Sneak Preview: N.Y. To Increase Reviews Under Waiver Program

October 12, 2012 | By Jerry Ashworth | Post a Comment

(The following was excerpted from an article in the Federal Grants Management Handbook.) New York health officials will expand their reviews of service plans for individuals with developmental disabilities to ensure that health care providers participating in a state Medicaid waiver program maintain the required documentation and claim Medicaid reimbursement for services actually provided.

In response to a Department of Health and Human Services Office of Inspector General audit that found the state overbilled Medicaid for more than $7 million, the New York Department of Health and the state Office of People With Developmental Difficulties are taking steps to limit unallowable costs under the program.

States may seek Centers for Medicare and Medicaid Services approval for the Home and Community-Based Services waiver program, which would allow states to claim federal reimbursement for developmentally disabled care services not usually covered by Medicaid. In New York, the Office for People With Developmental Disabilities provides services to individuals with intellectual and developmental disabilities under a cooperative agreement with the New York Department of Health, which administers its Medicaid program. Under a memorandum of understanding with the New York DOH, OPWDD administers a waiver program intended to enable adults and children with developmental disabilities to live in the community as an alternative to intermediate care facilities.

Under the state’s HCBS waiver program, all services must be furnished according to a written plan of care that is subject to a six-month review. OPWDD also must maintain documentation of each plan of care, and service providers must maintain all information regarding claims submitted for payment. From 2006 to 2008, DOH claimed reimbursement totaling $2.26 billion ($1.16 billion federal share) for certain OPWDD waiver program services provided by New York City providers for 458,751 beneficiary-months. (A beneficiary-month includes all HCBS for a beneficiary for one month.)

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