SIOUX FALLS, S.D. (KELO) — This summer the South Dakota Department of Social Services announced Governor Kristi Noem’s Stronger Families Together initiative recruited more than 300 new foster families.

It’s a tough, but important job and one the state needs more families to fill. KELOLAND Investigates one of the surprise challenges many foster families are facing.

“I’m a unique case, I decided to be a foster parent specifically for one kid in particular,” foster mom Frances Abbott said.

Frances Abbott with foster child
Frances Abbott with her foster daughter

At age 23, Frances Abbott became an emergency foster placement for a teenager she was mentoring through Big Brothers Big Sisters.

“When you’re a young foster parent caring for a teen, it feels like you have just this weird roommate,” Abbott said.

Albeit a roommate you’re responsible to care for and provide everything from clothes to health care.

“It’s difficult because a lot of times they might enter your home and they have a couple years of health care that needs to be caught up,” Abbott said.

Much of that catch up is covered by state Medicaid, a benefit every South Dakota foster child receives.

“The out-of-pocket expenses are something that I don’t think they fully prepare you for,” Abbott said.

Abbott has fostered two teens over the past decade and says the Medicaid program has many limitations.

“Contacts, specific types of therapy,” Abbott said. “One that stood out for us, especially for our most recent placement was braces.”

“In order for someone to qualify for Medicaid coverage, they need to have what’s considered a handicapping malocclusion. There’s a scoring system that we as orthodontists will go through and fill out to submit to the state,” Orthodontist Rachel Soyland, owner of 605 Orthodontics + Smile Design, said.

It’s a severity level kids rarely qualify for. The South Dakota Department of Social Services says in the past two fiscal years, just four foster kids have had braces covered by the state.

As of June 2022, South Dakota had 587 teens in foster care; thirty percent of them have been in the system for three years or more, meaning they’ve only had access to Medicaid during the time braces are usually recommended.

“We like to start kids in braces when all their permanent teeth are in, so on average between 12 and 13 years old,” Soyland said. “It’s easier to do that as a teen when your peers are going through it.”

It’s one of the many typical teen experiences many foster kids miss out on.

Sioux Falls lawyer Kasey Olivier shares her experience in the foster care system

“So much of foster care is related to trauma, abuse, instability,” former foster teen Kasey Olivier said. “They’re moving between homes; maybe they’re separated from siblings. There is a complete upheaval emotionally, stability wise. They don’t have a place to call home anymore.”

It’s a feeling Olivier knows well; she entered foster care while still in high school.

“You’re in survival mode, you’re just trying to figure out how do I survive this moment to make it to the next. Your health, your wellness is the last part of your mind,” Olivier said.

Even if a health need comes up, many foster kids are afraid to ask for help.

“Children, when they go into the foster care system, lock down,” Olivier said.

But putting off important care can impact kids for years. 

“I lived with a cracked molar for probably five years,” Olivier said. “You learn to adjust; you chew on the other side of your mouth. You avoid those things and you get by.”

In her work as an attorney, Olivier also knows the abuse or neglect that leads to a child entering care can also mean even more physical challenges.

“Neglect in childhood, if a child is given juice or milk at bedtime, their teeth tend to rot,” Olivier said. “What we can do is remove those teeth and then they might have to go through life without them.”

It’s the kind of need many foster parents work to identify and fulfill.

“You want to care for these kids how they deserve to be cared for, how anyone would want to be cared for their kids,” Abbott said.

But in order to fulfill needs like dental implants or braces, foster parents are left to decide whether they can foot the bill.

“It would have been thousands of dollars,” Abbott said of a quote for braces for one of her foster kids.

It’s a question many families with financial hardships face when their teens need braces.

“You know what when I was a kid I did too, but my parents couldn’t afford it,” South Dakota Representative Kevin Jensen said. “It’s always sad to say, ‘We can’t pay for this.’ I know a lot of parents that children want things, and they just say, ‘Well, you can’t have them because we just don’t have the money.'”

Orthodonist office

Jensen was the chair of the Health and Human Services Committee. He says funding braces for everyone on Medicaid would be a stretch for the state’s budget.

“What’s troubling about Medicaid in general is it’s not free, like a lot of people think. For every dollar that we spend on Medicaid, the state has to come up with 42 cents,” Jensen said. “It comes down to, can we afford every service that everybody wants? We just have to draw the line somewhere.”

For many teens in foster care that line defines the health care coverage they’ll receive while in the system. But some are lucky enough to be placed with someone who acts as their advocate.

“Who is willing to run the gamut as far as researching, asking the questions and being tenacious about it, is so much better than a child who doesn’t have that level of advocacy for them,” Paul Knecht, the Executive Director of the South Dakota Dental Association and Dental Foundation, said.

“You have to seek out your own answers or talk to people on your own,” Abbott said. “It’s really another job, and sometimes it feels like a full-time job.”

KELOLAND Investigates also spoke to other foster parents who did not wish to go on camera, but shared their struggles trying to access orthodontic care for kids in their home. Some ended up paying thousands to cover the cost themselves. Other foster parents said they reached out to friends or people they knew who work in orthodontics to try and find someone who would help cover or reduce the cost. 

All of that advocacy work can reveal more resources, like the South Dakota Dental Foundation’s Sunshyne Smiles Program.

“It was created by a pediatric dentist who saw children in his practice that needed braces, but couldn’t afford it and didn’t qualify for Medicaid,” Knecht said.

Donors and dozens of orthodontists across the state help the nonprofit cover the cost of braces for roughly 50 teens every year, as long as their families commit to contributing $1,000.

“In increments as small as $25/month for up to three and a half years so we really try to keep that financial burden affordable for families,” Knecht said. “What we’ve found is that small level of participation makes sure that the family and the child are engaged in the treatment.”

Treatment that can last anywhere from 18 to 24 months; a long-term commitment that can be difficult for foster families.

“I do think it is a challenge to put up a large amount of money when they’re taking these kids in, not knowing what the future holds, not knowing how long they’re going to be caring for these kids,” Soyland said. 

It’s why many foster parents feel a sense of urgency in advocating for a child as long as they’re in their care.

“You have to be aggressive about it so they can get caught up, especially with teens because you only have a couple of years before they age out of the system,” Abbott said.

A short window to help a teen who’s experienced trauma.

“A lot of times they feel like they don’t matter in school; that they’ve been unseen. They’ve been unheard. They just want to melt into the background and not be noticed,” Olivier said.

Olivier says being denied something like braces is just another blow to a foster child’s sense of worth.

“It truly says, it’s another thing that, ‘You don’t matter.’ And so many kids in the foster system have had that their entire lives, you don’t matter. You don’t matter at home; that’s why they’re in the foster care system,” Olivier said.

It’s why the benefits of braces go beyond a straight smile, especially for kids who’ve experienced trauma.

“Set these kids up for success in the future, set them up for good dental care long term,” Soyland said. “Straighter teeth is going to make it easier to keep their teeth clean, get jobs down the road. It’s going to give them more self esteem and higher confidence and really set them up for the future.”

“It affects the psyche of these kids, and it is life changing. The letters that we get from the children that have completed care, their self-image, how they feel about themselves, their aspirations are just so great,” Knecht said.

A boost in self confidence advocates wish more kids could experience. Knecht says at 50 kids each year, the Sunshyne Smiles program only covers a small fraction of the need.

“For a kid in foster care to get medical care or braces that really feels like the standard and should be the standard for all kids across the board,” Abbott said.

It’s why many foster parents would like to see state lawmakers make changes.

“I understand that the foster care kids, maybe we need to look at as a state, rather than Medicaid, look at a different way to insure them,” Jensen said.

While Representative Jensen isn’t sure what that might look like, he says it’s a topic lawmakers can certainly discuss.

“More help and resources to help them succeed, giving them a hand up not a hand out to use those resources to transition into being productive community members,” Olivier said.

Olivier shares her foster care experience with others, showing them their future can change.

“I’ve been in your shoes,” Oliver said. ” And it does get better.”

A brighter future she says could be more easily attained with increased support from everyone in the state.

“Letting them know they do matter, their lives matter, their careers and their lives they do matter. They matter to all of us and the community as a whole and it’s a huge benefit for us to help them and help them succeed,” Olivier said.

These issues apply to all of the nearly 93,000 children receiving Medicaid benefits in South Dakota.

This November voters will cast their decision on Medicaid Expansion; that ballot issue would allow more people to qualify for Medicaid benefits. It would not expand what health care needs are currently covered.

The South Dakota Department of Social Services did not accommodate a request from KELOLAND News for an interview for this story. DSS did respond with written answers to questions, which you can review below. Information is from Department of Social Services Cabinet Secretary Laurie Gill.

#1 How many teens are currently in foster care in South Dakota? How has the number changed over the last 5 years or so
In State Fiscal Year (SFY) 2018, there were 541 teens in foster care. In SFY 2022, there were 587.

#2 What percentage of those teens in care are new to foster care and how many have been in the system for a number of years?
Of the 587 teens in custody during SFY 2022
28 % entered care during SFY 2022.
25% entered care in SFY 2021
17% entered care in SFY 2020
30% entered care in SFY 2019 or prior years

#3 Why do teens usually end up in foster care? What are some of the reasons a teen might go into state custody?

Teens come into the custody of the Department of Social Services when it has been determined they are unsafe in their homes due to conditions in the home or the capacity of their parents to provide safe care for them. When any child is placed into the Department of Social Services emergency custody, the final determination of emergency or ongoing custody is made by a circuit or tribal judge based on the jurisdiction.

#4 How many of those teens are in foster homes, how many in group homes/centers and how many in JDC or other state run facilities?
On June 30, 2022, the 587 teens in custody were in the following placement settings:
Foster Home-192
Placed with a relative-96
Group or Psychiatric Residential Treatment Facility- 179
JDC- 13
The remaining 107 teens are in another setting such as trial reunification with family, boarding schools, or hospital psychiatric facilities.

-Does that medical/dental coverage apply to braces?
Yes, Medicaid covers orthodontic services for Medicaid recipients under 21 that meet the coverage criteria for medical necessity. Medically necessary orthodontic treatment is:
Treatment necessary to correct a condition which scores 30 or higher on the Handicapping Labio-Lingual Deviations Form (HLD Index); or Treatment necessary to correct a condition that constitutes a handicapping malocclusion. A malocclusion is handicapping if there is an impairment of or a hazard to the ability to eat, chew, speak, or breathe that is related to the malocclusion.

5-Do you know how many teens in foster care have received braces?
In the last two state fiscal years, four children in foster care initiated orthodontic treatment.

6-What does it take for the state to cover teen orthodontic care?
Orthodontic services are prior authorized to ensure the services meet the coverage criteria before treatment begins. In general, the process includes obtaining documentation from the recipients general dentist and an orthodontist completing a qualitative, objective assessment called the Handicapping Labio-Lingual Deviations (HLD) index used to measure malocclusion. South Dakota Medicaid dental consultants review the HLD index score and related documentation during the prior authorization process to make a coverage determination. The parent/legal guardian is also provided education regarding the orthodontic process.

7-Where is that care available and what is it like to try and access it? (wait times, etc)
Medicaid has both orthodontists and general dentists enrolled that perform orthodontic services. Wait times vary by provider.

8-Are braces an issue you’ve heard from foster families or group homes about?
Medicaid orthodontic coverage is the same for Medicaid recipients that live with a foster family as it is for any other child with Medicaid coverage. Medicaid does not specifically track inquiries regarding orthodontic coverage by whether or not the individual lives with a foster family.