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Missouri Claimed Unallowable and Unsupported Medicaid Payments for Group Home Habilitation Services

The Missouri Department of Social Services, Missouri HealthNet Division's (State agency) Medicaid payment rates for group home habilitation services provided and paid for during State fiscal years (SFYs) 2011 through 2013 were not always in accordance with Federal requirements. Specifically, the State agency included room-and-board costs in some of its payment rates for group home habilitation services. Because this practice is prohibited under Federal requirements, the associated payments were unallowable. In addition, the State agency could not provide supporting documentation for some of its payment rates, and as a result we could not determine whether those payment rates included room-and-board costs.

We recommended that the State agency (1) refund $3 million to the Federal Government; (2) obtain supporting documentation (that is, provider cost reports) from the group home providers for the unsupported Medicaid payments of $39.1 million and recalculate any payment rates that include room-and-board costs, apply any recalculated payment rates to actual claims, and refund any additional unallowable amount to the Federal Government; (3) follow Federal requirements by ensuring that room-and-board costs are excluded when determining the payment rates for group home habilitation services; and (4) follow Federal requirements by maintaining supporting documentation to show how payment rates for group home habilitation services are calculated. The State agency disagreed with our first two recommendations and stated that it would continue to follow Federal requirements with respect to our third and fourth recommendations.

Filed under: Center for Medicare and Medicaid Services