September/October 2015Vol. 16, No. 7Health-Care Screening for Children in Foster Care

Children and youth in foster care are more likely to develop health problems than any other group of children, according to a guide produced by the American Academy of Pediatrics. These health conditions are often underidentified, undertreated, and can be chronic, impacting children's lives in multiple ways, both after they have exited foster care and throughout their adult lives. Children in foster care should receive regular and periodic health and developmental screenings in order to recognize and address potential delays in their growth and development.

The Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Program is a service of Medicaid that focuses on child health and is required in every State. The program includes services such as mental health, developmental, dental, and preventive care for eligible children and youth. EPSDT benefits are intended "to assure that children receive early detection and care, so that health problems are averted or diagnosed and treated as early as possible. When children's health problems are not diagnosed or treated, they not only require more costly treatment later but can inhibit healthy development in other areas as well."¹

In 2010, the Office of Inspector General (OIG) issued a report that found 76 percent of children in nine States did not receive the required health screening services. The report, Most Medicaid Children in Nine States Are Not Receiving All Required Preventive Screening Services, also found that nearly 60 percent of children who received health screenings did not receive a complete screening, missing at least one component.

The OIG cited a number of barriers to ensuring children receive health screenings, including:

• Not all eligible children are enrolled
• Increase in Affordable Care Act's (ACA) provider rates for primary care services
• Lack of dependable and consistent data
• Incomplete reporting by managed care companies in States that contract for Medicaid services

The OIG report recommended that the Center for Medicare and Medicaid Services (CMS) improve both the low participation and incomplete screenings by:

• Requiring States to report the number of vision and hearing screenings of eligible children and youth
• Strategizing ways to encourage participation of beneficiaries in EPSDT screenings
• Developing incentives for providers to encourage complete screenings
• Identifying State practices to increase children's participation in and provider delivery of complete screenings

In an effort to improve the number of eligible children who receive health-care screenings and preventive care, CMS organized a National EPSDT Improvement Workgroup. The development of a set of strategy guides is one outcome of the workgroup. The guides, which each focus on a specific topic, present approaches to improving the access to and utilization of the EPSDT benefit for eligible children.

The U.S. Departments of Health and Human Services and Education also created a guide for child welfare caseworkers that is focused on the importance of behavior screening and child development. The guide, produced in 2014, is part of the Birth to 5: Watch Me Thrive initiative, a part of a Federal effort to encourage healthy development in children.

While there are issues that disrupt the rate at which eligible children receive health screenings, there are some States that have been successful in their implementation. The Center for Health Care Strategies (CHCS) and the Annie E. Casey Foundation's report, Making Medicaid Work for Children in Child Welfare: Examples From the Field, provides case studies of Arizona, Massachusetts, Michigan, and New Jersey. The 2013 report provides a snapshot of the collaborative work the States implemented to "make Medicaid work" for children and families involved in the child welfare system.

Some of the lessons learned reported across each State include:

• Understand the importance of delivering customized responses to children and families. The States interviewed recognized that the life experiences of children and youth in foster care can include types of trauma, separation from family and friends, and multiple placements, meaning a customized response strategy is necessary. No case or need is the same, requiring tailored health-care plans for children in foster care.
• Recognize the importance of cross-agency relationships and collaboration. Interviewees in each State discussed the significance in sharing responsibilities when it comes to meeting the needs of children in foster care, noting that State-level collaboration is essential. However, relationships at the local level are also critical. This can include collaboration with local system leaders and front line staff; cross-agency relationships not only help solve problems, but can also help develop new strategies.
• Create multiple strategies instead of relying on just one approach. Each State in the report had numerous strategies for each of the areas discussed, including service coverage, screening, and financing, among others. "It's hard to identify the most effective strategy. It's a combination—one can't work without the others," said an interviewee.

To find information about the Medicaid program and the Children's Health Insurance Program in your State, call 1.877.KIDS.NOW (1.877.543.7669) or visit http://www.insurekidsnow.gov/qa/index.html.

Birth to 5: Watch Me Thrive!: A Child Welfare Caseworker's Guide for Developmental and Behavioral Screening is available at https://www.acf.hhs.gov/sites/default/files/ecd/child_welfare_guide_march2014.pdf (155 KB).

Making Medicaid Work for Children in Child Welfare: Examples From the Field is available at http://www.chcs.org/media/Making_Medicaid_Work.pdf (821 KB).

The OIG report Most Medicaid Children in Nine States Are Not Receiving All Required Preventive Screening Services, OEI-05-08-00520, May 2010, is available at http://oig.hhs.gov/oei/reports/oei-05-13-00690.asp.

¹ Health Resources and Services Administration. (n.d.). EPSDT & Title V Collaboration to Improve Child Health. Retrieved from http://mchb.hrsa.gov/epsdt/