All children in foster care are eligible to receive basic medical care. Health care services may be available to children in foster care through a managed care system, a public health clinic or private health care providers. How a child’s services will be paid for, and how a state arranges for payment, will determine which health care providers are available and how those health care providers will be reimbursed. If a child enters care and is covered by his or her parents’ health insurance, in all likelihood, health care services will be rendered according to that plan. If a child enters care and has been enrolled in the states’ Child Health Insurance Plan (CHIP), a determination will be made about whether the child will continue under the CHIP program or be transitioned to Medicaid. Factors directing that decision include the anticipated length of stay in foster care, permanency planning and the states’ eligibility rules and regulations for the CHIP program. This information may not be immediately available but should be considered as the care plan is developed. In any case, foster parents must be informed about how health care services will be paid and how they will be reimbursed for out of pocket expenses.

Children in foster care are categorically eligible for Medicaid if they receive services in foster care under the Adoption Assistance and Child Welfare Act, Title IV-E of the Social Security Act. Depending upon their status as determined by the courts, some children’s birth families have financial resources that make the children ineligible for Medicaid.

Medicaid (Title XIX of the Social Security Act) is a program that purchases medical care services for low-income children, families and the elderly. It is financed by each state in partnership with the federal government. The delivery of Medicaid services differs from state to state. State Medicaid agencies determine the types of benefits that will be provided, who will provide the services and the rate of reimbursement for health care services. Physical and mental health services for children in foster care are funded primarily by one of two systems.

A fee-for-service system, is the traditional model for health insurance in the United States. Health care practitioners provide a health care service and bill the insurer, such as Medicaid, a set fee for the service. It may be difficult to find health care providers who accept Medicaid reimbursement due to low reimbursement rates and complicated paper work. The state Medicaid office will have a list of Medicaid vendors that includes primary care physicians, specialists, and mental health providers. Experienced foster parents may have information about the primary care physicians and specialists within their community who accept Medicaid reimbursement.

A Medicaid managed care system offers health care to individuals eligible for Medicaid by setting up contractual agreements with providers to offer a set of health care services. Ideally, Medicaid managed care could ensure immediate access to services, comprehensive care and improved record keeping at reduced costs. An added benefit is that all services may be available in one place. However access to specialists, mental health providers and more intensive health care services often require referrals, which may delay treatment. A trend exists for states to shift Medicaid beneficiaries from traditional fee-for-service systems to lower-cost managed care plans.¹

If Medicaid services are turned down, the caseworker must generate an appeal. Medical necessity is determined by each state regulatory Medicaid plan. If Medicaid is implemented through a managed care organization (MCO), there may be other regulations in the plan. In some instances children in foster care are assigned a provider without special consideration for their level of need. The managed care organization may have an agreement to serve a certain number of children with a specific type of special need. If a child’s needs exceed what the plan has contracted for with the state, the service may be denied. Social workers must often find creative methods to ensure that children’s needed health care services are covered. Social workers, foster parents, physicians and court representatives shared with us some formal and informal strategies to arrange for payment of health care services.

Find out if there is a Care Coordinator within a managed care organization if a child is receiving services from an MCO. A Care Coordinator is a medical case manager who may be available to work with the foster parent and/or the social worker in navigating the system.

Communicate with the Care Coordinator. It is imperative for the physician, caseworker and representatives from the courts to work closely with the managed care organization.

Contact the state or MCO Ombudsman if available. Some states have instituted the position of an Ombudsman who may be located in the Office of the Attorney General, the State Medicaid Office, or State Bureau of Insurance that has authority to investigate complaints in a managed care organization within the state. Social workers, foster parents, and guardians ad litem can contact the state Ombudsman to help address problems with access to Medicaid services, the quality of services, or payment of services. Currently, only a few states have instituted the role of an Ombudsman.

An appeal process exists in every managed care organization. Social workers should become familiar with that process and the regulatory agency that oversees the MCO.

It may be helpful for the social worker to include the opinions of the primary care physician, specialists, the foster parent and GAL in an appeal process to strengthen the case for the "medical necessity" of requested services. The appeal process may take some time to complete. If waiting for a service will cause undue harm or further injury to a child and the team agrees that it is an emergency, alternative-funding sources must be located.

Alternative funding may be available through general welfare accounts, other state subsidies or community programs.

Diapers, special formula, over the counter medications, some therapeutic services, and some durable medical equipment are examples of things that may be ineligible for reimbursement by Medicaid or private insurance. In some cases Medicaid systems are designed to deny coverage of these items the first and second times. They may require filing an appeal several times before they are accepted. Getting a referral from the child’s physician may be helpful but above all persistence is what may be required.

The State Parent Training and Information Center (PTI) funded through the U. S. Department of Education, Office of Special Education and Rehabilitative Services, provides information to families and professionals about accessing educational and some therapeutic services mandated under the Individuals with Disabilities Education Act (IDEA).

If a child is identified as needing special education services, the child’s school may provide some therapies or specialized services, at no cost to the families. These therapies must be written into a child’s Individualized Education Program (IEP). The IEP is developed for children three through 21 under Part B of IDEA by a committee, comprised of parents, teachers, specialists and others. The IEP committee may be convened at any time if there are questions or concerns pertaining to the child’s progress, behavior or other issues that may affect the goals of the plan.

Ø Infants and toddlers, ages birth to three, suspected of having a developmental delay, or a diagnosed disability may be eligible for local early intervention services. If a child is found eligible for Part C services under IDEA, those services will be outlined in an Individual Family Service Plan (IFSP). The designated state agency responsible for overseeing Part C develops the provisions and guidelines for the funding of services. Funding sources include private health insurance, or Medicaid and families may have additional financial responsibilities.

Ø Local service systems often have flexible wrap-around money that may be available for social workers to access on a case by case basis.