One night last month, a 9-year-old boy who suffered from autism and talked about suicide was among about 70 children and youth in state-supervised foster care sleeping in Georgia hotels.
Georgia’s designated foster care health insurer, Amerigroup Community Care, has refused to place the boy in a psychiatric facility, said Audrey Brannen, coordinator of complex care for the Georgia Child Welfare Agency. He stayed in a hotel for more than a month before receiving a temporary emergency placement in a foster home, she said.
The boy and the other children staying at the hotels do not have permanent housing, Brannen said, and many do not receive help for their complex mental and behavioral needs.
Frustration over gaps in care had become so great that Candace Bross, commissioner of the Georgia Department of Human Services, sent a scathing six-page letter to the state Medicaid agency in August — signaling an unusual interagency conflict. She claims that Amerigroup, a unit of Elevance Health, is not responsible for care failures and that her foster care contract should not be renewed.
“Simply put, the state’s most vulnerable children are not accessing the physical, mental or behavioral treatment they need — and deserve,” Brose wrote.
Amerigroup declined to comment specifically on Broce’s remarks, saying it had not seen her letter. But Michael Perry, a spokesman for Amerigroup Georgia, said the insurer hosts joint monthly meetings with state agencies to hear any concerns and will “continue to work on behalf of these vulnerable individuals to ensure they have access to the appropriate health care and support services they need to be successful.”
According to Sandy Santana, executive director of the national advocacy group Children’s Rights, such problems extend beyond Georgia’s borders. While foster care grabs the headlines mainly in cases of abuse or neglect — even deaths — the failures of states and insurers to provide adequate health care for these children are widespread and occur largely without public scrutiny.
“These kids are in and out of emergency rooms and others are not accessing services,” said Santana, whose group has filed lawsuits in more than 20 states over foster care issues. “It’s a problem across the country.”
Almost all children in foster care are eligible for Medicaid, the state-federal program for low-income people, but states decide how to provide it. Georgia is among 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, getting timely access to care for many of these vulnerable children is a problem, Santana said.
Getting mental health care for privately insured children can also be difficult, of course, but for children in state custody the challenge is even greater, said Dr. Lisa Zetley, a Milwaukee pediatrician and chair of the American Academy of pediatrics of Foster care, adoption and kinship care.
“This is a unique population,” she said. “They’ve been through quite a bit of toxic stress before entering foster care.”
For states that use special managed care for these children, transparency and oversight remain spotty, and the quality of care remains a troubling unknown, said Andy Schneider, a research professor at Georgetown University’s Center for Children and Families.
Illinois, for example, has paid more than $350 million since 2020 to insurance giant Centene Corp. to manage health coverage for more than 35,000 current and former children in foster care. But an Illinois Answers Project newsroom investigation last year found that Centene’s YouthCare division repeatedly failed to provide basic medical services like dental visits and immunizations to thousands of those children. Federal officials are now investigating allegations about the contract.
Centene said YouthCare has not been informed of any investigation. In a statement, the company said the Illinois Answers Project’s reporting is based on outdated information and does not account for recent progress as it works “to ensure families have the access they need to high-quality care and services.”
In some cases, child advocates say the care the children are receiving is not adequate. 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, accusing it of failing to adequately oversee the prescribing of psychotropic drugs for children in its system. foster care. As many as 34 percent of the state’s foster children are receiving psychotropic medication, court documents say, even though most of them have no documented psychiatric diagnosis.
In Georgia, Lisa Rager said she and her husband, Wes, know all too well the obstacles to receiving foster care services. The suburban Atlanta couple has cared for more than 100 foster children and adopted 11 of them from state custody.
She said one child waited more than a year to see a specialist. Getting approvals for speech or occupational therapy is “a lot of trouble.”
Rager said she pays out of pocket for psychiatric medication for three of her children because of insurance issues. “It’s better for me to pay cash than wait for Amerigroup,” she said.
Such problems happen frequently, Breus said in his letter. “Amerigroup’s narrow definition of ‘medically necessary services’ is — on its face — more restrictive than state and federal standards,” she wrote.
“All too often, case managers and foster families are told that the next available appointment is weeks or months away,” she told the state’s Joint Budget Committee on Jan. 17. Brose added that her agency has formed a legal team to fight Amerigroup’s treatment of waivers.
Amerigroup’s Perry said its clinical policies are state-approved and follow regulatory guidelines and care guidelines.
In the past 12 months, Amerigroup received $178.6 million in state funding for its special foster care plan, which serves about 32,000 children in Georgia, the vast majority of whom are foster children and children adopted out of state custody. The contract is currently up for re-bidding.
David Graves, a spokesman for the Department of Public Health, which manages 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 state custody receive. He pointed to a state report that showed Amerigroup was doing well on several metrics, such as asthma drug use.
But Melissa Haberlen DeWolf, research and policy director for the nonprofit Voices for Georgia’s Children, said the majority of children cycling through the state’s mental health emergency departments are in foster care .
“The caregivers we talk to desperately need help coordinating behavioral health care — finding providers and getting appointments, understanding how to manage behavior and medications and crisis prevention, and sharing health information between providers,” she said. .
To address these issues, Zetley, the pediatrician, recommends creating a larger benefit package for foster children, coordinating care better and raising Medicaid reimbursement rates to attract more providers to these networks for managed care.
Contracts with managed care companies should also be performance-based, with financial penalties if necessary, said Kim Lewis, managing attorney at the National Health Care 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 to just, you know, hope for the best and ‘Here’s the check.'”
But in Georgia, the state has never financially penalized Amerigroup for failing to meet contract quality standards, confirmed Graves, the Department of Public Health spokesman. He said the agency and Amerigroup are working to resolve any issues brought to their attention.
Georgia established an oversight committee with public meetings to monitor the quality of Amerigroup’s work. But the commission has not met since August 2020, the state said last month. After inquiries from KHN, Graves said the group will begin meeting again this year.
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