXAS 
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 Departmen t 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 follo wing 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. 

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 Medicaid 

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. 
ABSTRACT

Our study determined that all 50 sampled children in the Texas 

foster care program received Medicaid services, and the majority 

received their most recent required Early and Periodic Screening, 

Diagnosis, and Treatment (EPSDT) medical examinations. 

However, the percentage of children receiving their required initial 

medical and dental screenings was substantially lower, and 

compliance with guidelines for vision and hearing screenings was 

undocumented. The Office of Inspector General (OIG) also 

determined that case plans were not completed within required 

timeframes for over half of the sampled children, and foster care 

providers for almost half of the children never received a written 

medical history for the children in their care. OIG recommends 

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

the Texas Department of Protective and Regulatory Services to 

increase the number of: initial medical and dental screenings that 

are received within required timeframes; initial case plans that are 

completed within required timeframes; and, foster care providers 

who are supplied available medical information for the children in 

their care, as required by Federal regulations. OIG recommends 

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

with the Texas Department of Health to evaluate the need for 

documentation to ensure compliance with routine EPSDT vision 

and hearing screening guidelines. ACF noted that it is working 

with the State to accomplish goals established in a Program 

Improvement Plan (PIP) developed as a result of a Child and 

Family Services Review. One of the goals of the PIP focuses on the 

health and mental health care of children in the child welfare 

system. CMS concurs with our recommendations and indicates 

that they are available to provide technical assistance to the State 

to promote provider education regarding the frequency schedule 

requirements and appropriate documentation of vision and hearing 

screenings. 

OEI - 07 - 00 - 00641 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : T EXAS i 
EXECUTIVE SUMMARY

OBJECTIVE 

To determine whether sampled children in the Texas foster care 

program receive health care services. 

BACKGROUND 

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

nationwide, many of whom are reportedly in poor health. 

Compared with children from the sam e socioeconomic backgrounds, 

these children suffer much higher rates of serious physical and 

psychological problems. Texas 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 children in the Texas foster care program are eligible for 

Medicaid. Federal Early and Periodic Screening, Diagnosis, and 

Treatment (EPSDT) guidelines require each State to provide 

coverage of preventive health care services to Medicaid-eligible 

individuals under the age of 21, at intervals which meet reasonable 

standards of medical and dental practice, as outlined in 

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

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 health. 

This inspection is based on information gathered from multiple 

sources: reviews of Federal and State policies; analysis of 

child-specific Medicaid claims data and case file documentation for 

50 randomly sampled children in the Texas foster care program; 

interviews with foster care providers and caseworkers for the 

children in our sample; and interviews with Tex as Department of 

Protective and Regulatory Services, Department of Health, and 

other State agency officials. Our analysis focused on a 3-year 

Medicaid claims history for the period September 1, 1999 through 

August 31, 2002. 

FINDINGS 

All sampled children had Medicaid coverage and claims for 

services 

All of the sampled children had Medicaid coverage and at least one 

Medicaid claim for health care services. 

OEI - 07 - 00 - 00641 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : T EXAS ii 
EXECUTIVE SUMMARY EXECUTIVE SUMMARY 

Ninety-four percent of sampled children received their most 

recent EPSDT medical examinations, and 92 percent 

received their most recent EPSDT dental examinations, in 

accordance with State guidelines 

Nearly all of the sampled children had received their most recent 

EPSDT medical and dental examinations at the time of our review. 

A high percentage of the children who had received their most 

recent EPSDT medical and dental services, according to the State’s 

frequency guidelines, had a foster care provider that knew the 

correct EPSDT frequency schedule for the child in its care. 

Seventy-five percent of sampled children received initial 

medical examinations, and 66 percent of sampled children 

received initial dental examinations, within required 

timeframes 

Substantially fewer sampled children received initial medical and 

dental examinations within required State timeframes than 

children who received EPSDT medical and dental examinations 

that met State frequency guidelines. Data collected by the Office of 

Inspector General suggest that it may be difficult to quickly locate 

dental providers for initial visits. 

Compliance with State guidelines for vision and hearing 

screenings was undocumented 

Texas requires that a hearing and vision screening be performed 

during each EPSDT medical examination. Our review of case file 

documentation provided no evidence of a vision screening for 

58 percent (29/50) of the children in our sample, and no evidence of 

a hearing screening for 66 percent (33/50) of the children in our 

sample at the time of their most recent EPSDT medical 

examination. The Centers for Medicare & Medicaid Services (CMS) 

no longer requires States to submit data on the number of children 

who received a vision or hearing screening through the State’s 

EPSDT program. Likewise, medical providers in Texas are not 

required to “itemize” the components of an EP SDT medical 

examination when billing for reimbursement. 

Seventy-six percent of sampled children received Medicaid 

mental health services 

Federal law requires that a case plan be developed for each child in 

Title IV-E foster care that includes a plan for en suring that the 

OEI - 07 - 00 - 00641 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : T EXAS iii 
EXECUTIVE SUMMARY EXECUTIVE SUMMARY 

child’s needs are addressed while s/he is in foster care. Texas 

requires that a case plan be developed for each child in foster care 

that includes an assessment of the child’s mental health needs. For 

the 50 children in our sample, 44 percent (22/50) had initial case 

plans that were completed within the required timeframe (within 

45 days of entering care). Seventy-six percent (38/50) of the 

children in our sample had Medicaid claims for mental health care 

services. The case plans for the 12 children who did not have 

Medicaid mental health claims indicated that their mental health 

needs were assessed, and only 2 indicated a need for services that 

were not received. 

Forty-six percent of foster care providers reported never 

receiving a medical history for the sampled child in their care 

Federal law requires that a child’s health records be given to the 

foster care provider at the time of placement. The provision of this 

information is important to ensure that appropriate health care 

services are provided to children in foster care. Foster care 

providers for 46 percent (23/50) of the sampled children reported 

never receiving a medical history for the child in their care. 

However, caseworkers for 19 of these 23 children reported receiving 

or compiling a medical history for the child. Foster care providers 

for children assigned a lower level of care (i.e., children with few or 

no medical and/or mental health problems) were less likely to 

report receiving a medical history for the child in their care than 

providers caring for a child assigned a higher level of care (i.e., a 

child with moderate to severe medical and/or mental health 

problems). 

RECOMMENDATIONS 

To ensure that children in foster care receive health care services in 

accordance with Federal guidelines, we recommend that: 

The Administration for Children and Familes (ACF) work with the 

Texas Department of Protective and Regulatory Services to 

increase the number of 

o Initial medical and dental screenings that are received within 

required timeframes 

o Initial case plans that are completed within required 

timeframes 

OEI - 07 - 00 - 00641 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : T EXAS iv 
EXECUTIVE SUMMARY 

o Foster care providers who are supplied available medical 

information for the children in their care 

The Centers for Medicare & Medicaid Services work with the Texas 

Department of Health to 

o Evaluate the need for documentation to ensure compliance with 

routine EPSDT vision and hearing screening guidelines 

AGENCY COMMENTS 

ACF indicated that it is working with the Texas Department of 

Protective and Regulatory Services, to assist the State in 

accomplishing goals established in a Program Improvement Plan 

developed as a result of a Child and Family Services Review. Child 

and Family Services Reviews measure individual States’ 

performance related to the health and well-being of children in the 

child welfare system. ACF stated that indicators in the Child and 

Family Services Review specifically track the areas of concern 

highlighted in this report, and that one of the goals of Texas’ 

Program Improvement Plan focuses on the health and mental 

health care of children in the child welfare system. Upon 

completion of this plan in March 2005, ACF will conduct another 

Child and Family Services Review. The full text of ACF’s 

comments to the draft report is located in Appendix F. 

CMS concurs with our recommendation and indicates that it is 

available to provide technical assistance to the State to promote 

provider education regarding the periodicity schedule 

requirements, and appropriate documentation of vision and hearing 

screenings. The full text of CMS’s comments to the draft report is 

located in Appendix G. 

OEI - 07 - 00 - 00641 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : T EXAS v 
TABLE OF CONTENTS

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

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

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

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

All sampled children had Medicaid coverage and claims for services ............. 8

Ninety-four percent of sampled children received their most recent EPSDT 

medical examinations, and 92 percent received their most recent EPSDT 

dental examinations, in accordance with State guidelines............................. 9

Seventy-five percent of sampled children received initial medical 

examinations, and 66 percent of sampled children received initial dental 

examinations, within required timeframes...................................................10

Compliance with State guidelines for vision and hearing screenings was 

undocumented .............................................................................................11

Seventy-six percent of sampled children received 

Medicaid mental health services..................................................................12

Forty-six percent of foster care providers reported never receiving 

a medical history for the sampled child in their care ....................................13

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

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

Appendix A: Texas Foster Care and Medicaid Programs ....................17

Appendix B: Sampled Children ..........................................................18

Appendix C: Medicaid Claims for Sampled Children ..........................20

Appendix D: Level of Care Categories for Texas .................................22

Appendix E: Analysis of Medical History and Level of Care ...............25

Appendix F: Agency Comments - ACF ................................................26

Appendix G: Agency Comments - CMS...............................................28

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

OEI - 07 - 00 - 00641 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : T EXAS 
INTRODUCTION

OBJECTIVE 

To determine whether sampled children in the Texas foster care 

program receive health care services. 

BACKGROUND 

Currently, there are an estimated 534,000 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. Texas was selected because of its large size, geographic 

location, and fee-for-service provision of Medicaid services. Texas 

had 21,353 children in foster care at the end of the Federal fiscal 

year 2002, based on the most recent Federal data available. 3 The 

Administration for Children and Families (ACF) has regulatory 

oversight of Title IV-E foster care programs, including approval of 

State plans to ensure State foster care programs are operating 

within Federal guidelines. The Texas Department of Protective 

and Regulatory Services manages the State’s Title IV-E foster care 

program. 

Compared with 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 health 

1Retrieved December 10, 2003 from 

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

refers to children in foster care on September 30, 2002, the most recent available 

nationwide estimate. 

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

York, North Dakota, and Oregon. 

3Retrieved December 10, 2003 from 

http://acf.hhs.gov/programs/cb/ddis/tables/entryexit2002.htm. Both Title IV-E 

eligible and non-Title-IV-E eligible children are included in the total 

“21,353 children in foster care.” 

4Health 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. 

OEI - 07 - 00 - 00641 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : T EXAS 1 
INTRODUCTION INTRODUCTION 

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, 6 yet many 

foster care providers report having difficulty finding health care 

professionals who are willing to care for these children. The health 

care available for children in foster care is often characterized by 

lack of access, lack of information sharing among health providers, 

child welfare workers, and foster care providers, 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 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 EPSDT 

services is very low.8 

Preventive dental care is also included as part of EPSDT. 

Adherence to American Dental Association recommendations for 

preventive dental care leads to better oral health, and practicing 

preventive behaviors over the long term produces greater benefits 

than doing so over the short term.9 

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

America. Retrieved October 21, 2002 from 

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

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

Pediatrics, 93:2, 1994. 

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

October 17, 2002 from http://www.aap.org/policy/re0054.html. 

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

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

9Journal of Dental Research, March 2003; 82 (3): 223-7. 

OEI - 07 - 00 - 00641 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : T EXAS 2 
Medicaid for Children in Foster Care 

All children in the Texas 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 (Title XIX 

of the Act), 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; 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.10 Texas provides Medicaid coverage to all children in 

foster care, regardless of IV-E eligibility status. In 2000, Medicaid 

payments for children in foster care nationwide totaled over 

$3.3 billion.11 Texas Medicaid expenditures to provide health care 

services to children in the Texas foster care program totaled 

approximately $156 million in 2000. 12 The Centers for 

Medicare & Medicaid Services (CMS) is responsible for Federal 

oversight of individual State Medicaid programs. 

States 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. 13 

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. Texas established the Texas Health Steps program 

to meet Federal EPSDT requirements. The current EPSDT 

frequency schedule for the Texas Health Steps program requires 

that medical screenings occur at: birth; 2 weeks; 2, 4, 6, 9, 12, 15 

10Retrieved November 1, 2002 from http://cms.hhs.gov/medicaid/mover.htm and 

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

11Medicaid Statistical Information System (MSIS) Report Fiscal 2000. Retrieved 

December 10, 2003 from http://www.cms.gov/medicaid/msis/00total.pdf. Fiscal 

2001 numbers for all States were not available. 

12Medicaid Statistical Information System (MSIS) Report Fiscal 2000: Texas. 

Retrieved December 10, 2003 from http://www.cms.gov/medicaid/msis/00tx.pdf. 

Fiscal 2001 expenditures for Texas totaled approximately $185 million. Retrieved 

December 10, 2003 from http://www.cms.gov/medicaid/msis/01tx.pdf. 

13Section 1905(r) of the Social Security Act. 

OEI - 07 - 00 - 00641 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : T EXAS 3 
INTRODUCTION 

and 18 months of age; 2, 3, 4, 5, 6, 8, and 10 years of age; and 

annually between the ages of 10 and 20. Vision and hearing 

screenings are required at each medical checkup, beginning at 

birth. Dental examinations are required every 6 months beginning 

at 1 year of age. Dental examinations are conducted separately 

from medical checkups. 

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 are provided quality services that protect their safety 

and health. Sections 422(b)(10)(B)(ii) and 475(1)(B) of the Act 

require that a case plan be developed for each child that includes a 

plan for ensuring that the child’s needs are addressed while s/he is 

in foster care. The case plan must be developed no more than 

60 days after the child’s removal from home. 14 Sections 

422(b)(10)(B)(ii) and 475(5)(D) of the Act require procedures to 

ensure that a child’s health records are 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. In 

accordance with these Federal laws, the Texas foster care program 

requires: that each child receive a medical examination within 

30 days after the date the child entered State custody, unless the 

child received a medical examination within 30 days before 

entering custody, and a dental examination within 90 days after 

placement;15 that a case plan (Initial Child’s Service Plan), which 

includes an assessment of a child’s mental health needs, be created 

within 45 days of a child’s removal from home; 16 and that the 

child’s medical and dental history be supplied to the foster care 

provider before, or at the time of, the child’s placement.17 

1445 CFR § 1356.21 (g)(2). 

15Texas Department of Protective and Regulatory Services Child Protective Services 

(CPS) Handbook 6520. 

16Texas Department of Protective and Regulatory Services CPS Handbook 6411. 

17Texas Department of Protective and Regulatory Services CPS Handbook 6123.3. 

OEI - 07 - 00 - 00641 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : T EXAS 4 
INTRODUCTION INTRODUCTION 

Each State establishes eligibility standards, determines services, 

sets payment rates, and administers its own foster care and 

Medicaid programs in accordance with general Federal guidelines. 

The resulting diversity produces variations in what types of 

services children receive while in foster care, and when they receive 

services. As such, the experiences reported in this State-specific 

report will be unique to the sampled children’s experiences in 

Texas. 

METHODOLOGY 

This inspection focused on the receipt of Medicaid health care, 

dental, and mental health care services that meet EPSDT 

guidelines; requirements for initial health screenings and mental 

health assessments upon entry into foster care; 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 and case file documentation for 50 randomly 

sampled children; interviews with caseworkers and foster care 

providers for each of 50 children in our sample; and interviews with 

Texas State agency officials. 

Reasons for State Selection 

Texas was selected due to its large size, geographic location, and 

fee-for -service payment of Medicaid health care services (Texas 

does not utilize managed care for children in foster care). The 

Texas Department of Protective and Regulatory Services is 

responsible for the welfare of children in State custody. An 

overview of the administration of child welfare services in Texas is 

included in Appendix A. 

Sample 

Children who met the following criteria were included in the study 

sample: (1) were in foster care on September 30, 2002; (2) resided 

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

placements for at least 6 months. The Texas Department of 

Protective and Regulatory Services provided us with a list of the 

9,030 children who met these criteria. We selected a simple 

random sample of 50 children in Texas from the list of children who 

OEI - 07 - 00 - 00641 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : T EXAS 5 
INTODUCTION 

met the specified criteria. 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 Texas State foster care 

and Medicaid policies. All Texas children in foster care 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 

determined by the State after consultation with recognized medical 

and dental organizations. The Texas Health Steps program 

satisfies the Federal EPSDT requirement. Therefore, we used 

Texas Health Steps policy guidelines to determine whether children 

had received their most recent EPSDT examination within required 

frequency guidelines. 

Medicaid Claims Data Review – The Texas Health and Human 

Services Commission 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 September 1, 1999 and August 31, 2002. We 

paid particular attention to the types of health and mental health 

services provided, dates of service, 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 

frequency of services (i.e., met Texas Health Steps guidelines). 

Case File Documentation Review - We requested and reviewed case 

file documentation from the Texas Department of Protective and 

Regulatory Services local offices for all the children in our sample. 

Information requested included documentation of medical and 

mental health services provided, the child’s initial and most recent 

case plan, duration of the child’s stay in foster care, and 

information regarding the child’s general well-being. 

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. One hundred 

percent of the foster care providers responsible for the children in 

our sample responded to our request for an interview. We 

conducted structured interviews with each child’s foster care 

OEI - 07 - 00 - 00641 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : T EXAS 6 
INTRODUCTION 

provider (10 in-person and 40 by telephone) between 

December 30, 2002 and February 6, 2003. The interviews with 

foster care providers focused on Medicaid programs and services 

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

and their experiences procuring health care services for the 

children included in our sample.

Caseworker Interviews - We conducted structured telephone 

interviews with each child’s current caseworker between 

December 16, 2002 and January 7, 2003. Each of these interviews 

focused on the caseworker’s understanding of the Medicaid program 

and services available, training related to the health and well-being 

of the children, his/her 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.

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 Texas Department of Protective and 

Regulatory Services, Texas Health and Human Services 

Commission, and Texas Department of Health officials who are 

responsible for the administration of both the foster care and 

Medicaid programs in Texas. Our discussions covered a wide 

spectrum of information, including the overall provision of Medicaid 

services for children in foster care, the State’s EPSDT program 

(Texas Health Steps), the structure of the State’s foster care service 

organization, and Medicaid claims for children in foster care.

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 - 00641 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : T EXAS 7 
FINDINGS

All sampled children had Medicaid coverage In Texas, all children in foster care 

and claims for services are eligible for Medicaid, which 

includes EPSDT services. All 

children in our sample had Medicaid coverage and at least one 

Medicaid claim for health care services between 

September 1, 1999 and August 31, 2002. Table 1 (below) details the 

various types of Medicaid-covered services, and the numbers of 

claims by type of service for the 50 sampled children. 

Table 1: Number and Type of Medicaid Claims 

for 50 Children in Sample* 

Claim type Number of children 

with at least one claim 

Total number of 

claims** 

Physican's office 49 782 

Dental 47 761 

Mental health 38 2,077 

Prescription drug 35 283 

Optometry/Audiology 34 178 

Laboratory test 33 813 

Hospital/ASC*** 31 852 

Diagnostic 24 235 

Supplies 23 780 

Medication management 22 288 

Physical/Occupational 

therapy 12 833 

Transportation 10 128 

Case management 8 33 

Home nursing 6 2,423 

Other 3 4 

Total 10,470 

*Claims for 09/01/99 to 08/31/02, or entry into care to 08/31/02. 

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

***Includes emergency room visits. 

Source: OIG analysis of Texas Medicaid claims data 

OEI - 07 - 00 - 00641 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : T EXAS 8 
FINDINGS 

Ninety-four percent of sampled children 

received their most recent EPSDT medical 

examinations, and 92 percent received their 

most recent EPSDT dental examinations, in 

accordance with State guidelines 

Federal law requires that State 

EPSDT programs 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. The 

Texas Health Steps program meets Federal EPSDT requirements. 

For their most recent EPSDT services, 94 percent (47/50) of the 

children sampled for this inspection received their most recent 

EPSDT medical examinations, and 92 percent (45/49) received their 

most recent EPSDT dental examinations in accordance with Texas 

Health Steps guidelines.18 

We analyzed Medicaid claims and interview data in an attempt to 

identify factors that explain the high (over 90 percent) percentages 

of children that were receiving EPSDT medical and dental 

examinations at the time of our review. Although sev eral factors, 

such as geographical region, caseworker involvement in the child’s 

health care, caseworker caseload size, and child’s date of entry into 

foster care were analyzed, we detected no differences between 

children who received services within required timeframes and 

those who did not.19 Of the 47 children who were receiving EPSDT 

medical examinations according to the Texas Health Steps 

guidelines, 77 percent (36/47) of their foster care providers knew 

the frequency schedule established by Texas Health Steps. For the 

45 children who were receiving EPSDT dental examinations 

according to Texas Health Steps guidelines, 87 percent (39/45) of 

the providers knew the frequency schedule. While the number of 

children who were not receiving medical and dental examinations 

according to Texas Health Steps guidelines was relatively small 

18Percentage of children receiving dental examinations is based on 49 of the 

50 sampled children. One child was medically exempt from receiving dental 

services and was excluded. 

19Due to the small size of the groups who did not receive medical and dental 

examinations according to State guidelines (3 and 4 children, respectively), 

detecting any statistically significant differences with the larger groups who 

received medical and dental examinations (47 and 45 children, respectively) is 

difficult. 

OEI - 07 - 00 - 00641 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : T EXAS 9 
FINDINGS FINDINGS 

(three and four, respectively), we believe it is significant to note 

that only one of the three foster care providers knew the EPSDT 

frequency schedule for medical examinations, and two of the four 

foster care providers knew the EPSDT frequency schedule for 

dental examinations. 

Seventy-five percent of sampled children 

received initial medical examinations, and 

66 percent of sampled children received 

initial dental examinations, within 

required timeframes 

The Texas foster care program 

requires that each child in foster 

care receive a medical examination 

within 30 days after the date the 

child entered State custody, if the 

child had not received an 

examination within 30 days prior to entering custody, and a dental 

examination within 90 days after placement. Seventy-five percent 

(27/36) of the children in our sample received initial medical 

examinations within 30 days prior to or after entering State 

custody. 20 Sixty-six percent (23/35) of the children in our sample 

received initial dental examinations within 90 days after 

placement.21 These percentages are substantially lower than the 

number of children who received current EPSDT medical and 

dental services that met State frequency guidelines. 

We analyzed Medicaid claims and interview data in an attempt to 

identify factors that would explain the lower percentages of 

children receiving initial examinations within required timeframes, 

compared to those receiving current EPSDT medical and dental 

services that met frequency guidelines. Although several factors, 

such as geographical region, caseworker involvement in the child’s 

health care, caseworker caseload size, child’s age, child’s level of 

care, 22 and child’s date of entry into foster care were analyzed, we 

20The percentage of children receiving initial medical examinations is based on a 

subset of 36 sampled children. Fourteen sampled children were excluded because 

they entered foster care outside of the timeframe included in our claims data. 

21The percentage of children receiving initial dental examinations is based on a 

subset of 35 sampled children. Fourteen sampled children were excluded because 

they entered foster care outside of the timeframe included in our claims data, and 

one child was medically exempt from receiving dental services. 

22“Level of care” is a category of care assigned by the State based on the child’s 

clinical, psychosocial, and related needs. See Appendix D for an explanation of 

level of care categories in Texas. 

OEI - 07 - 00 - 00641 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : T EXAS 10 
FINDINGS 

found no evidence of differences between children who received 

initial medical and dental examinations within required 

timeframes and those who did not.23 However, 20 percent (10/50) of 

foster care providers reported that dentists willing to accept new 

Medicaid patients were difficult to locate. Data suggest that it may 

be difficult for foster care providers to quickly locate dental 

providers for initial examinations, but dentists will continue to see 

the child once a relationship has been established with the foster 

care provider. If children in foster care are not receiving required 

initial medical services, it causes the State to be out of compliance 

with guidelines established in its State plan, and may delay the 

discovery of serious health care problems. 

Compliance with State guidelines for vision The Texas Health Steps 

and hearing screenings was undocumented program requires that a 

hearing and vision screening 

be performed during each EPSDT medical examination. 

Our review of case file documentation provided no evidence of a 

vision screening for 58 percent (29/50) of the sampled children, and 

no evidence of a hearing screening for 66 percent (33/50) of the 

sampled children at the time of their most recent EPSDT medical 

examination. In addition to a lack of case file documentation, for 

17 of the 29 children in our sample with no evidence of a vision 

screening in their case files, and for 23 of the 33 children in our 

sample with no evidence of a hearing screening, there was no 

indication from the foster care provider that a screening was 

performed. 

Foster care providers indicated that children might receive vision 

and hearing screenings from various sources: at school, through 

local Head Start programs, or through Early Childhood 

Intervention (the State’s agency that serves families who have 

babies or toddlers with disabilities or developmental delays). 

Foster care providers for 12 of the 29 children lacking evidence of a 

vision screening reported that the child received a separate vision 

23Due to the small size of the groups who did not receive initial medical and dental 

examinations according to State guidelines (nine and twelve children, 

respectively), detecting any statistically significant differences with the larger 

groups who received initial medical and dental examinations (27 and 23 children, 

respectively) is difficult. 

OEI - 07 - 00 - 00641 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : T EXAS 11 
FINDINGS 

screening from the most recent EPSDT medical examination. 

Foster care providers for 10 of the 33 children lacking evidence of a 

hearing screening reported the children received a separate hearing 

screening. Nevertheless, the State’s rules require that vision and 

hearing screenings be conducted as part of every EPSDT medical 

examination. 

Prior to Federal fiscal year (FFY) 1999, CMS required States to 

report the number of children receiving vision and hearing 

screenings through the State’s EPSDT program as part of the 

State’s annual report to CMS on EPSDT participation 

(CMS Form 416). However, effective FFY 1999, CMS eliminated 

the requirement to report vision and hearing screenings on 

CMS Form 416 in an attempt to clarify and simplify reporting 

requirements wherever possible. Section 1902(a)(43) of the Social 

Security Act, which requires the annual reporting of EPSDT 

participation for each State, does not specifically require the 

reporting of the number of children receiving vision and hearing 

screenings. Likewise, medical providers in Texas are not required 

to “itemize” the individual components of an EPSDT medical 

examination, such as developmental assessment, unclothed 

physical inspection, vision screening, hearing screening, etc., when 

they bill for reimbursement. 

The State’s Medicaid reimbursement for Texas Health Steps 

medical screenings is provided with the understanding that the 

provider is performing all components of an EPSDT examination, 

which, according to Texas Health Steps guidelines, includes a 

vision and hearing screening. The lack of documentation of vision 

and hearing screenings makes it impossible to determine if medical 

providers are performing all of the services for which they are paid, 

and if children are receiving all EPSDT services according to Texas 

Health Steps guidelines. 

Seventy-six percent of sampled children Federal law requires that a case 

received Medicaid mental health services plan be developed for each child in 

Title IV-E foster care that includes 

a plan for ensuring that the child’s needs are addressed while s/he 

is in foster care. The Texas Department of Protective and 

Regulatory Services requires that a case plan be developed for each 

child who enters foster care that includes an assessment of the 

child’s mental health needs. Case plans that included an 

OEI - 07 - 00 - 00641 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : T EXAS 12 
FINDINGS 

assessment of the child’s mental health needs had been completed 

for 86 percent (43/50) of the children in our sample, and 76 percent 

(38/50) of the children in our sample had Medicaid claims for 

mental health care services. 

We reviewed case file documentation for the 12 children who did 

not have Medicaid mental health claims to determine if mental 

health care needs for these children were identified. The case plans 

for these 12 children indicated that their mental health needs were 

assessed. Eight of the children had no needs identified, two 

children had mental health needs identified and had scheduled 

appointments outside the timeframe of our claims data, and two 

children had mental health needs identified, and no services were 

received or planned. 

The case plan is the only Federal or State requirement for assessing 

mental health care needs. The Texas Department of Protective and 

Regulatory Services requires that the child’s case plan (Initial 

Child’s Service Plan) be completed within 45 days of the child’s 

removal from home. For the 50 children in our sample, 44 percent 

(22/50) had initial case plans that were completed within the 

required timeframe established by the State. It is important that 

initial case plans be completed within required timeframes so that 

needed mental health services can be provided. 

Forty-six percent of foster care providers Federal law requires that a child’s 

reported never receiving a medical history for health record is reviewed, updated, 

the sampled children in their care and supplied to the foster care 

provider at the time of placement. 

Foster care providers for 46 percent (23/50) of the children in our 

sample reported never receiving a medical history for the children 

in their care. However, caseworkers for 19 of these 23 children 

reported receiving or compiling a medical history for the children. 

Foster care providers for children assigned a lower level of care 

(1 through 3), as defined in Appendix D, were less likely to report 

receiving a medical history for the children in their care than those 

providers caring for a child assigned a higher level of care 

(4 through 6).24 Of the 23 foster care providers that reported they 

did not receive a medical history for the sampled children, 74 

24The difference between these two groups was statistically significant. See 

Appendix E. 

OEI - 07 - 00 - 00641 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : T EXAS 13 
FINDINGS 

percent (17/23) were caring for children assigned a level of care 1, 2 

or 3, and 26 percent (6/23) of these foster care providers were caring 

for children assigned a level of 4, 5, or 6. Overall, 59 percent 

(17/29) of foster care providers for children in a level of care 1 

through 3 did not receive a medical history, and 29 percent (6/21) of 

foster care providers for children in a level of care 4, 5 or 6 did not 

receive a medical history. Foster care providers and caseworkers 

may not realize the importance of a medical history for children 

with few or no medical conditions. The requirement that foster care 

providers are supplied a medical history for the child in their care 

helps to ensure that all children receive the most effective care 

possible, regardless of a child’s level of care. 

Other conditions explaining why foster care providers may not have 

received medical histories include the following: 

o Foster parents stated they did not know they should have 

received a medical history for the children in their care. 

o Foster parents were unable to obtain medical information 

because the physician for the children in their care was 

concerned about patient confidentiality. 

o Private foster care agencies allow foster parents to view a 

child’s medical record at the agency office, but will not release 

the information to the foster parent. 

Foster care providers for children in our sample who reported that 

they did not receive a medical history revealed that not having this 

information made it difficult for them to effectively care for the 

children placed in their homes. One foster parent who reported not 

receiving a medical history indicated that it resulted in the child in 

her care having to receive multiple immunizations at one time so 

that he could be enrolled in school. Other foster parents reported 

that children with histories of serious health problems, such as 

collapsed lungs, severe malnutrition, and chronic ear infections, 

had been placed in their care without the foster care providers 

receiving medical histories. 

OEI - 07 - 00 - 00641 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : T EXAS 14 
RECOMMENDATIONS

RECOMMENDATIONS 

It is important to conduct initial medical, initial dental, and EPSDT 

examinations for children in foster care, in accordance with Federal 

guidelines, in order to detect the health care needs of this 

vulnerable population. Timely completion of initial case plans and 

the provision of available medical information to these childrens’ 

foster care providers are also important aspects of their care. 

Therefor e, we recommend that: 

ACF work with the Texas Department of Protective and Regulatory 

Services to increase the number of 

o Initial medical and dental screenings that are received within 

required timeframes 

o Initial case plans that are completed within required 

timeframes 

o Foster care providers who are supplied available medical 

information for the children in their care 

In Texas, State regulations require that all EPSDT examinations 

include vision and hearing screenings. Therefore, we recommend 

that: 

CMS work with the Texas Department of Health to 

o Evaluate the need for documentation to ensure compliance with 

routine EPSDT vision and hearing screening guidelines 

OEI - 07 - 00 - 00641 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : T EXAS 15 
RECOMMENDATIONS 

AGENCY COMMENTS 

ACF indicated that it is working with the Texas Department of 

Protective and Regulatory Services to assist the State in 

accomplishing goals established in a Program Improvement Plan 

developed as a result of a Child and Family Services Review. Child 

and Family Services Reviews measure individual State’s 

performance related to the health and well-being of children in the 

child welfare system. ACF stated that indicators in the Child and 

Family Services Review specifically track the areas of concern 

highlighted in this report, and that one of the goals of Texas’ 

Program Improvement Plan focuses on the health and mental 

health care of children in the child welfare system. Upon 

completion of this plan in March 2005, ACF will conduct another 

Child and Family Services Review. The full text of ACF’s 

comments to the draft report is located in Appendix F. 

CMS concurs with our recommendation and indicates that it is 

available to provide technical assistance to the State to promote 

provider education regarding the periodicity schedule 

requirements, and appropriate documentation of vision and hearing 

screenings. The full text of CMS’s comments to the draft report is 

located in Appendix G. 

OEI - 07 - 00 - 00641 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : T EXAS 16 
APPENDIX~A

Texas Foster Care and Medicaid Programs 

The Health and Human Services Commission is the State agency 

with primary responsibility for ensuring the delivery of all State 

health and human services in Texas. The Health and Human 

Services Commission’s State Medicaid Office is responsible for 

administering medical assistance programs for all eligible 

recipients enrolled in the Texas Medicaid program. All children in 

foster care in Texas are eligible for fee-for-service Medicaid. 

The Health and Human Services Commission has oversight 

responsibility for the Texas Department of Protective and 

Regulatory Services. This agency is charged with protecting 

children, elder adults, and persons with disabilities from abuse, 

neglect, and/or exploitation, and with licensing child-care facilities 

and child-placing agencies. Within the Department of Protective 

and Regulatory Services, Child Protective Services manages foster 

care programs in the State. Texas’s foster care system utilizes both 

public (State-administered) and private (contracted) placement 

agencies, although final responsibility for each child in the 

managing conservatorship (custody) of the State lies with 

Department of Protective and Regulatory Services. Funding for 

foster care services in Texas can come from a variety of sources, 

including Federal, State, county, community, and private funds, 

and there is a great deal of variation in sources of funding and 

methods of service provision by region. 

The Health and Human Services Commission also has oversight 

responsibility for the Texas Department of Health. This agency 

administers the Texas Health Steps program. The Texas Health 

Steps program satisfies the Federal requirement that States 

establish EPSDT programs that provide coverage for preventive 

child health services to all Medicaid eligible individuals under the 

age of 21. All children in foster care in Texas are eligible for Texas 

Health Steps services. 

OEI - 07 - 00 - 00641 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : T EXAS 17 
OEI - 07 - 00 - 00641 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : T EXAS 18

Sampled Children

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 at the end of February 2003.

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 17 Residential 1 24 3 5 1 24

2 F 3 Therapeutic 1 12 2 12 1 11

3 F 15 Therapeutic 1 61 2 54 2 22

4 F 7 Family 1 11 2 7 1 11

5 M 11 Therapeutic 1 53 5 4 3 24

6 M 16 Residential 1 10 5 5 2 4

7 F 11 Residential 2 65 2 60 3 7

8 M 10 Family 3 39 2 39 1 38

9 F 3 Family 1 16 1 16 1 14

10 M 11 Therapeutic 1 38 2 30 2 4

11 F 13 Family 1 54 4 24 4 24

12 M 18 Family 1 29 9 2 2 20

13 M 13 Family 1 40 1 24 4 16

14 F 15 Family 1 11 5 9 2 7

15 M 5 Therapeutic 1 13 2 11 4 13

16 F 9 Family 1 27 3 21 1 25

17 F 15 Therapeutic 1 50 7 1 2 1

18 F 11 Family 1 33 1 33 3 10

19 F 17 Residential 1 23 12 2 4 2

20 F 16 Residential 1 36 11 3 3 12

21 M 15 Therapeutic 1 66 4 18 2 8

22 M 3 Rehabilitation 1 13 1 13 1 12

23 F 3 Rehabilitation 1 13 1 13 1 12

24 M 8 Residential 1 30 4 12 2 30

25 F 14 Therapeutic 1 16 2 13 2 7

26 F 4 Rehabilitation 1 17 2 16 (+) 3

27 M 17 Residential 1 28 7 8 1 28

28 F 8 Residential 1 14 3 10 2 7

29 F 2 Family 1 27 4 13 2 7

30 M 17 Residential 2 12 2 12 1 12

31 M 4 Rehabilitation 1 39 1 39 1 38

32 F 1 Family 1 19 2 15 (+) 6

33 F 17 Residential 1 57 14 1 (+) 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) 

34 F 18 Residential 1 58 2 15 2 44 

35 F 3 Therapeutic 3 16 4 9 2 5 

36 F 3 Therapeutic 1 34 1 34 2 6 

37 M 6 Family 1 19 1 19 3 9 

38 F 17 Family 1 46 2 18 2 42 

39 F 18 Residential 1 28 2 19 (+) 3 

40 F 18 Therapeutic 1 75 5 4 3 8 

41 F 15 Residential 1 47 11 5 3 11 

42 M 11 Family 2 14 2 12 3 2 

43 M 3 Family 2 30 4 1 2 26 

44 F 14 Residential 1 12 3 10 3 3 

45 F 3 Family 1 44 2 33 1 43 

46 M 2 Rehabilitation 1 21 2 20 2 4 

47 F 6 Family 1 43 1 43 2 36 

48 F 5 Therapeutic 1 51 1 51 6 6 

49 M 11 Family 1 37 5 7 1 37 

50 M 1 Therapeutic 1 20 2 17 1 12 

KEY 

(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 January 2003, 

which coincides with the period of interviews with caseworkers and 

foster care providers. “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. “Months caseworker with 

case” is the length of time from the date the caseworker initially 

took over the child’s case until the date the caseworker was 

interviewed. 

(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. 

(+) Number of caseworkers since last entry into foster care is 

unknown. 

OEI - 07 - 00 - 00641 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : T EXAS 19 
OEI - 07 - 00 - 00641 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : T EXAS 20

Medicaid Claims for Sampled Children

The table below indicates each child’s receipt of required services 

and total claims for September 1, 1999 to August 31, 2002, or entry 

into care to August 31, 2002, whichever is shorter.

Number of Medicaid Claims Initial Exams Current EPSDT Exams

ID Physician’s 

office

Dental

services

Prescription 

medications

Mental health

services

Medical history 

provided to care 

provider

Medical Dental Medical Dental

1 9 19 0 80 Y Y Y N* Y

2 3 2 0 0 Y N N Y Y

3 5 10 1 1 N N* N*

4 2 21 0 13 N Y Y Y Y

5 23 32 4 97 N Y N

6 4 4 0 15 Y N N Y Y

7 30 23 0 14 N N* Y

8 19 25 7 72 N Y Y Y Y

9 13 2 7 4 Y Y N* Y Y

10 1 18 0 29 Y N N N Y

11 33 25 0 28 N Y Y

12 9 20 4 67 Y Y Y N* Y

13 8 21 5 28 N Y Y N* Y

14 1 14 1 21 Y Y Y Y Y

15 3 11 9 20 N N N Y Y

16 16 9 1 53 N N Y Y Y

17 43 49 1 106 Y Y Y

18 11 16 0 62 Y N* Y Y Y

19 15 12 7 98 Y Y Y Y N

20 17 39 1 88 Y N* N Y Y

21 10 28 0 21 N Y Y

22 2 2 4 0 N N* Y N* Y

23 0 2 4 0 N N* Y N* Y

24 9 10 0 62 N Y N Y N*

25 3 8 1 60 N N* Y N* Y

26 11 1 6 0 Y Y N* Y N*

27 12 22 0 42 Y Y Y Y Y

28 3 13 0 33 N Y Y Y Y

29 7 2 3 2 Y Y N Y Y

30 5 11 0 20 Y Y Y N* Y

31 76 8 35 0 N Y N N Y

32 15 0 14 0 Y Y N Y N

33 16 17 6 101 N Y Y

A PPENDIX~C
APPENDIX~C 

Number of Medicaid Claims Initial Exams Current EPSDT Exams 

ID Physician’s 

office 

Dental 

services 

Prescription 

medications 

Mental health 

services 

Medical history 

provided to care 

provider 

Medical Dental Medical Dental 

34 29 25 21 184 Y N* Y 

35 8 16 0 26 Y N Y Y Y 

36 10 2 8 0 Y Y E Y E 

37 5 7 7 24 N Y Y N Y 

38 30 17 3 191 Y Y Y 

39 12 41 4 87 Y N Y N* N* 

40 33 32 2 60 N Y Y 

41 22 33 8 104 Y Y Y 

42 1 8 3 13 N Y N* Y Y 

43 21 6 8 3 N Y Y Y N* 

44 12 12 0 34 Y N* N Y Y 

45 31 6 10 0 N Y Y 

46 16 0 24 0 Y Y N Y N* 

47 7 34 5 0 Y N* Y 

48 81 4 35 0 Y Y Y 

49 12 22 7 114 Y N Y Y Y 

50 18 0 17 0 N N N N* N 

KEY 

Initial Exams: Medical/Dental: “Y” indicates that initial 

medical/dental examination was received within required 

timeframes. “N” indicates examination was not received within 

required timeframes. “N*” indicates that Medicaid claims data did 

not support a positive finding, but evidence was found in the case 

file to support the positive finding. “E” indicates child was exempt 

from the requirements. 

Current EPSDT Exams: Medical/Dental: “Y” indicates that an 

EPSDT medical/dental examination was received according to 

Texas Health Steps frequency timeframes. “N” indicates 

examination was not received according to Texas Health Steps 

frequency timeframes. “N*” indicates that Medicaid claims data 

did not support a positive finding, but evidence was found in the 

case file to support the positive finding. “E” indicates child was 

exempt from the requirements. 

OEI - 07 - 00 - 00641 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : T EXAS 21 
APPENDIX~D

Level of Care Categories for Texas 

The Texas Department of Protective and Regulatory Services 

contracts with a behavioral health care company, Youth for 

Tomorrow, to assist in the implementation of the Level of Care 

(LOC) Service System.25 Youth For Tomorrow uses LOC definitions 

to determine a child's level of care service needs. Clinically-trained 

professionals use these definitions to synthesize their knowledge 

about a child's psychological and social functioning and then assign 

a single LOC rating from LOC 1 services to LOC 6 services. The 

LOC rating is determined in the context of a broad review of the 

clinical information submitted by the Department of Protective and 

Regulatory Services caseworker.26 

Level of Care Definitions for Physical and Mental Health27 

Level of Care 1 Needs

Medically Fragile and Developmentally Delayed: Medical condition 

is maintained within the normal structure and supervision of a 

family type environment. No additional services are necessary.

Mental Health: Adequate functioning in all developmental and or 

environmental areas. There may be transient difficulties, 

"every-day" worries, and occasional misbehavior, but would be 

regarded as a "normal" child; responds to "normal" discipline. The 

caregiver provides routine home environment with guidance and 

supervision to meet the needs of the child.

Level of Care 2 Needs

Medically Fragile and Developmentally Delayed: Medical condition 

is maintained within the normal structure and supervision of a 

family type environment. No additional services are necessary. 

25The Department of Protective and Regulatory Services is currently revising its 

policies to create a new system to replace the LOC service system. Once the new 

policies are developed, the LOC system will no longer be used. The information 

contained in this report reflects policy effective at the time of our review in 2001 

and 2002. 

26Retrieved August 6, 2003, from http://www.yft.org/faq/initial_loc.htm. 

27Retrieved August 6, 2003, from http://www.yft.org/loc_def.htm. 

OEI - 07 - 00 - 00641 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : T EXAS 22 
APPENDIX~D 

Mental Health: No more than occasional problems in functioning in 

any area, some acting-out behavior in response to life stresses, but 

these are brief and transient; minimally disturbing to others, and 

not considered deviant by those who know them. The caregiver 

provides routine home environment with supplemental guidance 

and discipline to meet the needs of the child.

Level of Care 3 Needs

Medically Fragile and Developmentally Delayed: Limited self-care 

skills require minimal medical assistance. Follow-up medical 

services and replacement of medical equipment are routine. The 

child may be ambulatory with assistance. Verbal skills may be 

limited to communicating basic needs. The child may have frequent 

or repetitive minor behavioral problems requiring minimal 

supervision and no more than a minimal risk to self or others. 

Mental Health: Frequent or repetitive minor problems in one or 

more areas; may engage in non-violent antisocial acts, but is 

capable of meaningful interpersonal relationships. Requires 

supervision in structured, supportive setting with counseling 

available from professional or paraprofessional staff.

Level of Care 4 Needs

Medically Fragile and Developmentally Delayed: Requires ongoing 

assistance in order to perform essential self-care or independent 

living skills. Medical involvement requires on-site staff skilled in 

providing appropriate medical assistance with a nurse available on 

an on-call basis. Periodic adjustments or replacement of medical 

equipment may be necessary. The child may be non -ambulatory or 

limited to nonverbal communications. The child may have 

substantial behavioral problems that require constant supervision 

and be no more than a moderate risk to self or others. 

Mental Health: Substantial problems; has physical, mental, or 

social needs and behaviors that may present a moderate risk of 

causing harm to themselves or others, poor or inappropriate social 

skills, frequent episodes of aggressive or other antisocial behavior 

with some preservation of meaningful social relationships; requires 

treatment program in a structured setting with therapeutic 

counseling available by professional staff.

Level of Care 5 Needs

Medically Fragile and Developmentally Delayed: Requires total 

care with all essential self-help skills. The child may be 

non-ambulatory or confined to bed. Medical involvement may 

OEI - 07 - 00 - 00641 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : T EXAS 23 
APPENDIX~D 

require 24-hour on-site (campus) medical or nursing supervision 

with continuous medical equipment necessary to sustain life 

support. The child may have severe behavioral problems that 

require close 24-hour supervision and is a severe risk to self or 

others. 

Mental Health: Severe problems, unable to function in multiple areas. 

Sometimes willing to cooperate when prompted or instructed, but may 

lack motivation or ability to participate in personal care or social 

activities or is severely impaired in reality testing or in communications. 

May exhibit persistent or unpredictable aggression, be markedly 

withdrawn and isolated due to either mood or thought disturbance, or 

make suicidal attempts. Presents a moderate to severe risk of causing 

harm to self or others. Requires 24-hour supervision by multiple staff in 

limited access setting. 

Level of Care 6 Needs 

Medically Fragile and Developmentally Delayed: N/A 

Mental Health: Very severe impairment(s), disabilities or needs, 

consistently unable or unwilling to cooperate in own care. May be 

severely aggressive or exhibit self-destructive behavior or grossly 

impaired in reality testing, communication, cognition, affect, or 

personal hygiene. May present severe to critical risk of causing 

serious harm to self or others. Needs constant supervision (24-hour 

care) with maximum staffing, in a highly structured setting. 

OEI - 07 - 00 - 00641 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : T EXAS 24 
APPENDIX~E

Analysis of Medical History and Level of Care 

Level of Care/ 

Received Medical History Did Receive History Did Not Receive History Total 

Level of care 1-3 12 17 29 

Level of care 4-6 15 6 21 

Total 27 23 50 

p = 0.0354 (degrees of freedom = 1; chi-square = 4.4275) 

OEI - 07 - 00 - 00641 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : T EXAS 25
APPENDIX~F

Agency Comments - ACF 

OEI - 07 - 00 - 00641 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : T EXAS 26
APPENDIX~F 

OEI - 07 - 00 - 00641 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : T EXAS 27
APPENDIX~G

Agency Comments - CMS 

OEI - 07 - 00 - 00641 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : T EXAS 28
ACKNOWLEDGMENTS

This report was prepared under the direction of Brian 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 

Steven Milas, Lead Analyst 

Linda Paddock, Program Analyst 

Michala Walker, Program Analyst 

Brian T. Whitley, Program Analyst 

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

Barbara Tedesco, Mathematical Statistician (Baltimore) 

OEI - 07 - 00 - 00641 C HILDREN’ S USE OF H EALTH C ARE S ERVICES WHILE IN F OSTER CARE : T EXAS 29