Some of New Jersey's Claims for Medicaid Global Options for Long-Term Care Waiver Services Were Unallowable

The New Jersey Department of Human Services (State agency) claimed Federal Medicaid reimbursement for some Global Options for Long-Term Care (GO-LTC) waiver services that did not comply with certain Federal and State requirements. Of the 131 beneficiary-months in our sample, the State agency properly claimed Medicaid reimbursement for all GO-LTC waiver services during 69 beneficiary-months. However, the State agency claimed Medicaid reimbursement for unallowable GO-LTC waiver services during the remaining 62 beneficiary-months. Of the 62 beneficiary-months with services for which the State agency improperly claimed Federal Medicaid reimbursement, 29 contained more than 1 deficiency.

The State agency made claims for unallowable services because it lacked clear guidance on claiming and documenting Medicaid services for beneficiaries enrolled in the GO-LTC waiver program and providers did not ensure that (1) services claimed were adequately documented, (2) services were provided only to beneficiaries with completed and approved care plans, (3) provider qualifications were documented, (4) beneficiaries' level-of-care evaluations were documented, (5) providers maintained State licenses authorizing them to provide services, (6) services were appropriately billed to the waiver, and (7) services were billed at the appropriate FMAP. On the basis of our sample results, we estimated that the State agency improperly claimed at least $47.3 million in Federal Medicaid reimbursement for unallowable GO-LTC waiver services.

We recommended that the State agency (1) refund $47.3 million to the Federal Government and (2) reinforce guidance to the provider community on Federal and State requirements for claiming and documenting Medicaid services for beneficiaries. The State agency did not concur with our first recommendation and generally concurred with our second recommendation.