Difficulty of Care

Difficulty of care rates are available to assist resource parents in the additional care and supervision required due to a child’s physical, mental or emotional disability. Resource parents contact the child’s child welfare specialist regarding the qualifications and to request difficulty of care. If difficulty of care is approved, the resource parent receives the difficulty of care rate in addition to the monthly maintenance payment amount. Please contact your resource specialist to obtain the current difficulty of care rates.
The criteria for each level of difficulty of care is as follows:

DOC Level I

A child approved for DOC Level I has one or more of the needs, conditions, or behaviors. The child:

  • Requires ongoing scheduled medical or psychological appointments that routinely occur more than twice weekly
  • Displays emotional difficulties that result in destruction of property
  • Requires medical supplies, special equipment, or educational supplies on a routine basis that are not compensable through Medicaid
  • Requires daily physical therapy performed by the foster or adoptive family

DOC Level II

A child approved for DOC Level II has one or more of the needs, conditions, or behaviors described in DOC Level I and, in addition:

  • Requires 24-hour awake intensive supervision due to severe medical or emotional needs
  • Requires special food preparation and feeding due to a condition that restricts normal eating
  • Requires special equipment for transportation that results in restricted mobility for the child and foster or adoptive family
  • Displays incontinence of the bladder or bowel that is not age appropriate
  • Displays multiple disabilities, birth defects, or brain damage that prevents normal intellectual or physical functioning
  • Requires strict monitoring of medication
  • Requires assistance in movement that is very difficult due to the child’s size
  • Requires post-hospitalization care, such as frequent changing of bandages and tubes and special hygiene techniques
  • Displays emotional disturbances, developmental delay, or mental retardation that results in behavior, such as constant difficulties in school, aggressive and delinquent activities, destructiveness, resistance to authority, and sexual disturbances


A child approved for Level III has one or more of the needs, conditions, or behaviors described in DOC Levels I and II and, in addition, requires:

  • Specialized substitute care

DOC Level IV

A child approved for DOC Level IV has one or more of the needs, conditions, or behaviors described in DOC Levels I, II, and III and requires such specialized care that normally the child would be in institutional or inpatient psychiatric care. The child:

  • Requires special equipment such as: apnea monitor, suction machine, gastrostomy tube, oxygen, tracheotomy tube or shunt
  • Requires special feeding or nursing care around-the-clock
  • Requires frequent nighttime supervision and care that is not age appropriate
  • Displays frequent seizures or other abnormal physical reactions that require 24-hour monitoring
  • Displays bizarre, socially unacceptable behavior, violent tendencies, potentially harmful behavior to self or others, or sexually predatory behavior to others or animals
  • Required previous inpatient mental health treatment or was recently discharged from an inpatient facility
  • Requires such intensive care that the foster or adoptive family is severely restricted in normal daily activities and is frequently homebound
  • Requires frequent 24-hour awake supervision
  • Requires post-hospitalization care for severe burns

DOC Level V

A child approved for DOC Level V has one or more of the needs, conditions, or behaviors described in DOC
Levels I, II, III, and IV and has a significant number of intense needs. The child’s level of need is likely to become more severe over time and is likely at some time to require personal attendant care or specialized care outside of the home, when prescribed by a professional. A current medical or psychological report within the last six months is required from a qualified physician.

This report must include a diagnosis, prognosis, and recommended treatment. Conditions considered in the determination of DOC Level V include a child who has:

  • Been diagnosed by a qualified physician as having severe mental illness, such as child schizophrenia, severe developmental disabilities, brain damage or autism
  • Severe physical disabilities or medical conditions that are not expected to improve over time and adversely impact life expectancy when compared with others who have similar physical disabilities or medical conditions
  • Severely inhibiting mental health conditions, defined by the Diagnostic and Statistical Manual of Mental Disorders, diagnosed within the past year, that severely limit normal social and emotional development and require ongoing outpatient behavioral health services
  • Severe mental retardation as determined by the Social Security Administration and defined by the DSM
  • Been waiting for organ transplant or is up to one year post transplant
  • A physical condition uncontrolled by medication or treatment, such as Tourette’s syndrome or epilepsy
  • Levels I through IV are approved at the County level. Level V is approved by the Foster Care field administrator

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