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Depar tm ent of Hea lth an d Hu ma n Services

OFFICE OFINSPECTOR GENERAL

Inspector General

J une 2004

OEI-02-00-00363

FOSTER CARE CHILDREN’S USE

OF MEDICAID SERVICES IN

OREGON



Office of In spector Generalhttp://oig.hhs.gov

The m ission of th e Office of Inspector Genera l (OIG), as ma nda ted by Pu blic Law 95 -452,as am ended, is to protect the int egri ty of th e Departm ent of Health an d Hum an Ser vices

(HHS) programs, a s well as th e health an d welfare of beneficiar ies served by those

progra ms. This s tat ut ory mission is carr ied out th rough a n at ionwide network of audits ,

investigations, and in s pections conducted by th e following operat ing componen ts:

Office of Au dit S ervices

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

conducting audits with its own au dit resources or by overseeing audit work done by oth ers.

Audits exam ine the per form ance of HHS programs and/or i ts grant ees and contr actors

in carrying out t heir r espective responsibi l it ies an d a re int ended to provide independent

assessment s of HHS pr ogram s and operat ions in order to reduce waste, abus e, and

misman agement an d to promote economy and efficiency thr oughout t he depar tm ent.

Office of Evaluat ion an d In spections

The OIG's Office of Evaluat ion and Inspections (OEI) conducts short -term ma na gement

an d program evalua tions (called inspections) tha t focus on issu es of concern t o th e

depart ment , the Congress, an d th e public. The findings and r ecommendat ions cont ained

in th e inspections r eports generat e ra pid, accurat e, and u p-to-date informa tion on th e

efficiency, vulner ability, an d effectiveness of depar tm ent al program s. The OEI also

oversees s tat e Medicaid fraud cont rol units , which invest igate an d prosecute frau d an d

patient a buse in the Medicaid program .

Office of Invest igations

The OIG's Office of Invest igations (OI) condu cts crimin al, civil, an d adm inistr at ive

investigat ions of allegat ions of wrongdoing in HHS p rogram s or to HHS ben eficiar ies

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 th e Inspector General

The Office of Coun sel to th e Ins pector Gener al (OCIG) provides gener al legal ser vices t o

OIG, rendering advice an d opinions on HHS programs a nd operat ions a nd pr oviding al l

legal support in OIG's interna l operat ions. The OCIG imposes program exclusions and

civil monetar y penalt ies on health care providers an d l i t igates th ose act ions with in th e

depart ment . The OCIG also represent s OIG in the global set t lement of cases ar is ing

under the Civil False Claims Act , develops and monitors corporat e integri ty a greements,

develops model complian ce plan s, rend ers a dvisory opinions on OIG sa nctions to th e

health care commu nity, and issues fra ud alerts a nd other indust ry guidance.



,t"'C'S.

DEPARTMENT OF HEALTH &, HUMAN SERVICES Office of Inspector General

.l.""JOWashington , D.C. 20201

JUN - 8 2004

TO: Wade F. Horn, Ph.

Assistant Secretary for Children and Families

FROM:

SUBJECT: OIG Final Report: "Foster Care Children s Use of Medicaid Services inOregon " OEI-02-00-00363

Attached for your review is a final report that assesses whether sampled Oregon foster

care children are receiving Medicaid health care services. We conducted this inspection

in response to concerns about the health care that foster care children are receiving.

Oregon is one of eight States being evaluated.

Our analysis of2 years of Medicaid claims for a random sample of 50 Oregon foster carechildren and interviews with their caseworkers and caregivers reveal that the children in

the sample have Medicaid coverage and access to services. Targeted case management isthe most common and most costly Medicaid claim for children in our sample. Yet , wefound that recipients do not receive any extra, or even ordinary, health care as a result oftargeted case management. Twenty of the 50 sampled foster care children do not have

. preventive care claims during the study period. This lack of preventive care may be duein part, to the belief of some Oregon offcials that Oregon is not bound by any Early andPeriodic Screening, Diagnosis, and Treatment (EPSDT) requirements. In fact, Oregon isbound by EPSDT requirements and is relieved only from its obligation to pay for services

required to treat a condition identified during an EPSDT screening that are beyond the

scope of the benefits package available to an individual receiving Medicaid. For somefoster care children in the sample, caregivers have diffculty obtaining medical records

and accessing dental and mental health services. In addition , sampled children placedout-of-State experience problems obtaining medical coverage.

We believe that the Administration for Children and Families (ACF) and the Centers for

Medicare & Medicaid Services (CMS) should work with the State of Oregon to ensure

that all eligible foster care children receive appropriate health care services. Accordingly,

we recommend that CMS review the use of targeted case management for foster care



Page 2 - Wade F. Horn, Ph.D. and Mark B. McClellan, M. , Ph.

children in Oregon to ensure that it is consistent with State plan provisions and current

CMS requirements for this service. CMS may want to review the use of targeted casemanagement for foster care children in other States to determine the nature and cost of

this service. Also , CMS should work with Oregon to clarify the intent of Oregon s lll5waiver and the State s obligations under EPSDT. ACF and CMS should work withOregon to promote preventive health care that is consistent with EPSDT guidelines.Finally, ACF should work with Oregon and involved paries , such as the State childwelfare administrators and the administrators of the Interstate Compact on the Placement

of Children, to address the health care needs of foster care children placed across Statelines.

In response to our recommendations, CMS is completing a policy letter to the StateMedicaid Directors that wil define targeted case management activities that can beclaimed for Federal financial paricipation from the Medicaid program; adding two

authorities to Oregon s waiver list that wil clarify the intent; and working with the State

to promote preventive health care that is consistent with EPSDT guidelines. ACF reports

that it is actively working with Oregon in the areas of managed care , training, and follow-up care. ACF plans to form a panel of State child welfare administrators , State fostercare managers, State adoption managers, and Interstate Compact on the Placement ofChildren administrators to address the issues of placing foster care children across Statelines. We also received comments from the State of Oregon. Oregon stated that theyplan to continue to work with ACF and CMS to clarfy current policies and practices andto improve future program delivery.

Please send us your final management decision, including any action plan, as appropriate

within 60 days. If you have any questions or comments about this report, please do nothesitate to call me or one of your staff may contact Elise Stein , Director, Public Healthand Human Services Branch, at (202) 619-2686 or through e-mailElise.Stein(loig.hhs. gov). To facilitate identification, please refer to report number

OEI-02-00-00363 in all correspondence.

Attachment



� A B S T R A C T

We reviewed a r an dom sam ple of 50 children in foster car e an d

found that they have Medicaid coverage and access to services.

Targeted case man agement is the most common a nd m ost costly

Medicaid claim for children in our sa mple. Yet, we foun d th at

recipients do not receive any extra , or even ordinar y, health care

as a resu lt of receiving ta rgeted case mana gement. Twenty of

th e 50 sampled foster car e children did n ot have pr eventive car e

claims dur ing the st udy period. This lack of prevent ive car e

ma y be due, in pa rt , to th e belief of some Oregon officials t ha t

Oregon is n ot bound by any Ea rly and Periodic Screening,

Diagnosis, an d Treat ment (EPSDT) requirem ents . In fact,

Oregon mu st comply with E PSDT requiremen ts an d pay for

preventive car e un less the E PSDT screening ident ifies a

condition that is beyond the scope of the benefits package

available to an in dividua l. For some foster care children in t he

sample, caregivers have difficulty obtaining medical records and

accessing denta l an d menta l healt h services. In addition,

sampled children placed out-of-State experience problems

obtainin g medical covera ge. The Cent ers for Medicar e &Medicaid Services (CMS) an d t he Administra tion for Children

an d Fa milies (ACF) concurred with OIG r ecommendat ions t ha t:

CMS review th e use of tar geted case m an agement ; CMS clar ify

th e int ent of th e EP SDT port ion of Oregon’s 1115 waiver ; ACF

an d CMS remind Or egon t o cover an d pay for pr eventive health

car e consistent with EP SDT; an d ACF addr ess the hea lth care

needs of foster car e children placed a cross St at e lines.

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E X E C U T I V E S U M M A R Y

OBJECTIVE

To determ ine wheth er Or egon’s foster car e children ar ereceiving Medicaid h ealth care ser vices.

BACKGROUND

Curr ently, there ar e an estima ted 534,000 children in foster care

na tionwide, an d man y of th em ar e reportedly in poor hea lth.

Compared with children from the same socioeconomic

backgroun d, foster care children suffer m uch higher ra tes of

serious emotional and behavioral problems, chronic physical

disabilities, birth defects, an d developmenta l delays. Despite

th eir need, it appear s tha t ma ny foster car e children ar e notreceiving adequa te health car e.

This inspection focuses on t he St at e of Oregon a nd is p ar t of a

larger body of work in which eight Stat es ar e being evalua ted.

The a na lysis includes 2 year s of Medicaid claims for 50 Oregon

foster car e children a nd int erviews with th eir caseworkers a nd

caregivers.

FINDINGS

Forty-nine of 50 foster care children in the sample haveMedicaid coverage and access to services

The foster car e children in th e sam ple in Or egon h ave medical

covera ge and ar e accessing health car e services. Dur ing the 2-

year inspection per iod, the va st m ajority of children in th e

sa mple (49 out of 50) ha ve at lea st 1 Medicaid claim for th e time

th ey were in foster care. Overa ll, th e num ber of Medicaid claim s

per child in th e samp le ranges from 0 to 472. The ma jority of

caseworkers a nd caregivers r eport th at th eir foster car e children

ha ve access to needed m edical car e.

Targeted case management is the most common and most

costly Medicaid claim for Oregon foster care children in the

sample

Representa tives of Oregon Medicaid define ta rgeted case

man agement services as assisting an individual in gaining

access to additional services. Targeted case man agement claims

account for 75 percent of all Medicaid h ealth car e pa yments for

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E X E C U T I V E S U M M A R YE X E C U T I V E S U M M A R Y

th e sample Oregon foster care children. Over the stu dy period,

Oregon's Sta te Office for Services to Childr en a nd F am ilies

collected approximately $604 to $800 per month, per foster care

child from Medicaid for ta rgeted case man agement . These

payment s total $710,420 for our sa mple. We estimat e the total

payment s for targeted case ma na gement for our sam ple

un iverse t o be approximately $71 million over t he st udy per iod.

It a ppear s th at recipients do not receive any extra , or even

ordina ry, health care a s a r esult of receiving targeted case

management.

Twenty of the 50 foster care children in the sample do not

have preventive care claims

Twenty children in t he sa mple sh ow no preventive claims at all

over 2 year s. Eighteen of th ese 20 have been in cont inuous

foster care for a year or more. None of th e 50 children h ave

Ear ly and P eriodic Screening, Diagnosis, and Tr eatm ent

(EPSDT) claim s. The lack of pr eventive car e cla ims ma y be du e

to Oregon's lack of a clear p eriodicity schedu le for pr event ive

care a nd t he belief of some Sta te officials t ha t Or egon is n ot

boun d by an y EPSDT requirem ents . In addition, we foun d tha t

confus ion exists r egar ding th e EPSDT port ion of th e State’s

Section 1115 wa iver, which relieves Oregon only from its

obligation to pay for ser vices requ ired t o tr eat a cond itionidentified dur ing an E PSDT screening tha t ar e beyond the scope

of the benefits pa ckage a vailable to an individua l receiving

Medicaid.

Some children face problems due to incomplete medical

records, access to certain health care services, and out-of-

State medical coverage

Medical records for children in the sample are often incomplete,

and it appears t hat caseworkers ma y not be tran sferring the

medical history to caregivers. Fost er car e children also facedifficulties a ccessing dent al a nd ment al h ealth services,

alth ough most children ar e able to get needed care eventua lly.

Pr oblems in clude wa it tim e for appoint men ts , lack of Medicaid

providers, dissa tisfaction with quality of car e, and tr ouble

determ ining which dent ists in th e area a re Medicaid providers.

In addition, foster care children placed out-of-Sta te ha ve

difficulty obtaining medical coverage in their new State.

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E X E C U T I V E S U M M A R YE X E C U T I V E S U M M A R Y

RECOMMENDATIONSWe believe that th e Administr at ion for Ch ildren an d Fa milies

(ACF) an d th e Cent ers for Medicar e & Medicaid Ser vices (CMS)

should work with t he Sta te of Oregon t o ensu re t ha t a ll eligible

foster care children r eceive appr opriate h ealth car e services.

Accordin gly, we recomm end t ha t:

o CMS review the u se of targeted case ma na gement for foster

care children in Oregon to ensu re th at it is consistent with

Sta te plan provisions an d cur rent CMS requiremen ts for th is

service. CMS may also want to consider reviewing t he u se of

ta rgeted case man agement for foster car e children in other

Sta tes to determine th e nat ur e and th e cost of th is service.

o CMS work with Or egon t o clarify the Sta te’s waiver a nd th e

Sta te’s obligations un der EP SDT. CMS sh ould also revise

the incorrect citation in the EPSDT portion of Oregon’s 1115

waiver.

o ACF a nd CMS work with Oregon t o promote pr eventive

health car e tha t is consisten t with EP SDT guidelines.

o ACF work with Or egon a nd involved part ies, such as t he

State child welfare a dministrators an d th e administra tors of

th e Inter sta te Compa ct on the Placement of Children

(ICPC), to addr ess th e healt h care n eeds of foster care

children p laced across Stat e lines.

Agency Comments

We received comm ent s from CMS and ACF. The full text of th e

comment s ar e included in Appendix G. CMS concurs with our

recomm endat ions. In regard to ta rgeted case mana gement

(TCM), CMS notes t ha t it is “complet ing a m ajor policy lett er t o

th e Sta te Medicaid Directors th at will define TCM activities tha tcan be claimed for Federa l fina ncial part icipation from t he

Medicaid progra m.” We encoura ge CMS to issu e this policy

letter a s soon a s possible and t o shar e it with all Sta te child

welfare a gencies as well as th e Sta te Medicaid Directors.

We are pleased th at CMS is adding t wo au th orities to th e list of

waived stat ut ory provisions for Or egon t ha t will clarify the

term s of th e waiver. CMS will also work with Oregon t o ensu re

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E X E C U T I V E S U M M A R Y

the Stat e understa nds th at Oregon ha s obligations un der the

EPSDT program .

CMS agrees to work with th e Stat e to promote pr eventive healthcar e tha t is consistent with E PSDT guidelines. It is our h ope

th at th ese effort s will include t he form ulat ion of a clear

periodicity schedule, as required by the E PSDT pr ogram .

In its commen ts, ACF n otes t h at it is actively workin g with

Oregon in t he a reas of ma na ged car e, trainin g, and follow-up

car e. We encour age ACF to cont inue its curren t efforts. We also

encour age ACF to add ress actively the issu e of prevent ive car e

for foster care children, possibly th rough th e Oregon Pr ogra m

Improvement Plan. The Oregon Pr ogram Impr ovement P lan

was developed as a r esult of an ACF Child an d Fa mily Services

Review, which m easu res ind ividual St at es’ perform an ce related

to the h ealth an d well being of children in th e child welfar e

system. Action Step 23.2.3 in the Oregon Program Im provement

Pla n calls for a clear policy for children receiving adequ at e,

timely, necessary and cultu ra lly-competent men ta l health,

medical an d dent al services. We believe preventive car e should

be th oroughly addr essed in th is policy.

ACF plan s to form a pa nel of State child welfar e adm inistra tors,

State foster care ma nagers, State a doption m ana gers, and ICPC

adm inistra tors. This panel will “identify bar riers, issues an d

suggested resolutions related t o placing children across Stat e

lines.” We encour age the timely form at ion of th is panel and

look forwar d to receiving th e pan el’s findings.

We also received commen ts from th e Stat e of Oregon. The full

text of th ese comments can be found in Appendix G. The Sta te

responded th at a m edical chart review would ha ve given a m ore

accur at e assessm ent of the services provided. The Sta te believes

th at th e text of the E PSDT portion of th e 1115 waiver is corr ect

and t hat the Stat e carefully administers th e targeted caseman agement program. Oregon comm ented that th e medical

service problem in inter sta te placements n eeds to be addr essed

at t he na tional level. Oregon plan s to continue t o work with

ACF a nd CMS to clarify cur ren t policies and pra ctices an d t o

improve fut ur e program delivery.

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T A B L E O F C O N T E N T S

A B S T R A C T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i

E X E C U T I V E S U M M A R Y . . . . . . . . . . . . . . . . . . . . . . . . . . . i i

I N T R O D U C T I O N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

F I N D I N G S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Foster children ha ve Medicaid covera ge an d a ccess t o services........ 7Targeted case ma na gement is t he m ost comm on a nd costly claim…9Man y children do not ha ve pr eventive car e claims ......................... 11 Some children face pr oblems ............................................................ 13

R E C O M M E N D A T I O N S . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 6

A P P E N D I C E S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 8

Appendix A: Oregon Adminis tr at ive Rules ...................................... 18 Appendix B: Compa rison of Sam ple t o Universe ............................. 22 Appendix C: Demograph ics ............................................................. 23Appendix D: Description of 50 Foster Childr en in S am ple ............ 25 Appendix E : Medicaid Cla ims for Sa mp le ....................................... 26 Appendix F : Oregon Waiver , Excerpts from Social Securit y Act .... 27 Appendix G: Comments ................................................................... 28

A C K N O W L E D G M E N T S . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 6

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I N T R O D U C T I O N

OBJECTIVE

To determ ine wheth er Or egon’s foster car e children ar ereceiving Medicaid h ealth care ser vices.

BACKGROUND

Curr ently, there ar e an estima ted 534,000 children in foster care

nationwide,1 and man y of them a re r eportedly in poor h ealth.

Compared with children from the same socioeconomic

backgroun d, foster care children suffer m uch higher ra tes of

serious emotional and behavioral problems, chronic physical

disabilities, birth defects, development al d elays, and educational

difficulties.2 Accordin g to one source, ha lf of all children in t hechild welfar e system suffer from development al delays or m enta l

health problems t ha t a re serious enough to need clinical

intervention.3 In a ddition t o the needs they shar e with other

children, su ch as immun izat ions, r out ine well-child

examinat ions, an d tr eatm ent of childhood diseases, foster care

children clearly have a greater need for s pecialized healt h care

services.

Despite th eir n eed, it appears tha t m any foster care children a re

not receiving adequa te health care. Many foster parent s report

difficult y in findin g healt h car e professiona ls who are willing to

car e for th eir children. It is estimat ed tha t 60 percent of all

children in out-of-home care h ave moderat e to severe menta l

health problems, yet less th an one-thir d of th ose children receive

ment al health ser vices.4 A General Accounting Office (GAO)

report issued in May 1995, entitled Health N eeds of Many

Young Children are Unk nown and Unm et , found tha t a

significant proport ion of young fost er car e childr en did n ot

receive critical health-related services in the three locations

1 Retr ieved from ht tp://www.acf.dhhs.gov/progra ms/cb/dis/afcars/cwstats.ht ml on

1/27/042 Health Care of Young Children in Foster Care , Committee on E ar ly Childhood,

Adoption and Dependent Care, American Academy of Pediat rics, Pediatr ics,

Volume 109, Number 3. Mar ch 2002, pp 536-5413 Pamphlet on “Ensuring the Healthy Development of Foster Care Children”, New

York St ate P erma nent J udicial Commission on Just ice for Children , 1999, page 44 Fa ctsheet: The Hea lth Of Children In Out-Of-Home Care. Child Welfare League of

America. Retr ieved 3/14/2003 from:

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

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I N T R O D U C T I O NI N T R O D U C T I O N

stu died (Los Angeles Coun ty, New York City, and Ph iladelphia

County).5 In fact, GAO estima ted t ha t only 1 percent of these

children r eceived E ar ly and Periodic Screenin g, Diagnosis, an d

Treatm ent (EPSDT) services.

Medicaid for Foster Care Children

The Medicaid program provides health care to specified groups

of needy individuals. It is administ ered by the Centers for

Medicar e & Medicaid Ser vices (CMS) an d joint ly fun ded by th e

Federal and State Governm ents. Within broad national

guidelines, each of th e Stat es does th e following: esta blishes its

own Medicaid eligibility stan dar ds; determines th e type,

am ount, du ra tion, and scope of services; sets t he r ate of

payment for ser vices; an d adm inisters its own St at e Medicaidprogram.6

Almost a ll foster care children ar e eligible for Medicaid s ervices.

Accord ing t o section 1902 (a)(10)(A)(i)(I) of th e Social Secur ity

Act, fost er car e children covered u nder Title IV-E of th e Social

Securit y Act are eligible for Medicaid. Foster care children wh o

ar e not eligible for Tit le IV-E u su ally qua lify for Med icaid

th rough other eligibility cat egories set fort h by each Stat e. In

fiscal year 2000, Medicaid pa ymen ts for fost er car e childr en

na tionwide wer e over $3.3 billion.7

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

EPSDT is a Federa l entitlement to compr ehensive medical

services for Medicaid-eligible children un der th e age of 21.

While States have the flexibility to design their own Medicaid

programs, th e EPSDT progra m requires each Sta te to provide

coverage for comprehensive and preventive child health services

to Medicaid-eligible individu als un der t he age of 21. In gener al,

EPSDT tr eatm ent ser vices include all ma nda tory and optiona l

services available under t he Medicaid program. Diagnostic

services are covered whenever there is a medical need to conduct

furt her examination. Treatment or medical care mu st be

5 Healthy Needs of Many Young Children are Unknown and Unmet, General Account ing Office,

GAO/HEH S-95-114, 1995, pages 2 a nd 56 Retrieved 3/14/2003 from: http://www.cms.hhs.gov/medicaid/mover.asp7 Medicaid Expen ditures for Federal Fiscal Y ear 2000, By T ype of S ervice for

Maintenance Assistan ce Status an d Basis of Eligibility A ll States; MSIS Report for

Feder al fiscal year 2000. Nat ional Tota l for Foster Car e children, page 3. Retrieved

from CMS website on 3/13/03: http://www.cms.gov/medicaid/msis/00total.pdf




I N T R O D U C T I O NI N T R O D U C T I O N

provided for any physical or mental conditions discovered by the

screening services.

Under EP SDT, States m ust set distin ct per iodicity schedules forscreening, dent al, vision a nd hear ing services, and services mu st

be provided at intervals that meet reasonable standar ds of

medical pra ctice. Sta tes mu st consu lt with r ecognized medical

organ izations in volved in child health care, such as t he

American Academy of Pediatrics, in developing reasonable

standards. 8

Oregon

Child Welfare - Oregon's foster care system is centr ally mana ged.

At the time of th is inspection, th e Stat e had just fewer th an

7,400 children in foster care.9 Also, at th at time, the Or egon

Sta te Office for Services to Children an d Fa milies was

responsible for adm inistering child welfar e pr ogra ms, including

foster care a nd a doptions. Since th e inspection was condu cted,

Oregon h as r eorgan ized its social service system. The Children,

Adults an d Fam ilies group within t he Departm ent of Hum an

Services is cur rent ly responsible for adm inistering child welfar e

program s. Dur ing our st udy period, Oregon ha d 16 districts

with 42 child welfar e offices and employed about 949 child

welfar e casework ers. Casework ers in child welfar e offices are

responsible for th e placement, m onitoring, a nd coordina tion of services for foster car e children .

Oregon Medicaid - The Office of Medical Assista nce Progra ms

(OMAP) is also within t he Depar tm ent of Huma n Ser vices.

OMAP adm inisters t he Medicaid program in Or egon a nd is

responsible for th e Medicaid claims da ta .

In Oregon, Medicaid is administer ed thr ough the Or egon H ealth

Pla n (OHP). OHP offers t hr ee types of bas ic medical covera ge: a

fee-for-service plan; a ma na ged car e plan; and a prima ry care

case man agement plan.Oregon Administr at ive Rules sta te th at foster care children

ha ve th e r ight t o "ordinary m edical, denta l, psychiat ric,

psychological, and hygienic car e an d t reat ment when th e child's

8 Retr ieved from CMS Website 3/28/03: ht tp://www.cms.gov/medicaid/epsdt/ 9 Child Welfare Out comes 1999: Annu al Report, Section IV-C, Stat e dat a pa ges,

Oregon (from AFCARS dat abase, FY 99)

htt p://www.acf.dhhs.gov/progra ms/cb/publicat ions/cwo99/sta tedata /or.ht m





condition requires it."10 Also under Or egon Administr at ive

Rules, all foster care children in t he care a nd cust ody of the

Depar tm ent of Hu ma n Ser vices receive th e Stat e's medical plan

benefits. A sma ll nu mber of th ese children h ave too mu ch

income, su ch as su rvivor benefits, t o be eligible for Medicaid

un der Title XIX. In t hese cases, health ben efits ar e paid with

State funds.11

Waivers - Un der s ection 1115 of the Social Secur ity Act, wh ich

provides th e Secretar y of the Departm ent of Health an d Hu man

Services (HHS) with a ut hority to au th orize experimenta l, pilot,

or demonst ra tion projects t ha t a re likely to assist in promoting

th e objectives of the Medicaid st at ut e, HHS appr oved waivers

for th e OHP Demonst ra tion Project.

HHS granted Or egon a part ial waiver of the EPSDT

requirem ent in 1995. The Section 1115 waiver allows Oregon t o

elimina te cert ain h ealth car e services in order to extend

Medicaid covera ge to more people. The text of th e waiver sta tes

th at Oregon is no longer obligated t o pay for services r equired t o

treat a condition identified during an EPSDT screening th at are

beyond t he scope of th e benefit packa ge available to an

individua l receiving Medicaid.

Oregon n ow offers a benefits package under th e OHP t ha t is

based on a list of prima ry an d acute medical and men ta l illness

conditions an d services ra nked by the H ealth Services

Comm ission in Or egon.12 It is called th e prioritized list of

services and is approved by CMS.

METHODOLOGY

This inspection is ba sed on inform at ion ga th ered from mult iple

sources: Medicaid claims dat a; a review of Federal and St at e

laws, regulations, an d policies; an d int erviews with Sta te a gency

officials, casewor ker s, an d car egivers.

10 See Appendix A, Oregon Administrative Rules (OAR): 413-010-018011 See Appen dix A, OAR 416-610-0140

12 Fr om Center s for Medicar e & Medicaid Services website, retr ieved 3/18/2003:

http://www.cms.gov/medicaid/1115/default.asp ;

http://www.cms.gov/medicaid/1115/orfact.asp





Reasons for State Selection

This inspection focuses on t he St at e of Oregon a nd is p ar t of a

larger body of work in which eight Sta tes a re being evaluat ed.

Oregon wa s selected because of its size, centr alized child welfare

system, and geographic location.

Sample

Our population consisted of 5,004 Oregon children in continuous

foster care placement for a t least 6 month s prior to Ju ly 2002.

From t his population, a simple ra ndom sa mple of 50 children

was selected. See Appen dices B thr ough D for a compa rison of

th e children in t he sam ple to th e populat ion a nd a m ore detailed

description of children in t he sa mple.

The size of the sam ple limits our a bility to estimate t he

population from the sa mple. However, in the case of th e amount

spent for tar geted case ma na gement claims, the variability of

th ese amoun ts wa s relat ively sma ll (either $674 or $800,

depending on wha t month t he claim was submitt ed). Since th e

variability was sma ll, we were able to produce an estima te of

the am ount spent on targeted case man agement claims in th e

population usin g stan dar d sta tistical formulas for a simple

random sa mple.

Review of Medicaid Claims Data and State Laws and Policy

Medicaid Claims Dat a - Oregon Medicaid provided a claims

history for 2 year s for a ll of the children in our sa mple. The

dat a include claims with ser vice dates between J uly 2000 an d

J uly 2002. En counter da ta for children in mana ged car e are

also included in t hese dat a. We refer to all fee-for-ser vice claims

an d ma na ged car e encoun ters as "claims," un less oth erwise

specified.

In r eviewing the Medicaid claims, we paid pa rt icular at tent ion

to the types of services, dates of service, and settings, where

available. Medicaid claims dat a ar e organ ized into broadcat egories for ana lysis. We excluded claims th at were not healt h

car e related, such as th ose for tra nsport at ion a nd ph otocopying

of medical records . We deter min ed th e periods of tim e the child

was in foster car e, based on informat ion given by the Sta te

Medicaid office an d caseworker s. We exclud ed claim s with a

service date for a time our da ta clearly show that th e child was

not in foster car e. If it was not clear t ha t th e child was in foster




I N T R O D U C T I O NI N T R O D U C T I O NI N T R O D U C T I O N

care du rin g a cert ain p eriod of tim e, we included Medicaid

claims corr esponding to tha t t ime in our a na lysis.

Law and Policy Reviews - We reviewed Federal and Stat e lawsan d policies perta ining to th e health car e of foster car e children.

Interviews

Caseworker Interviews - We inter viewed caseworkers for th e

children in th e sample eith er in person or by telephone. We

spoke with 45 caseworkers, repr esentin g 47 children. (Two

caseworkers were responsible for more th an one child in th e

sam ple). Thr ee caseworkers r efused t o coopera te, despite our

repeated att empts t o interview them an d our repeated attempts

to enlist th e Sta te's help in en couraging caseworker coopera tion.

The caseworker s we spoke with were th e ones responsible for

th e children at t he time the sample was pulled. Each interview

focused on the caseworker's understanding of Medicaid, his or

her experience accessing services for the sampled foster care

children, an d an y barr iers faced by foster car e children in

general for t he time per iod of our inspection. Caseworkers a lso

provided a writt en placement history for ea ch child.

Caregiver Interviews - We inter viewed car egivers for 44 of th e 50

children in our sa mple. We were una ble to rea ch an d gain the

cooperat ion of six car egivers . We use th e term "caregiver" to

refer to a foster par ent or sta ff member of a r esidential facility

wh o is respons ible for th e child. The caregivers we spoke with

were the ones responsible for t he children at t he time t he

sam ple was pu lled. Like the caseworker inter views, our

inter views with car egivers focused on tr aining, Medicaid, an d

procurin g healt h ser vices for t he child for t he t ime period of our

inspection.

State Agency Officials - We held severa l meetings, both in person

an d by telephone, with officials from th e Oregon Sta te

Depart ment of Hu ma n Ser vices, Stat e Office for Ch ildren an dFa mily Services (now Children, Adults an d F am ilies group).

Our discussions covered a wide spectr um of inform at ion to help

us un derst an d how th e Stat e's foster care an d Medicaid systems

are organized.

This inspection wa s condu cted in accorda nce with t he Quality

St andards for Inspections issued by th e Pr esident's Council on

Integrity and Efficiency.




F I N D I N G S Forty-nine of 50 foster care children in the sample The children in th e sample in

have Medicaid coverage and access to services Oregon have medical coverage,

which is r equired by Federal

and St ate laws. Forty-nine out of 50 foster car e children in th e

sam ple have at least 1 Medicaid claim between J uly 2000 and

J uly 2002. Caseworkers an d/or caregivers reported th at 47 of

th e children in th e sam ple had Medicaid coverage in Oregon at

th e time of th e interview. The caseworkers a nd caregivers for

the remaining children could not confirm Medicaid coverage.

Most children in the sample have access to Medicaid services

An a na lysis of Medicaid claims sh ows th at th e children in t he

sam ple are accessing health care services. As seen in Table 1,

the majority of children in th e sa mple (44 out of 50) have atleast 1 office visit claim in a 2-year p eriod while th ey were in

foster care. The children in t he sa mple with a n office visit claim

ha ve an a vera ge of over six office visits each. In a ddit ion, 80

percent of th e children in th e sam ple have a labwork or

diagnost ic claim.

Overall, th e nu mber of Medicaid claims per child in t he sa mple

ra nges from 0 to 472. The ma jority of caseworker s an d

car egivers believe tha t t heir foster care children ha ve access to

needed medical care. Eighty-seven percent of th e caseworkers

an d 82 percent of th e car egivers interviewed report th at th eirchild receives needed medical care.

Fur th er, despite reported bar riers to access tha t will be

discussed la ter, foster care children seem t o be accessing ment al

health services in addition t o oth er medical services. Thirty -

th ree children in t he sam ple (66 percent) have 2,079 ment al

health claims over th e 2-year inspection period.




F I N D I N G S

Table 1: Number and Type of Medicaid Claims for 50 Childrenin Sample

Claim Type

Number of Childrenwith at Least OneClaim

Total Number ofClaims

Targeted case management 49 962

Office visit 44 295

Labwork/Diagnostic 40 374

Mental health 33 2079

Prescription drug 31 683

Immunization 30 199

Preventive 30 59

Dental 28 314

Emergency Room 23 59

Supplies 22 86

School-based services 19 54

Vision 18 99

Physical/Occupational therapy 8 138

Hospital 7 29

Clinic 7 24

Hearing/Speech 6 27

Other 4 10

Home visit 3 5

Total 5,496

Source: OIG Analysis of Oregon Medicaid Claims Data

The foster care children in th e sam ple have a var iety of report ed

cond itions. Accord ing to caseworker s an d car egivers, 82 percent

(41 out of 50) of the children in our sa mple h ave a m edical or

ment al health pr oblem. These problems include ast hm a,

seizur es, depression, an xiety, developmen ta l delays, an d abu se.

See Appendix D for a description of report ed medical and ment al

health problems of children in t he sa mple.




F I N D I N G S

Foster care children in Oregon sometimes receive health care services

outside of Medicaid

Accordin g to car egivers a nd casework ers , 19 children r eceive

health car e services paid for by a source oth er t ha n Medicaid.

These other ser vices ar e paid for by foster par ents , bran ch

fund s, or by schools or non-profit orga nizat ions . Bra nch offices

ha ve State fun ds ava ilable to them to be used for ser vices not

covered by Medicaid. Most of th e addit iona l services received

were related to menta l health t reatment s or prescription dr ugs.

Targeted case management is the most common Case man agement is allowable

and most costly Medicaid claim for Oregonun der Medicaid (section

1905(a)(19) of the Social S ecurit yfoster care children in our sample

Act), an d defined in section

1915(g)(2) as ser vices wh ich will as sist an individua l eligible

un der t he St at e plan in gaining access to needed medical, social,

educationa l and other s ervices. Represent at ives of Oregon

Medicaid define ta rgeted case man agement services as a ssisting

an individua l in gain ing access t o additiona l services.

Targeted case ma na gement claims accoun t for t he m ajority of

Medicaid paymen ts for Or egon foster car e children. Forty -nine

out of 50 foster care children in our sam ple have a Medicaid

claim for t ar geted case man agement services paid t o Oregon's

Sta te Office for Services to Childr en an d Fam ilies. These

ta rgeted case ma na gement paym ents occur virt ua lly every

month t he children ar e in care dur ing the 2-year stu dy period.

This includes children in fee-for-service an d m an aged care

plans.

Oregon’s St at e Office for Ser vices t o Children a nd Fa milies

collected a ppr oxima tely $604 to $800 per mont h per fost er child

for tar geted case ma na gement over th e study period. By way of

comparison, Medicaid pays $101 for Medicaid managed care permonth per foster child in Oregon. In t otal, the Sta te collected

$710,420 from Medicaid for t ar geted case ma na gement for t he

50 childr en over the 2-year st ud y per iod. (See Appendix E.)

This amoun t repr esents a n estima ted 75 percent of all Medicaid

health car e payment s for t hese children over this period.

We estimate t argeted case ma nagement pa yments for our

sam ple population to be $71 m illion over th e st udy period (plus




F I N D I N G S

or minu s $7 million at t he 95 percent confidence level). Our

population is a subgroup of all Oregon children in foster car e

(5,004 out of 7,400).

The Sta te collects t he sa me am oun t for ea ch child each month

th e child is in foster care. For insta nce, all tar geted case

man agement claims in November 2000 are $800 each. All

ta rgeted case man agement claims in December 2001 are $674

each. The type and degree of physical an d ment al health

impairm ents a mong children sh owing these tar geted case

man agement claims vary widely. While some children a ppear t o

ha ve complex medical an d emotiona l problems, others a ppear to

ha ve none. In fact, six children h ave no reported physical or

menta l health impairments at all; yet, they each h ave a ta rgetedcase man agement claim every month a long with th e rest of th e

sample.

It a ppear s th at recipients do not receive any extra , or even

ordina ry, health care a s a r esult of receiving targeted case

man agement . As noted earlier, Oregon Medicaid

represen ta tives define tar geted case ma na gement services as

assistin g an individua l in gaining a ccess t o additiona l services.

Yet, some children s how repeated ta rgeted case man agement

claims du ring long stret ches of time without a ny other Medicaid

services. For example, 1 child has a t ar geted case ma na gementclaim every mont h for 21 consecutive month s with only 1 oth er

Medicaid claim for th at en tir e time period. This child's

caseworker a nd caregiver report t ha t t he child does not receive

oth er h ealth car e services outside of Medicaid. In a ddition, 17

children in t he sa mple show no prevent ive car e claims but ha ve

ta rgeted case ma na gement claims for virtu ally every month t ha t

th ey were in foster care.




F I N D I N G S

Twenty of the 50 foster care children in the sample Sampled children lack EPSDT

do not have preventive care claims claims andpreventive care

The children in th e sample

may not be r eceiving an appr opriate level of preventive car e

even though pr eventive car e is covered un der th e Oregon H ealth

Plan. The Medicaid dat a sh ow no claims at all for EPSDT

services for t he children in our s am ple. Twenty children also

show no preventive car e claims over t he 2-year st udy per iod.

Eighteen of th ese children ha ve been in continuous foster care

for a year or more. Table 2 provides the ages for t hese 18

children.

Table 2:Continuous Foster Care for

At Least One Year with NoPreventive Claims

Age

Number of ChildrenWithout PreventiveClaims

4 2

6 3

7 2

10 1

12 2

13 1

15 1

16 4

17 2

Total 18

Number of Children in

Source: OIG Analysis of Oregon Medicaid Data

The EPSDT program r equires th at each Sta te establish a

periodicity schedule at int ervals tha t meet rea sonable sta nda rds

of medical pr actice. Oregon's pr iorit ized list of Medicaid s ervices

includes pr eventive care, but it does not provide a specific

schedu le for th ese ser vices, nor does it pr ovide recipients or

providers with a clear periodicity schedule for preventive care.




F I N D I N G SF I N D I N G S

Confusion exists regarding the EPSDT portion of the State's waiver

and implementation

There app ears t o be confusion regar ding the brea dth of th e

EPSDT portion of th e 1115 waiver. We learn ed during

interviews that some State representa tives are un der the

impression tha t Oregon is waived from all EPSDT requirem ents ,

which, in fact, it is not. Since EPSDT r equires periodic health

screenings of children, t he belief th at Oregon is n ot boun d by

EPSDT m ay cont ribut e to th e lack of preventive car e we see in

th e sample children.

The E PSDT port ion of Oregon’s Section 1115 waiver elimin at es

the requirement t hat the Sta te must pay for services to treat a

condition identified dur ing an E PSDT screening tha t a re beyondth e scope of the ben efit pa ckage a vailable to the individua l.

(The benefit packa ge is Oregon’s Healt h Ser vices Commission

Pr iorit ized List of Hea lth Ser vices.) However, the waiver

app roval incorrectly cites th e section of th e Social Secur ity Act

th at is being waived as s ection 1902(a)(43)(A). Section

1902(a)(43)(A) is th e requiremen t t ha t St ates mu st inform

Medicaid-eligible childr en of th e EP SDT benefits a vailable to

th em. (Appendix F includes t he full text of th e EPSDT portion

of th e waiver an d th e Social Secur ity Act citat ion.)

Oregon’s Depar tm ent of Huma n Services ha s recentlycomm ented t ha t t he “Stat e believes th at th e text of th e waiver is

corr ect a nd t ha t t he St ate is wa ived from pa yments of conditions

identified dur ing an EPS DT screening.” The State’s commen ts

do not address other E PSDT requirement s. CMS, also in recent

comm ent s, explains Oregon’s resp onsibilities. CMS st at es th at

th e inten t of th e waiver was t ha t “Oregon would not pa y for

tr eatm ent of conditions identified as pa rt of an EP SDT

screening if th e tr eatm ent of th at condition was not covered on

th e Prioritized List of Healt h Care Services. When gran ting this

waiver, CMS inten ded th at Oregon would be required to complywith all other requirem ents of th e ent ire EPSDT program .”




F I N D I N G S

Medical records are often incompleteSome children face problems due to incomplete Caregivers may n ot be able to

medical records, access to certain health care meet their legal obligation if

services, and out-of-State medical coverage they do not receive available

medical records. Oregon

requires caregivers to maint ain a h ealth care record for th e

child, including m edical h istory an d imm un ization records for a

period of 3 years. If a child moves, records mu st be t ra nsferred

to th e child's new h ome. (See Appendix A, OAR 309-046-0190

(11).)

Caseworker s ma y not be tr an sferr ing medical histories to

car egivers. Nineteen of th e 44 caregivers int erviewed say th ey

did not r eceive any of th eir fost er child's medical hist ory at a ll.Yet, 46 out of the 47 casework ers int erviewed indicat e th at th ey

ha d r eceived at least s ome medical h istory on t he foster child in

the sample.

Some children encounter problems accessing dental and mental

health services

Difficulties accessing denta l and ment al hea lth s ervices ar e

reported, alth ough m ost children a re able to get n eeded car e

eventu ally. Car egivers for 16 children report a pr oblem

accessing needed denta l car e. Pr oblems include wait time for

appointments, lack of Medicaid providers, dissatisfaction withquality of care, and tr ouble determin ing which dent ists in th e

ar ea were Medicaid pr oviders. Twelve of the 16 children who

experienced a pr oblem report eventu ally being able to get th e

car e they needed. For example, some caseworker s find

altern at ive sour ces of funding in t he comm un ity for br aces or

oth er cosmetic dental procedures. When ask ed about all foster

care children, not just children in our sa mple, near ly half th e

caseworkers int erviewed ment ion t ha t foster car e children in

general h ave problems a ccessing denta l car e.

Of th e 35 children in th e sample with a reported men ta l health

problem, caregivers of 14 complain about ment a l hea lth services.

Specifically, the car egivers of seven of these childr en feel th at

the tr eatment t hat their child receives is inadequat e. The

car egivers of th e rem aining children en counter problems or

barr iers accessing menta l health services, such a s wait t ime for

app ointm ent s, lack of Medicaid providers, lack of

ser vices/covera ge, an d difficulty findin g good qu ality of care.




F I N D I N G S

Caseworkers, too, cite problems with ment al hea lth s ervices.

Caseworkers for 16 children feel tha t foster care children in

gener al, not just t hose in t he sam ple, experience barr iers

accessing ment al h ealth services.

Caregivers an d caseworker s a lso report p roblems a ccessing

prescription medicat ions. Nine children in the sam ple

experience problems gettin g needed prescriptions. Eight of th e

nine children ar e event ua lly able to get th e prescriptions t hey

need.

Foster care children placed out-of-State experience problems

accessing care

Our d at a sh ow th at five children in t he sa mple were placed out-

of-Sta te for a t leas t some port ion of th e 2-year inspection period.

One of the 5 wa s out of Stat e for 22 month s of the inspection

period. The oth er four were out of Sta te for less tha n 1 year.

It a ppear s from t he claims da ta th at all five out-of-State

children ha d Medicaid coverage in Or egon while th ey were

living in Or egon. Yet, only one of th em seem s to ha ve Medicaid

covera ge in th e oth er Sta te in which th ey were placed. Thr ee of

th e five car egivers cite problems gett ing a Medicaid card as a

barr ier to th e child's access to health car e.

All 50 Stat es, including Oregon, are members of th e Inter sta teCompa ct on th e Placement of Children (ICPC), which requir es

th at a foster child placed over St at e lines r eceive adequa te

protections and su pport services. It esta blishes pr ocedur es for

placement an d compels t he pla cing agency, sometimes called th e

“send ing agency,” to main ta in respons ibility for the child. The

lan gua ge of th e ICPC, however, does not specifically requir e th at

a fost er child placed over St at e lines receive a Medicaid car d in

his/her n ew Stat e. According to Oregon’s Depart ment of Hu ma n

Services Client Ser vices Man ua l, the s ending a gency is

responsible for ar ra ngin g for medical covera ge for th e childbefore the child is placed in a nother Sta te.

Caseworker in volvement with th e five out-of-State children in

our s am ple varies. Two caseworker s say tha t th ey do not know

if th eir child has a Medicaid card. The caregivers for t hese

children r eport th at th eir Oregon caseworker is not involved in

th eir child’s health car e. Two other caseworker s ar e more

involved. For example, one caseworker sa ys she knows that th e




F I N D I N G S

child does not h ave Medicaid covera ge, an d it is her

responsibility to get it, but sh e has n ot been su ccessful yet. The

child ha s been with out coverage for over a year , and th e

caregiver is pa ying for a ll of the child's m edical car e out-of-

pocket . A second casework er report s difficulties in gettin g a

Medicaid card in th e new Stat e and dir ecting th e child to the

right place to get car e. The caseworker for t he rem aining child,

according t o the car egiver, is involved in th e child’s h ealt h car e,

alth ough the child does not yet ha ve a Medicaid car d in th e new

State.

Despit e a la ck of medical covera ge, all five car egivers of th e out-

of-State children say t ha t t heir foster car e child ha s r eceived a

well-child exam wh ile in th eir car e. In some cases, the caregiverpa ys out-of-pocket for th is car e. These services ar e not captu red

in Medicaid claims dat a.




R E C O M M E N D A T I O N S We believe that th e Administr at ion for Ch ildren an d Fa milies

(ACF) and CMS should work with t he Sta te of Oregon t o ensu re

th at all eligible foster care children r eceive appr opriat e hea lth

care services. Accordin gly, we recommen d tha t:

o CMS review the u se of targeted case ma na gement for foster

care children in Oregon to ensure t h at it is consisten t with

Sta te plan provisions an d cur rent CMS requiremen ts for th is

service. CMS may also want to consider reviewing th e use of

ta rgeted case man agement for foster car e children in other

Sta tes to determine th e nat ur e and th e cost of th is service.

o CMS work with Or egon t o clarify the Sta te’s waiver a nd th e

Sta te’s obligations un der EP SDT. CMS sh ould also revise

the incorrect citation in the EPSDT portion of Oregon’s 1115

waiver.

o ACF a nd CMS work with Oregon t o promote pr eventive

hea lth care th at is consisten t with EP SDT guidelines.

o ACF work with Or egon a nd involved part ies, such as t he

State child welfare a dministrators an d th e administrat ors of

ICPC, to address t he h ealth car e needs of foster car e

children placed a cross Sta te lines.

Agency Comments

We received comm ent s from CMS and ACF. The full text of th e

comment s ar e included in Appendix G. CMS concurs with our

recomm endat ions. In regard to ta rgeted case mana gement

(TCM), CMS notes t ha t it is “complet ing a m ajor policy lett er t o

the St at e Medicaid Directors th at will define TCM activities tha t

can be claimed for Federa l fina ncial part icipation from t he

Medicaid program which a re int egral an d insepar able fun ctions

of the foster car e an d child welfar e programs, a nd t he social

service block gr an t (Social Secur ity Act (the Act) titles IVB, IVE

an d XX).” We encoura ge CMS to issu e this policy lett er as soon

as possible an d to sha re it with all Stat e child welfar e agencies

as well as t he St at e Medicaid Directors.

We ar e pleased th at CMS is adding two aut horities to the list of

waived stat ut ory provisions for Or egon t ha t will clarify the

term s of th e waiver. CMS will also “work with Oregon t o ensu re

th e Stat e recognizes tha t th e cur rent waiver…is not a wa iver of

the r equirements of the entire EP SDT program, but rat her for




R E C O M M E N D A T I O N S

th e payment of tr eatm ent for conditions identified as pa rt of an

EPSDT s creening, if such conditions a re n ot covered by th e

Pr ioritized List.”

CMS agrees to work with t he Sta te to promote preventive health

care tha t is consistent with E PSDT guidelines. It is our h ope

th at th ese effort s will include t he form ulat ion of a clear

periodicity schedule, as required by the E PSDT pr ogram .

In its comm ents , ACF n otes tha t it is actively work ing with

Oregon in th e ar eas of mana ged car e, training, and follow-up

services. The action st eps for these efforts ar e included in th e

Oregon P rogram I mpr ovement Plan , developed in response t o an

ACF Child and F am ily Services Review. These reviews measur e

individua l Stat es’ perform an ce related t o the hea lth a nd well-

being of children in th e child welfar e system. We encourage

ACF to contin ue its cur ren t efforts. We also encoura ge ACF to

addr ess a ctively th e issue of preventive care for foster car e

children. Action Step 23.2.3 in t he Oregon Program

Imp rovemen t P lan calls for a clear policy for childr en r eceiving

adequa te, timely, necessar y and cultur ally competen t men ta l

health , medical an d dent al services. We believe prevent ive car e

should be th oroughly addr essed in t his policy.

ACF plans t o form a pa nel of State child welfare adm inistra tors,

State foster care ma nagers, State a doption m ana gers, and ICPC

adm inistra tors. This panel will “identify bar riers, issues an d

suggested resolutions r elated to placing children across Stat e

lines.” We encour age the timely form at ion of th is panel and

look forwar d to receiving th e pan el’s findings.

We also received commen ts from th e Stat e of Oregon. The full

text of th ese comment s is included in Appendix G. Oregon

sta tes t ha t a file review would give a more accura te assessmen t

of ser vices provided. Oregon believes tha t th e text of th e EPSDT

portion of th e 1115 waiver is corr ect a nd t ha t t he St at e car efullyadministers the tar geted case mana gement program. Oregon

commented th at t he medical service problem in inters ta te

placement s needs to be addressed at t he na tional level. Oregon

plans t o cont inue t o work with ACF an d CMS to clarify curren t

policies and pra ctices a nd t o impr ove fut ur e program delivery.




A P P E N D I X ~ A Oregon Administrative Rules (OAR)

413-010-0180 Basic Rights of Children in the State Office for Services

to Children and Families’s (SOSCF's) Custody.Ea ch child placed in t he legal cust ody of SOSCF h as t he

following rights:

(1) To be physically placed in th e least r estr ictive environm ent

th at can appr opriately meet th e child's needs;

(2) To be pr ovided ba sic needs su ch as a dequ at e food, cloth ing,

and shelter;

(3) To receive care, su pervision, an d discipline, an d to be tau ght

to act responsibly and respect th e rights of oth ers;

(4) To be provided ordin ar y medical, dent al, psychiatr ic,

psychological, and hygienic car e an d t reat ment when th e child's

condition requires it ;

(5) To be provided with free a nd appr opriate edu cat ion;

(6) To be protected from physical an d sexua l abuse, emotiona l

abus e an d exploitation;

(7) To be provided ser vices wh ich will reu nit e th e child with h is

or h er own family except when th ere is clear evidence th at th e

family will not pr otect th e child's welfare;

(8) To be provided ser vices t o develop a sa fe, perm an ent

altern at ive to the child's own family, when suita ble fam ily

resources are n ot available;

(9) To be accorded t he least restr ictive legal sta tu s th at is

consistent with th e child's n eed for protection or th e protection

of th e commu nit y, and t o receive advocacy an d/or legal

represent at ion, when needed, to assu re th at t he child's best

interest s are presented to the court;

(10) To receive respect an d be nu rt ur ed in a ccorda nce with h is or

her ba ckground, religious h erita ge, ra ce and cultu re;

(11) To visit an d comm un icat e with members of his or h er family

within r easonable guidelines as set by th e service plan an d by

the court ;

(12) To be involved, in accord an ce with his or h er a ge an d ability

an d with t he law, in ma king ma jor decisions t ha t a ffect h is or

her life;




A P P E N D I X ~ A

(13) To receive encouragement and be afforded reasonable

opportun ities to par ticipat e in s ports, yout h activities in school

an d neighborhood, an d oth er enrichment pr ogra ms;

(14) To earn an d keep h is or h er own money an d to receive

guidance in man aging resources to prepa re him or her for

independence.

416-610-0140 GA Medical Policy

All children in pa id substitu te care who do not m eet th e

eligibility r equir emen ts for Title XIX, will be eligible for Gen era l

Assistance (GA) medical through OMAP.

309-046-0190 Standards and Practices for Care and Services:

(11) Child Record s. A record sha ll be developed, kept cur ren t

an d available on t he prem ises for each child adm itted to th e

foster home:

(a) Genera l Informat ion. The provider shall maint ain a record

for each child in th e home. The record must include:

(A) The child's na me, dat e of ent ry int o the foster h ome, date of

birth, gender, religious pr eference, an d guar diansh ip stat us;

(B) The n am e, addresses, an d telephone nu mber of the child's

guar dian, fam ily, advocat e, or other significan t person;

(C) The n am e, address, an d telephone nu mber of the child's

preferred primary health provider, designated back up health

care provider and/or clinic, dentist, preferred hospital, medical

card n umber an d any private insura nce informa tion, an d

Oregon H ealth Plan choice;

(D) The n am e, address, an d telephone nu mber of the child's

school program; and

(E) The na me, address, an d telephone num ber of th e CMHP

case ma na ger and r epresent at ives of other a gencies providing

services to the child.

(b) Child records sha ll be available to repr esenta tives of the

Division and SOSCF conducting inspections or investigations, as

well as t o th e child, if appr opriate, and t he gua rdian , or other

legally au th orized persons.




A P P E N D I X ~ A

(c) Child records sh all be kept for a per iod of th ree yea rs . If a

child moves or th e foster home closes, copies of pertin ent

inform at ion sh all be tra nsferred t o the child's new home.

(d) Medical In form at ion sh all include:

(A) History of ph ysical, emotional a nd m edical pr oblems,

accidents, illnesses or menta l statu s th at may be pertinent to

curr ent care;

(B) Cur rent orders for medications, tr eatm ents , thera pies, use

of restr aint s, special diets a nd an y known food or medicat ion

allergies;

(C) Completed Medicat ion Administ ra tion Records (MAR) from

previous months ;

(D) Pertinent medical inform at ion su ch as h ospitalizations,

accidents, immun izat ion r ecords including Hepat itis B stat us

an d previous TB t ests, incident s or injuries affecting th e health ,

sa fety or em otional well-being of th e child; an d

(E) Document at ion or oth er n otation of guar dian consent for

medical treat ment tha t is not routine, including surgery and

anesthesia.

(e) Individual Support P lan. The child's ISP is prepa red by the

ISP tea m, and a ddresses each child's behavior, medical andsupport n eeds. The ISP sh all be developed within 60 days of

placement a nd up dat ed ann ua lly or when ever the child's needs

cha nge. The ISP sh all describe the child's behavior, medical,

support needs a nd capa bilities, and will include by whom, when,

an d how often care a nd services will be pr ovided.

(f) Fina ncial r ecords:

(A) A separ at e fina ncial record mu st be main ta ined for ea ch

child if th e provider m an ages or ha ndles t he child's m oney.

(B) Ea ch child's fina ncial record sha ll documen t t he r eceipt of th e room an d boar d fee that is paid to th e provider at th e

beginn ing of each mont h.

(C) Any single item over $50 pur chased wit h t he child's

personal funds, un less oth erwise indicat ed in th e child's ISP,

will be docum ent ed including r eceipt s, in th e child's finan cial

record.




A P P E N D I X ~ A

(D) The child's ISP t eam will addr ess how th e child's personal

spending money will be mana ged and docum ent ed.

(E) If the child has a s epara te commer cial bank accoun t, recordsfrom th at account m ust be maint ained with t he fina ncial record.




A P P E N D I X ~ B Comparison of Children in Sample to Universe of Oregon Foster Care

Children in Continuous Care for 6 Months

As sh own in th e ta ble below, gender an d ages of the children in

th e sam ple are similar t o that of th e un iverse of all Oregon

foster care children in continu ous car e for 6 month s pr ior t o

sam ple selection. Slightly more than h alf of th e sample and

un iverse ar e male. Thirt y percent of both t he sample and

universe are a ge 5 or u nder, roughly 34 percent a re between the

ages of 6 and 12, about 36 percent ar e age 13 or over.

Comparison of Children in Sample to Universe

50 Children in Sample Universe

GENDERCount % of Total Count % of Total

Male 27 54% 2619 52%

Female 23 46% 2385 48%

Total 50 100% 5004* 100%

AGE

0-2 10 20% 647 13%

3-5 5 10% 859 17%

6-9 10 20% 981 20%

10-12 7 14% 861 17%

13-17 18 36% 1484 30%

18+ 0 0% 172 3%

Total 50 100% 5004* 100%

Source: Oregon Medicaid Data

* The u niverse of foster care children in cont inu ous foster care for 6

months pr ior t o sample selection was 5,004 children. The total

num ber of foster car e children in care at th e time of sample

selection was a pproximat ely 7,400.




O E I - 0 2 - 0 0 - 0 0 36 3 F O S T E R C A R E C H I L D R E N’ S US E O F ME D I C A I D S E R V I C E S I N O R E G O N 23

Demographics

The ta ble below shows demographic and health chara cteristics

of each of 50 sam pled children , inclu ding t he a moun t of tim e

th ey were in foster care dur ing our 2-year stu dy period.

Placement set ting refers to th e type of foster care placement th e

child was in at the time our sam ple was pulled in J uly 2002.

ID SexAge

(years)Placement

Setting

Caseworker orCaregiver ReportedMedical Problem(s)

Caseworker orCaregiver Reported

Mental HealthProblem(s)

Amount of Time inCare (Months)

1 M 15 Residential Y Y 24

2 M 12 Family N Y 19

3 M 15 Family Y Y 244 M 11 Family N Y 24

5 F 6 Family N N 23

6 M 16 No Information Y Y 24

7 M 13 Family Y Y 24

8 M 4 Kinship Y N 24

9 F 13 Kinship N Y 24

10 M 2 Family Y N 24

11 F 14 No Information N Y 24


13 M 9 Kinship N Y 22

14 F 5 Family Y Y 24

15 F 12 Family N Y 24

16 F 5 Family N N 21

17 M 10 No Information Y Y 24

18 M 14 Residential N Y 24





23 M 2 Family N N 24


25 F 2 No Information N N 24

26 M 6 Kinship Y Y 10


28 M 13 Residential Y Y 23

29 M 13 Residential N Y 10

A P P E N D I X ~ C



A P P E N D I X ~ C

ID SexAge

(years)Placement

Setting

Caseworker or

Caregiver ReportedMedical Problem(s)

Caseworker orCaregiver Reported

Mental HealthProblem(s)

Amount of Time inCare (Months)


31 M 16 Kinship Y Y 24




35 M 0 Family N N 9





40 M 1 Kinship N N 16

41 F 5 Kinship Y N 24


43 F 4 No Information No Information No Information 24




47 F 16 Family Y N 24

48 F 11 Kinship Y Y 17



Source: Oregon Medicaid Data, OIG analysis of interview data.




A P P E N D I X ~ D Description of 50 Oregon Foster Care Children inSample

Medical problemsCaseworker s or car egivers report t ha t a pproxima tely 50 percent

of the children in our sam ple have at least one m edical problem.

Medical problems included a cne, asthm a, cerebra l palsy, drug

affected, vision problems, obesity, seizur es, allergies, hear t

problems, and genet ic disorder s. Caseworkers or caregivers also

report th at a t least 70 percent of th e children in our sample

ha ve a minimu m of 1 menta l health problem. The most common

ment al health problems a re relat ed to depression, an xiety, or

emotiona l disorder s. Caregivers, in part icular , note many

problems with a nger or behaviora l issues. A nu mber of childrenalso suffer from at ten tion-deficit or at ten tion-deficit-

hypera ctivity disorder an d/or post-tr au ma tic str ess disorder.

Still oth er children ha ve development al delays, learn ing

disabilities, an d su ffer from some form of abu se or neglect.

Types of Medicaid enrollment

Foster care children sometimes h ave several different

placemen ts or go in a nd out of fost er car e, so th ey often

par ticipat e in a few plans. Most children in our s am ple were

enrolled in more tha n one type of plan u nder t he Oregon Health

Plan dur ing our inspection period. Forty-two children wereenrolled in a ma na ged car e plan for a t least some port ion of our

stu dy period. Thirt y-t hr ee were enr olled in a fee-for-service

plan, and t hr ee were enr olled in a pr imar y car e case

man agement plan at some poin t. In addition, some children

were en rolled in one type of plan for m edical covera ge an d

an other t ype of plan for denta l and/or m enta l health s ervices.

For exam ple, a child might h ave a fee-for-ser vice medical plan

but be enr olled in a dental health main tenan ce organization

plan.




A P P E N D I X ~ E

FEE FOR SERVICE MANAGED CARE

962 962 $710,420 0 **

295 109 $4,934 186 **

374 158 $3,693 216 **

2079 517 $57,136 1562 **

683 666 $55,711 17 **

199 74 $8,914 125 **

59 34 $2,108 25 **

314 19 $669 295 **

59 25 $1,751 34 **

86 18 $1,486 68 **

54 54 $5,386 0 **

99 22 $565 77 **

138 44 $2,500 94 **

29 7 $1,398 22 **

24 3 $433 21 **

27 10 $342 17 **

10 9 $1,886 1 **

5 0 0 5 **

Source: OIG Analysis of Oregon Medicaid Data

** Medicaid pays an average capitated rate of $101.22 per child per month for managed care services.13 Children in the samplewere in managed care a total of 731 out of 1101 months.

Number and Amount of Fee-for-Service and Managed Care Claims

for 50 Children in Sample During the 2-year Inspection Period:

Claim Type

Targeted case management

Office visit

Labwork/Diagnostic

Mental health

Prescription drug

Immunization

Preventive

Dental

Emergency Room

Supplies

School-based services

Vision

Physical/Occupational therapy

Hospital

Clinic

Hearing/Speech

Other

Home visit

T O T A L

13 htt p://www.dh s.stat e.or.us/healt hplan /data_pubs/archives/capr at es01-02.pdf

Pr icewater houseCoopers LLP report on Oregon Hea lth Pla n Medicaid

Demonstr at ion, Capita tion Rate Development, Feder al Fiscal Year 2002; 9/25/01,

page 18, Exhibit 2, Stat ewide Capitat ion Rate for F iscal Year 2002




A P P E N D I X ~ F EPSDT Portion of Oregon’s Section 1115 Waiver

(Excerpt from October 15, 2002, Approval Letter from CMS)

“Un der t he a ut horit y of section 1115(a)(1) of the Act, th e

following waivers of Medicaid an d SCH IP Sta te p lan

requirem ents contained in section 1902 and 2103 of th e Act a re

gran ted to enable Oregon to carry out the Oregon Health P lan 2

demonstr ation thr ough this period:

7. Early and Periodic Screening, Section 1902(a)(43)(A)Diagnosis and Treatment (EPSDT)To waive the requirement that States must pay for servicesrequired to treat a condition identified during an EPSDT

screening that are beyond the scope of the benefit package

available to the individual.”

Excerpt from Social Security Act: Section 1902 (a)(43)(A)

“SEC. 1902. [42 U.S.C. 1396a] (a) A Stat e plan for m edical

assistan ce mu st-

(43) provide for-

(A) inform ing all persons in th e Stat e who are un der t he age of 21 an d who have been det erm ined to be eligible for medical

assistance including services described in section 1905(a)(4)(B),

of th e ava ilability of early an d per iodic screen ing, diagnost ic,

an d tr eatm ent s ervices as described in section 1905(r) and the

need for a ge-appropriate imm un izat ions a gainst vaccine-

preventable diseases,”




� A P P E N D I X ~ G




A P P E N D I X ~ G




A C K N O W L E D G M E N T S This report was prepa red un der t he direction of J ohn I. Molnar , former Regiona l Inspector Genera l for E valuat ion a nd Ins pections in th e New York Regiona l Office, an d J odi Nudelma n, Assista nt Regional Inspector Genera l. Oth er principal Office of Evaluation a nd Inspections sta ff who cont ribut ed include:Nancy Harr ison, Team L eader Laura Torres, Lead Analyst Nata sha Besch, Program An alyst Nicole Gillett e, Program Analyst Thomas Zimmerm ann , Program An alyst Linda Hall, Program Specialist Barba ra Tedesco, Statistician

foster care children s use of medicaid services in oregon " oei-02-00-00363

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