Background EPSDT Benefit Federal law specifies that the EPSDT benefit covers screening, vision, dental, and hearing services, as well as other Medicaid coverable services that are necessary to correct or ameliorate any conditions discovered through screening. The EPSDT benefit generally entitles beneficiaries to these services regardless of whether such services are covered in a state’s Medicaid state plan and regardless of any restrictions that the state may impose on coverage for adult services. The EPSDT screening component includes a wide range of preventive services, such as comprehensive child health assessments known as well-child screenings and age-appropriate blood lead screenings. Because EPSDT covers any medically necessary service that could be covered for adults in addition to the specified preventive screenings, the EPSDT benefit is generally more comprehensive than the benefits provided for adult beneficiaries. The federal government and states jointly share responsibility for implementing the EPSDT benefit. CMS, as part of its Medicaid oversight responsibilities, approves state Medicaid plans, which describe how the state administers its Medicaid program, including components related to the provision of EPSDT services. CMS also develops and issues general guidance to states about the EPSDT benefit, such as explanations of covered services and strategies for providing those services. Additionally, CMS has developed a goal for EPSDT, which is to assure that beneficiaries get the health care they need when they need it: the right care to the right child at the right time in the right setting. Further, CMS established performance measures, some with associated targets, to guide states’ implementation of EPSDT. For example, CMS set performance measures and performance measure targets as part of its Oral Health Initiative. CMS developed the performance measure targets to carry out statutory requirements, quality improvement efforts, and agency policy. (See table 1 for EPSDT performance measures that have associated targets.) States have flexibility, within federal parameters, to determine how EPSDT services are provided. For example, states are required to ensure that Medicaid-eligible beneficiaries and their families are aware of the EPSDT benefit and have access to required services, but states can choose whether to administer the benefit themselves or to oversee managed care organizations that are contracted to provide the benefit. States may also determine the frequency of screening services and communicate them through periodicity schedules that meet federal requirements. EPSDT Reporting CMS uses various sources of information to oversee the EPSDT benefit, such as the CMS-416, the Child Core Set, and the Medicaid and CHIP Scorecard. CMS-416 and Child Core Set States report information about the provision of select ESPDT services to CMS annually through the CMS-416 and measures on the Child Core Set. The CMS-416 provides CMS with basic information about EPSDT services, such as the participant ratio and number of beneficiaries receiving a preventive dental service. It includes the information necessary for CMS to assess states’ performance on the participant ratio and the screening ratio, among other things. The agency then can compare performance on the two ratios with the agency’s ESPDT performance measure targets. The Child Core Set provides CMS with information about the quality of health care provided to Medicaid and CHIP beneficiaries, and supports state efforts to improve health care quality and health outcomes. Child Core Set reporting becomes mandatory on an annual basis beginning with the state reports on fiscal year 2024. As of 2019, the Child Core Set included performance measures related to the provision of EPSDT services, such as well-child visits in the first 15 months of life. Because reporting is currently voluntary, states vary in the number of performance measures they choose to report. In fiscal year 2017, for example, 50 states and the District of Columbia voluntarily reported on at least one of the 27 Child Core Set performance measures, with states reporting a median of 18 Child Core Set performance measures. (See app. II for the information reported in the CMS-416 and Child Core Set.) As shown in table 2, there are both similarities and differences between the CMS-416 and Child Core Set. Since the Child Core Set performance measures include CHIP beneficiaries who may not be entitled to the EPSDT benefit, data from the Child Core Set are not directly comparable with reporting on the CMS- 416. In addition, CMS-416 data cover a longer period of time, as they are available from 1995, while Child Core Set data are available from 2011. CMS officials said that having more years of CMS-416 data helps identify trends in the provision of EPSDT services over a longer period of time than possible with the Child Core Set. On the other hand, CMS officials said it is difficult to compare states’ performance using the CMS- 416, because some performance measures are based on periodicity schedules, which vary state-to-state and over time. In contrast, the Child Core Set allows for more consistency in comparing data across states, because each state is expected to calculate performance measures in the same way. Medicaid and CHIP Scorecard In June 2018, CMS published the first Medicaid and CHIP Scorecard, which includes performance measures about the provision of services to Medicaid and CHIP beneficiaries. The scorecard includes 17 performance measures related to the provision of EPSDT services, six of which are performance measures from the Child Core Set—and one of these six measures is derived from the CMS-416. In January 2019, CMS officials reported that the scorecard will be used to provide increased transparency about state Medicaid program administration and beneficiary health outcomes, and drive health care quality improvement across states. According to CMS officials, CMS envisions that the scorecard will be strengthened as state reporting of data through T-MSIS becomes more timely, accurate, and complete. CMS has been working since 2011 to implement T-MSIS as a replacement for some current reporting to improve and increase states’ reporting of Medicaid and CHIP data. CMS intends for T-MSIS to provide a national data repository to support federal and state Medicaid and CHIP program management, among other things. T-MSIS includes data not previously reported by states and is intended to improve Medicaid and CHIP program efficiency, in part, by allowing states to compare their data with other states’ data. T-MSIS includes data that can measure the provision of EPSDT services. According to CMS officials, T-MSIS also includes aspects designed to improve the accuracy of available state data. For example, states’ T-MSIS submissions undergo approximately 2,800 automated quality checks, which provide states with feedback on data format and consistency. As of January 2019, all 50 states and the District of Columbia were submitting data monthly, according to CMS, but T-MSIS data were not being used to create the CMS-416, Child Core Set, or the scorecard. Agency officials said research-ready files are in development and T-MSIS data are improving in quality over time with historical state resubmissions. CMS Reports Indicate that Approximately Half of Beneficiaries Received Recommended Screenings and Services in 2017, but Nearly as Many Did Not According to our analysis of CMS-416 data for fiscal year 2017, millions of Medicaid beneficiaries received recommended EPSDT well-child screenings and preventive dental services. However, nearly as many eligible beneficiaries did not receive the various recommended screenings and services, and few states met CMS’s performance measure targets for EPSDT services. Additionally, while available data show that millions of blood lead screenings were performed, the total number of beneficiaries receiving blood lead screenings is unknown, because the data are incomplete. Well-Child Screenings In fiscal year 2017, 20.2 million (59 percent) of the 34.2 million beneficiaries who should have received at least one recommended well- child screening received that screening, known as the participant ratio, according to our analysis of state-reported CMS-416 data. Additionally, our analysis indicates that the national participant ratio has declined 5 percentage points since fiscal year 2010. Three states met CMS’s participant ratio target of 80 percent in fiscal year 2017, as shown in figure 1. Our analysis also indicates that no more than four states met CMS’s participant ratio target in any one fiscal year from 2010 through 2017. (See app. III, table 6, for participant ratios in each state and nationally from fiscal years 2010 through 2017.) Our analysis also indicates that as beneficiaries age, they tend to receive fewer recommended well-child screenings, which results in lower participant ratios. (See fig. 2 for participant ratios and numbers of beneficiaries receiving and not receiving well-child screenings for each CMS-416 age group in fiscal year 2017.) CMS has issued a guide on serving older eligible beneficiaries, stating that regular preventive care visits can lead to early identification of health issues. CMS officials said the agency included measures focusing on these beneficiaries on the Child Core Set and Medicaid and CHIP Scorecard to recognize the importance of addressing these beneficiaries and to encourage states to focus on this population. CMS officials noted that some states have already taken steps to increase the number of well-child screenings that older eligible beneficiaries receive, for example, by partnering with schools. In fiscal year 2017, 18.3 million (48 percent) of the 38.3 million Medicaid beneficiaries aged 1 to 20 received a preventive dental service, according to our analysis of CMS-416 data. This is an increase from the 42 percent of beneficiaries receiving preventive dental services in 2011—the baseline year for measuring state progress toward CMS’s Oral Health Initiative targets—but less than CMS’s 52 percent national performance measure target. Our analysis also shows that from fiscal years 2011 through 2017, nine states met CMS’s performance measure target of a 10 percentage point increase in each state’s percentage of beneficiaries aged 1 to 20 receiving a preventive dental service. (See fig. 3 and table 8 in app. III for the percentage of beneficiaries aged 1 to 20 that received preventive dental services in each state and nationally from fiscal years 2011 through 2017.) Available data on blood lead screenings in the CMS-416 are incomplete and, as a result, do not provide information necessary to determine how many beneficiaries received the screenings. According to CMS’s November 2016 guidance, CMS-416 data do not accurately represent the number of beneficiaries receiving blood lead screenings. The CMS-416 data capture screenings paid for by Medicaid, but not those performed using funding from other sources, such as the Centers for Disease Control and Prevention. This could under-count the number of screenings performed. In addition, the blood lead screening data reported on the CMS-416 show how many screenings were performed, but do not identify the number of beneficiaries who received a blood lead screening. Our analysis of available CMS-416 data shows that in fiscal year 2017 states reported 2.0 million blood lead screenings for beneficiaries aged 12 through 24 months, and there were 4.6 million beneficiaries aged 12 through 24 months. CMS Has Improved EPSDT Data Quality; Additional Actions Are Needed to Improve Oversight of EPSDT Services, Particularly Blood Lead Screening Data CMS Is Improving EPSDT Data, yet Does Not Regularly Take Action Based on Assessing the Appropriateness of the CMS-416 for Oversight CMS has regularly taken actions to use both the CMS-416 and the Child Core Set to improve the quality of information about the provision of EPSDT services. These actions have made the data reported about EPSDT services more complete and reliable. For example, CMS collects data annually from states on performance measures for both the CMS- 416 and the Child Core Set. (See table 3.) Additionally, CMS annually reviews the Child Core Set measures to determine whether measures need to be added, deleted, or revised. CMS also regularly provides technical assistance to states about data reliability, such as through its monthly Quality Technical Advisory Group. For example, during one group meeting, states shared challenges with reporting information about developmental screenings on the Child Core Set and suggestions for how to overcome these challenges. These actions are generally consistent with federal internal control standards regarding information and communication, which specify that management should use quality information to achieve the entity’s objectives. While CMS has taken actions to improve the quality of information about EPSDT, and agency officials said they regularly assess whether the information CMS collects on the CMS-416 is appropriate and useful for EPSDT oversight, CMS has not taken action, as needed, based on such assessments. For example, CMS has not added, removed, or amended any performance measures on the CMS-416 since 2010, even though officials acknowledge limitations in these measures. The participant ratio, for example, is dependent, in part, on a state’s chosen periodicity schedule, which means that the measure is not consistently defined across states. The screening ratio reflects the extent to which beneficiaries received the recommended number of well-child screenings during the year, but this information is aggregated and therefore cannot be used to determine whether individual beneficiaries received the recommended number of well-child screenings. Although federal law requires collecting certain information about the provision of EPSDT services, it provides the agency with flexibility to determine the form and manner in which data are collected and to set performance measures. For example, CMS could change the way states are required to calculate the participant ratio or the screening ratio, and could examine ways to do so to address the limitations that the agency has identified and improve the quality of information about the provision of EPSDT services. Because CMS has not taken action, as needed, based on assessments of the appropriateness of its CMS-416 performance measures, the agency cannot be sure that it has the information it needs to oversee state implementation of EPSDT. This is inconsistent with federal internal control standards regarding information and communication, which specify that management should identify information requirements in an iterative and ongoing manner and ensure information remains relevant. We have previously reported that results-oriented organizations set performance goals to define desired program outcomes and develop performance measures that are clearly linked to these performance goals and outcomes. CMS Has Set Some Performance Measure Targets, yet Does Not Consistently Evaluate States’ Performance against These Targets CMS has taken steps to develop, assess, and use CMS-416 information to improve states’ performance in providing EPSDT services. For example, CMS has set performance measure targets for participant and screening ratios reported on the CMS-416, and CMS publishes state-level results of the participant and screening ratios. In addition, after identifying issues with calculating the performance measure and target for the permanent molar sealants, CMS removed them from the Oral Health Initiative. CMS also convenes affinity groups and technical advisory groups to provide assistance to states in improving performance, often centered on specific services, such as dental services. However, CMS and state Medicaid officials told us that CMS does not consistently (1) communicate CMS-416 performance measure targets to states, (2) evaluate state performance against performance measure targets, or (3) provide states with assistance in reaching performance measure targets. While it has not done so across all performance measure targets, CMS did take these actions regarding targets for preventive dental services as part of its Oral Health Initiative. For example, CMS communicated with states about the preventive dental service performance measure target after it developed the Oral Health Initiative; disseminated a national oral health strategy and published a review of eight states identifying innovative approaches in providing preventive dental services; and provided targeted outreach to states with the lowest performance on the preventive dental service performance measure. Improvements in the provision of dental services occurred in many states. For example, in 2013, CMS met with state Medicaid officials in Florida about improving the provision of preventive dental services. Five years later, the percentage of beneficiaries receiving preventive dental services had increased 18 percentage points. CMS has not taken action in other areas. For example: CMS does not communicate the participant and screening ratio targets. Officials from CMS and from each of our 16 selected states told us that CMS does not mention these targets in communications with states, including discussions related to performance improvement. CMS has not evaluated state performance in meeting the participant and screening ratio targets, nor has it provided focused assistance to states to resolve gaps in states’ performance in reaching these targets comparable to the assistance provided for the preventive dental screening performance measure as part of the Oral Health Initiative. CMS did not provide formal written notification to states when in March 2016 the agency informed participants in two meetings that CMS no longer planned to use the target for measuring states’ performance on the permanent molar sealants performance measure. The notification was not provided through an official policy document, such as an agency informational bulletin distributed to all states. Despite removing the target, CMS issued a technical assistance brief in March 2018 that referenced it, which could have led to confusion among state officials. With regard to the Child Core Set, CMS has not established any performance measure targets and agency officials were not able to provide information about plans for setting targets. CMS officials said that the CMS-416 will remain a part of its EPSDT oversight. However, because its information is not standardized across states, CMS plans to increasingly rely on the standardized Child Core Set data to assess and improve states’ performance on the provision of EPSDT services. CMS officials noted that it publishes median, top quartile, and bottom quartile information for each state for all the Child Core Set measures that are publicly reported. Officials further reported in June 2019 that CMS and states use these as performance benchmarks, with an aim of reaching the national median on these measures if not the top quartile. Reporting these data is an important step in ensuring better oversight of EPSDT. However, CMS has not developed fixed targets that explicitly track states’ progress in increasing beneficiaries’ receipt of EPSDT screenings and services. Using a median to assess states’ performance ensures that half the states will not meet this target, regardless of their individual performance. Further, CMS officials have not provided plans or timelines for when the Child Core Set would be used to help states achieve performance measure targets. CMS’s inaction regarding using the CMS-416 and Child Core Set to improve performance on the provision of EPSDT services limits the agency’s oversight and is inconsistent with federal internal control standards for monitoring, and practices of leading organizations. Federal internal control standards specify that management should (1) set performance measure targets in measureable, numeric terms; (2) communicate necessary information to achieve performance targets; (3) evaluate progress toward desired targets; and (4) take action to resolve identified issues. Without regularly using the CMS-416 and Child Core Set to improve the provision of EPSDT services, CMS is unable to identify whether state or federal efforts and policies are increasing the number of beneficiaries receiving EPSDT services. As a result, CMS’s oversight is limited and beneficiaries may not be receiving appropriate EPSDT services when they need them—CMS’s stated goal for EPSDT. (See table 4 for examples of actions CMS has and has not taken regarding using the CMS-416 and Child Core Set for improving the provision of EPSDT services.) CMS Has Taken Limited Actions to Improve Data on the Number of Blood Lead Screenings, which Are Critical to Identifying Harmful Lead Exposure CMS is unable to determine whether all eligible EPSDT beneficiaries are receiving blood lead screenings in accordance with CMS policy. As previously noted, CMS-416 data are incomplete, because they only include blood lead screenings paid for by Medicaid, and the form reports the number of screenings performed instead of the number of beneficiaries receiving screenings. State examples of collecting blood lead screening data Nebraska. Medicaid officials said that the state has developed a database with the Nebraska Health Information Initiative containing laboratory testing data. Treating providers and managed care organizations can access the database to determine whether a Medicaid beneficiary has received a blood lead screening. New Jersey. Medicaid officials said that it can be difficult to track blood lead screenings that are performed using funding from sources other than Medicaid; for example, those performed by the state health department. Officials said that they have been building a lead registry to capture data on lead screenings performed, regardless of how they are funded. New Jersey Medicaid officials said they collect data every 6 months on screenings not paid for by Medicaid and enter the data into the state’s blood lead registry. CMS has stated that screenings are important for identifying beneficiaries with elevated blood lead levels at as young an age as possible, because lead exposure can harmfully affect nearly every system of the body and cause developmental delays. According to a presidential task force on environmental health and safety risks to children, co-chaired by HHS, early identification of developmental delays allows providers and communities to intervene earlier to improve health outcomes. The presidential task force issued goals in December 2018 to reduce lead exposure and associated harms, including a goal to identify lead-exposed individuals and improve their health outcomes. Without complete information about blood lead screenings, CMS cannot identify the number of beneficiaries who have not received blood lead screenings. As a result, the agency may be unaware of beneficiaries with unidentified lead exposures. CMS issued guidance in 2016 to states on improving blood lead screening reporting, including correcting reporting errors and partnering with providers to ensure beneficiaries receive blood lead screenings. (See sidebar for examples of efforts states have taken to improve available data about blood lead screenings.) However, as of February 2019, the screening data remained incomplete, according to agency officials. CMS officials also told us they are currently in discussions with the Centers for Disease Control and Prevention about how to capture more complete information about Medicaid beneficiaries who are receiving blood lead screenings through programs funded by that agency. However, as of February 2019, CMS officials had not identified specific actions to gather this data. The lack of data is inconsistent with federal internal control standards, which specify that management should obtain relevant data from reliable sources based on identified information requirements, and use such data for effective monitoring. CMS Replicated Some CMS-416 and Child Core Set Information Using T- MSIS, but Lacks Time Frames and Interim Milestones for Using T-MSIS Data to Streamline State Reporting According to CMS, the results of recent pilot studies indicate that T-MSIS data can be used to replicate some information on the CMS-416 and Child Core Set. CMS officials said that the results also suggest that CMS may eventually be able to use T-MSIS data to produce the CMS- 416 and Child Core Set data, thus eliminating the need for states to report this information themselves separately. As previously noted, CMS intends for T-MSIS to both reduce the number of reports CMS requires states to submit and to provide more information to improve Medicaid oversight. CMS officials said that they were encouraged that the pilot studies to replicate portions of the CMS-416 and Child Core Set generally yielded positive results. For example, CMS was able to use T-MSIS to replicate the total number of Medicaid beneficiaries aged 20 and under eligible for EPSDT from the CMS-416 within 5 percent of state-reported values for eight of nine pilot states—which CMS officials viewed as a positive result. CMS officials noted some concerns with inaccurate state Medicaid eligibility data; for example, multiple dates of birth reported through T-MSIS for the same beneficiary. However, CMS officials believe the accuracy and completeness of T-MSIS data has improved since the pilot studies, which were conducted using data from 2015 and 2016. Regarding the Child Core Set, CMS was able to use T-MSIS to replicate some of the information, such as adolescent well-care visits, but not other information, such as emergency department visits. While CMS found generally positive results from the pilots, the agency has not developed a plan with time frames and interim milestones for when it will use state-reported T-MSIS data to produce the CMS-416 and Child Core Set data sets instead of states separately producing both T- MSIS data and the two data sets. In April 2019, CMS officials said that they were planning additional pilots beginning in fiscal year 2019 to replicate portions of the CMS-416 and the Child Core Set. However, CMS officials were unable to provide planned next steps, including time frames and interim milestones, for using T-MSIS data to replace the CMS-416 and Child Core Set. This is inconsistent with federal internal control standards related to using and communicating quality information to achieve objectives. Without a specific plan with time frames with interim milestones, CMS may miss opportunities to use T-MSIS data to streamline state reporting and better oversee states’ provision of EPSDT services. This limitation is similar to one we reported in December 2017 about the initial steps CMS had taken for using T-MSIS data. We found CMS was limited in using T-MSIS for its broader oversight efforts of state Medicaid programs, in part, due to the absence of an articulated plan and time frames. Conclusions Under EPSDT, millions of Medicaid’s youngest beneficiaries received well-child screenings and dental services in fiscal year 2017; however, nearly as many of them did not. Further, existing data on blood lead screenings are incomplete and inaccurate, leaving CMS unaware of beneficiaries with unidentified lead exposures that can cause developmental delays. The EPSDT data collected—whether via the CMS- 416, Child Core Set, or T-MSIS—have the potential to improve CMS oversight of beneficiaries’ receipt of necessary services and screenings. However, CMS has not taken sufficient steps to help ensure the appropriateness of its state data collection, evaluations, and assistance; and its plans for new reporting, including time frames and interim milestones, are lacking. Recommendations for Executive Action We are making the following six recommendations to CMS: The Administrator of CMS should work with states and relevant federal agencies to collect accurate and complete data on blood lead screening for Medicaid beneficiaries in order to ensure that CMS is able to monitor state compliance with its blood lead screening policy, and assist states with planning improvements to address states’ compliance as needed. (Recommendation 1) The Administrator of CMS should regularly assess the appropriateness of performance measures and targets for the EPSDT benefit, and take any necessary actions to ensure their relevance and use, including adding, changing, or removing measures, or targets, and regularly communicating performance measures and targets to states. (Recommendation 2) The Administrator of CMS should conduct regular evaluations of state performance by comparing states’ performance measurement data with CMS’s EPSDT targets to identify gaps in states’ performance and areas for improvement. (Recommendation 3) The Administrator of CMS should assist states with planning needed improvements, including providing focused assistance, to resolve gaps in states’ performance in meeting CMS’s EPSDT targets. (Recommendation 4) The Administrator of CMS should develop a plan with time frames and interim milestones for using T-MSIS data to generate the necessary data from the CMS-416 to improve EPSDT oversight and streamline state reporting. (Recommendation 5) The Administrator of CMS should develop a plan with time frames and interim milestones for using T-MSIS data to generate the necessary data from the Child Core Set to improve EPSDT oversight and streamline state reporting. (Recommendation 6) Agency Comments and Our Evaluation We provided a draft of this report to HHS for comment, and its comments are reprinted in appendix IV. HHS also provided us with technical comments, which we incorporated in the report as appropriate. Overall, HHS concurred with three recommendations and did not occur with three recommendations. HHS concurred with our first recommendation that CMS should work with states and relevant federal agencies to collect accurate and complete data on blood lead screening for Medicaid beneficiaries and assist states with planning improvements to resolve gaps in states’ performance as needed. However, HHS stated that it would not be possible to obtain complete data on blood lead screenings, because some screenings are not paid for by Medicaid. In our report, we noted some state and CMS efforts to improve available data on blood lead screenings. We continue to believe CMS needs to take additional actions to collect accurate and complete data to oversee whether eligible EPSDT beneficiaries are receiving blood lead screenings in accordance with CMS policy. HHS did not concur with our second recommendation, which stated that CMS should regularly assess the appropriateness of performance measures and targets for the EPSDT benefit, and take any necessary actions to ensure their relevance and use. HHS noted that it assesses the appropriateness of Child Core Set measures annually and may update existing measures based on that assessment, including measures on the CMS-416. We acknowledge CMS’s actions to assess the appropriateness of Child Core Set measures annually and update those measures as appropriate, and we found these actions generally consistent with federal internal control standards regarding information and communication. However, CMS has not taken action, as needed, related to any assessments of the CMS-416 performance measures, even though officials acknowledge limitations in these measures, such as the participant and screening ratios. HHS also stated that it may set targets in key areas as appropriate, and has done so as part of the Oral Health Initiative, but that HHS does not believe it would be productive at this time to set targets for every measure. We are encouraged that HHS agreed that it may set targets in key areas as appropriate. This is consistent with our recommendation for CMS to regularly assess the appropriateness of its targets. Our recommendation does not assume that targets should be set for every measure—rather, that CMS needs to regularly assess the appropriateness of performance measures and targets for the EPSDT benefit and communicate them to states. HHS did not concur with our third recommendation, which stated that CMS should conduct regular evaluations of state performance by comparing states’ performance measurement data with CMS’s EPSDT targets. HHS stated that it offers a wide range of technical assistance on quality improvement to help states address performance goals. HHS commented that it believes this is the most effective method of helping states identify and address areas for potential improvement. We acknowledge that CMS has provided states with technical assistance and individual state snapshots of selected Child Core Set measures over time. However, regular evaluations of states’ performance against appropriate EPSDT targets are necessary to help identify gaps in states’ performance and areas for improvement. HHS noted that states recently received snapshots about their performance on publicly reported Child Core Set measures for the past 5 years, through fiscal year 2017. According to HHS, the snapshots include information about a state’s performance on each measure relative to other states’ performance and highlights significant changes in a state’s performance for each measure. However, these snapshots include descriptions of all states’ performance—using medians, and top and bottom quartiles—which are subject to change over time. Moreover, because the median is the midpoint of all states’ performance, this target ensures that half of states will not meet it, regardless of their individual performance. A fixed target—or targeted improvement goal, such as the one developed as part of the Oral Health Initiative—would provide states with the opportunity to measure performance over prior years’ results, which is a more meaningful measure that all states can strive to achieve. HHS did not concur with our fourth recommendation, which stated that that CMS should assist states with planning needed improvements to resolve gaps in states’ performance in meeting EPSDT targets. HHS stated that it has developed national and state-specific improvement goals for children enrolled in Medicaid with respect to receipt of at least one preventive dental service and provided targeted technical assistance to the lowest performing states. In this report, we noted states’ progress in meeting targets once CMS developed a performance measurement target for preventive dental services, including actions to improve state performance. Developing additional targets on performance measures critical to beneficiaries’ health and well-being could help improve oversight of EPSDT. HHS also described other examples of targeted technical assistance to remedy gaps in states’ performance, which included working with states on improving their performance on certain Child Core Set measures and improving access to EPSDT services by better leveraging schools as settings for care. Such technical assistance could be valuable for CMS to provide to states after identifying gaps in states’ performance relative to EPSDT targets. Doing so would allow CMS to share additional strategies to help states plan and implement needed improvements. HHS concurred with our fifth and sixth recommendations that CMS should develop a plan with time frames and interim milestones for using T-MSIS data to generate the necessary data from the CMS-416 and Child Core Set to improve EPSDT oversight and streamline state reporting. As agreed with your office, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report date. At that time, we will send copies to the Secretary of Health and Human Services, the Administrator of the Centers for Medicare & Medicaid Services, and other interested parties. In addition, the report is available at no charge on the GAO website at http://www.gao.gov. If you or your staff have any questions about this report, please contact Carolyn L. Yocom at (202) 512-7114 or yocomc@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. Major contributors to this report are listed in appendix V. Appendix I: Selected States’ Practices for Delivering Early and Periodic Screening, Diagnostic, and Treatment Services Selected states used several types of practices to promote and facilitate the delivery of Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services, according to Medicaid officials in the 16 selected states we interviewed and profiles of these states created by the American Academy of Pediatrics. The practices selected states used included outreach and education, financial incentives, collaboration in EPSDT administration, and EPSDT service delivery initiatives, as shown in figure 4. Appendix II: Information Reported on Form CMS-416 and Child Core Set States annually report information about Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services to the Centers for Medicare & Medicaid Services (CMS), through the Form CMS-416 and the Child Core Set. The CMS-416 provides basic information about EPSDT for Medicaid beneficiaries aged 20 and under, such as the participant ratio and number of beneficiaries receiving a preventive dental service. The Child Core Set provides CMS with information about the quality of health care provided to Medicaid beneficiaries and individuals aged 18 and under who are covered under the Children’s Health Insurance Program. In fiscal year 2024, annual reporting of the Child Core Set will become mandatory. As of 2019, the Child Core Set included performance measures related to the provision of EPSDT services, such as well-child visits in the first 15 months of life. Because Child Core Set reporting is currently voluntary, states vary in the number of performance measures they choose to report. In fiscal year 2017, for example, 50 states and the District of Columbia voluntarily reported on at least one of the 27 Child Core Set performance measures, with states reporting a median of 18 Child Core Set performance measures. Some information is only reported on the CMS-416 or Child Core Set, while other information— well-child visits, preventive dental services, and dental sealants—is reported on both CMS-416 and Child Core Set. (See table 5 for information reported on the CMS-416, the Child Core Set, or both.) Appendix III: Summary of Selected Early and Periodic Screening, Diagnostic, and Treatment Data Tables 6 through 8 present annual state-reported data from the Centers for Medicare & Medicaid Services’ (CMS) Form CMS-416 on the provision of selected Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services by state and nationally. Well-child screenings are presented from fiscal year 2010, the year in which the current reporting template was implemented, through fiscal year 2017, the most recent year for which data were available at the time of our review. Preventive dental services data are presented from fiscal year 2011, the baseline year for measuring states’ progress toward CMS’s Oral Health Initiative targets, through fiscal year 2017, the most recent year for which data are available. Appendix IV: Comments from the Department of Health and Human Services Appendix V: GAO Contact and Staff Acknowledgments GAO Contact Carolyn L. Yocom at (202) 512-7114 or yocomc@gao.gov. Staff Acknowledgments In addition to the contact named above, Karen Doran (Assistant Director), Peter Mangano (Analyst-in-Charge), Matthew Green, Erika Huber, Drew Long, Jennifer Rudisill, and Kelly Turner made key contributions to this report. Also contributing were Muriel Brown, Giselle Hicks, Erika Lessien, and Madeline Ross.


Background ESSA Provisions Related to the Educational Stability of Youth in Foster Care Enacted in December 2015, ESSA’s amendments to Title I, Part A (Title I) of the ESEA included a number of requirements for SEAs and school districts to ensure the educational stability of children in foster care. For the purposes of this report, we refer to these requirements collectively as the “ESSA educational stability provisions.” Specifically, SEAs are required to describe in their Title I state plans the steps they will take to ensure collaboration with the state child welfare agency to ensure the educational stability of children in foster care, including assurances that: Such children enroll or remain in their school of origin, unless a determination is made that it is not in the child’s best interest to attend the school of origin. This decision shall be based on all factors relating to the child’s best interest, including consideration of the appropriateness of the current educational setting and the proximity to the school in which the child is enrolled at the time of placement. When a determination is made that it is not in a child’s best interest to remain in the school of origin, the child is immediately enrolled in a new school, even if the child is unable to produce records normally required for enrollment. The enrolling school shall immediately contact the school last attended by the child to obtain relevant academic and other records. The SEA will designate an employee to serve as a point of contact for child welfare agencies and to oversee implementation of the above provisions. LEAs are required to provide in their Title I LEA plans assurances that they will collaborate with the state or local child welfare agency to: designate a point of contact, if the corresponding child welfare agency notifies the LEA in writing that the child welfare agency has designated a point of contact for the LEA; and develop and implement clear written procedures governing how transportation to maintain children in foster care in their school of origin when in their best interest will be provided, arranged, and funded for the duration of the time in foster care. The ESSA requirements described above were generally required to be implemented by December 10, 2016. In addition, SEAs and school districts are required to publicly report on the academic achievement and graduation rates of youth in foster care on their annual report cards. States and localities also have some flexibility in implementing the ESSA educational stability provisions. For example, ESSA does not prescribe a specific process for determining whether it is in a child’s best interest to remain in their school of origin. In making this determination, state and local agencies have flexibility in determining which factors should be considered when evaluating the appropriateness of a child’s current educational setting, as well as any additional factors that pertain to a child’s best interest. Similarly, school districts and child welfare agencies generally determine the transportation procedures to use, provided they meet the minimum statutory requirements. In addition, SEAs may choose various approaches to help LEAs implement the ESSA educational stability provisions. For example, SEAs may decide to independently, or with their state child welfare agency, issue policies or guidance, disseminate question and answer documents, or hold informational meetings and webinars. Federal Technical Assistance and Oversight Education and HHS collaborated to provide states with joint non- regulatory guidance specific to the ESSA educational stability provisions. In addition to this written guidance, Education provides technical assistance to states, such as through the State Support Network, one of its technical assistance providers. Each state also has a point of contact at Education for questions, according to Education officials. Education’s Office of School Support and Accountability oversees state implementation of Title I, Part A of the ESEA, including the amendments made by ESSA. Education’s oversight of SEAs includes reviewing state Title I plans that describe how states will follow a variety of federal requirements outlined in Title I, and periodic reviews of how each state is implementing Title I. These reviews occur every few years. HHS’s Children’s Bureau oversees state child welfare agencies’ implementation of Title IV-E, including the provisions in the Fostering Connections Act, and also provides related technical assistance. State and Local Officials Reported Several Challenges Related to Implementing the ESSA Educational Stability Provisions State and local officials reported facing several challenges related to implementing the ESSA educational stability provisions. Specifically, officials reported challenges with (1) turnover among local child welfare and educational agency staff, (2) obtaining school district input during the process for determining whether it is in a youth’s best interest to remain in their school of origin (referred to as best interest determinations), (3) providing and funding transportation, (4) ensuring accurate identification of youth in foster care, and (5) monitoring how school districts implement these provisions. In addition, while we did not ask on our survey about the requirement to immediately enroll youth in a new school if it is determined that remaining in the school of origin is not in their best interest, or about the requirement for the enrolling school to immediately contact the last school attended to obtain relevant records, education and child welfare officials we interviewed said they experienced challenges with immediate enrollment and records transfer for special populations of youth. Turnover among Local Child Welfare and Educational Agency Staff Turnover of local educational and child welfare agency officials was reported as a significant challenge that affects how many states and localities implement the ESSA educational stability provisions, according to our survey and interviews. Specifically, in our survey, 43 of 51 SEAs reported turnover of local child welfare agency points of contact as at least somewhat challenging. A similar number of respondents (39) reported facing challenges with turnover of school district points of contact (see fig. 1). During our discussion group, state child welfare agency officials highlighted turnover of local child welfare agency and school district staff as one of the most significant challenges their states face in ensuring educational stability for youth in foster care. In addition to turnover itself being a challenge, several other challenges reported by SEAs are related to staff turnover, according to officials we spoke with from four state and local educational and child welfare agencies. Specifically: Thirty-two SEA survey respondents identified maintaining an accurate list of school district foster care points of contact for their state as challenging, and officials from four state and local educational and child welfare agencies we spoke with stated turnover makes it difficult to keep these lists updated. One SEA point of contact said that when she sends emails to school district points of contact, she receives numerous responses each time from school district staff saying they are no longer the point of contact. Officials we interviewed at one school district noted that they tried to identify a new point of contact at another school district, but the list on the state website had not been updated. Thirty-eight SEAs reported on our survey that ensuring that school district points of contact are aware of their responsibilities is a challenge. Eight state and local educational and child welfare agency officials we interviewed echoed this observation and cited staff turnover as leading to a lack of awareness of responsibilities or protocols related to the ESSA educational stability provisions. Local staff being unaware of their responsibilities under ESSA can lead to conflicts, according to officials from two state and three local agencies we interviewed, and resolving conflicts between school districts and local child welfare agencies was a challenge reported by three-quarters (38) of SEA survey respondents. For example, officials at one local child welfare agency said they encountered school district officials who did not believe a youth in foster care could attend their current school, since their foster parent lived outside the school district. To resolve the conflict, the school district point of contact discussed the provisions with the school officials. To alleviate challenges related to turnover, SEA points of contact we surveyed and interviewed explained that they regularly provide information to local school district and child welfare agency officials on the ESSA educational stability provisions. To inform and remind local officials about the provisions, a few of these officials said they send emails to school district points of contact or provide training on the provisions at orientation for new staff at child welfare agencies. In all three states we visited, the SEAs and/or state child welfare agencies said they held joint presentations for both school districts and local child welfare agencies, and SEA officials in Georgia said they are considering holding regional collaborative meetings every four to six months. In addition, most SEAs reported on our survey that they work with their state child welfare agencies to provide or develop assistance, guidance, and sample documents or templates to facilitate implementation of the ESSA educational stability provisions at the local level. (See tables 1 and 2 in appendix II for more information on this assistance.) School District Input for Best Interest Determinations On our survey, 34 of 50 SEAs reported that ensuring school districts participate in best interest determinations is a challenge (see fig. 2). Two of five state child welfare agency officials in our discussion group also described challenges related to the lack of collaboration between child welfare agencies and schools on best interest determinations. While ESSA does not prescribe who should be involved in the best interest determination, the joint federal guidance encourages state and local child welfare and educational agencies, including school districts, to develop a process that involves all relevant parties. School district involvement, however, depends on child welfare agencies informing them when a child enters foster care or changes homes. Officials we interviewed at several child welfare agencies indicated they may not include school districts or schools in these determinations due to time constraints. Child welfare officials explained that removing a child from a home and placing them into foster care is a chaotic time and many steps need to be taken to quickly provide the child with a safe environment. During this time, caseworkers may lack the capacity to collaborate with school districts or schools. Child welfare agency officials at two local offices we visited explained that they prioritize a child’s health and safety when placing a child in a new foster home and that they place a greater focus on these issues than on educational stability. Some child welfare agency officials we spoke with said they do not always need school district input to make a best interest determination. For example, officials at two local child welfare agencies said that in some cases, the commute to a child’s current school may be so long that remaining there is clearly not in a child’s best interest. Officials from one state and two local child welfare agencies told us they assume it is in the best interest of the child to remain at their current school. Officials from the state child welfare agency said they do not believe they need to consult with school districts to make that decision. Officials at another local child welfare agency said it would not be helpful to collaborate with school districts on the best interest determination, since the child welfare officials do not believe where the child attends school is the highest priority. However, youth we spoke with in our discussion groups told us that changing schools can create several challenges (see text box). Officials from other state and local child welfare agencies told us they recognize the need to involve school districts and are taking steps to try to include them in best interest determinations. For example, one state child welfare agency we visited includes a line for the school district point of contact’s signature on the state’s best interest determination form; however, we heard from officials at a local child welfare agency that the school district point of contact may not be involved in making the best interest determination, and the form may not be consistently used. Officials at a local child welfare agency told us that they hold best interest determination meetings with the school district by phone because these meetings are faster to schedule than in-person meetings. Rather than speaking with school district staff, officials from four local child welfare agencies said they try to contact school staff that may be close to a child, such as a counselor or teacher, but officials from three of these agencies said they may not do so in every case. Thirty-seven of 50 SEAs reported on our survey that assisting school districts with identifying or arranging transportation is at least somewhat challenging (see fig. 3). To help school districts and local child welfare agencies identify transportation options, SEAs in two states we visited provide guidance or other documents to these agencies that describe potential transportation options. School district and local child welfare agency officials we spoke with reported using different approaches to transport youth, including having foster parents, school district or child welfare staff, or the youth drive to school; rerouting buses; hiring a taxi or other private transportation service; or using public transportation. Sometimes they reported combining these methods to transport youth to their current school. However, eight school district and local child welfare officials noted difficulties with their options, including limited options in rural areas and lack of appropriate transportation for younger youth and those with behavioral issues. For example, an Arizona local child welfare official explained that while they can use taxis to transport youth, they are not approved for use for children age 6 and younger. Foster parents and youth we spoke with shared challenges they have experienced with transportation to the school of origin (see text box). Experiences of Selected Foster Parents and Youth with Transportation to School of Origin Multiple foster parents in two states we visited shared that they were told by child welfare case workers that the foster parent(s) would have to transport children in their care to school for those children to remain in their current school. They told us that sometimes they could not drive the child due to distance or the needs of other youth in their care, and the child transferred to a new school. We also heard that other modes of transportation may be unreliable or cause difficulties for a child’s schedule. For example: One child in foster care in Arizona told us that she missed a week of school because the taxi provided by the child welfare agency failed to pick her up. A child in a foster care group home in Ohio said that despite being placed in a school which was in the same school district as her school of origin, her commute was long—she needed to take two public buses—and she sometimes missed dinner. On our survey, 30 of 50 SEAs reported that helping school districts determine how to fund the additional transportation costsdefined in the joint federal guidance as the difference between what a school district would otherwise spend transporting a student to their assigned school and the cost of transporting a child in foster care to their school of origin is also challenging. Among these 30 SEAs, 12 noted it was very or extremely challenging. Six school district and child welfare agency officials we interviewed also indicated that funding was a concern and some noted that transporting youth to their school of origin can result in extensive additional costs (see text box). Examples of Transportation Costs to Maintain Youth in Foster Care in Their School of Origin Over a school year, officials from a local child welfare agency said it spent $155,000 to transport students in one school district. According to officials at one school district, to transport one student, the school district had to hire a van at an estimated cost of up to $30,000 per year. In one month, another school district reported paying over $4,000 to transport five students. School district and child welfare officials said that they can rely on multiple funding streams—local, state, and/or federal—to cover these additional costs. Districts and local child welfare agencies reported that they sometimes split these costs, depending on their state’s policies. (See fig. 9 in appendix II for state-specific cost-sharing requirements reported in our survey.) For example, in Arizona, one agency transports the child to school and the other transports the child home and each pays for the cost of their one-way trip. To assist localities with funding additional transportation costs, nine SEAs said their state provides funding that partially or fully covers these costs. While educational and child welfare agencies may use federal funding through Title I or Title IV-E for the additional transportation costs, some SEA, school district, and child welfare agency officials we interviewed noted that they do not use these funds. Officials at a few school districts said they use Title I funding for other needs, while some child welfare agency officials explained their agency does not use Title IV-E funds because they did not have state “matching” funding, did not understand how to use the funds to reimburse schools for their costs, or had some youth who are not Title IV-E eligible. Ensuring Accurate Identification of Youth in Foster Care Thirty-two SEA survey respondents reported that ensuring school districts can accurately identify youth in foster care is at least somewhat challenging (see fig. 4). School district officials we spoke with expressed similar concerns. Officials we interviewed in nine of 10 districts stated they are not consistently aware of which students in their district are in foster care, and seven explained that there is no systematic way for school districts to be notified when a child enters or leaves care. Similarly, officials in four local child welfare agencies said they have no systematic way to inform schools when youth in foster care leave care or when their status in foster care changes. Officials from two school districts also stated their data systems have no way to indicate that a student is in foster care, so even if the child welfare agency notifies them of a youth’s status, they may not easily track the information. Officials from two school districts said not knowing the status of youth in foster care in their district impedes their ability to effectively implement the ESSA educational stability provisions. For example, one district official stated they would probably be transporting more youth to their school of origin if they knew which students were in foster care. In addition, two school district officials said that if they do not know which students are in foster care, they cannot provide additional supports that may be available to these youth, such as tutoring, financial assistance, or mental health services. The ability of school districts to accurately identify youth in foster care can also affect the accuracy of state and local report cards. Nine SEAs reported on our survey that they rely exclusively on school districts’ identification of youth in foster care for their state report cards. Of those nine, seven reported that ensuring that school districts accurately identify these youth is a challenge, which may affect the accuracy of the additional report card data required by ESSA. Some states and localities we visited had different ways to inform school districts when a youth’s foster care status changes, but officials noted varying degrees of consistency in notifying the districts of changes. Officials at two state child welfare agencies we visited told us they require the person enrolling the youth in school to present an official document that shows the youth is in state custody; however, they said schools are not informed when a child leaves foster care. One county and one state we visited had electronic data sharing agreements between child welfare and educational agencies for the purposes of updating school district records when a child enters and leaves foster care. Specifically, in that county, once a child enters foster care under the custody of the county child welfare agency, the school district’s database automatically receives pertinent information from the child welfare agency, according to officials. School and child welfare agency officials meet monthly to ensure data accuracy. In Georgia, officials from the state educational agency said they signed a data sharing agreement in spring 2018 with the state child welfare agency to allow information about youth in foster care to be provided to school districts. The previous data sharing agreement prevented the SEA from sharing the data with the school districts, according to officials. In Idaho (a state that participated in our discussion group), state officials said they ensure school districts are aware of youth in foster care by using an automated letter (see text box). Idaho’s iCARE System for Youth in Foster Care When a youth enters foster care or changes placements, Idaho’s iCARE system produces an automated letter that provides an initial communication from a child welfare social worker to the school district, SEA foster care points of contact, and the school principal. When the youth’s school of origin is entered into the system, the letter automatically populates the email addresses of the appropriate school district point of contact, SEA point of contact, and school principal. The letter contains the social worker’s initial best interest determination, and indicates if the student will need transportation to attend their school of origin, which the school district point of contact is responsible for coordinating. The school district point of contact has three days to provide input on the best interest determination when school is in session and 14 days during the summer months. The school district foster care point of contact and the child welfare social worker both must sign off on the plan identified within the electronic letter. Monitoring School Districts’ Efforts to Implement ESSA Educational Stability Provisions Under federal grant regulations, SEAs, which subgrant Title I funds to school districts, are required to conduct regular monitoring and oversight to ensure appropriate implementation of Title I by their school districts, and 43 SEA survey respondents reported that their states used one of the methods asked about in our survey to monitor how school districts implement at least one of the ESSA educational stability provisions. For example, over half (33) of SEAs reported that the Title I plans they receive from school districts include an assurance related to at least one of the ESSA educational stability provisions we asked about on the survey. More than two-thirds (36) of SEAs reported on our survey that effectively monitoring school districts’ implementation of the provisions is a challenge (see fig. 5). In their survey comments, eight SEA points of contact said limited state resources hinder their ability to ensure that the hundreds of school districts in their states properly execute the provisions. Officials we interviewed from all three SEAs in our site visits told us their states incorporate the educational stability provisions into their existing procedures for overseeing implementation of federal education programs. For example, SEA officials in Georgia told us that during one of their state reviews, they look for evidence of local agency collaboration, such as meeting agendas or emails. In Arizona, the SEA point of contact said he examines school district transportation procedures during on-site reviews. These on-site reviews occur for one- sixth of school districts in the state every year. (See table 3 in appendix II for more information on SEA monitoring of school districts.) Ensuring Immediate Enrollment and Obtaining Records While we did not ask on our survey about challenges related to immediate enrollment or obtaining records, seven state or local officials we spoke with noted difficulties with enrolling or obtaining records for students with disabilities who have individualized education programs, or students who previously attended juvenile justice or residential treatment facilities. Officials at a local child welfare agency and two school districts said that if an individualized education program is missing from a child’s records, they cannot know which services or classes a child might need and it may delay the child’s enrollment in the school or require switching classes again. Officials from Georgia’s SEA said they mitigate this challenge by providing school districts the option to share individualized education programs electronically, which enables other school districts that need the records to more easily obtain them. Education Could Take Steps to Improve Access to Technical Assistance and Plans to Begin Monitoring of the ESSA Educational Stability Provisions Education Provided Technical Assistance, At Times Collaborating with HHS, but Could Improve Access to Information Education has provided technical assistance to states, at times in collaboration with HHS, to help states implement the ESSA educational stability provisions. Education’s technical assistance included written guidance, webinars, and in-person meetings, according to Education officials. Written guidance: Education and HHS jointly issued non-regulatory guidance on June 23, 2016 to help state and local educational agencies meet their obligations related to educational stability for youth in foster care under ESSA. On the same day, Education and HHS also issued a joint letter to chief state school officers and state child welfare directors that provided an overview of the ESSA educational stability provisions. Education sent an additional letter to chief state school officers on December 5, 2016, that provided information about the timelines for implementing the provisions. The letter also requested states to provide Education with their state foster care point of contact. Webinars: Education and HHS hosted several webinars for state educational and child welfare agencies that addressed a number of issues related to implementation of the ESSA educational stability provisions. In late summer 2016, Education and HHS hosted four webinars on the roles and responsibilities of educational and child welfare agency points of contact; best interest determinations and immediate enrollment; transportation; and effective collaboration. These webinars described the related ESSA requirements and featured selected states’ approaches to implementing the provisions. The State Support Network, one of Education’s technical assistance providers, facilitated another series of webinars that were offered in summer 2018 to address areas of implementation that states reported to be particularly problematic. HHS staff also participated in the webinar series, and topics included collaboration with child welfare agencies, data systems, transportation, and roles and responsibilities of points of contact. In-person and other assistance: Education provided additional assistance to state educational agencies through an in-person meeting and continuously provides assistance upon request. Education and HHS jointly held a session on sharing data to support students in foster care during its Combined Federal Programs Meeting for SEA officials in December 2018 in Washington, DC. At this meeting, Education also facilitated a session during which foster care points of contact networked with each other and subject matter experts, shared resources, and discussed outstanding implementation challenges. In addition, Education officials told us that they assign each state a point of contact at Education, and states can request technical assistance at any time through their assigned contact. This contact can work with the appropriate offices within Education to provide information requested by states and can facilitate further technical assistance through the State Support Network. Education officials said they respond to questions from states generally asking about expectations and requirements for the ESSA educational stability provisions. Thirty-seven SEAs reported on our survey that they would like additional federal assistance as they continue to implement the ESSA educational stability provisions. Our survey showed that most SEAs were interested in receiving additional guidance related to transportation cost sharing, transportation funding options, and arranging transportation; data privacy; and state monitoring of school districts’ efforts to implement these provisions, among other topics (see fig. 6). (Also see fig.10 in appendix II for all survey responses on these topics.) With respect to transportation issues, several state officials commented that they would like more information on how other states and localities are arranging and funding transportation. Regarding data privacy, a few other officials commented that they could use more information regarding privacy laws and what information can be shared across agencies. A few SEA officials noted that guidance on how they could monitor school district implementation would be useful. A majority of SEAs reported that opportunities for in-person and virtual meetings with a federal point of contact and their SEA and state child welfare agency counterparts, and a federally supported clearinghouse of information with sample documents from other states, would be moderately to extremely helpful (see fig. 7). (Also see fig. 11 in appendix II for all survey responses on this topic.) State educational and child welfare officials we interviewed explained that in-person and virtual meetings are helpful because they allow them to ask the federal contact questions and share and discuss issues with each other. Similarly, SEA officials in our discussion sessions said they would like federal agencies to organize more collaborative opportunities for SEA points of contact to interact with their peers to help identify best practices they can adapt in their state. Some states suggested Education could adopt methods it uses for other programs, such as the Education for Homeless Children and Youth program, to provide assistance and support to foster care points of contact, such as facilitating regional phone calls and identifying a point of contact specific to foster care at the federal level. According to Education officials, in June 2019 the agency selected a staff person to serve as the federal point of contact to work directly with SEA foster care points of contact, and they told us Education maintains a designated mailbox for all foster care-related correspondence (FosterCare@ed.gov). Education officials informed us that they plan to develop a community of practice for a small group of SEA foster care points of contact who will meet regularly for several months, which may facilitate more peer to peer interaction for a select number of states. Education plans to work with the Legal Center for Foster Care and Education to convene and facilitate the community of practice. According to Education officials, the community of practice will provide networking opportunities for participants to ask questions and obtain answers from their peers, and may include discussions of promising practices at the state and local level, among other areas. Officials said they will solicit interest from all SEAs about the opportunity to participate in the community of practice. However, they will limit the number of participants, depending on the level of interest, to 10 to 12 SEAs to promote discussion and sharing among states. Officials noted that if more states are interested in participating in the community of practice than they can accommodate, they will consider additional ways to support and share information with those additional states. Education officials also noted that they are exploring other types of technical assistance to facilitate more interaction and information exchange among states, such as a web portal where states can upload and share documents. Although Education is planning to develop a community of practice and is exploring other types of technical assistance, it may not have effective methods to reach all SEA points of contact to inform them of this assistance. In the course of our follow up on our survey, we determined that 22 of the current SEA points of contact were missing from Education’s email list. Education primarily disseminates information pertaining to the ESSA educational stability requirements to states through email. Twenty-three SEAs reported on our survey that they were not aware of webinars that Education offered in summer 2018. We discussed the email list with Education officials in June 2019 and they told us they had not conducted outreach to states to update the email list since they initially identified the SEA points of contact in 2016. Rather, officials said the email list was updated on an ad hoc basis, and Education depended on states to inform them when they want someone added to the email list. Subsequent to that discussion, in response to a recommendation included in a draft of this report which Education reviewed, Education officials told us they updated the email list in July and August 2019, and planned to update it quarterly moving forward. Education officials also acknowledged it could be useful to publicize the email list on its website. Education does not maintain information about its technical assistance webinars or other relevant materials in a centralized online location. Information relevant to implementing the ESSA educational stability provisions is located on multiple Education web pages, and the materials from the most recent 2018 webinars, including the recorded session and related sample documents shared by a number of states, are only available on a third party website for which there is no link from Education’s website. In our survey, SEA points of contact reported that they are interested in receiving additional information from other states. Thirty-seven SEAs reported in our survey that a clearinghouse of information with sample documents from other states would be helpful, and 22 of these 37 reported that this would be extremely helpful. One SEA official commented that it would be useful to have a clearinghouse that could be shared with school districts and other relevant parties nationwide. Federal standards for internal control maintain that management should select appropriate methods of communication, such as providing hard copy or electronic documents or conducting face-to- face meetings, and should periodically evaluate the methods of communication in order to communicate quality information on a timely basis. Without creating and maintaining a centralized online location for SEAs to access all related information, Education cannot ensure that all SEAs have access to technical assistance and guidance that could help them implement the ESSA educational stability provisions. Education Plans to Begin Monitoring Implementation of the ESSA Educational Stability Provisions in Fall 2020 Education officials told us that in 2020, they expect to fully implement the monitoring protocols for reviewing how states are implementing the ESSA educational stability provisions. Education officials said they plan to test draft protocols as part of a pilot by fall 2019 to determine necessary revisions and expect the final protocols to be implemented by fall 2020. According to Education officials, once the protocols are implemented, they plan to use a risk assessment approach to determine which states to review each year, and anticipate reviewing approximately nine states each year, depending on staff and resources. As part of their reviews, Education officials told us they plan to visit two school districts in each state under review to assess how the selected states are implementing the ESSA requirements, and to determine whether districts are getting appropriate support from the states. According to the draft monitoring protocols, during its state reviews, Education plans to obtain information on the following areas related to educational stability: SEA collaboration with the child welfare agency, best interest determinations, immediate enrollment, SEA foster care point of contact, and school district points of contact and transportation procedures. Education reviewed states’ plans for implementing Title I, however, Education officials said that the plans contain little information about the ESSA educational stability provisions. To receive Title I funds, states are required to submit state plans to the Secretary of Education, and the Secretary is required to approve the state plans if they meet the requirements in the law. While state plans are required to describe the steps the SEA will take to ensure collaboration with the state child welfare agency to ensure the educational stability of children in foster care, including various assurances, Education did not include specific instructions for information states should include on these provisions in the state plan template it developed for states. Conclusions Youth in foster care face enormous challenges in their everyday lives and school can offer a stabilizing environment. Maintaining connections with teachers and friends, in addition to remaining in a familiar academic environment, can enhance the chances that a student is academically successful. However, many children in foster care are at higher risk of frequently changing schools, which can affect their academic achievement. ESSA made changes to the Title I program to help improve the educational stability of children in foster care. In the years since ESSA was enacted, SEAs and school districts have taken different approaches to implement its educational stability provisions, including collaborating with their child welfare agency counterparts. Most SEAs we surveyed reported common challenges with staff turnover and assisting districts with arranging transportation, among others, which can affect the successful implementation of the educational stability provisions. In addition, SEA officials are seeking more opportunities to understand how other states and localities have implemented the provisions and learn from their peers. Despite the assistance Education has provided to SEAs on a range of topics, the mechanisms Education uses to inform states of assistance are limited. The email list it uses to notify SEA foster care points of contact had not been systematically updated until July 2019, and resources on educational stability are not housed in one space. Without improvements in areas like these, states will not have access to all of the available resources that can help them improve the educational stability of youth in foster care, and ultimately, their academic success. Recommendation for Executive Action The Secretary of Education should develop an online clearinghouse of sample documents from states and localities who wish to share them, past webinar recordings and their related documents, and links to other relevant resources that all SEAs can access. (Recommendation 1) Agency Comments and Our Evaluation We provided a draft of this report to Education and HHS for review and comment. Education provided written comments, which are reproduced in appendix III, as well as technical comments, which we incorporated as appropriate. HHS did not have comments. We also provided relevant excerpts to states we visited and incorporated their technical comments as appropriate. In its written comments, Education agreed with our recommendation to develop an online clearinghouse and noted actions it plans to take to implement it. Specifically, Education said in fall 2019, its Office of Elementary and Secondary Education will restructure its entire website to better organize its information, and create a new web page to house all foster care-related information and resources. Additionally, Education said this office will launch a virtual portal through which SEA foster care points of contact may collaborate and share resources. In addition, in a draft report sent to Education in August 2019, we included a recommendation to Education to update its foster care point of contact email list, and develop a process to update it at regular intervals. Education noted in its comment letter that it had updated its email list and that it will solicit updates to the email list on a quarterly basis, so we subsequently removed this recommendation. As agreed with your offices, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report date. At that time, we will send copies to the appropriate congressional committees, the Secretaries of Education and Health and Human Services, and other interested parties. In addition, the report is available at no charge on the GAO website at http://www.gao.gov. If you or your staff have any questions about this report, please contact me at 617-788-0580 or nowickij@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of our report. GAO staff who made key contributions to this report are listed in appendix IV. Appendix I: Scope and Methodology This report examines (1) the challenges states and selected local educational agencies face implementing the requirements of the Every Student Succeeds Act (ESSA) related to educational stability for youth in foster care, and (2) how the Department of Education (Education) provided technical assistance and monitored states and localities to ensure compliance with these requirements, including collaborating with the Department of Health and Human Services (HHS). To address both objectives and obtain national information, we held three discussion groups with officials from state educational agencies and child welfare agencies and conducted a web-based survey of state educational agencies in the 50 states, the District of Columbia, and Puerto Rico. To obtain more in-depth information, we visited three states—Arizona, Georgia, and Ohio—where we interviewed officials from state and local educational agencies and child welfare agencies. We reviewed relevant federal laws and regulations, Education and HHS guidance to states, and other research publications. We also interviewed officials from Education and HHS’s Administration for Children and Families, and other organizations that carry out efforts related to education and child welfare, including the Legal Center for Foster Care and Education and Casey Family programs, regarding the provisions, federal requirements and guidance, and state and local implementation. State Educational and Child Welfare Agency Discussion Groups To learn about actions states have taken to implement the ESSA educational stability provisions and challenges they have encountered, we held three discussion groups, two with state educational agency (SEA) officials, and one with state child welfare agency officials, during a national meeting for SEA foster care points of contact and state child welfare agencies in Greensboro, North Carolina in October 2018. To solicit participants for these groups, we asked the meeting organizers to forward an invitation we drafted to all individuals who registered for the meeting to participate in our discussion groups, and also allowed individuals to sign up once they arrived at the conference. Meeting attendees self-selected to participate in the groups. Each of our discussion groups with SEA officials had seven participants, for a total of 14 state agency officials representing 14 states. Our discussion group of state child welfare agency officials had six participants representing five states. Discussion groups were guided by a GAO moderator using semi- structured interview protocols. These protocols included open-ended questions that encouraged participants to share their thoughts and experiences on implementing the ESSA educational stability provisions, including how they monitored local agencies, and whether any additional federal assistance is needed. To reach group consensus on the top challenges facing states as they implement the provisions, we used a nominal group technique. Officials from each state identified their state’s top three implementation challenges. The group then created a list from those named challenges and officials from each state used stickers to identify their top challenges from the list. Discussion groups are intended to generate in-depth information about the reasons for participants’ attitudes on specific topics and to offer insights into their concerns about and support for an issue. They are not designed to (1) demonstrate the extent of a problem or generalize results to a larger population, (2) develop a consensus to arrive at an agreed- upon plan or make decisions about what actions to take, or (3) provide statistically representative samples or reliable quantitative estimates. For these reasons, and because discussion group participants were self- selected volunteers, the results of our discussion groups are not generalizable. Survey of State Educational Agency Officials To learn about actions states have taken to implement the ESSA educational stability provisions and challenges they have encountered, we conducted a survey of SEA officials in the 50 states, the District of Columbia, and Puerto Rico. The survey was administered from January to March 2019 and we had a 98 percent response rate. The survey used a self-administered, web-based questionnaire, and state respondents received unique usernames and passwords. Our survey population was foster care points of contact at SEAs. We used multiple sources to create an initial list of points of contact, including a list provided by the Department of Education, SEA website pages related to foster care, and information from knowledgeable experts in the field. We reached out to each point of contact to ask them to confirm they were the foster care point of contact for their state or identify the appropriate point of contact. We instructed respondents to consult with others who were familiar with their state’s implementation of the provisions, if doing so would provide more accurate responses. Our survey included 20 fixed-choice and open-ended questions. We asked how SEAs collaborated with the state child welfare agency, how they assisted local educational and/or child welfare agencies, what challenges they encountered, and what assistance has been and would be helpful from the Department of Education in implementing the provisions. To draft the closed-ended questions and answer choices on the survey, we drew from recommended practices suggested in HHS and Education’s joint non-regulatory guidance to states, information shared during webinars sponsored by HHS and Education, and interviews with stakeholders, including our discussion groups with state educational and child welfare agencies. A draft of the survey questionnaire was reviewed by officials at Education, a knowledgeable stakeholder organization, and an independent GAO survey professional for completeness and accuracy. We made revisions based on their comments. We conducted three pretests—one by phone and two in-person—with SEA foster care points of contact from three different states to check that (1) the questions were clear and unambiguous, (2) terminology was used correctly, (3) the questionnaire did not place an undue burden on agency officials, (4) the information could feasibly be obtained, and (5) the survey was comprehensive and unbiased. To obtain our 98 percent response rate (51 out of 52 SEAs), we made multiple follow-up contacts by email and phone from January to March 2019 with points of contact who had not yet completed the survey. While 51 surveyed officials affirmatively checked “completed” at the end of the web-based survey, not all officials responded to every question or the sub-parts of every question. We conducted additional follow-up with a small number of respondents to verify key responses. Because this was not a sample survey, the survey has no sampling errors. However, the practical difficulties of conducting any survey may introduce errors, commonly referred to as non-sampling errors. For example, unwanted variability can result from differences in how a particular question is interpreted, the sources of information available to respondents, or how data from respondents are processed and analyzed. We tried to minimize these factors through our reviews, pre-tests, and follow-up efforts. In addition, the web-based survey allowed SEA foster care points of contact to enter their responses directly into an electronic instrument, which created an automatic record for each state in a data file. By using the electronic instrument, we eliminated the potential errors associated with a manual data entry process. Site Visits to Selected States To learn about actions states and localities have taken to implement the ESSA educational stability provisions and challenges they have encountered, we conducted site visits to three states to obtain information from state and local educational agency officials, state and local child welfare officials, foster parents, and current and former youth in foster care. We selected the three states—Arizona, Georgia, and Ohio—to represent a mix of factors, including type of child welfare agency (state or county administered), number of children in foster care, number of school districts, geographic dispersion, and variety in types of school districts (urban, suburban, rural). In each state we visited an urban, suburban, and rural school district, where we met with the school district officials responsible for implementing the ESSA educational stability provisions, and their primary child welfare agency counterparts. We also met with state educational and child welfare agency officials. We used a semi- structured interview protocol for these meetings. We held discussion groups with a total of 13 youth in foster care or formerly in foster care in three states, and in two states, we held discussion groups with a total of 14 foster parents, to obtain their perspectives on implementation of the provisions and educational stability generally. Although we cannot generalize our findings beyond these states and localities, these visits provided us with illustrative examples of how states and localities are implementing the ESSA educational stability requirements. We conducted this performance audit from June 2018 to September 2019 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. Appendix II: Additional Survey Data Appendix II: Additional Survey Data to the question: “How much of a challenge, if at all, is each of the following items in implementing the ESSA educational stability provisions?” The term “ESSA educational stability provisions” refers to the amendments made by the Every Student Succeeds Act (ESSA) to Title I, Part A of the Elementary and Secondary Education Act of 1965 that are related to the educational stability of youth in foster care. These provisions have been codified at 20 U.S.C. §§ 6311(g)(1)(E), 6311(h)(1)(C), and 6312(c)(5). Assistance Best interest determination documents, like meeting documentation templates, questions to consider during the meeting, or sample notices to inform parties of the decision Sample memorandum of understanding/agreement for data sharing between school districts and local child welfare agencies for the purposes of identifying youth in foster care for the report card reporting 17 10 school of origin when in their best interest will be provided, arranged, and funded for the duration of the time in foster care. This includes states that reported that they solely respond when alerted to issues and do not conduct any other systematic monitoring activities. Specifically, nine states reported responding when alerted to issues regarding the provisions on best interest determinations and immediate enrollment, and did not report conducting any other monitoring activities. Similarly, 14 states reported solely responding when alerted to issues regarding new enrolling schools immediately contacting schools of origin to obtain relevant academic and other records, and did not report conducting any other monitoring activities. Finally, seven states reported responding when alerted to issues related to the provision on transportation procedures, and did not report conducting any other monitoring activities or did not know if their state monitors LEAs in other ways. educational stability of youth in foster care. These provisions have been codified at 20 U.S.C. §§ 6311(g)(1)(E), 6311(h)(1)(C), and 6312(c)(5). Appendix III: Comments from the U.S. Department of Education Appendix IV: GAO Contact and Staff Acknowledgments GAO Contact Staff Acknowledgments In addition to the contact named above, the following individuals made important contributions to this report: Elizabeth Morrison (Assistant Director), Kate Blumenreich (Analyst-in-Charge), Aimee Elivert, and Kelsey Kreider. Also contributing to this report were Steven Campbell, William Chatlos, Sarah Cornetto, Holly Dye, Jill Lacey, Jessica Orr, Catherine Roark, and Curtia Taylor.