Department of Health and Human Services 


OFFICE OF 

INSPECTOR GENERAL 

CHILDREN’S USE OF HEALTH 


CARE SERVICES WHILE IN 


FOSTER CARE: GEORGIA


Inspector General 

January 2005 

OEI-07-00-00644 
Office of Inspector General 
 http://oig.hhs.gov 

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

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

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

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

investigations, and inspections conducted by the following operating components: 

Office of Audit Services 

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

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

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

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

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

mismanagement and to promote economy and efficiency throughout the department. 

Office of Evaluation and Inspections 

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

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

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

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

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

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

patient abuse in the Medicaid program. 

Office of Investiga ions t

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

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

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

convictions, administrative sanctions, or civil monetary penalties. 

Office of Counsel to the Inspector General 

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

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

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

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

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

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

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

the health care community, and issues fraud alerts and other industry guidance. 
∆ E X E C U T I V E S U M M A R Y 

OBJECTIVE 

To determine whether sampled children in the Georgia foster care 

program receive health care services. 

BACKGROUND 

Section 471(a)(22) of the Social Security Act (the Act) requires States to 

provide children in foster care with quality services that protect their 

health and safety. Section 472(h)(1) of the Act deems children in foster 

care eligible for Medicaid health care services. Georgia is the focus of 

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

a diverse cross section of foster care nationwide. All Title IV-E children 

in the Georgia foster care program are eligible for Medicaid. 

Federal Early and Periodic Screening, Diagnosis, and Treatment 

(EPSDT) guidelines require each State to make preventive health care 

services available to Medicaid-eligible individuals under the age of 21. 

The guidelines also require States to establish intervals for providing 

EPSDT examinations that meet reasonable standards of medical and 

dental practice as outlined in sections 1902(a)(43) and 1905(r) of the 

Act. A unique aspect of the Georgia foster care program is its First 

Placement, Best Placement (FP/BP) Comprehensive Child and Family 

Assessment policy, which requires that all children entering foster care 

receive initial medical and dental examinations and a developmental 

assessment or psychological evaluation. 

This inspection is based on information gathered from multiple 

sources. We reviewed Federal and State policies; analyzed 

child-specific Medicaid claims data and case file documentation for 

50 randomly sampled children in the Georgia foster care program; and 

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

facility staff), caseworkers for the children in our sample, and relevant 

Georgia State staff. Our analysis focused on a 3-year claims period for 

children in foster care ending on March 26, 2003. 

FINDINGS 

All 50 sampled children had Medicaid coverage, and 49 children had 

claims for health care services. The 49 children with Medicaid claims 

had a total of 3,574 claims during our review period. 

OEI-07-00-00644 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE I N F OSTER CARE : GEORGIA i 
EXECUTIVE SUMMARY 

Thirty of forty-three sampled children required to receive an EPSDT 

medical examination received their most recent EPSDT medical 

examination within State-established frequency guidelines. 

According to State guidelines, 43 sampled children should have received 

EPSDT services based on their age and length of time in foster care. 

However, 13 of the 43 children did not receive an EPSDT medical 

examination within State-established guidelines. Seven of the fifty 

sampled children had been in foster care less than the time period that 

would have required an EPSDT examination based on the EPSDT 

guidelines established by the State. 

Twenty-one of thirty-five sampled children required to receive an 

EPSDT dental examination received their most recent EPSDT dental 

service within State-established frequency guidelines. The EPSDT 

frequency guidelines adopted by Georgia required that children 3 years 

of age or older receive dental services every 6 months. Thirty-five of the 

sampled children were 3 years of age or older and, therefore, should 

have received dental services. 

Many of the sampled children did not receive First Placement, Best 

Placement assessments within the State-required timeframe. 

Georgia State guidelines required that 39 of the 50 sampled children 

receive FP/BP services upon entry into foster care during the period 

covered by our Medicaid claims. Fourteen children did not receive 

required FP/BP medical examinations within the required timeframe. 

Thirteen of the twenty-four children required to have an FP/BP dental 

examination did not receive it timely, and 4 of the 16 children required 

to receive a developmental assessment and 8 of 23 children required to 

receive a psychological evaluation did not receive it within the required 

timeframe. 

Four sampled children did not receive services to address 

documented mental health needs, and mental health needs were 

not documented for five children who received such services. 

Federal law requires that case plans be developed, and the Georgia 

Division of Family and Children Services requires that these plans 

include information regarding the child’s current emotional and 

psychological status. Case plans or State-required FP/BP assessments 

for four sampled children clearly indicated a need for mental health 

services. However, no Medicaid claims for mental health services 

existed, and the caseworkers and foster care providers for these children 

stated they were not receiving mental health services. Medicaid claims, 

caseworkers, and foster care providers for five other sampled children 

OEI-07-00-00644 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE I N F OSTER CARE : GEORGIA ii 
EXECUTIVE SUMMARY 

indicated the children received mental health services, but the need for 

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

children. 

Twenty-four of the fifty foster care providers reported never 

receiving medical information for the children in their care. 

Section 475(5)(D) of the Act requires that the health records of children 

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

providers at the time of placement. Caseworkers for 21 of the 

24 children whose foster care providers reported they did not receive 

medical information stated they had received or compiled some medical 

information for the sampled children. 

RECOMMENDATIONS 

The Administration for Children and Families (ACF) and the Centers 

for Medicare & Medicaid Services (CMS) should work with the Georgia 

Department of Community Health to ensure that: 

 The EPSDT medical examinations and dental services are received 

timely. 

ACF should work with the Georgia Department of Human Resources, 

Division of Family and Children Services (DFCS) to ensure that: 

 Assessments are completed within the required timeframe. 

 Foster care providers receive initial and updated medical 

information for children placed in their care. 

In addition, ACF should work with DFCS to ensure that case files 

contain required documentation, including mental health needs. 

Further, during the course of this study, we noted that some of the 

components of the FP/BP Comprehensive Child and Family 

Assessments mirrored the components required as part of EPSDT. 

We encourage ACF, CMS, DFCS, and the Georgia Department of 

Community Health to consider allowing services provided under either 

program to count for meeting the requirements of both programs, as 

appropriate. 

AGENCY COMMENTS 

ACF described actions it is taking that will address our 

recommendations. The ACF is monitoring the State of Georgia’s actions 

through quarterly reports relative to the State’s efforts to ensure that 

EPSDT medical examinations and dental services are received timely 

OEI-07-00-00644 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE I N F OSTER CARE : GEORGIA iii 
EXECUTIVE SUMMARY 

and to ensure that foster care providers receive appropriate medical 

information for children placed in their care. 

CMS concurred with the Office of Inspector General (OIG) 

recommendation and will have CMS regional office staff work with the 

Georgia Department of Community Health to ensure that EPSDT 

services are provided according to the State-established EPSDT 

frequency guidelines. CMS also notes that its staff are available to the 

State and to ACF to provide any necessary technical assistance. 

Additionally, in response to an OIG suggestion, CMS will not prohibit 

FP/BP assessments from serving as EPSDT screenings if the screenings 

are provided in accordance with the State-established EPSDT frequency 

guidelines and meet the definition of an EPSDT screening, with all age 

appropriate screens and services being provided. 

OEI-07-00-00644 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE I N F OSTER CARE : GEORGIA iv 
∆ TABLE OF CONTENTS T A B L E O F C O N T E N T S 

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

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

FINDINGS ...................................................... 10 

Medicaid coverage for children in foster care................... 10 

Receipt of EPSDT medical examinations ...................... 11 

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

Timeliness of First Placement, Best Placement services ........ 12 

Documentation and receipt of mental health services .......... 15 

Medical information for foster care providers .................. 16 

RECOMMENDATIONS ......................................... 17 

AGENCY COMMENTS ......................................... 18

APPENDIXES 

A: EPSDT and First Placement, Best Placement 

 Required Components ................................... 19 

B: Demographic Characteristics of Sampled Children .......... 20 

C: Medicaid Claims for Sampled Children .................... 22 

D: EPSDT Services for Sampled Children..................... 24 

E: First Placement, Best Placement Assessments.............. 26 

F: Agency Comments ....................................... 28 

ACKNOWLEDGMENTS ......................................... 32 
∆ I N T R O D U C T I O N 

OBJECTIVE 

To determine whether sampled children in the Georgia foster care 

program receive health care services. 

BACKGROUND 

At the time of our review, an estimated 542,000 children were in foster 

care nationwide,1 many of whom were 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. Georgia 

was selected for its medium population size based on Bureau of the 

Census data when compared to other States.3 It was also chosen for its 

southern geographic location, largely rural setting, county-administered 

child welfare system, and fee-for-service provision of Medicaid services. 

Georgia had 13,149 children in foster care at the end of fiscal year 

(FY) 2002, based on the most recent Federal data available at the time 

of this study.4 The Administration for Children and Families (ACF) 

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

approval of State plans to ensure State foster care programs are 

operating within Federal guidelines. Within Georgia, the Department 

of Human Resources, Division of Family and Children Services (DFCS), 

manages the Title IV-E foster care program. 

Compared with other children from the same socioeconomic 

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

physical and psychological problems.5 Vision, hearing, and dental 

problems are prevalent in the foster care population, and physical 

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

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

Foster Care Analysis and Reporting System Report for the period ending September 30, 2001. 

Retrieved July 6, 2004 from http://www.acf.hhs.gov/programs/cb/publications/afcars/report8.htm. 

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

Oregon, and Texas. 

3 Bureau of the Census, retrieved January 21, 2004, from http://www.factfinder.census.gov/. 

4 Department of Health and Human Services, Administration for Children and Families, Foster Care: 

Entries, Exits, and In Care on the Last Day. Retrieved on January 13, 2004, from 

http://www.acf.hhs.gov/programs/cb/dis/tables/entryexit2002.htm. 

5 Casey Family Programs, National Center for Resource Family Support, Health Care Issues for Children 

in Foster Care, March 25, 2002. 

OEI-07-00-00644 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE I N F OSTER CARE : GEORGIA 1 
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and asthma) affect 30 to 40 percent of children in the child welfare 

system.6

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

care providers reported having difficulty finding health care 

professionals who were willing to care for these children (we use the 

term “foster care provider” to refer to a foster parent or a residential 

care facility who is responsible for a child in foster care).7 The health 

care available for children in foster care is often characterized by lack of 

access; lack of information sharing among health care professionals; and 

long delays in obtaining services.8 Furthermore, studies have shown 

that low percentages of children in foster care are actually receiving 

services.9 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 the age of 21 that 

might otherwise go undetected or untreated. However, a Government 

Accountability Office report released in July 2001 stated that available 

data from short-range studies showed that the percentage of children in 

the general population receiving EPSDT services is very low.10 

Periodic dental care (i.e., oral screenings and examinations) is included 

as part of EPSDT and must be performed by a dentist. Georgia 

requirements for EPSDT services require that every child receive dental 

services in accordance with the frequency guidelines developed by the 

State and at other intervals as medically necessary. The EPSDT dental 

frequency guidelines must be established after consultation with 

recognized dental organizations involved in child health care. 

6 Fact Sheet: The Health of Children in Out-of-Home Care. Child Welfare League of America. 

Retrieved October 17, 2002, from http://www.cwla.org/programs/health/healthcarewfact.htm. 

7 Chernoff, R. et. al., (1994) Assessing the Health Status of Children Entering Foster Care, 

Pediatrics, 93:2, 594-601. 

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

Retrieved January 14, 2004, from http://www.aap.org/policy/re0054.html. 

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

Commission on Justice for Children, 1999 and Medicaid: Stronger Efforts Needed to Ensure 

Children’s Access to Health Screening Services, Government Accountability Office, GAO-01-749, 

July 2001. 

10 Medicaid: Stronger Efforts Needed to Ensure Children’s Access to Health Screening Services. 

Government Accountability Office, GAO-01-749, July 2001. 

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INTROD UCTION 

Medicaid for Children in Foster Care 

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

for Medicaid. Section 472(h)(1) of the Social Security Act (the Act) 

deems children eligible for Medicaid health care services and 

section 1902(a)(10)(A)(i)(I) of the Act requires that Medicaid services be 

made available to them. Federal EPSDT guidelines require each State 

to make comprehensive and preventive child health services available to 

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

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

each State establishes its own Medicaid eligibility standards; 

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

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

administers its own Medicaid program.11 

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

totaled over $3.3 billion.12 Georgia Medicaid expenditures for this 

population totaled approximately $36 million in 2000.13 The Centers 

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

oversight of individual State Medicaid programs. The Georgia 

Department of Community Health manages the State Medicaid 

program. 

Georgia Health Check 

In accordance with Federal law, participation in the Medicaid program 

requires States to establish EPSDT guidelines for all Medicaid-eligible 

individuals under 21 years of age.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.15 Georgia has established the 

Health Check program to meet Federal EPSDT requirements. 

11 Retrieved September 12, 2002, from http://cms.hhs.gov/medicaid/eligibility/criteria.asp. 

12 Department of Health and Human Services, Medicaid Statistical Information System (MSIS) Report 

Fiscal Year 2000: All States. Retrieved January 14, 2004, from 

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

13 Department of Health and Human Services, Medicaid Statistical Information System (MSIS) Report 

Fiscal Year 2000: Georgia. Retrieved January 14, 2004, from 

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

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

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

OEI-07-00-00644 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE I N F OSTER CARE : GEORGIA 3 
INTROD UCTION 

The current frequency schedule established for the Health 

Check EPSDT program requires a complete physical examination at 

birth; 1, 2, 4, 6, 9, 12, 15, and 18 months of age; annually from 2 to 

5 years of age; and every other year between 6 and 21 years of age. 

The frequency schedule requires that vision and hearing screenings be 

included as part of every Health Check physical screening for all 

children regardless of their age, if determined necessary based on their 

medical history. Health Check also requires dental services, separate 

from the medical examinations, and that all children 3 years of age and 

older receive dental services every 6 months.16 

Georgia requires that caseworkers refer all children entering foster care 

to the Medicaid eligibility office and that caseworkers coordinate with 

Medicaid-eligibility workers to determine the Title IV-E foster care and 

Medicaid program eligibility for the children they refer. All children 

determined eligible for Title IV-E foster care funds in Georgia are 

automatically eligible for Medicaid health care services.17 

Further, Georgia requires State child welfare staff (e.g., eligibility 

specialists and caseworkers) to inform all foster care providers caring 

for Medicaid-eligible children of the availability of EPSDT services and 

to document that such services were offered. The foster care caseworker 

is also responsible for arranging appropriate and timely medical care for 

children in foster care, obtaining health-related documents for the case 

record, and making arrangements for the children to receive initial 

health examinations as soon as possible after placement.18 

First Placement, Best Placement 

Georgia designed the First Placement, Best Placement (FP/BP) program 

in response to the Adoption and Safe Families Act, Public Law 105-89.19 

This Act requires States to develop case plans for children entering 

foster care to ensure reasonable efforts are made to reunite them with 

their families, ensure their health and safety while they are in foster 

care, and ensure appropriate decisions are made regarding permanency 

(e.g., reunification with the child’s family or adoption). 

16 Georgia Multihealthnet System, Department of Community Health, Report Specification, 

Health Notification Letter-Dental Screening, May 30, 2002. 

17 Georgia Department of Community Health Manual, Section 2801-1, April 1, 2003. 

18 Georgia Department of Human Resources, Social Services Manual, Chapter 1000, 

Section 1007.3, May 2000. 

19 The Adoption and Safe Families Act, Administration for Children and Families, Program Instruction, 

ACYF-CB-PI-98-02, January 8, 1998. 

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INTRODUCTION

The FP/BP program policy requires that all children entering foster care 

after July 1999 receive a Comprehensive Child and Family Assessment, 

which includes (1) the completion of a family assessment detailing the 

child’s family history, a summary of the child’s strengths, needs, and 

functional level,20 (2) a medical examination, (3) a dental examination, 

and (4) a developmental assessment for children 3 years of age or 

younger or a psychological evaluation for children 4 to 21 years of 

age. 21 Information obtained through the Comprehensive Child and 

Family Assessments aid child welfare agency staff, juvenile courts, 

families, and foster care providers in making decisions that will assure 

the safety and well-being of children in foster care.22 

All children entering foster care in Georgia must be referred for 

FP/BP services within 5 working days of the 72-hour detention 

hearing.23 The FP/BP caseworkers then have 30 days from the date of 

the referral to complete the Comprehensive Child and Family 

Assessment. At the time of our review, DFCS was contracting with 

80 private entities to provide FP/BP services, which included the 

development of a case plan and determination of needed interventions 

and services for all children entering foster care in Georgia. 

Medical and dental examinations to rule out conditions that may impact 

the child’s overall well-being are required each time a child enters foster 

care.24 Some of the components required as part of the Comprehensive 

Child and Family Assessment (e.g., medical and dental examinations 

and developmental assessments and psychological evaluations) are also 

required as part of an EPSDT screening, as shown in Appendix A. 

However, FP/BP examinations and assessments are not used by the 

State to satisfy the EPSDT frequency guideline requirements. 

20 First Placement, Best Placement Manual, Section VI, June 2002 requires that a child’s functional 

level be based on the Child and Adolescent Functional Scale, or Preschool and Early Childhood 

Functional Scale. 

21 First Placement, Best Placement Manual, Introduction Section, June 2002.

22 Ibid., p. 1.

23 The 72-hour detention hearing is used to determine if the State should retain custody of the child 

and maintain them in foster care. 

24 First Placement, Best Placement Manual, Sections III and IV, June 2002. 

OEI-07-00-00644 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE I N F OSTER CARE : GEORGIA 5 
INTRODUCTION

Initial Case Plan 

To meet Federal requirements,25 Georgia child welfare policy stipulates 

that caseworkers must develop an initial case plan for each child 

entering foster care within 30 days of entering State custody.26 Each 

child’s case plan must include information obtained from his/her 

FP/BP assessment, information regarding family strengths and 

resources, and goals established for the child and his/her family. To the 

extent available, information regarding each child’s health (e.g., medical 

history, known medical problems, medications, immunizations, current 

health status, and dental status), the names and addresses of the child’s 

health care professionals, and the child’s emotional and psychological 

status are included in the initial case plan. State policy requires that 

all case plans be reviewed and updated every 6 months. 

Section 475(1)(B) of the Act requires States to develop a plan for each 

child entering foster care to ensure their needs are addressed. Pursuant 

to section 475(1)(C) of the Act, available and accessible health 

information about a child is required to be included in the plan. Section 

471(a)(15)(A) of the Act provides that the health and safety of children 

in foster care be considered of paramount concern. Section 475(5)(D) of 

the Act requires that a child’s health record be updated and supplied to 

the foster care provider with whom the child is placed. Medical 

information plays a role in ensuring children receive required health 

care services. In response, Georgia requires caseworkers to discuss with 

foster care providers the health status and health care needs of each 

child in their care, and to give foster care providers medical health 

information about each child placed in their care. Caseworkers are also 

required to document that the foster care provider received the health 

information on each child. The information provided to foster care 

providers should include, at a minimum and where available and 

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

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

problems, medications, and any other relevant health information 

determined appropriate to share with the foster care provider.27 If any 

of this information is unknown or unavailable at the time the child is 

25 45 CFR § 1356.21(g)(2) states that case plans must be developed no later that 60 days from the child’s 

removal from the home. 

26 Georgia Department of Human Resources, Social Services Manual, Chapter 1007.2, p.8, May 2000. 

27 Georgia Department of Human Resources, Social Services Manual, Chapter 1007.2, p. 4, May 2000. 

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 INTRODUCTION 

placed with a foster care provider, the caseworker is to provide an 

explanation regarding the missing information in the initial case plan. 

Caseworkers are instructed not to leave the medical portion of the case 

plan blank.28 

OEI-07-00-00644 

METHODOLOGY 

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

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

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

did not focus on 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: review of Federal 

and State policies; child-specific Medicaid claims data and case file 

documentation for 50 sampled children; interviews with caseworkers 

and foster care providers for the 50 sampled children; and interviews 

with Georgia State agency officials. 

Reasons for State Selection 

Georgia was selected for its medium population size based on 

Bureau of the Census data when compared to other States. It was also 

chosen for its southern geographic location, largely rural setting, 

county-administered child welfare system, and fee-for-service provision 

of Medicaid services. 

Sample 

Children who met the following criteria were included in the study 

population: (1) were in foster care on March 26, 2003; (2) resided in 

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

maintenance funds; and (4) had been in continuous foster care 

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

9,711 children who met these criteria.29 Appendix B provides 

information on the 50 children included in our study. 

28 Georgia Department of Human Resources, Social Services Manual, Chapter 1011.2 (7), p. 4, 

November 2000. 

29 Based on the Adoption and Foster Care Analysis and Reporting System information regarding children 

in foster care in Georgia, the Atlanta metropolitan area is underrepresented in the universe of 

children in IV-E foster care. The percentage of children in foster care in the Atlanta region eligible 

for IV-E foster care maintenance is significantly lower than the remainder of the State. 

CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE I N F OSTER CARE : GEORGIA 7
INTROD UCTION

Review of Law, Regulations, Policies, Medicaid Data, and Case File 

Documentation 

Law, Regulation, and Policy Review—We reviewed Federal laws and 

regulations and Georgia State foster care, Medicaid, and EPSDT 

program policies. The Georgia Health Check program meets the 

Federal EPSDT requirements. Therefore, we used State-established 

Health Check frequency guidelines to determine whether children in 

foster care were receiving required EPSDT medical examinations and 

dental services timely. 

Medicaid Claims Review—DFCS provided us with up to 3 years of 

Medicaid claims data for each of the children in our sample. The 

data included Medicaid claims for physician, dental, pharmaceutical, 

and mental health services paid between March 26, 2000, and 

March 26, 2003. For children entering foster care on or after 

March 26, 2000, we analyzed Medicaid claims data from the date they 

entered foster care through March 26, 2003. Appendix C provides the 

number of Medicaid claims for each child in the sample who received 

services during the period covered by our review. 

Case File Documentation—We requested case file documentation from 

Georgia DFCS local offices for all of the children in our sample, 

including documentation of medical, dental and mental health services 

provided, the child’s medical history, the child’s case plan, the FP/BP 

Comprehensive Child and Family Assessment, verification of the 

duration of the child’s stay in foster care, and information regarding the 

child’s health and general well-being. We received case file 

documentation for all 50 children. 

We reviewed case file documentation to determine if each sampled child 

had been referred for, scheduled for, or had actually received medical, 

dental, or mental health services (e.g., EPSDT form signed by a 

physician or other health care professional). Appendix D provides 

information regarding each sampled child’s EPSDT services. 

We also reviewed the case file documentation and Medicaid claims data 

provided to determine if sampled children received FP/BP family 

assessments, medical and dental examinations, and developmental 

assessments or psychological evaluations, within the required 

timeframes. To determine the timeliness of these assessments, we used 

the dates listed on the copies of the assessment or evaluation reports. 

Therefore, all children should have received a Comprehensive Child and 

Family Assessment within 38 days of entering care. The 38 days 

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INTROD UCTION 

included completion of the court hearing required within 72 hours of 

entering care, 5 days to complete a referral for a FP/BP assessment, and 

30 days to complete the FP/BP assessment. We also reviewed Medicaid 

claims data to identify initial medical examinations provided in 

outpatient and emergency room settings. Appendix E identifies those 

children who received FP/BP services and the types of services they 

received. 

Interviews 

Foster Care Provider Interviews—We conducted structured interviews with 

50 foster care providers responsible for the children in our sample (16 in 

person and 34 by telephone). The interviews with foster care providers 

(i.e., foster parent or residential care facility staff) focused on the 

Medicaid program and the services available, the training they received 

related to the health and well-being of children, and their experiences 

procuring health care services for the children in our sample. 

Caseworker Interviews—We conducted structured telephone interviews 

with the caseworkers assigned to all 50 sampled children. Each of these 

interviews focused on the caseworker’s understanding of the Medicaid 

program and the health and mental health services available, the 

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

their experiences accessing health care services, and any barriers to 

obtaining needed health care. Each caseworker spoke specifically about 

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

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

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

consensus or disagreement within and between the two groups. 

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 DFCS and the Georgia Department of Community 

Health staff. 

This inspection was conducted in accordance with the Quality 

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

and Efficiency. 

OEI-07-00-00644 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE I N F OSTER CARE : GEORGIA 9 
∆ FINDINGS 


Federal law requires that all 

children eligible for the 

All 50 sampled children had Medicaid coverage, 

and 49 had claims for health care services 

Title IV-E foster care program be 

provided Medicaid services.30 In Georgia, all children in Title IV-E 

foster care are automatically eligible for Medicaid, including EPSDT 

services.31 Forty-nine of the fifty sampled children had Medicaid claims 

for health care services during the 3-year period covered by our study. 

One of the fifty sampled children, in foster care for over a year, had no 

Medicaid claims for health care services during the period covered by 

this study. Table 1 details the various types of Medicaid-covered 

services and the number of claims by type of service provided for the 

49 sampled children with claims for health care services. 

Claim Type 

Case Management* 

Dental 

Diagnostic

Hospital/Emergency Care 

Laboratory

Mental Health 

Miscellaneous** 

Optometry/Audiology

Physical/Occupational 

Therapy 

Physician Office 

Prescription Drug 

Skilled/Residential Care 

Surgical Procedures 

Transportation/Supplies 

Vaccines 

Total 

Number of 

Children with at 

Least One Claim 

Table 1: Number and Type of Medicaid Claims for 

49 Sampled Children 

45 839 

31 121 

14 28 

18 43 

23 80 

37 494 

38 121 

19 65 

3 15 

44 326 

46 1,335 

5 49 

4 10 

7 8 

22 40 

Total Number of 

Claims 

3,574 

* Case management includes four Medicaid claims for Targeted Case Management. 

The remaining Case Management claims are for child protective services and residential 

care services case management. 

** Paid claims for which no diagnosis or procedure codes were given.

 See Appendix C for the number and type of Medicaid claims for the sampled children. 

Source: Office of Inspector General, 2004. 

30 Section 1902(a)(10)(A)(i)(I) of the Social Security Act. 

31 Georgia Department of Community Health Manual, Part II-Chapter 700, April 2003.

OEI-07-00-00644 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE I N F OSTER CARE : GEORGIA 10 
FINDINGS 

Thirty of forty-three sampled children 

required to receive an EPSDT medical 

examination received their most recent 

EPSDT medical examination within 

State-established frequency guidelines 

The EPSDT medical 

examinations are intended to 

screen for and identify health 

needs that may not be detected 

during a medical examination 

for a specific condition. All 

age-appropriate EPSDT examinations must be completed in accordance 

with the State-established EPSDT frequency guidelines. If a child 

entering foster care has not received the required age-appropriate 

EPSDT examinations in accordance with the frequency guidelines, the 

child should receive the needed services at the earliest possible time.32 

The Georgia DFCS is responsible for arranging appropriate and timely 

medical care for all children in foster care and arranging for an initial 

health examination as soon as the child is placed in foster care. Seven 

of the fifty sampled children had been in foster care less than the time 

period specified by the EPSDT frequency guidelines for their age group 

and were not required to receive EPSDT examinations during that time. 

Of the remaining 43 sampled children, 30 received their most recent 

required EPSDT medical examinations within State-established 

guidelines. However, 13 of the 43 sampled children who should have 

received EPSDT medical examinations did not receive them within the 

required timeframe. Caseworkers for 9 of these 13 children stated they 

were familiar with the Health Check program and indicated they had 

received training regarding EPSDT screenings or understood the 

required health examination policies for children in foster care. 

Twenty-one of thirty-five sampled 

children required to receive EPSDT 

dental services received their most 

recent EPSDT dental service within 

State-established frequency guidelines 

The EPSDT frequency guidelines 

adopted by Georgia require that all 

children 3 years of age or older 

receive dental services every 

6 months and allow for all children 

to be referred for dental services at 

any time. Thirty-nine of the 

sampled children were 3 years of age or older. However, we could 

evaluate receipt of required dental services only for the 35 sampled 

children with a full 6 months of Medicaid claims during our study 

period. 

32 Georgia Department of Community Health Manual, Part II, Chapter 900, Section 902, April 2003. 

OEI-07-00-00644 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE I N F OSTER CARE : GEORGIA 11 
FINDINGS 

Only 21 of the 35 children required to receive dental services received 

their most recent required dental service, in accordance with the 

State-established EPSDT frequency guidelines. We were unable to 

determine why the remaining 14 children did not receive their most 

recent required dental services within the required timeframe. Only 

1 foster care provider for the 14 children reported experiencing 

problems finding a dentist that would accept Medicaid and treat the 

sampled child in his/her care. 

Section 471(a)(22) of the Act 

required States to develop and 

Many of the sampled children did not receive 

First Placement, Best Placement assessments 

implement standards to within the State-required timeframe ensure the health and safety 

of children in foster care by January 1, 1999. In response to this 

statute, Georgia DFCS established the FP/BP program in 1998 

beginning with five demonstration counties. They implemented the 

program statewide in July 1999.33 Policies governing the 

FP/BP program require that children entering foster care after 

July 1999 receive all services required as part of a Comprehensive Child 

and Family Assessment (i.e., family assessment, medical and dental 

examinations, and developmental assessment or psychological 

evaluation) within 30 days from the date the DFCS caseworker makes 

the referral to the FP/BP agency. In most respects, FP/BP components 

mirrored those required as part of EPSDT examinations. See 

Appendix A for a comparison of EPSDT and FP/BP required 

components. 

Forty of the fifty sampled children entered foster care after 

July 1999 and, therefore, were required to receive a Comprehensive 

Child and Family Assessment. However, we could determine 

FP/BP compliance for only 39 of the sampled children because 1 child 

entered foster care during the period covered by FP/BP policy, but 

before the beginning of our Medicaid claims window. Not all children 

received all of the required assessment services, and some services were 

not received timely. 

33 Georgia Department of Human Resources, Division of Family and Children Services, First 

Placement/Best Placement Fact Sheet dated February 2003. 

OEI-07-00-00644 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE I N F OSTER CARE : GEORGIA 12 
FINDINGS FINDINGS 

Family Assessments are not completed timely. 

The goal of a family assessment is to gather information about the child 

and his/her family. The family assessment includes information about the 

child’s history and aids in identifying services relating to the health and 

safety of the child and his/her needs while in foster care. Caseworkers 

provided us with family assessments for 26 of the 39 sampled children 

covered by FP/BP. Fifteen of the twenty-six assessments were dated, but 

only 2 of the 15 were completed within the required 30-day timeframe. 

Eleven of the twenty-six assessments were not dated, and we were unable 

to determine if they were completed within the required 30-day 

timeframe. We did not receive family assessments for the remaining 

13 sampled children and, therefore, were unable to determine if family 

assessments for these children were completed or completed timely. 

Fourteen of thirty-nine sampled children did not receive FP/BP medical 

examinations within the State-required timeframe. 

The initial medical examination documents the child’s medical history 

upon entering foster care. This information is used by DFCS to assure 

that the medical needs of children in foster care are addressed. Some of 

the FP/BP initial medical examination components mirrored those 

components required as part of EPSDT medical examinations. 

Twenty-five of the thirty-nine sampled children required to receive FP/BP 

services received their initial medical examinations timely. Twelve of 

these thirty-nine children did not, waiting 46 to 435 days after entering 

foster care to receive an initial medical examination. Two of the thirtynine sampled children did not have case file information or Medicaid 

claims data to indicate they received the required medical examination 

even though one child had been in foster care 242 days and the other had 

been in foster care 398 days at the end of the period covered by our 

Medicaid claims window. 

Thirteen of twenty-four sampled children did not receive FP/BP dental 

examinations within the State-required timeframe. 

The initial dental examination, required for children age 3 and older, 

documents the child’s dental history upon coming into foster care. DFCS 

uses this information to ensure that the dental needs of children in foster 

care are addressed. Like the initial FP/BP medical examinations, 

FP/BP dental examination components mirrored those required as part 

of EPSDT dental services. 

Twenty-four of the thirty-nine sampled children were age 3 or older on the 

date they entered foster care, and were required to have a dental 

OEI-07-00-00644 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE I N F OSTER CARE : GEORGIA 13 
FINDINGS 

examination completed within 30 days from the date of referral to FP/BP. 

However, only 7 of these 24 sampled children received their initial dental 

examination timely. Thirteen children waited from 43 to 371 days after 

entering foster care to receive their initial dental examinations, and four 

children had no Medicaid claims for dental examinations. 

Some sampled children did not receive developmental assessments or 

psychological evaluations within the State-required timeframe. 

Developmental Assessments—The initial developmental assessment screens 

and assesses developmental milestones and characteristics for children 3 

years of age or younger when they enter foster care. The information 

from these assessments is critical in making placement decisions, 

developing case plans, assuring the safety and well-being of the child, and 

obtaining services for children who have developmental delays. The 

EPSDT guidelines do not require that children receive an initial 

developmental assessment but some of the aspects of the initial 

assessment meet the EPSDT developmental/behavioral component 

requirements. 

Sixteen of the thirty-nine sampled children referred to FP/BP were 

3 years of age or younger when they entered foster care. Two of these 

sixteen sampled children received their developmental assessment timely. 

Ten of the sixteen sampled children received their developmental 

assessments 40 to 885 days after entering foster care. We were unable to 

document the receipt of the required initial developmental assessment for 

4 of the 16 children because there was no Medicaid claim to indicate an 

assessment had been completed and no developmental assessment report 

was included in the case file. 

Psychological Evaluations—Initial psychological evaluations differ 

from developmental assessments and are only required for children age 

4 and older. These evaluations should include, but are not limited to, the 

psychological status of the child or adolescent at the time they enter foster 

care. If a psychological evaluation yields any mental health concerns, the 

psychological summary and report must provide detailed 

recommendations and actions to be taken.34 DFCS uses this information 

to identify the child’s mental health service needs and to assure his/her 

safety and well-being. The initial psychological evaluation is not required 

34 First Placement, Best Placement Manual, Section IV, June 2002. 

OEI-07-00-00644 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE I N F OSTER CARE : GEORGIA 14 
FINDINGS 

by the EPSDT frequency guidelines, but meets some of the EPSDT 

developmental/behavioral component requirements. 

Twenty-three of the thirty-nine sampled children referred to FP/BP were 

4 to 21 years of age when they entered foster care. Fifteen of the twentythree sampled children received their psychological evaluations within 

required timeframes. Eight of the twenty-three sampled children who 

received a psychological evaluation did not receive it within the required 

30-day timeframe, with receipt ranging from 41 to 461 days after referral. 

Four sampled children did not receive services to 

address documented mental health needs, and 

mental health needs were not documented for five 

children who received such services 

Section 475(1)(B) of the Act 

requires a case plan to be 

developed for each child entering 

foster care, and that the plan 

should include steps for assuring 

that the child receives safe and proper care. Section 475(1)(C) of the Act 

requires the health records of the child including names and addresses 

of providers, a record of immunizations, any known medical problems, 

medications, and any other relevant health information also be included 

in the plan. The Georgia DFCS further requires that case plans contain 

information regarding the child’s current emotional and psychological 

status.35 The Georgia DFCS requires caseworkers to complete case 

plans within 30 days from the date a child enters foster care, and to 

update the plans every 6 months. 

Discrepancies existed in the documentation and receipt of mental health 

services for 9 of the 50 sampled children. Four of the nine sampled 

children had an assessment indicating a need for mental health 

services. However, these four children received no additional mental 

health services. The remaining five children had Medicaid claims 

indicating they received mental health services, and caseworkers and 

foster care providers for these children acknowledged the children were 

getting their mental health services needs met, but the need for mental 

health services was not documented. Documentation is essential to 

ensure the continuation of needed services. 

35 Georgia Department of Human Resources, Social Services Manual, Chapter 1007.8, p. 19, May 2000. 

OEI-07-00-00644 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE I N F OSTER CARE : GEORGIA 15 
FINDINGS FINDINGS 

Section 471(a)(15)(A) of the Act

Twenty-four of the fifty foster care providers provides that the health and 

reported never receiving medical information safety of children in foster care be 

for the children in their care considered of paramount concern. 

Medical information supplies 

foster care providers with information necessary to ensure that the child 

in their care receives proper care and that the child’s needs are met. 

Section 475(5)(D) of the Act requires that a child’s health records be 

reviewed and updated and supplied to the foster care provider with 

whom the child is placed at the time of each placement. Georgia 

requires all caseworkers to supply the foster care provider with a copy of 

the health information on the child, and to document that the foster 

care provider received the health information.36 

Of the 50 foster care providers we interviewed, 24 stated they received 

no medical information for the sampled children in their care. However, 

caseworkers for 21 of these 24 children reported they had received or 

compiled some medical information for the sampled children. While we 

were unable to determine the reasons that available medical 

information was not given to these 21 foster care providers, failure to 

share this information indicates a problem in the communication of 

medical information from caseworkers to foster care providers and could 

result in children’s needs not being met. 

36 Georgia Department of Human Resources, Social Services Manual, Chapter 1000, 

Sections 1011.2, p.4, November 2000. 

OEI-07-00-00644 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE I N F OSTER CARE : GEORGIA 16 
∆ R E C O M M E N D A T I O N S 


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

provided quality health care services that protect their health. States 

are also required to develop a plan for each child that includes their 

health care needs and medical information and to supply foster care 

providers with a child’s health record at the time the child is placed 

with them. Medical information plays a role in ensuring that children 

receive required health care services. The EPSDT program is intended 

to detect various health needs. The Georgia FP/BP program requires 

that each child who enters foster care receive a Comprehensive Child 

and Family Assessment. However, if children do not receive the 

required EPSDT services or FP/BP assessments, or do not receive those 

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

ACF and CMS should work with the Georgia Department of Community 

Health to ensure that: 

o The EPSDT medical examinations and dental services are 

received timely. 

ACF should work with the Georgia Department of Human Resources, 

DFCS to ensure that: 

o Assessments are completed within the required timeframe. 

o Foster care providers receive initial and updated medical 

information for children placed in their care. 

In addition, ACF should work with DFCS to ensure that case files 

contain required documentation, including mental health needs. 

Further, during the course of this study, we noted that some of the 

components of the FP/BP Comprehensive Child and Family 

Assessments mirrored the components required as part of EPSDT. 

We encourage ACF, CMS, DFCS, and the Georgia Department of 

Community Health to consider allowing services provided under either 

program to count for meeting the requirements of both programs, as 

appropriate. 

OEI-07-00-00644 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE I N F OSTER CARE : GEORGIA 17 
∆ AGENCY COMMENTS 


ACF described actions it is taking that will address our 

recommendations. It is monitoring the State of Georgia through 

quarterly reports relative to the State’s efforts to ensure that EPSDT 

medical examinations and dental services are received timely and to 

ensure that foster care providers receive appropriate medical 

information for children placed in their care. 

CMS concurred with the OIG recommendation and will have CMS 

regional office staff work with the Georgia Department of Community 

Health to ensure that EPSDT services are provided according to the 

State-established EPSDT frequency guidelines. CMS also notes that its 

staff is available to the State and to ACF to provide any necessary 

technical assistance. Additionally, in response to an OIG suggestion, 

CMS will not prohibit FP/BP assessments to serve as EPSDT screenings 

if the screenings are provided in accordance with the State-established 

EPSDT frequency guidelines and meet the definition of an EPSDT 

screening, with all age appropriate screens and services being provided. 

OEI-07-00-00644 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE I N F OSTER CARE : GEORGIA 18 
∆ APPENDIX ~ A 

EPSDT and First Placement, Best Placement Required Components 

The table below provides a comparison of EPSDT and FP/BP 

components. 

Screening/Examination 

Components 

EPSDT Required 

Component 

FP/BP

Required 

Component 

INITIAL/INTERVAL Y Y 

MEASUREMENTS 

Height and Weight Y Y 

Head Circumference Y Y 

Blood Pressure Y Y 

SENSORY SCREENING 

Vision Y Y 

Hearing Y Y 

MENTAL HEALTH Y* Y** 

PHYSICAL EXAMINATION Y Y 

PROCEDURES Y Y 

Hereditary/Metabolic Y Y 

Screening (newborn) Y Y 

Immunization Y Y 

Tuberculin Test Y Y 

Hematocrit or Hemoglobin Y Y 

Urine Y Y 

Lead Screening Y N 

ANTICIPATORY GUIDANCE Y Y 

DENTAL EXAMINATION Y Y 

*The EPSDT mental health component requires developmental/behavioral assessments 

be performed by the physician who conducts the EPSDT medical examination. 

**The FP/BP mental health component requires developmental assessments and 

psychological evaluations be performed by trained professionals who specialize in the 

field of mental health, and are more extensive than those required as part of an EPSDT 

medical examination. 

OEI-07-00-00644 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE I N F OSTER CARE : GEORGIA 19 
∆ APPENDIX ~ B 

Demographic Charactertics of Sampled Children 

The table below provides the demographic characteristics of each of 

the 50 sampled children and his or her foster care placement history 

as of June 1, 2003. 

OIG 

ID 

Age in 

Years Sex Placement Setting 

Entries 

into 

Foster 

Care (1) 

Months Since 

Foster Care 

Entry (2) 

Placements 

Since Last 

Entry (3) 

Months Since 

Last 

Placement (4) 

Caseworkers 

Since Last 

Entry (5) 

Months 

Caseworker 

with Case (6) 

1 3 M Family 1 33 1 33 3 24 

2 14 F Family 1 26 2 20 * 7 

3 15 M Residential 2 13 5 4 1 13 

4 1 M Family 1 21 1 21 2 17 

5 11 F Family 1 28 6 18 3 5 

6 2 F Family * 18 1 18 1 18 

7 11 M Family 1 14 1 14 1 14 

8 7 M Family 1 13 1 13 * 5 

9 16 F Residential 1 40 7 30 4 22 

10 3 F Family 1 21 1 21 2 4 

11 5 F Family 1 25 2 12 3 12 

12 2 M Family 1 12 2 9 1 12 

13 13 F Family 2 14 1 14 4 1 

14 17 F Kinship 1 91 1 91 2 12 

15 10 F Kinship 2 19 4 12 4 1 

16 16 F Family * 44 3 16 * 24 

17 12 F Family 1 19 2 15 2 12 

18 3 M Family 1 9 1 9 1 9 

19 16 F Residential 2 35 8 7 3 24 

20 17 F Family 1 52 2 9 3 1 

21 7 M Therapeutic 1 29 * 19 5 1 

22 3 M Family 1 22 3 1 1 22 

23 12 M Family 2 11 1 11 * 6 

24 8 M Family 1 20 1 20 3 16 

25 16 F Family 3 20 2 18 3 4 

26 9 M Therapeutic 1 116 6 1 5 12 

27 1 M Family 1 15 2 1 4 12 

28 2 F Family 1 31 1 31 3 2 

29 9 F Family 1 75 3 13 2 12 

30 15 M Residential 1 22 10 2 3 3 

31 7 F Family 1 56 2 6 8 6 

OEI-07-00-00644 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE I N F OSTER CARE : GEORGIA 20 
APPENDIX~B 

OIG 

ID 

Age in 

Years Sex Placement Setting 

Entries 

into 

Foster 

Care (1) 

Months Since 

Foster Care 

Entry (2) 

Placements 

Since Last 

Entry (3) 

Months Since 

Last 

Placement (4) 

Caseworkers 

Since Last 

Entry (5) 

Months 

Caseworker 

with Case (6) 

32 1 F Family 1 10 1 10 2 6 

33 11 M Kinship 2 131 * 120 3 5 

34 11 `F Family 2 10 2 8 1 10 

35 17 F Institution 1 102 3 32 5 18 

36 8 F Family 1 26 1 26 * 24 

37 3 F Family 2 36 2 14 3 5 

38 1 F Family 1 10 1 10 1 10 

39 2 F Family 1 24 2 2 3 11 

40 2 F Family 1 30 1 30 2 29 

41 17 F Residential 1 19 1 19 1 19 

42 9 F Kinship 1 37 1 37 2 3 

43 1 F Family 1 9 1 9 1 9 

44 17 M Institution 1 28 5 13 * 27 

45 10 M Family 1 21 3 1 * 13 

46 1 M Family 1 14 2 5 2 12 

47 17 M Therapeutic 1 48 1 48 3 2 

48 8 F Kinship 2 12 2 7 * 10 

49 13 F Family 1 54 * 10 6 16 

50 15 M Residential 1 21 10 3 3 3 

KEY 

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

(2) Months Since Foster Care Entry—length of time from the date of the child’s 

most recent entry into foster care until June 1, 2003, when interviews were 

conducted with caseworkers and foster care providers, or the date the child left 

care if that date precedes June 1, 2003. 

(3) Placements Since Last Entry—total number of placements, in all settings 

(e.g., Foster Home, Residential Care Facility), the child experienced during their 

most recent entry into foster care. 

(4) Months Since Last Placement—length of time from the date of the most 

recent foster care placement to the date the foster care provider was interviewed. 

(5) Caseworkers Since Last Entry—number of caseworkers assigned 

responsibility for the child since his/her last entry into foster care. 

(6) Months Caseworker with Case—number of months the most recent 

caseworker has been assigned responsibility for the child. 

(*) Indicates an unknown value. 

OEI-07-00-00644 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE I N F OSTER CARE : GEORGIA 21 
∆ APPENDIX ~ C 

Medicaid Claims for Sampled Children 

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

claims for physician visits, dental services, prescription medications, 

and mental health services from March 26, 2000, to March 26, 2003. 

Number of Medicaid Claims* 

OIG ID Medical and 

Physician's Visits 

Dental 

Services 

Prescription 

Medications 

Mental Health 

Services 

1 36 0 54 0 

2 2 1 11 21 

3 2 0 16 11 

4 13 0 10 0 

5 8 3 80 25 

6 10 0 50 1 

7 2 2 27 28 

8 1 3 12 1 

9 6 0 11 62 

10 0 0 6 0 

11 1 0 8 1 

12 0 0 25 0 

13 1 3 0 0 

14 15 5 30 7 

15 2 0 10 4 

16 12 10 22 5 

17 3 4 34 14 

18 6 0 16 1 

19 14 3 19 12 

20 5 5 4 7 

21 8 4 47 26 

22 9 0 27 0 

23 2 1 27 2 

24 4 2 24 8 

25 0 5 0 19 

26 17 3 54 30 

27 0 0 0 0 

28 35 1 19 0 

29 6 4 19 84 

30 4 3 40 10 

31 1 1 0 1 

32 11 0 5 1 

33 1 3 2 18 

34 0 2 7 1 

OEI-07-00-00644 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE I N F OSTER CARE : GEORGIA 22 
APPENDIX~C 

OIG ID 

Number of Medicaid Claims* 

Medical and 

Physician's Visits 

Dental 

Services 

Prescription 

Medications 

Mental Health 

Services 

35 7 4 5 28 

36 9 6 22 10 

37 10 0 9 1 

38 5 0 15 0 

39 1 0 1 0 

40 14 0 27 0 

41 1 5 137 1 

42 3 13 4 1 

43 2 0 1 1 

44 13 8 108 1 

45 3 7 22 22 

46 7 0 13 0 

47 7 4 187 0 

48 5 1 20 2 

49 0 1 31 24 

50 2 4 17 3 

TOTAL 326 121 1335 494 

KEY 

* Includes only services for which a Medicaid claim was paid. Services 

documented in the case file for which no Medicaid claims were paid are 

not included. 

OEI-07-00-00644 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE I N F OSTER CARE : GEORGIA 23 
∆ APPENDIX ~ D 

EPSDT Services for Sampled Children 

The table below reflects EPSDT services received by each of the 

50 sampled children from March 26, 2000, to March 26, 2003, or from 

entry into foster care to March 26, 2003, whichever is shorter. 

OIG ID 

Medical 

History In 

Case File 

(1) 

Case Plan 

Completed In 

30 Days

(2) 

EPSDT Services Current (3) 

Medical Dental 

1 Y Y A D 

2 Y Y C A 

3 Y Y B D 

4 Y Y A D 

5 Y N B A 

6 Y Y A D 

7 Y Y B C 

8 Y N B C 

9 Y NP D C 

10 Y Y C D 

11 Y Y C C 

12 Y NP C D 

13 Y Y B C 

14 Y NP B A 

15 Y Y B C 

16 Y Y B A 

17 Y NP D A 

18 Y N B D 

19 Y Y B C 

20 Y Y B A 

21 Y NP C A 

22 Y Y A D 

23 Y Y C A 

24 Y Y B A 

25 Y Y B A 

26 Y NP D C 

27 Y NP C D 

28 Y NP A B 

29 Y Y C C 

30 Y NP A C 

OEI-07-00-00644 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE I N F OSTER CARE : GEORGIA 24 
APPENDIX~D 

OIG ID 

Medical 

History In 

Case File 

(1) 

Case Plan 

Completed In 

30 Days

(2) 

EPSDT Services Current (3) 

Medical Dental 

31 Y NP A A 

32 Y Y A D 

33 Y Y B A 

34 Y N C C 

35 Y NP D C 

36 Y Y A A 

37 Y NP C C 

38 Y NP C D 

39 Y NP C D 

40 Y Y A D 

41 Y Y A A 

42 Y Y D A 

43 Y N A D 

44 Y Y A A 

45 Y NP D A 

46 Y Y A D 

47 Y Y B C 

48 Y Y A A 

49 Y NP C B 

50 Y NP D B 

KEY 

(1) Medical History in Case File—case file documentation provided by the 

sampled child’s caseworker included a medical history 

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

after the child entered foster care or was not provided to us. 

Y - Case plan completed within 30 days. 

N - Case plan not completed within 30 days. 

NP - Case plan not provided to us. 

(3) EPSDT Services Current—Medical and Dental 

A - Most recent required service was received. 

B - One or more services were received, but the sampled child would not 

have been considered out of compliance if the service had not been 

received based on his/her age or the length of time the child had been in 

foster care at the time of our review. 

C - Most recent required service was not received. 

D - No services were received, but none were required during our 

claims window (i.e., the length of time the child had been in foster 

care and the period covered by our claims window did not extend 

the full length of time covered by the EPSDT frequency guidelines 

for the child’s age, or the child was under 3 years of age and not 

required to receive dental services). 

OEI-07-00-00644 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE I N F OSTER CARE : GEORGIA 25 
∆ APPENDIX ~ E 

First Placement, Best Placement Assessments 

The table below reflects the number of days from the date of entry into 

foster care to the date child received initial assessment services from a 

First Placement, Best Placement professional. 

Child Entered 

Care During the 

Medicaid 

Claims Window 

OIG 

ID 

(1) 

1 Y 

2 Y 

3 Y 

4 Y 

5 Y 

6 Y 

7 Y 

8 Y 

9 N 

10 Y 

11 Y 

12 Y 

13 Y 

14 N 

15 Y 

16 N 

17 Y 

18 Y 

19 Y 

20 N 

21 Y 

22 Y 

23 Y 

24 Y 

25 Y 

26 N 

27 Y 

28 Y 

29 N 

30 Y 

FP/BP Initial 

Services 

Required 

(2) 

Y 

Y 

Y 

Y 

Y 

Y 

Y 

Y 

Y 

Y 

Y 

Y 

Y 

N 

Y 

N 

Y 

Y 

Y 

N 

Y 

Y 

Y 

Y 

Y 

N 

Y 

Y 

N 

Y 

Initial Required Services 

Developmental 

Assessment 

(3) 

X 

●

●

42 

●

335 

●

●

X 

●

X 

●

●

●

21 

●

●

85 

●

●

●

90 

58 

●

Psychological 

Evaluation 

(3) 

●

 27 

26 

●

 33 

●

 55 

84 

●

 461 

●

 37 

28 

** 

●

 35 

41 

●

 98 

23 

15 

●

●

 33 

Medical 

Examination 

(4) 

9 

4 

3 

2 

25 

46 

19 

61 

8 

1 

243 

34 

435 

49 

26 

20 

38 

17 

148 

1 

9 

X 

294 

2 

Dental 

Examination 

(4) 

●

4 

X 

●

371 

●

145 

21 

●

X 

●

34 

X 

1 

●

43 

216 

●

168 

123 

290 

●

●

23 

OEI-07-00-00644 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE I N F OSTER CARE : GEORGIA 26 
APPENDIX~E 

Child Entered 

Care During the 

Medicaid Claims 

Window 

OIG 

ID 

(1) 

31 N 

32 Y 

33 N 

34 Y 

35 N 

36 Y 

37 Y 

38 Y 

39 Y 

40 Y 

41 Y 

42 Y 

43 Y 

44 Y 

45 Y 

46 Y 

47 N 

48 Y 

49 N 

50 Y 

FP/BP Initial 

Services 

Required 

(2) 

N 

Y 

N 

Y 

N 

Y 

Y 

Y 

Y 

Y 

Y 

Y 

Y 

Y 

Y 

Y 

N 

Y 

N 

Y 

Initial Required Services 

Developmental 

Assessment 

(3) 

40 

●

●

885 

X 

54 

150 

●

●

26 

●

●

140 

●

●

Psychological 

Evaluation 

(3) 

●

 17 

25 

●

●

●

●

 16 

73 

●

 13 

41 

●

 13 

102 

Medical 

Examination 

(4) 

5 

X 

204 

158 

21 

2 

7 

1 

121 

9 

356 

1 

4 

6 

340 

Dental 

Examination 

(4) 

●

15 

156 

X 

●

●

●

13 

128 

●

213 

125 

●

130 

349 

KEY 

(1) Child Entered Care During the Medicaid Claims Window—child entered foster care 

between March 26, 2000, and March 26, 2003. 

(2) FP/BP Initial Services Required—child entered foster care after July 1999, and, 

therefore, was required to receive FP/BP initial services. 

(3) Developmental Assessment or Psychological Evaluation—number of days from the date 

the sampled child entered foster care and receipt of a developmental assessment or 

psychological evaluation. We used either the date of the psychological report from the child’s 

case file or the Medicaid claims data date, whichever was closest to the child’s foster care 

entry date. 

(4) Medical Examination or Dental Examination—number of days from the date the sampled 

child entered foster care and receipt of a medical examination or dental services. We used 

the Medicaid claims data date or medical documentation from the case file, whichever was 

closest to the child’s foster care entry date, to determine when the child received his/her first 

outpatient, emergency room, or EPSDT medical examination. 

X Indicates service not received. 

● Indicates that the service was not required based on the sampled child’s age at the time of 

our review. 

** Child received a psychological evaluation 125 days before coming into foster care. 

OEI-07-00-00644 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE I N F OSTER CARE : GEORGIA 27 
∆ APPENDIX ~ F 

OEI-07-00-00644 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE I N F OSTER CARE : GEORGIA 28 
APPENDIX~F

OEI-07-00-00644 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE I N F OSTER CARE : GEORGIA 29 
APPENDIX~F

OEI-07-00-00644 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE I N F OSTER CARE : GEORGIA 30 
OEI-07-00-00644 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE I N F OSTER CARE : GEORGIA 31 
∆ 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 that 

contributed include: 

Deborah Walden, Team L ad e er

Zula Crutchfield, P oj e er r ect L ad

Elander Phillips, Program Analyst 

Linda Paddock, Pro ram Analyst g

Brian Whitley, Pro ram Analyst g

Steve Milas, Pro ram Analyst g

Michala Walker, Pro ram Analyst g

Linda Hall, Pro ram Specialist g

Barbara Tedesco, Math l Statisticia ematica n 

OEI-07-00-00644 CHILDREN ’ S USE OF HEALTH CARE S ERVICES WHILE I N F OSTER CARE : GEORGIA 32