New York Claimed Hospital-Based Continuing Day Treatment Services that were not in Compliance with Federal and State Requirements.

摘要

Pursuant to Title XIX of the Social Security Act (the Act), the Medicaid program provides medical assistance to low-income individuals and individuals with disabilities. The Federal and State Governments jointly fund and administer the Medicaid program. At the Federal level, the Centers for Medicare & Medicaid Services (CMS) administers the program. Each State administers its Medicaid program in accordance with a CMS-approved State plan. Although the State has considerable flexibility in designing and operating its Medicaid program, it must comply with applicable Federal requirements. In New York State (the State), the Department of Health (DOH) administers the Medicaid program. Section 1905(a)(2)(A) of the Act authorizes outpatient hospital services. Federal regulations (42 CFR SC 440.20) define outpatient hospital services as preventive, diagnostic, therapeutic, rehabilitative, or palliative services that are furnished to outpatients, by or under the direction of a physician, by an institution that is licensed or formally approved as a hospital. The State elected to include Medicaid coverage of continuing day treatment (CDT) services, a form of outpatient hospital services, among its Licensed Outpatient Programs, which are administered by its Office of Mental Health (OMH). OMHs CDT program provides active treatment to Medicaid beneficiaries designed to maintain or enhance current levels of functioning and skills, to maintain community living, and to develop self-awareness and self-esteem through the exploration and development of strengths and interests. CDT services include assessment and treatment planning, discharge planning, medication therapy, case management, psychiatric rehabilitation, and activity therapy, among others. To be eligible for the CDT program, the beneficiary must have a designated mental illness diagnosis and a dysfunction due to a mental illness. CDT services are provided in hospital and nonhospital settings.