Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

INTERSTATE COMPACT ON ADOPTION


AND MEDICAL ASSISTANCE


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JUNE GIBBS BROWN 

Inspector General 

JUNE 1996 

OEI-02-95-00040 I 
OFFICE OF INSPECTOR GENERAL 

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 nationwidenetwork of audits, investigations,and inspectionsconductedby three OIG operating 

components: the Office of Audit Services, the Office of Investigations,and the Office of Evaluation and 

Inspections. The OIG also informs the Secretary of HHS of program and management problems and 

recommends courses to correct them. 

OFFICE OF AUDIT SERVICES 

The OIG’SOffice of Audit Services(OAS)provides all auditing servicesfor 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 

responsibilitiesand are intendedto provide independentassessmentsof HHS programs and operationsin 

order to reduce waste, abuse, and mismanagementand to promote economy and efficiency throughout 

the Department. 

OFFICE OF INVESTIGATIONS 

The OIG’SOffice of Investigations(01) conducts criminal, civil, and administrative investigations of 

allegations of wrongdoing in HHS programs or to HHS beneficiaries and of unjust enrichment by 

providers. The investigativeefforts of 01 lead to criminal convictions, administrative sanctions, or civil 

moneypenalties. The 01 also overseesStateMedicaidfraud controlunits which investigateandprosecute 

fraud and patient abuse in the Medicaid program. 

OFFICE OF EVALUATION AND INSPECTIONS 

The OIG’SOffice 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 findingsand recommendationscontainedin these inspectionreports generate rapid, accurate, 

and up-to-date informationon the efficiency, vulnerability, and effectivenessof departmental programs. 

This report was prepared in the New York regional office under the direction of Alan S. Meyer, Ph.D., 

Regional Inspector General. Project staff included: 

REGION 11 HEADQUARTERS 

Nancy Harrison, Project Leader Tina Fuchs 

Demetra Arapakos W. Mark Krushat 

Renee Dunn Dave Wright 

For additional copies of this report, please contact the New York regional office at (212) 264-1998. 
Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

INTERSTATE COMPACT ON ADOPTION 

AND MEDICAL ASSISTANCE 
EXECUTIVE SUMMARY 

PURPOSE 

To assess how membership in the Interstate Compact on Adoption and Medical Assistance 

(ICAMA) affects States’ efforts to protect the interests of special needs adopted children who 

move from one State to another. 

BACKGROUND 

Adopted Children with Special Needs 

The Administration for Children and Families (ACF) has asked the Office of Inspector 

General (OIG) to look at a number of issues regarding interstate compacts, including the 

advantages to State membership in the Interstate Compact on Adoption and Medical 

Assistance and how non-member States are handling cases of special needs adopted children. 

The Adoption Assistance and Child Welfare Act established a federally aided adoption 

assistance program under IV-E of the Social Security Act that provides contributions to State 

subsidies given to parents who adopt special needs children. These children are entitled to 

adoption assistance payments and medical assistance (Medicaid), both of which offset some 

of the extra expense of raising a special needs child. If children are covered by IV-E and 

move to another State, they must be issued a Medicaid card by the State to which they move. 

Interstate Agreements 

A State enters into adoption assistance agreements with adoptive parents which must contain 

“provisions for the protection . . . of the interests of the child in cases where the adoptive 

parents and child move to another State. ” A State may enter into an interstate compact or 

use some other mechanism to fulfill this requirement. The States, however, are not required 

to join a compact and no guidelines or definitions are offered for the other mechanisms they 

may employ. 

The Interstate Compact on Adoption and Medical Assistance (ICAMA) established a formal 

mechanism to ensure that Title IV-E children continue to receive medical and other services 

on an interstate basis, as envisioned under the Adoption Assistance Act. The compact has 

the force of law within and among member States. Currently, 30 States are members of 

ICAMA. 

We gathered information from the ICAMA administrators in all 29 States that were members 

of the compact and representatives from 21 non-member States in 1995. We also 

interviewed selected advocacy groups, ACF staff, American Public Welfare Association 

representatives, and a few adoptive parents to gain their insights on issues of IV-E children 

moving. 

i 
FINDINGS 

ICAMA Membership Provides States with Significant Administrative Advantages in 

Maintaining Medical Assistance for Adopted Children with Special Needs 

Member States benefit from the following administrative advantages: active involvement in 

assisting IV-E children, an accessible contact person, standard forms and instructions, the 

ability to issue timely Medicaid cards, good coordination, and an active Secretariat. As a 

result, virtually all member States are satisfied with the compact. In contrast, most nonmember States do not enjoy these benefits. 

Despite the Advantages of Compact Membership, More Than Hay of the Non-Member 

States See No Need to Join 

Most non-member States are satisfied with their system and think it is easy for IV-E children 

who move into their State to get a new Medicaid card. Many non-member States are 

reluctant to join the compact. They feel the compact offers these children no additional 

medical or financial benefits. Non-member States point to increased staff time and ICAMA 

dues as disadvantages to joining. 

Some non-member States nevertheless feel positively about the compact, noting possible 

advantages of an improved or quicker process in handling IV-E cases and a contact person. 

In fact, four non-member States are planning to join the compact and six more say it is 

possible they will join in the future. 

CONCLUSION 

Overall, we conclude that compact membership is advantageous to States and families with


IV-E children. We recognize that it is each State’s prerogative to join the compact. We also


recognize that such considerations as a State’s size and organizational structure may


discourage the State from joining. However, even if a State elects not to join the compact, it


may still benefit by adopting some of the compact’s procedures, such as designating a contact


person to whom other States and family members can turn for information and assistance.


States that elect not to join might also consider using mechanisms for further educating


parents and local Medicaid workers about IV-E benefits and the obligations that States have


to IV-E children moving across State lines.


The ACF may want to inform all States of the administrative benefits of compact


membership and the resulting benefits to IV-E families. We suggest that ACF work with the


compact’s Secretariat and adoption advocacy groups to disseminate this information. We


believe that compact membership is worthwhile and encourage the States that are planning to


join to do so as expeditiously as possible.


ii 
COMMENTS 

We received favorable comments from ACF on the draft report. They believe it will be a 

useful tool for them to encourage State membership and to positively impact on States’ 

efforts to protect the interests of adopted children with special needs. The actual comments 

received are included in Appendix B. 

... 111 
TABLE OF CONTENTS


EXECUTIVE SUMMARY


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


FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..4


� ICAMA Provides States with Significant Advantages . . . . . . . . . . . . . . . . . . . 4


� Non-member states see No Needto Join . . . . . . . . . . . . . . . . . . . . . . . . 10


CONCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11


APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..< . . . . . . . .


A: Population Data of Member and Non-member States . . . . . ,... . . . . . . . A-1


Map ofMember States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-4


B: Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..B-l

INTRODUCTION


PURPOSE 

To assess how membership in the Interstate Compact on Adoption and Medical Assistance 

(ICAMA) affects States’ efforts to protect the interests of special needs adopted children who 

move from one State to another. 

BACKGROUND 

The Administration for Children and Families (ACF) has asked the Office of Inspector 

General (OIG) to look at a number of issues regarding interstate compacts, including the 

advantages to State membership in ICAMA and how non-member States are handling cases 

of special needs adopted children. 

The Adoption Assistance and Child Welfare Act 

In 1980 Congress amended Title IV of the Social Security Act with the Adoption Assistance 

and Child Welfare Act (P. L. 96-272). The Adoption Assistance Act established a federally 

aided adoption assistance program under Title IV-E of the Social Security Act. It provides 

Federal contributions to State subsidies given to parents who adopt special needs children. 

Special needs children (hereafter referred to as “Title IV-E children”) are children who are 

eligible for Aid to Families with Dependent Children or Supplemental Security Income and 

who are defined by the State as having special needs. “Special needs” refers to factors that 

make a child difficult to place for adoption, such as having emotional or behavioral 

problems, being part of a large sibling group, being a member of a minority, having 

developmental problems or having serious medical conditions. Title IV-E children are 

entitled to adoption assistance payments and medical assistance (Medicaid), both of which 

offset some of the extra expense of raising a special needs child. 

In order for a State to receive Federal contributions it must enter into adoption assistance 

agreements with the adoptive parents. A State that does so is called the adoption assistance 

State. These written agreements must meet certain Federal requirements, such as specifying 

the nature and amount of any adoption assistance payments and services to be provided. The 

agreement must also contain “provisions for the protection . . . of the interests of the child in 

cases where the adoptive parents and child move to another State while the agreement is 

effective. ” A State may enter into an interstate compact or use some other mechanism to 

fulfill this requirement. The Adoption Assistance Act directs the Secretary of Health and 

Human Services to encourage and assist States to enter into interstate compacts so that the 

interests of Title IV-E children are adequately protected if the child moves to another State. 

The States, however, are not required to join a compact and no guidelines or definitions are 

offered for the other mechanisms they may employ. 

It is important that a child continue to receive adoption assistance payments and medical 

assistance (Medicaid) when they move to a new State just as they would if they moved from 

1 
one place to another within the same State. Continuation of the adoption assistance payments 

is not a problem since the adoption assistance State (the State the child moves from) can 

easily mail the payments to the child’s address in the new State (hereafter referred to as 

“residence State”). Continuing medical assistance, however, is more complicated. It is 

almost impossible to find health care providers who will accept another State’s Medicaid 

card. Therefore, the child needs a new card issued in the new residence State as soon as 

possible. Ideally, there should be no delay. 

Interstate Compact on Adoption and Medical Assistance 

In the absence of Federal guidelines, nine States, with ACF’S help, adopted the Interstate


Compact on Adoption and Medical Assistance (ICAMA) in 1986. The compact established a


formal mechanism to ensure that Title IV-E children continue to receive medical and other


services on an interstate basis, as envisioned under the Adoption and Assistance Act. The


compact has the force of law within and among member States. It provides uniform


procedures and forms to conduct interstate transactions. Each member State must designate a


compact administrator who is responsible for the operation of the compact. The


administrator processes ICAMA forms and serves as an information resource. Currently, 30


States are members of ICAMA. Appendix A contains population data of member and non-


member States.


The compact is administered by the Association of Administrators of the Interstate Compact


on Adoption and Medical Assistance (AAICAMA) under a cooperative agreement with ACF.


The American Public Welfare Association (APWA) acts as the compact’s Secretariat under a


subcontract with the AAICAMA. The Secretariat provides technical assistance to compact


members and helps handle interstate problems involving the provision of services and


benefits for interjurisdictional adoption cases falling under the compact,


Consolidated Omnibus Reconciliation Act 

The Consolidated Omnibus Reconciliation Act (COBRA) of 1986 mandated that residence 

States confer Medicaid eligibility to children who have Title IV-E adoption assistance 

agreements with another State. This means that children covered by an adoption assistance 

agreement in one State must be issued a Medicaid card by the State to which they move. 

COBRA did not, however, provide interstate administrative guidance for this transfer 

process. COBRA also gives States the option of providing Medicaid to children who are not 

IV-E eligible but who are adopted pursuant to State-funded adoption subsidy programs and 

meet certain criteria. 

METHODOLOGY 

We conducted telephone interviews in 1995 with the ICAMA administrators in all 29 States 

that were then members. Texas has just recently joined the compact, bringing the total 

membership up to 30 States. At the time of data collection, however, Texas was not a 

member and therefore is treated as a non-member State in this report. We asked each 

administrator about the process that takes place when Title IV-E children move into and out 

2

of his or her State. We also discussed the administrator’s experiences with ICAMA, the 

advantages and disadvantages of being a compact member, and how the compact could be 

improved. 

In this inspection, States belonging to the compact are referred to as member States while 

States not in the compact are called non-member States. 

We also conducted telephone interviews with an adoption specialist, or other representative 

from the State’s office responsible for youth and family services, from 21 of the 22 nonmember States, including Washington, D. C. One State refused to be interviewed. We 

discussed what the States are doing to protect the interstate interests of Title IV-E children 

and how those processes are working. We also asked the 21 non-member States why they 

had not joined the compact and what they see as the compact’s advantages and disadvantages. 

We asked each State to provide us with any written policies and procedures they use in 

processing interstate cases. We developed a review sheet to evaluate the States’ written 

policies and procedures to determine their clarity, thoroughness, and degree of detail. We 

also asked for other supporting documentation. This included any cost-benefit analysis they 

may have done regarding membership in the compact (no State had done any), any data they 

may have on how many days it takes the State to issue a Medicaid card to incoming Title IVE children, and the numbers of IV-E children they have moving into or out of their State. 

The APWA provided additional data on the numbers of IV-E children who have moved 

across State lines. (See Appendix A). 

We constructed an index of State involvement in IV-E cases using data from the telephone 

interviews and written policies and procedures. This index was based on four key variables: 

whether the State, at the State level, is generally aware that a IV-E child has moved into the 

State; whether the State, at the State level, knows when a child moves out; whether the State 

in some way notifies the family that they are IV-E and are entitled to medical assistance in 

their new State; and whether the State or local level sends paperwork to the new State for 

families moving out. A State earned one point for a positive action on each variable. For 

instance, if a State usually sends the family’s adoption assistance agreement to the State the 

family is moving to, the State would earn one point for that variable. Since there were four 

variables, scores could range from O to 4 points. 

Finally, we interviewed selected advocacy groups, ACF staff, an APWA representative, and 

three parents who have adopted a total of ten IV-E children to gain their insights on issues of 

IV-E children moving. The experiences of the parents interviewed include the four possible 

moving scenarios: member State to member State; member State to non-member State; nonmember to member; and non-member to non-member. 

This inspection was conducted in accordance with the Quality Standards for Inspections 

issued by the President’s Council on Integrity and Efficiency. 

3

FINDINGS


ICAMA MEMBERSHIP PROVIDES STATES WITH SIGNIFICANT 

ADMINISTRATIVE ADVANTAGES IN MAINTAINING MEDICAL ASSISTANCE 

FOR ADOPTED CHILDREN WITH SPECIAL NEEDS 

Member States benefit from the following administrative advantages in their efforts to 

maintain IV-E children’s medical assistance: active involvement, a contact person, standard 

forms and instructions, the ability to issue timely medical cards, good coordination, and an 

active Secretariat. As a result, virtually all member States are satisfied with the compact. 

Member States are More Actively Involved than Non-member States in Assisting IV-E 

Children 

Interviews with States and a review of member State procedures show that member States are 

actively involved in ensuring that IV-E children maintain their medical assistance when they 

move across State lines. The State’s compact administrator takes an active role whether the 

IV-E child is moving out of or into his or her State. Most compact administrators report 

spending less than two hours a week on compact duties. When a IV-E child moves out of a 

member State, the administrator verifies the child’s IV-E status and sends the appropriate 

paperwork to the new State of residence. When a IV-E child moves into a member State, 

the administrator is usually notified and facilitates the issuing of new Medicaid cards. If a 

IV-E child moves from one member State to another the transition can be completed by mail, 

and the family does not have to go to any Medicaid offices in either State. 

Non-member States, on the other hand, often do not know when a IV-E child leaves their 

State. When they are aware a child is moving out, over half of the non-member States (11 

of 21) advise the family to go to the Medicaid office in the new residence State to apply for a 

Medicaid card, thus placing the responsibility for maintaining assistance on the family. In 

five non-member States, when a IV-E child moves out, the local offices will notify their 

State office, and one of the two offices will send some paperwork, such as a letter regarding 

IV-E status, to the new residence State. 

Two-thirds of the non-member States say they are usually unaware on a State level when a 

IV-E child moves into their State, especially from other non-member States, because it is 

handled at a local level. In many cases, the State may only become aware of the case if the 

family or adoption assistance State calls with a complaint. Often the State office, when 

aware a IV-E child is moving in, will refer the case to the local office. In many instances, 

however, the family has to find their own way to the local office. Only three non-member 

States say they will issue the Medicaid card and take care of the case at the State level. 

The index of State involvement we have developed, as described in the Methodology, is 

based on two indicators of active notification and two indicators of awareness at the State 

level. State scores on the index show the contrast between active member States and much 

less active non-member States. Based on one point for each indicator in which the State is 

4 
actively involved, possible scores range from zero to four. We consider scores of three or 

more to indicate relatively high involvement and scores of two or less to show relatively low 

involvement. As Table 1 below shows, 93 percent of the member States score three or more 

compared to only 29 percent of the non-member States. Conversely, 71 percent of the nonmember States score relatively low on the index while only four percent of member States 

do. A major reason the non-member States score lower is that while most member States 

(79 percent) usually handle IV-E cases at the State level, fewer non-member States do (33 

percent). 

Table 1 

Scores on Index of Active State Involvement with IV-E Cases 

SCORE I MEMBER STATES I NON-MEMBER STATES I TOTAL II 

4 26 (90%) 1 (5%) 27 

3 1 (3%) 5 (24%) 6 

2 1 (3%) 10 (48%) 11 

1 0 4 (19%) 4 

0 0 1 (5%) 1 

nla 1* (3%) o 1 

II 

TOTAL 29 (100%)# 21 (loo%)# , 1 , 

50 {1 

*One member State could not be scored due to lack of information 

# Percentages do not add up to 100 due to rounding 

Handling IV-E cases at the local level creates more opportunity for problems and 

inconsistency. One problem non-member States identify is that families have difficulty 

finding the appropriate office to go to in their State, thereby delaying the process of getting a 

new card. A few non-member States point out that in non-member States the office that 

handles IV-E is not always located in the adoptions unit and, therefore, is more difficult to 

track down. 

Some member States say it is not uncommon for non-member States to advise a IV-E family 

to go to a local Medicaid office in their residence State but not tell them the child has IV-E 

status. One adoptive mother tells the story of going to the local office in her new residence 

State, which is a non-member, and having to fill out a Medicaid application. She was told 

that eligibility depended on income. The mother was sophisticated enough in IV-E matters to 

know the case worker was mistaken. Once the supervisor was brought in, the case was 

handled properly. Unfortunately, if a IV-E family is not familiar with the law, or is not 

aware their child is IV-E, the child may not receive a new Medicaid card. One State tells a 

story of a family that moved from a non-member State and lived in the new State for 2 years 

before learning they could get Medicaid in the residence State. Another State recalls a case 

of a IV-E child being in her State for 8 or 9 months before the family happened to visit a 

local office and learned the child was eligible for Medicaid. 

5

Non-member States are more likely than member States to feel handling cases of IV-E 

children moving is burden. Seven (33 percent) of the 21 non-member States say it is a 

burden compared with 3 (10 percent) of the 29 member States. All but one of the nonmember States feeling burdened handle the IV-E cases on the local level. 

In Contrast to Non-member States, Member States Have an Accessible Contact Person 

The process for continuation of medical assistance is made easier, both for States and IV-E 

children, by the existence of an ICAMA contact person in each member State. Along with 

other compact duties, the compact administrator serves as the contact person whom States 

and IV-E families can contact for information and assistance. A majority of member States 

(18 of 29) say that having a contact person available to answer questions and provide 

assistance makes the move easier for IV-E families and lessens the stress of the move. Some 

non-member States (4 of 21) agree, saying IV-E children in their State would benefit from 

having a contact person if the State joined ICAMA. 

Most member States (24) believe that having a contact person is one of the biggest 

advantages to compact membership in that it helps facilitate communication between States. 

Many member States say that having a contact is also one of the reasons why they prefer to 

work with member States over non-member States when dealing with IV-E children. 

Many member States (12) consider not having a contact in non-member States a major 

problem, one that could make a move more difficult for a IV-E family. Several member 

States complain of spending many hours on the phone trying to track down the right person 

to talk with about a IV-E case, especially in States that handle IV-E at the local level. This 

was confirmed during this study when we often experienced problems finding the person 

responsible for IV-E cases in non-member States. Reaching these people in member States, 

in comparison, was much easier. 

Member States Have Standard Forms, Instructions and Procedures, While Those Used by 

Non-member States are Inconsistent 

Standard forms and instructions facilitate a smooth administrative process when IV-E 

children move between member States. All member States follow standard procedures and 

use the same four ICAMA forms to process incoming or outgoing IV-E children. These 

forms serve the following functions: to report on the IV-E child’s status; to take the place of 

a Medicaid application in the residence State; to notify States and adoptive families that the 

necessary information has been sent to the new residence State so Medicaid cards can be 

issued; and to give notice to the adoption assistance State that a Medicaid case has been 

opened in the new residence State. The ICAMA forms have clear guidelines for their 

completion and distribution, and instructions for sending the appropriate supporting 

documentation, such as the current adoption assistance agreement. The Association of 

Compact Administrators and the Secretariat are currently working on further streamlining the 

forms. 

6

While all member States use ICAMA forms, about half (14 of 29) have additional policies 

and procedures to clarify the process in their State. Most of these policies and procedures 

clearly detail the steps to be taken when a IV-E child moves into or out of the State. 

Policies from 6 of the 14 member States are comprehensive with precise instructions. 

About half of the non-member States (10 of 21) also have written policies and procedures. 

Although most of the 10 outline the steps to follow when a IV-E child moves into or out of 

the State, only half specify the documentation to expect from an adoption assistance State. 

Three of the 10 States have comprehensive policies and procedures with precise instructions. 

All the written policies and procedures we received from States verify the information we 

were told in the telephone interviews. 

Membership Helps States Issue Timely Medicaid Cards 

Since member States recognize ICAMA forms as eligibility for Medicaid, the card can be 

issued without delay when both States are members of the compact. When States do not use 

standard forms and procedures it is more probable that the documentation the child brings to 

the new residence State will be incomplete and the family will experience delays in getting a 

new card in the new State, whether member or non-member. Fourteen member States say it 

takes longer to issue cards to children from non-member States. They say the children 

coming from these States often do not have proper documentation of IV-E status and getting 

the documentation can be time-consuming, especially if there is no contact person in the 

adoption assistance State. One member State reports that when a child comes without a copy 

of the adoption assistance agreement it can take more than 6 months to get the necessary 

documentation to issue a new card. 

Five non-member States agree that not getting the proper documentation poses problems for 

their State in issuing new cards. They also feel getting the documentation is burdensome. 

Non-member States do not agree, however, that it generally takes longer to issue cards to 

children coming from other non-member States. Almost all of them (19) say it takes the 

same amount of time to issue cards to children coming from non-member States as it does 

for children coming from member States. Five of these non-member States say that their 

local offices issue cards, thereby making it difficult to say how long it takes. Only two nonmember States say it takes longer when they are dealing with a child from a non-member 

State. 

Most States have guidelines or requirements that they must issue Medicaid cards to those 

eligible within a given timeframe, such as 1 month or 45 days. States do not keep data on 

how long it takes to issue individual cards. Many States issue cards only at certain times of 

the month. For instance, one State may issue cards on the 15th of every month so if 

someone applies on the 8th and is deemed eligible, he or she may get the card in a week. If 

that same person had applied on the 20th, he or she would have to wait until the 15th of the 

following month to receive the card. All States report some way of accommodating an 

emergency if the applicant cannot wait to get the card. 

7

Comparison of issuance time before and after membership in the compact is limited due to 

the way cards are issued and the lack of systematic data. Of the 17 member States that could 

compare, just over half (9) say it took longer for their State to issue a Medicaid card before 

their State joined the compact than it does now. Eight member States think it takes the same 

amount of time. The remaining 12 member States could not say how long it took to issue a 

card before the compact. 

Most member States (23) feel that, since they joined the compact, it has been easier for IV-E 

children who move into their State to get a Medicaid card. The main reasons for this, 

according to the States, is the improved administrative process and contact person. Three 

notice no change and the remaining States could not offer an opinion. All member States 

agree, however, that IV-E children benefit from the compact. They think it offers better 

service to families, which is why most member States joined. 

The majority of member States (18) say there are no problems issuing a new card to IV-E 

children who move into their State. The problems they do see mostly involve insufficient 

documentation from other States, usually non-members. 

Coordination is Easier with Member States 

Membership in ICAMA facilitates coordination among States. In contrast to non-member 

States, when a IV-E child moves out of a member State, that member State will notify the 

residence State the child is coming. Almost all (27) member States and 17 non-member 

States report that when a IV-E child moves from a member State into theirs, they find out 

from the other State’s compact administrator. Member States point out that they can begin 

the necessary paperwork right away if they know a child is coming. This helps ensure no 

lapse in assistance for the child. On the other hand, most member States say they usually 

find out about children moving from a non-member State only when the family visits the 

local office in the new State. Non-member States also say that they are usually unaware 

when a IV-E child moves into their State from another non-member State. When they do 

find out, it is through their local office or the other non-member State might call them. 

Twenty-one member States believe the compact usually helps resolve problems between 

States. The compact has the force of law in and among member States so these States can 

turn to the compact and its standards when questions arise, which might happen when an 

inexperienced compact administrator is learning the process. 

Coordination is more difficult when a non-member State is involved in a move. Problems 

between States are more likely to occur if one of those States is a non-member. While only 

a few (4) non-member States complain of problems with member States, almost three times 

as many (11) non-member States complain of problems with non-member States. The 

contrast is even greater with member States: 4 member States report major problems with 

other member States while 21 report major problems with non-member States. Problems 

often involve the lack of a contact person and incomplete IV-E documentation. 

8

A majority of both member (24) and non-member States (12) prefer to work with member 

States over non-member States. They give the following reasons: the ICAMA members are 

easy to work with and are very helpful; member States have a contact person; member States 

send the correct paperwork; and member States are more knowledgeable about IV-E. No 

State, member or non-member, prefers to work with non-member States over member States. 

An Active Secretariat is Another Compact Benefit 

The compact’s Secretariat helps States to better serve IV-E children. All States that 

volunteer an opinion, 21 members and 4 non-members, feel positively about the Secretariat. 

According to these States, the Secretariat helps resolve compact issues, offers technical 

assistance to member and non-member States, and disseminates information on a variety of 

adoption matters in the form of issue briefs. States appreciate the Secretariat’s annual 

conference that addresses many adoption issues. Member States, non-member States, child 

welfare advocates, adoptive parents, and other concerned parties attend the conference and 

are given the opportunity to learn and network. 

Member States are Satisfied with Compact 

Almost all member States are satisfied with the compact: 20 are very satisfied, while 8 are 

somewhat satisfied and 1 State is neither satisfied nor dissatisfied. None are dissatisfied. 

Member States cite many advantages to compact membership, such as an improved 

administrative process when IV-E children move, information sharing and networking, and 

better service for families. Most member States (20) say the compact has no disadvantages. 

Six member States cite the annual dues as a disadvantage. 

Membership does not present an administrative hardship for States. Most member States 

(26) do not feel managing the compact is burdensome. The three member States that say it 

is burdensome blame it on lengthy forms, which are currently being revised. Over half of 

the member States (16) report spending 1 hour or less a week performing ICAMA duties. 

Another five spend between 1 and 2 hours. The number of IV-E children in their State does 

not seem to have an effect on the amount of time spent. Of those 23 member States with 

data, 5 of the 6 with the largest IV-E population say they spend 1 hour or less on ICAMA. 

Almost all member States (27) feel all States should be ICAMA members. When asked for 

suggestions for improving the compact, 14 member States call for increased membership. 

Another suggestion made by many is for all member States to elect the COBRA option and 

grant Medicaid eligibility to non-IV-E special needs children. These children are deemed 

“special needs” by their State, but since they are not IV-E, they are not covered by the 

Adoption Assistance and Child Welfare Act and therefore not guaranteed Medicaid eligibility 

when they move to another State. In many cases, member States have agreed to offer 

eligibility to non-IV-E children who come from other States that will reciprocate and offer 

eligibility to their non-IV-E cases. Some member States cite this reciprocity as another 

compact advantage. 

9

DESPITE THE ADVANTAGES OF COMPACT MEMBERSHIP, MORE THAN HALF 

OF THE NON-MEMBER STATES SEE NO NEED TO JOIN 

Non-member States tend to be large, such as California, Florida, Illinois, New York, and 

Ohio. (See Appendix A). Two-thirds of the non-member States handle interstate IV-E cases 

at the local level. Only one-third handle them at the State level. 

Most Non-member States are Satisfied with their System 

More than half of the non-member States (12 of 21) say they experience no problems in 

issuing a new Medicaid card. In general, non-member States (17) are satisfied with how 

they are handling IV-E cases. Several could not offer any suggestions for improving their 

system. A few suggest adding staff. 

Most (18) non-member States think it is easy for IV-E children who move into their State to 

get a new Medicaid card. Many of these States (8 of 18) cite a lack of complaints as 

evidence. Others say it is easy because their State has a good process. Some non-member 

States (four) concede that it is easy only if the family knows where to go and difficult if they 

do not. 

Many Non-member States are Reluctant to Join the Compact 

When asked why they have not joined ICAMA, 12 States (57 percent) say they see no need 

to become members because they are already handling their IV-E cases and they have no 

problems issuing a new medical card. They feel the compact would not benefit IV-E 

children. They say that, by law, IV-E children are eligible for Medicaid in their residence 

State and the compact offers these children no additional medical or financial benefits. Some 

of them feel that there are too few children involved to justify the possible increased 

administrative costs. Others point to difficulty with their State legislature as an obstacle to 

joining the compact. However, some of these same States do admit that membership might 

make the IV-E process smoother. 

Eight non-member States say a disadvantage to joining the compact is the amount of staff 

time they feel is needed to administer the compact. A comparison of hours spent in both 

member and non-member States, however, shows non-member States report they spend 

roughly the same amount of hours handling IV-E cases as member States. Dues is another 

concern among non-member States. ICAMA dues are $3000 a year, $1500 of which is 

reimbursed by the Federal government. 

Non-member States give a variety of incentives the compact would need to offer to get their 

State to join, including staff, money, more services for children, or some other benefit that 

would convince the decision makers in the State to join. 

10

However, a Few States Plan to Join and Others are Considering It 

Some non-member States nevertheless feel positively about the compact. More than half (16) 

of the non-member States note advantages to ICAMA. The most frequently mentioned 

advantage is an improved or quicker process in handling IV-E cases. Another frequently 

mentioned advantage is the contact person the compact requires. Some States say joining the 

compact might improve information sharing, provide better service to children, and facilitate 

getting the correct, complete paperwork. In fact, for these same reasons, four non-member 

States are planning to join the compact and six more say it is possible they will join in the 

future. 

CONCLUSION 

Overall, we conclude that compact membership is advantageous to States and families with


IV-E children. We recognize that it is each State’s prerogative to join the compact. We also


recognize that such considerations as a State’s size and organizational structure may


discourage the State from joining. However, even if a State elects not to join the compact, it


may still benefit by adopting some of the compact’s procedures, such as designating a contact


person to whom other States and family members can turn for information and assistance.


States that elect not to join might also consider using mechanisms for further educating


parents and local Medicaid workers about IV-E benefits and the obligations that States have


to IV-E children moving across State lines.


The ACF may want to inform all States of the administrative benefits of compact


membership and the resulting benefits to IV-E families. We suggest that ACF work with the


compact’s Secretariat and adoption advocacy groups to disseminate this information. We


believe that compact membership is worthwhile and encourage the States that are planning to


join to do so as expeditiously as possible.


COMMENTS 

We received favorable comments from ACF on the draft report. They believe it will be a 

useful tool for them to encourage State membership and to positively impact on States’ 

efforts to protect the interests of adopted children with special needs. The actual comments 

received are included in Appendix B. 

11

APPENDIX A 

Population Data of Member and Non-member States+ 

State Population # of IV-E # of IV-E Total IV-E 

(Member States 1990 children out children in adopted 

are in bold) of State 1994 State 1994 children 

Alabama 4,040,587 25 197 222 

Alaska 550,043 96 215 311 

Arizona 3,665,228 107 721 828 

Arkansas 2,350,725 5 249 254 

California 29,760,021 * * 13109 

Colorado 3,294,394 177 1127 1304 

Connecticut 3,287,116 * * * 

Delaware 666,168 41 147 188 

D.C. 606,900 * * * 

Florida 12,937,926 * * 4026 

Georgia 6,478,216 116 922 1038 

Hawaii 1,108,229 35 84 119 

Idaho 1,006,749 57 174 231 

Illinois 11,430,602 583 4076 4659 

Indiana 5,544,159 * * 892 

Iowa 2,776,755 * * * 

Kansas 2,477,574 * * * 

Kentucky 3,685,296 231 845 1076 

Louisiana 4,219,973 50 1145 1195 

Maine 1,227,928 * * * 

Maryland 4,781,468 * * * 

Massachusetts 6,016,425 355 * * 

A-1

State Population 

(Member States 1990 

are in bold) 

Michigan 9,295,297 

Minnesota 4,375,099 

Mississippi 2,573,216 

Missouri 5,117,073 

Montana 799,065 

Nebraska 1,578,385 

Nevada 1,201,833 

New Hampshire 1,109,252 

New Jersey 7,730,188 

New Mexico 1,515,069 

New York 17,990,455 

North Carolina 6,628,637 

North Dakota 638,800 

Ohio 10,847,115 

Oklahoma 3,145,585 

I

Oregon 2,842,321 

Pennsylvania 11,881,643 

Rhode Island 1,003,464 

&South Carolina 3,486,703 

,South Dakota 696,004 

rennessee 4,877,185 

rexas 16,986,510 

(

Utah 1,722,850 

1 Vermont 562,758 

Virginia 6,187,358 

1

Washington 4,866,692 

# of IV-E 

children out 

of State 1994 

* 

217 

20 

* 

* 

97 

64 

* 

346 

159 

* 

* 

27 

* 

69 

353 

* 

82 

50 

98 

50 

502 

11


40 

* 

* 

# of IV-E Total IV-E 

children in adopted 

State 1994 children 

* * 

1053 1270 

220 240 

* * 

* * 

456 553 

133 197 

* 325 

1891 2237 

650 809 

* * 

* * 

116 143 

* * 

611 680 

1503 1856 

* * 

506 588 

716 766 

321 419 

723 773 

2921 3423 

363 374 

360 400 

* * 

* * 

A-2

State Population


(Member States 1990


are in bold)


West Virginia 1,793,477 

Wisconsin 4,891,769 

Wyoming 453,588 

#of IV-E


children out


of State 1994


32


100


*


#of IV-E Total IV-E 

children in adopted 

State 1994 children 

136 168


1609 1709


* 83


+ Table is based on 1990 census data and State-reported data of IV-E children as of June,


1994


* Data not available 

A-3

MAP OF MEMBER STATES 

.6 

. . 

. 

A 

A-4 
APPENDIX B 

B-1 
Ibw9m,, 

./ %

{~ DEPAR~ OF HEALTH & HUMAN SERVIC= 

‘%,-4

,	

ADMINISmAmON FOR CHILDREN AND FAMILIES 

Office of the AssistantSecfetafy,Suite 600 

370 L’Enfat Promenade, S.W. 

WashiWfon, D.C. 20447 

May 13, 1996 

TO:	 June Gibbs Brown 

Inspector General 

FROM: Mary Jo Bane 

Assistant Secretary kT~----

for Children and Families 

SUBJECT : OIG Draft Report: !llnterState compact on Adoption and 

Medical Assistance,?’ 0EI-02-96-OO040 

Congratulations on a well done draft report. Your conclusion


that “Interstate Compact on Adoption and Medical Assistance


ntembershi.p provides states with Significant zidmi.ni,strative


advantages in maintaining medical assistance for title IV-E


adopted children with special needstl supports our work to


encourage States to join the Compact.


Over the past three years, Children’s Bureau staff have worked


very closely with the Compact secretariat through a cooperative


agreement. We have been very pleased with the increase in mexob=


States, the excellent rnateri.als produced to keep members


informed, and the Secretariats demonstrated ability to resolve


problems between States (both member and non-member) that impact


on services for title IV-E children and their adoptive families.


We have encouraged States to join the Compact through our 

Regional Office staff and at meetings with the States. Your 

published report will give us an excellent tool to use and 

disseminate among member and non-member States to encourage 

membership and to positively impact on their State’s efforts to 

protect the interests of children with special needs and their 

adoptive families when they move from one state to another.