January 27, 2023

This story was provided by WABE content partner Kaiser Health News.

One night last month, a 9-year-old boy who had autism and had talked about killing himself was among about 70 foster children and juveniles under state custody who were staying in hotels across Georgia.

Georgia’s designated foster care health insurer, Amerigroup Community Care, had refused to place the boy in a psychiatric residential facility, said Audrey Brannen, coordinator of complex care for Georgia’s Youth Services. He stayed in a hotel for more than a month before receiving temporary emergency placement in a nursing home, she said.

The boy and the other children staying at the hotels lacked permanent housing, Brannen said, and many were not getting help for their complex mental and behavioral needs.

So great was frustration over coverage gaps that Candice Broce, commissioner of the Georgia Department of Human Services, sent a scathing six-page letter to the state Medicaid agency in August – a sign of an unusual conflict between agencies. She argued that Amerigroup, a unit of Elevance Health, should not be held responsible for failures in care and that her care contract should not be renewed.

“Put simply, the state’s most vulnerable children are not accessing the physical, mental or behavioral health care they need — and deserve,” Broce wrote.

Amerigroup declined to comment specifically on Broce’s comments, saying it had not seen her letter. But Michael Perry, a spokesman for Amerigroup Georgia, said the insurer holds monthly joint meetings with state agencies to hear concerns and will “continue to work on behalf of these vulnerable individuals to ensure they have access to the appropriate health and support services.” have what they need to be successful.”

According to Sandy Santana, executive director of the national advocacy group Children’s Rights, such problems go beyond Georgia. While foster families make headlines primarily in cases of abuse or neglect—even fatalities—the failure of states and insurers to provide adequate health care to these children is widespread and largely occurs without public scrutiny.

“These kids are cycling in and out of emergency rooms, and others aren’t accessing the services,” said Santana, whose group has filed lawsuits in more than 20 states over foster care issues. “It’s an issue across the country.”

Almost all children in foster care are eligible for Medicaid, the state-federal program for low-income people, but the states decide the delivery mechanism. 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.

Of course, getting mental health care for privately insured children can also be a struggle, but the challenge is even greater for children in government care, said Dr. Lisa Zetley, Milwaukee-based pediatrician and chair of the American Academy of Pediatrics’ Council on Nursing, Adoption, and Family Nursing.

“This is a unique population,” she said. “They experienced quite a bit of toxic stress before they went into foster care.”

For states that implement specialized managed care for these children, transparency and oversight remain patchy, and the quality of care remains a troubling unknown, said Andy Schneider, research professor at Georgetown University’s Center for Children and Families.

Illinois, for example, has pledged more than $350 million to insurance giant Centene Corp since 2020. paid 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 like dental visits and immunizations to thousands of these children. Federal officials are now investigating allegations about the contract.

Centene said YouthCare was not informed of any investigation. In a statement, the company said the Illinois Answers Project’s reporting was based on outdated information and did not reflect recent advances as it works to “ensure families have the access they need to quality care and services.”

In some cases, child advocates say child care is not appropriate. In Maryland, the local branch of the American Civil Liberties Union, Disability Rights Maryland and Children’s Rights filed a lawsuit against the state this month, accusing it of failing to adequately monitor the prescription of psychiatric drugs to children in its care system. Up to 34% of the state’s foster children are on psychiatric drugs, according to court documents, though most of them do not have a documented psychiatric diagnosis.

In Georgia, Lisa Rager said that she and her husband Wes know well the hurdles of obtaining foster child services. The couple, from suburban Atlanta, have cared for more than 100 foster children and adopted 11 of them from state care.

She said a child waited more than a year to see a specialist. Getting approval for speech therapy or occupational therapy is “a lot of hassle”.

Rager said she was paying for psychiatric medication for three of her children out of her own pocket because of insurance issues. “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 of ‘medically necessary services’ is, on the face of it, more restrictive than state and federal standards,” she wrote.

“Far too often, case managers and foster families are told that the next available appointment is weeks or months in advance,” she told the state’s Joint Appropriations Committee on Jan. 17. Broce added that her agency had formed a legal team to combat Amerigroup’s handling of denials.

Amerigroup’s Perry said its clinical guidelines are state-approved and follow regulatory and care guidelines.

In the past 12 months, Amerigroup received $178.6 million in federal funding for its Special Care Plan, which serves approximately 32,000 Georgia children, the vast majority of whom are foster and foster children. The contract is currently up for re-tendering.

David Graves, a spokesman for the Department of Community Health, which operates Medicaid in the state, said the agency will 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 government care receive. He pointed to a state report showing that Amerigroup performed 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 who cycle through the state’s emergency rooms for mental illness are in foster care.

“The caregivers we speak to are desperate for help with coordinating behavioral medicine — finding providers and making appointments, understanding how behaviors and medications are managed, preventing crises, and sharing health information between providers,” she said.

To address these issues, pediatrician Zetley recommends creating a larger benefits package for foster children, better coordinating care, and increasing Medicaid reimbursement rates to attract more providers to these managed care networks.

Contracts with managed care companies should also be merit-based, with penalties where appropriate, said Kim Lewis, senior counsel for the Los Angeles offices of the National Health Law Program.

“Managed care is only as good as the state’s ability to manage the contract and ensure they get what they pay for,” she said. “It doesn’t work by just hoping for the best and ‘Here’s the check.'”

But in Georgia, the state has never financially penalized Amerigroup for not meeting contractually mandated quality standards, confirmed Graves, a spokesman for the Department of Health. He said the agency and Amerigroup are working to resolve any issues brought to their attention.

Georgia has established an Oversight Committee with public meetings to oversee the quality of Amerigroup’s performance. But the committee has not met since August 2020, the state said last month. After inquiries from KHN, Graves said the panel would meet again this year.

The National Suicide Prevention Lifeline is a helpline for people in crisis or those who want to help someone else. Call 988 or text to speak to a certified listener.

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