Review of Medicaid Payments for Services Under New Jersey's Section 1915(c) Community Care Waiver Program From January 1, 2005, Through December 31, 2007

New Jersey (the State) claimed Federal Medicaid reimbursement for some Community Care Waiver (CCW) program services that did not comply with certain Federal and State requirements. We estimated that, as a result, the State improperly claimed $60.7 million in Federal Medicaid reimbursement. Of the 146 beneficiary-months in our random sample, the State properly claimed Medicaid reimbursement for all CCW program services in 23 beneficiary-months. However, the State claimed Medicaid reimbursement for services that were not allowable for the remaining 123 beneficiary-months. Of these 123 beneficiary-months, 28 contained more than 1 deficiency.

The CCW program allows the State agency to claim Medicaid reimbursement for home and community-based services (HCBS) provided to individuals with intellectual and developmental disabilities. Without HCBS, these individuals would require institutionalization in an Intermediate Care Facility for the Mentally Retarded (ICF/MR).

We recommended that the State (1) refund $60.7 million to the Federal Government; (2) require the New Jersey Division of Developmental Disabilities (division) and providers to ensure that they claim reimbursement only for documented, allowable CCW program services; (3) 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; and (4) 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. The State partly agreed and partly disagreed with our recommendations.