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One night last month, a 9-year-old boy who had autism and talked about suicide was one of about 70 foster children and youth sleeping under state surveillance in Georgia hotels.
Georgia’s designated foster care insurer, Amerigroup Community Care, had denied the boy’s placement in a psychiatric facility for residential treatment, said Audrey Brannen, complex care coordinator for Georgia’s child welfare service. He stayed in a hotel for more than a month before being temporarily placed in foster care, she said.
The boy and the other children staying at the hotels had no permanent placement, Brannen said, and many were not receiving help for their complex mental and behavioral needs.
Frustration over gaps in care had gotten so bad that Georgia Department of Human Services Commissioner Candice Broce sent a scathing six-page letter to the state’s Medicaid agency in August — a sign of unusual inter-agency conflict. She argued that Amerigroup, a part of Elevance Health, is not held responsible for failing care and that her foster care contract should not be renewed.
“Simply put, the state’s most vulnerable children do not have access to the physical, mental or behavioral health treatment they need — and deserve,” Broce wrote.
Amerigroup specifically declined to comment on Broce’s comments, saying it had not seen her letter. But Michael Perry, a spokesman for Amerigroup Georgia, said the insurer will hold monthly joint meetings with government agencies to hear any concerns and “will continue to work on behalf of these vulnerable individuals to ensure they have access to appropriate healthcare and support services that they need to be successful.”
Such problems extend beyond Georgia, according to Sandy Santana, executive director of the national advocacy group Children’s Rights. While foster care mostly makes headlines in cases of abuse or neglect — even deaths — the failure of states and insurers to provide adequate health care for these children is widespread and largely without public scrutiny.
“These kids cycle in and out of ERs, and others don’t have access to the services,” said Santana, whose group has filed lawsuits in more than 20 states over foster care issues. “This is a problem across the country.”
Nearly all children in foster care are eligible for Medicaid, the state federal program for low-income earners, but states decide the delivery mechanism. Georgia is one of at least 10 states that have turned to managed care companies to provide specialized services exclusively for foster children and others under state supervision. At least three others – North Carolina, New Mexico and Oklahoma – are taking similar steps. But regardless of the structure, accessing timely care for many of these vulnerable children is a problem, Santana said.
Of course, getting mental health care for privately insured children can also be a struggle, but for children in state custody, the challenge is even greater, said Dr. Lisa Zetley, a Milwaukee pediatrician and president of the American Academy of Pediatrics’ Council on Foster Care, Adoption, and Family Care.
“This is a unique population,” she said. “They went through quite a bit of toxic stress before coming into foster care.”
For states using specialized care for these children, transparency and oversight remain erratic and the quality of care remains a troubling unknown, said Andy Schneider, a research professor at Georgetown University’s Center for Children and Families.
For example, Illinois has paid more than $350 million to insurance giant Centene Corp since 2020. to administer health insurance for more than 35,000 current and former foster children. But last year, an investigation by the Illinois Answers Project newsroom found that Centene’s YouthCare unit repeatedly failed to provide basic medical services such as dental visits and vaccinations to thousands of these children. Federal officials are now investigating allegations about the contract.
Centene said YouthCare was not made aware of any investigation. In a statement, the company said Illinois Answers Project reporting was based on outdated information and did not take into account recent progress as it works “to ensure families have the access they need to quality care and services.” ”
In some cases, child advocates say, the care children receive is not appropriate. In Maryland, the local chapter of the American Civil Liberties Union, Disability Rights Maryland and Children’s Rights filed a lawsuit this month against the state accused of failing to adequately monitor the prescription of psychotropic drugs to children in its foster care system. As many as 34% of the state’s foster children are receiving psychotropic drugs, court documents said, though most of them have no documented psychiatric diagnosis.
In Georgia, Lisa Rager said she and her husband, Wes, know the hurdles of getting services for foster children well. The suburban Atlanta couple has fostered more than 100 foster children and adopted 11 from state prison.
She said one child waited more than a year to see a specialist. Getting approvals for speech or occupational therapy is “a lot of effort.”
Rager said she pays out of pocket for psychiatric drugs for three of her children because of insurance hassles. “It’s better for me to pay cash than wait for Amerigroup,” she said.
Such problems are common, Broce said in her letter. Amerigroup’s “narrow definition for ‘medically necessary services’ is — at first glance — more restrictive than state and federal standards,” she wrote.
“Far too often, case managers and foster homes are told the next available appointment won’t be for weeks or months,” she told the state’s Joint Appropriations Committee on Jan. 17. Broce added that her agency has formed a legal team to combat Amerigroup’s handling of denials.
Amerigroup’s Perry said the clinical policy has been approved by the state and follows regulatory and care guidelines.
In a recent 12-month period, Amerigroup received $178.6 million in government funds for its specialized foster care plan that serves approximately 32,000 children in Georgia, the vast majority of whom are foster children and children adopted from state prison. The contract is currently up for re-bidding.
David Graves, a spokesman for the Department of Community Health, which administers Medicaid in the state, said the agency would not comment on Broce’s letter because it is part of the contract renewal process. Graves said the agency regularly monitors the quality of care children in custody receive. He pointed to a state report showing that Amerigroup was doing well on several counts, such as use of asthma medications.
But Melissa Haberlen DeWolf, research and policy director for the nonprofit Voices for Georgia’s Children, said the majority of children who cycle through state emergency rooms for mental illness are in foster care.
“The healthcare providers we speak to are desperate for help with behavioral health care coordination – finding providers and getting appointments, understanding how to manage behaviors and medications, and preventing crises, and sharing health information between healthcare providers,” she said.
To solve these problems, Zetley, the pediatrician, recommends creating a larger benefit package for foster children, better coordinating care and increasing Medicaid reimbursements to attract more providers to these managed care networks.
Contracts with managed care companies should also be performance-based, with financial penalties if necessary, said Kim Lewis, general attorney for the National Health Law Program’s Los Angeles offices.
“Managed care is only as good as the state’s ability to manage the contract and make sure that what they get is what they pay for,” she said. “It doesn’t work by just, you know, hoping for the best and ‘Here’s the check.'”
But in Georgia, the state has never financially penalized Amerigroup for failing to meet contractually mandated quality standards, Department of Community Health spokesman Graves confirmed. He said the agency and Amerigroup are working to resolve issues brought to their attention.
Georgia has established an oversight committee, with public meetings, to monitor the quality of Amerigroup’s performance. But the commission has not met since August 2020, the state said last month. After questions from KHN, Graves said the panel would meet again this year.
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues. Together with Policy Analysis and Polling, KHN is one of the three major operational programs of KFF (Kaiser Family Foundation). KFF is an endowed non-profit organization that provides information about health issues to the nation.
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