Review of New Mexico Medicaid Personal Care Services Provided by Clovis Homecare, Inc.

摘要

Pursuant to 42 CFR S 440.167, personal care services may be provided to individuals who are not inpatients at a hospital or residents of a nursing facility, an intermediate care facility for individuals with intellectual disabilities, or an institution for mental disease. The services must be (1) authorized by a physician pursuant to a plan of treatment or, at the State agencys option, otherwise authorized in accordance with a service plan approved by the State agency; (2) provided by an attendant who is qualified to provide such services and who is not the recipients legally responsible relative; and (3) furnished in a home and, at the State agencys option, at another location. Examples of personal care services include, but are not limited to, cleaning, shopping, grooming, and bathing. The State agency contracts with a third-party assessor to perform an in-home assessment of each recipient that determines the types and amounts of care needed and to develop a personal care services plan. In addition, New Mexico law requires a supervisor from the personal care services provider agency to visit each recipient or his or her personal representative in the recipients home monthly. The State agency periodically reviews provider agencies to ensure compliance with Federal and State requirements. The State agency reported to CMS personal care services expenditures of approximately $57.6 million ($44.5 million Federal share) from October 1, 2008, through March 31, 2009. Of that amount, Clovis Homecare, Inc. (Clovis), a personal care services provider in Clovis, New Mexico, received $4,711,258 ($3,638,976 Federal share). Our objective was to determine whether the State agency ensured that Cloviss claims for reimbursement of Medicaid personal care services complied with certain Federal and State requirements.