How providers and CDPHP work together for patients in foster care

High-quality care is critical

CDPHP® reminds providers that access to comprehensive, high-quality health care is especially critical for foster children and youth.

• Compared to children from similar socioeconomic backgrounds outside of the foster care system, children in foster care have higher rates of birth defects, developmental delays, mental and behavioral health needs, and physical disabilities.*

• Children and youth in foster care utilize mental health services (inpatient and outpatient) at a rate 15 to 20 times higher than the general pediatric Medicaid population.*

Your role and responsibility

As a CDPHP network provider, you may find yourself in a position to provide trauma-informed care to Medicaid Managed Care (MMC) enrolled children or youth in direct placement foster care and in the care of voluntary foster care agencies (VFCAs).

Provision and coordination of services for children and youth in foster care must be done in compliance with the New York Medicaid Program 29-I Health Facility Billing Manual and the Transition of Children Placed in Foster Care and NYS Public Health Law Article 29-I Health Facility Services into Medicaid Managed Care guidance documents located on the NYS Department of Health website.

Pharmacy benefit requirements

The pharmacy benefit requirements for children and youth placed in foster care include, but are not limited to, rapid replacement of medically necessary prescriptions and transitional fills. 

Effective April 1, 2023, pharmacy benefits for MMC members were transitioned to NYRx, the Medicaid Pharmacy program. However, physician administered drugs, durable medical equipment, prosthetics, orthotics, and supplies are still covered by CDPHP when billed as a medical or institutional claim. Refer to the NYS Pharmacy Procedure Code Manual for details.

Fiscal Responsibility

When a community provider (Dental, Vision, Primary Care Provider (PCP), etc.) accepts an MMC enrollee as a patient, the community provider agrees to bill the MMC Plan for services provided. The community provider is prohibited from requesting any monetary compensation from the beneficiary, foster parent, foster care youth, the VFCA or Local Departments of Social Services (LDSS).

The community provider will not require the child/youth’s responsible relative, foster parent, foster care youth, or VFCA to sign any documents that would indicate a financial responsibility for any services that are covered under Medicaid or the MMC Plan. 

Consent

The foster parent is not permitted to consent to medical treatment on behalf of the child/youth in foster care. Community providers must contact the VFCA Managed Care Liaison before any community provider appointment to ensure any needed consents are signed by the medical consenter (i.e., birth parent, if parental rights are not terminated, or a designee from the agency, if parental rights are terminated). 

Initial Medical Assessment

Upon placement in foster care, a child/youth is required to have an initial medical assessment within the first 30 days of placement. The child/youth may utilize any PCP or qualified practitioner in the MMC Plan’s network for the purposes of this initial medical assessment.

Primary Care

For ongoing primary care visits, if there is a discrepancy with the assigned PCP on the MMC member ID card, the child/youth should not be turned away; instead, please immediately call the CDPHP foster card liaison at (518) 641-3479 to rectify the matter.

Vision

Emergency, preventive, and routine eye care services are covered by Medicaid Managed Care. Eye care coverage includes the replacement of lost, damaged, or destroyed eyeglasses. For children in foster care, replacement of eyeglasses and/or contact lenses must immediately be authorized as necessary upon placement into foster care, return from trial discharge, or return from home visit. Children/youth in foster care are not required to continuously use the same community vision provider and may access these services from any appropriate participating provider.

Additional information can be found in the Medicaid Managed Care/Family Health Plus/ HIV Special Needs Plan Model Contract located at: https://www.health.ny.gov/health_care/managed_care/providers/docs/mmc_fhp_hiv-snp_harp_model_contract.pdf. If there are any question or concerns, please immediately call the CDPHP foster care liaison, Brianne Sullivan, at (518) 641-3479 to rectify the matter.

Orthodontic Treatment

For ongoing community orthodontic care for children/youth, it is desirable and recommended to continue and finish the active orthodontic treatment utilizing the existing functional orthodontic appliances. In a situation when the new orthodontist cannot continue the active orthodontic treatment with the existing orthodontic appliances due to multiple missing brackets and/or different treatment plans, then a detailed narrative substantiating the need for new orthodontic appliances must be submitted with a prior approval request.

Additional information can be found in the NYS Medicaid Dental Policy and Procedure Manual located at: https://www.emedny.org/ProviderManuals/Dental/PDFS/Dental_Policy_and_Procedure_Manual.pdf.

CDPHP is here to help

If you have a patient in foster care and have questions or concerns – or if there’s a discrepancy with the assigned PCP on the MMC member’s ID card – the child or youth should not be turned away.

Please contact CDPHP foster care liaison Brianne Sullivan via email Briane.Sullivan@cdphp.com or phone (518) 641-3479.

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*American Academy of Pediatrics Task Force on Health Care for Children in Foster Care, Fostering Health: Health Care for Children and Adolescents in Foster Care. (New York: American Academy of Pediatrics, 2005).; and Mark D. Simms, Howard Dubowitz and Moira A. Szilagyi, “Health Care Needs of Children in the Foster Care System,” Pediatrics 2000;106(4 Suppl):909- 918.; and Dutton M Fiori T, Karl A, Sobelson M. Medicaid managed care for children in foster care. In: Fund Medicaid Institute at United Hospital, editor: UHF; 2013.

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