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Audit (A-02-09-01033)

07-28-2011
Review of Medicaid Payments for Services Provided Under New Jersey's Section 1915(c) Community Care Waiver by Elwyn New Jersey From January 1, 2005, Through December 31, 2007

Executive Summary

Based on our sample results, we estimated that the State improperly claimed $903,000 in Federal Medicaid reimbursement for Community Care Waiver (CCW) program services provided by Elwyn New Jersey (Elwyn) that did not comply with certain Federal and State requirements during calendar years 2005 through 2007. The State’s CCW program allows the State to claim Medicaid reimbursement for home and community-based services provided to mentally retarded or developmentally disabled individuals who would otherwise require institutionalization in an Intermediate Care Facility for the Mentally Retarded (ICF/MR).

The claims for unallowable services were made because (1) Elwyn and the State's Division of Developmental Disabilities (division) did not ensure that they only claimed for documented, allowable CCW program services, (2) the division did not ensure and document that all beneficiaries were assessed and certified to require an ICF/MR level of care, and (3) the division did not ensure that CCW program services were provided only to beneficiaries with completed and approved individual habilitation plans.

We recommended that the State (1) refund $903,000 to the Federal Government; (2) require Elwyn and the division to ensure that they only claim for documented, allowable CCW program services; (3) require the division to ensure and document that all CCW program beneficiaries approved for services have been assessed and certified to need an ICF/MR level of care; and (4) require the division to ensure that CCW program services are provided only to beneficiaries for whom there is a completed and approved individual habilitation plan. The State generally agreed with our recommendations.

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