Interstate Compact on the Placement of Children
Financial/Medical Plan
Complete one form per child. Must be completed by the Title IV-E specialist.
(Caseworker, please review financial and medical plan with the care provider.)
Child’s name:
Case #:
IV-E status:
{Select one}
Title IV-E specialist name:
Date of birth:
Case worker:
Placement type: {Select one}
Date:
As long as this child remains in the custody of Oregon Department of Human Services (DHS), Oregon
will be financially responsible for this placement and for authorized services provided to the child.
Financial plan
Placement is with a parent. The parent is expected to provide financial support for the child.
Placement is with a relative/foster care provider. Oregon DHS will make foster payments at
Oregon rate to the relative/foster care provider.
Placement is with a relative/foster care provider pending finalization of an Adoption Assistance
Agreement. Oregon DHS will make foster payments to the relative/foster care provider at Oregon
rate until adoption subsidy is open.
The child is receiving an adoption subsidy.
Medical plan
The parent is expected to provide medical coverage for the child or to apply for Medicaid in the
receiving state.
The child is eligible for Title IV-E foster care and therefore eligible under COBRA to receive
Medicaid in the receiving state.
The child is not eligible for Title IV-E foster care. The relative/foster care provider will apply for
Medicaid for the child. If Medicaid coverage is denied, Oregon will reinstate medical coverage for
the child. The medical service provider must enroll with the Oregon Health Plan (OHP) to receive
payment. If the relative/foster care provider is unable to locate a medical service provider willing
to enroll with OHP, the relative/foster care provider should contact the Oregon DHS caseworker
for additional guidance.
The child receives SSI and therefore is eligible for Medicaid in the receiving state.
The child is eligible for Medicaid through ICAMA.
Comments:
CF1044 (01/16)