Illinois’ top Medicaid contractor has repeatedly failed to deliver basic medical services to thousands of foster children, from dental visits to immunizations to well-being checks, forcing foster parents to scramble to find health care, wait months for appointments and pay medical expenses out of their own pockets for the abused and neglected children they take into their homes, an Illinois Answers Project investigation found.
Since 2020, Illinois has paid nearly $370 million to the for-profit insurance powerhouse Centene Corp. to manage health care for about 36,700 current and former foster children as part of the state’s YouthCare program. These payments were made even as internal data showed Centene repeatedly failed to meet common benchmarks, government records show.
When abused or neglected children are placed with foster parents, those children may need urgent medical care. The families who take them in often don’t receive the full story — or at times any details at all — on the children’s medical history or past traumas. That’s why foster parents especially need a program that can quickly provide health care assessments and effective medical treatment, experts say.
Instead, in Illinois, many of those parents are grappling with a health care program that’s often underperforming and in disarray, according to interviews with foster parents, frontline medical providers, state officials and former Centene employees, as well as a review of thousands of pages of state contracts.
Centene’s shortfalls were especially striking for children with serious behavioral health needs stemming from their histories of abuse.
During the first quarter of this year, Centene’s plan produced what’s called an individualized plan of care for fewer than 2% of Illinois foster children who had the highest level of need, government records show. The state said Centene later corrected the number — to 8%.
Centene’s data shows only 62% of foster children had an annual dental visit in 2021. Just 55% of foster children got standard immunizations and about 67% of adolescents had a “well-care visit” required under Centene’s state contract.
Figures are even worse for former state wards who are still under the state’s Medicaid program but have been reunified with their families, adopted or given another placement. Just 43% of those individuals had a dental visit and 47% had an adolescent well-care visit.
The state of Illinois initially declined to provide Centene’s performance data and other basic information. When the Better Government Association, the publisher of the Illinois Answers Project, sued for the data, the state fought for a year in court to keep the information secret from the public. Eventually, the state released heavily redacted documents.
Only then did Illinois Healthcare and Family Services leaders acknowledge Centene’s shortcomings as well as a previously undisclosed enforcement action against the company.
“The performance of YouthCare during this period of time was unacceptable,” a spokeswoman for HFS said in a written statement.
Centene Corp. leaders declined interview requests and did not respond to detailed written questions. In a statement, a company spokesman wrote in part: “We have progressively improved our metrics, including increasing the number of Health Risk Screenings, Health Risk Assessments, and Individual Plans of Care. We are committed to increasing access to care for our members, and compared to the program in place prior to YouthCare’s inception, our provider network has more than tripled its number of medical and behavioral health providers.”
In interviews, parents detailed how they struggled to get basic health services for their foster children.
“YouthCare is the lowest level of quality of Medicaid possible,” said Alicia Wehby, a foster parent for 15 years who helps run a Northern Illinois nonprofit that provides foster families with cribs, clothes and advice.
“You need a psych evaluation for a child in your care because you’re trying to figure out the root cause so you can help them. You have to basically jump through hoops to prove they may need additional help, because YouthCare is so bad. You are on a minimum one year wait just to get the evaluation done,” Wehby said.
She worries about other parents entering the fold of foster parenthood without support or knowledge about their foster child’s needs.
“There’s a lot of times where you don’t have their immunization records,” Wehby said. “Should we double immunize because, to be totally honest, we have absolutely no idea?
“These kids are being dropped off in people’s houses without their full story and then families don’t know how to respond because they don’t know why their child is acting the way that they’re acting,” Wehby said.
“They could be experiencing major, major trauma from abuse that nobody knows about. And something as simple as a shower is going to be a huge, triggering event and cause that child to behave in ways that that foster parent is like, ‘I have no idea what’s going on with them, they’re violent and they need to get out of my house.’ And so that kid is moved,” Wehby said.
“This poor kid has absolutely no idea what’s going on. And we’re just further traumatizing the children because we are not prepared as foster parents to have any idea how to deal with them. Because we’re not told their story.
“Now they’ve moved again, just reiterating the lesson that, ‘we’re not good enough, we’re not lovable.’”
Melissa Thomforde, a foster parent of 11 years, said she understands why her foster children might emulate the violence they’ve experienced or witnessed, and she recounted desperately seeking help for an 11-year-old foster child who attacked a sibling.
“We have all of our foster children on our own private insurance to get them the services that they need,” Thomforde said. “We pay to get them appropriate level care because, if you rely on YouthCare, you either get subpar providers or the wait list is so long, it’s just ridiculous.”
A Department of Children and Family Services contractor dropped off Eva Green’s new foster son with big bags of nebulizers and steroid medications, Green said.
In the weeks that followed, Green said “his eyes were swollen shut, he had cysts on his head that were rupturing from infection.”
Green said she navigated urgent care clinics, often paying out of pocket for her new son’s medications to avoid YouthCare delays, without the benefit of a comprehensive assessment of his health needs and history.
“They didn’t even give him a physical assessment,” Green said. “It’s like the system is causing further trauma to these kids by not having foster parents who are equipped to take care of them — because let me tell you, I was literally in a non-stop panic attack. We were on no sleep whatsoever. And this went on for months.”
The two state officials who oversee the YouthCare program – HFS Director Theresa Eagleson and DCFS Director Marc Smith – defended it and their oversight in an interview.
“YouthCare is relatively new, I want you to remember,” Eagleson said. “You don’t ever see the results that you want overnight. Progress is often slower than we’d all like it to be and progress is never linear, but these numbers are trending now in the way we want them to be trending. And we all think that this plan – and the services being brought to the kids – is better than what these children had before, and we’re working on making it even better.”
YouthCare was initially delayed for two years because of concerns from advocates about the low number of participating doctors. Eventually, it launched in 2020 with the promise that foster children “will receive additional benefits, such as care coordination for behavioral health needs, including trauma-informed care and a specialized program for adoptive families.”
Illinois cites Centene over problems
To get Centene’s basic performance records the BGA waged a year-long FOIA lawsuit in Sangamon County circuit court, ultimately forcing HFS to release records withheld after Centene argued its performance metrics should be considered “trade secrets.”
It was only after Illinois Answers began asking questions that HFS acknowledged for the first time that it took enforcement action earlier this year by stopping automatic enrollments of new Medicaid patients to the Centene subsidiary that runs YouthCare, Meridian Health Plan of Illinois.
HFS barred automatic enrollments of new Illinois Medicaid patients of all ages and types, not just foster youth, Eagleson said. In addition to the 36,700 current and former foster children in YouthCare, Meridian oversees medical care for 876,000 other Illinois Medicaid patients under a separate contract, according to state data.
Eagleson said the hold on new Medicaid enrollments stayed in effect for two months until May 2022: “We said, you’re not going to get any auto-assignments in the traditional plan until we see these numbers change . . . we did not want to let it fester.” HFS said in a statement that, as of June, YouthCare is now in “nearly complete or complete compliance.”
HFS’ disciplinary action was not posted publicly on the agency’s website, as is usual with sanctions.
The details were obtained through a public records request to California’s Medicaid agency. Centene had to disclose information on disciplinary actions in all states as part of an unsuccessful Medicaid contract bid in California this year.
Centene’s California bid submission says Illinois HFS cited YouthCare for three serious deficiencies: failing to identify and classify the risk level of children in a timely way, failing to conduct thorough Health Risk Assessments and failing to appropriately document Individualized Care Plans for complex and high-risk children.
Centene said in the California records it was subject to an official HFS Corrective Action Plan. However, Eagleson said in an interview last month that her department never publicly disclosed the enrollment freeze because it was not part of a formal Corrective Action Plan, and HFS said in a statement that the action was imposed by its contracted auditor and not the department itself.
Two weeks after Eagleson’s interview, HFS fined YouthCare $50,000 in a separate case for failing to report complete data about whether services were delivered for a variety of categories from medical transportation to clinical care.
Under Illinois’ privatized Medicaid program, HFS pays Centene a steady, monthly dollar amount per member, regardless of whether or how much patients access medical treatment. Those payments for all of Centene’s Illinois Medicaid and Medicare patients totaled $5.2 billion last year, state records show.
Foster parents said they’ve paid out of pocket for expensive medical services YouthCare was already being reimbursed to provide.
Wehby said wait lists for a psychiatric assessment or treatment can be as long as a year on YouthCare, but on her private insurance, “I could get my kids in within a couple of months.”
“I know plenty of foster parents who pay out of pocket for every single thing because they just can’t deal with waiting or a provider not taking it. They’ll pay thousands of dollars to have stuff done because they know the kid needs it.”
Before YouthCare, the state paid each doctor, clinic or hospital a fee for every Medicaid service rendered.
DCFS Director Smith said foster parents can seek reimbursements for their private medical expenses and he added that his agency wasn’t hearing many complaints about YouthCare from foster parents.
“I will say that, overwhelmingly, the feedback has been positive about our engagement with YouthCare. But I will say that as with all things, we have some people who do not get everything that they need. And it’s our responsibility at DCFS to support them,” Smith said. “We set up a hotline through our advocacy unit that’s available for our foster parents to call. They’re able to speak to somebody in advocacy and they get additional support from DCFS to work with YouthCare to get what they need. … We make sure that, if there’s a wait list, that they’re on the wait list.”
Assessments called unreliable
In official documents, HFS says that among all Medicaid plans statewide, it expects at least 70% of new enrollees to have a health screening within 60 days of joining enrollment.
But in the fourth quarter of last year, YouthCare said it enrolled 571 foster children but screened only 22% within 60 days. Only once in the previous 12 months did YouthCare’s percentage exceed 50%, according to state records.
“Those numbers are horrible,” said Charles Golbert, the Cook County public guardian whose office represents some 7,000 foster children in court proceedings.
“Two months and no health risk screening – and this is new kids who have just been taken away from their parents or been born drug exposed or endured physical abuse.”
Eagleson said she’s not happy with the 22% figure either but she partly blamed foster parents who don’t take responsibility for getting children screened.
“I’m not saying that 22% is ideal, and I’d much rather see it between 50 and 70%, but I also know that sometimes it’s hard to get a hold of families for all kinds of reasons,” Eagleson said.
“They’re at their jobs. They’re not at home when somebody might try to catch them at home. They decide not to return the phone call to do the health risk screening. People have choices, right? And we have workers out there trying to assess children’s and families’ needs. Again, not okay with 22%, but it’s better than where we were. And we’re working on improving it,” Eagleson said.
Even when children do get assessed, YouthCare’s performance has drawn questions about whether they are being properly categorized.
One of YouthCare’s key contract requirements was to quickly assess foster children and assign them to one of four risk levels — with additional care for children whose medical and behavioral needs were the most urgent and complex.
Golbert said he expected a substantial percentage of all foster children would be assigned to the top two categories. But since 2020, YouthCare has never assigned more than 17% of foster children to the top two categories, according to the documents released following the BGA lawsuit.
Golbert said that 17% figure suggests children with serious needs might not be properly classified and therefore not getting intensive care.
HFS said: “YouthCare was working to catch up on a backlog of members” who had not yet been assigned to a risk category.
One crisis YouthCare promised to address is the hundreds of foster children held in juvenile jails, emergency shelters and psychiatric hospitals beyond medical necessity.
Some juvenile state wards are held in Cook County detention cells weeks after their projected releases. Dozens more sit in psychiatric hospitals where they don’t belong. And others languish for weeks in emergency rooms and shelters.
In a 2021 federal court report, appointed expert Marci White examined the case files of 34 improperly placed foster children and criticized YouthCare for poor planning and provision of mental health services for foster children undergoing mental health crises.
“YouthCare did provide [Individual Plans of Care] for many youth in the study, but, to put it mildly, they did not reflect familiarity with the specific mental and behavioral health needs of youth assigned to them,” White wrote in her report to the court. “… The plans did not call for the types of intensive community-based services the youth involved clearly needed, much less reflect that YouthCare ‘owned’ responsibility and commitment to secure those services.”
Two former Centene employees said in interviews that Centene often produces those individual plans of care without a Centene employee actually meeting the foster child or family face-to-face.
“That is true, it happens more often than not,” said one of the former Centene employees, who both spoke on condition their identities were withheld because they were not authorized to speak for the company.
In a report covering the first quarter of this year, Centene told HFS it was not tracking how many of its “care coordination” encounters with patients were in person. “Face-to-Face (F2F) not tracked … caseload compliance not tracked in Q1 due to staffing deficits,” that report said.
Doctors paid little or late
HFS provided some data showing Centene dramatically expanded the network of frontline providers available to foster children since YouthCare was launched, from 8,600 in 2019 to nearly 42,000 today.
Other state records and interviews raise questions about the strength of Centene’s medical network.
YouthCare’s rollout was delayed for two years in part because public guardian Golbert made “secret shopper” calls to the doctors officially listed in Centene’s directory and found many would not actually accept YouthCare.
Last year, when state-contracted auditors tried to locate providers listed on the public websites of Illinois Medicaid contractors, the auditors could only locate 45.3% of those listed for YouthCare.
The scores for Illinois’ other Medicaid plans were as follows: Blue Cross and Blue Shield of Illinois, 85.5%; CountyCare, 79.3%; IlliniCare, 91.2%; Molina, 72.8%, and 97.5% for Meridian’s non-YouthCare program.
In interviews, Illinois medical providers said Centene sometimes pays them little, late or not at all for their services.
Stephanie Barisch, director of therapeutic services at The Center for Youth and Family Solutions in Bloomington, said her agency last year had $70,000 in unpaid YouthCare claims for services rendered to foster children.
Wehby, the long-time foster mother, said doctors have complained to her that “it takes YouthCare over a year to pay them, and sometimes if they get paid at all, it’s at a reduced rate by a lot.”
Wehby’s record of public service and her years of navigating this broken care system have given her relationships with doctors, therapists and dentists. But she’s seen first-time families simply give up because they can’t access treatment and medical services.
“I’ve established relationships with different doctors and people through the years who have said they’re going to see him for free because it’s not even worth dealing with YouthCare,” Wehby said. “Your teeth have to be beyond crazy for orthodontics to be paid for.”
Wehby said one of her foster children was “literally missing teeth and that wasn’t considered a reason” for treatment, so “we found an orthodontist who did it for free.”
“That was a lot of money he basically donated to her,” Wehby said.
Errors in data, records withheld
In response to queries, HFS revealed that Centene’s quarterly performance reports are marked by errors.
There were “data submission errors” on the percentages of youth who had health screenings and individualized plans of care, the portion of youth described as high risk, and the numbers of disputes and grievances filed by providers, HFS said. There were even serious errors in the numbers of foster children enrolled in the plan.
Eagleson said she expects Centene’s performance rates to change for the better due to adjustments Centene is making in how it calculates and reports data.
“Youthcare-Centene instituted some changes at the beginning of calendar year 2022 to change their logic for reviewing and analyzing that data for this specialized population, so it improved the accuracy of the data measured and the timeliness of completing the risk stratification process,” Eagleson said.
In one example, Centene said it had completed a care plan for just 2% of the highest risk children in the first quarter of 2022. In a written response to questions, HFS said that Centene had corrected that number to 8%.
HFS spokeswoman Munks explained the change as Centene catching up on a “backlog of members” who were not yet categorized, increasing the number of members who were assigned as complex risk.
“Since then, YouthCare leadership implemented additional oversight and monitoring of these operations and deadlines. The data fluctuation stabilized in Q2 2022, and HFS does not expect to see large variations going forward,” Munks said.
HFS said its corrective actions also led “to changes in leadership at YouthCare,” though the number of new leaders is hard to quantify.
There have been several top leaders connected to YouthCare over the past two years, though none have stayed in their roles long, according to Centene’s quarterly reports and interviews with state officials and frontline providers.
Centene asked HFS to redact the names of its executives from documents released publicly, and HFS complied until a reporter questioned the practice in a letter to HFS officials.
In some reports to the state, Centene acknowledged staff turnover and shortages extended down to the frontline workers assigned to coordinate care for Illinois foster children.
Multiple times in 2020, Centene reports explained that the company fell short on timely assessments and employee caseloads “due to staff shortage.”
HFS said it’s not concerned about the staff churn.
“There have been some growing pains since YouthCare launched and the pandemic has created additional challenges, but overall, HFS is seeing improvements in YouthCare’s performance and will continue to push for more,” HFS said in a written statement.
HFS in December 2021 extended Centene’s YouthCare contract through 2025, agreeing to pay the multinational insurance company an additional $1 billion, state records show.
HFS said the contract extension was a good policy move because the YouthCare contract was due to end that month. “The extension was needed so health care services did not revert back to fee-for-service,” HFS said in its written response.
In the two years since the launch of YouthCare, Centene and HFS still have not established benchmarks on the rates of care HFS expects, ranging from frequency of doctor visits to psychological assessments.
HFS said in a written statement it expects those YouthCare benchmarks to be in place by the end of this year.
“The expectation is that at a minimum YouthCare must meet or exceed the [HealthChoice Illinois] thresholds,” an HFS spokeswoman said in a written statement.
One Centene report compared 14 performance measures before and after the YouthCare contract launched, measuring care delivery rates in 2019 versus last year.
The results were mixed at best. YouthCare was worse for five basic measures — including dental check-ups, immunizations and adolescent well care visits. It was about the same on three, and better on six that included three categories of assessing children’s weight.
National Medicaid experts said an illuminating comparison might be YouthCare against the handful of other managed care organizations that exclusively serve foster children. HFS said it has not undertaken such a comparison.
Centene is a dominant player in the emerging market of Medicaid contracts for foster children, according to a report by the Center for Children and Families at Georgetown University that studied nationwide contracts from 2018.
Centene enrolled 120,000 youth in four states that year — Florida, Illinois, Texas and Washington — while three other insurance firms held similar contracts in Georgia, Kentucky, Tennessee and West Virginia, the Georgetown report said.
“Not enough data was publicly available to tell whether the MCOs were delivering the services the foster youth needed,” lead author Andy Schneider said.
Illinois requires less performance data from its contractor than other states.
Centene provides Illinois with data on 18 performance measures while Washington state, for example, uses 41 measures, and Tennessee demands tracking and public reporting for more than 100, records show.
In its written statement, Centene said: “Like other Medicaid managed care organizations, YouthCare reports on the metrics determined by the state in which it operates. …We anticipate changes to the metrics as the program evolves, which is a common practice in most states.”
Public Guardian Golbert, who reviewed HFS’ data submissions at a reporter’s request, said he was struck by the amount of data withheld from the public because Centene argued its performance metrics constituted trade secrets.
“Every word of YouthCare’s initiatives, redacted,” Golbert said. “All progress toward annual goals, redacted. Every single word about disparities and opportunities for action, redacted. You would think that that’s something taxpayers should be entitled to know about.”
Eagleson rejected any suggestion Centene and her department are withholding information from the public.
“We try in this administration to be very transparent, right, about what we’re working on and what we’re trying to improve. And just by the nature of us saying we’re trying to improve something you guys seem to want to say that means that something has gone awry, or something’s bad,” Eagleson said. “We’re trying to figure out every day how we can do a better job for the people that we serve.”