Review of Medicaid Claims Submitted by Continuing Day Treatment Providers in New York State

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) is the State agency responsible for operating the Medicaid program. The State elected to include Medicaid coverage of day treatment services, a form of clinic services, among its Licensed Outpatient Programs, which are administered by its Office of Mental Health (OMH). OMH's continuing day treatment (CDT) program provides active treatment to Medicaid recipients 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 recipient must have a designated mental illness diagnosis and a dysfunction due to mental illness. CDT services are provided in hospital and nonhospital settings. Pursuant to State requirements for Medicaid reimbursement of CDT services, a recipient's treatment plan must: (1) be completed in a timely manner, (2) be signed and approved by the recipient, (3) include criteria for discharge planning, and (4) be reviewed every 3 months. In addition, CDT services must be adequately documented (including type and duration of services) and provided in accordance with the recipient's treatment plan. Our objective was to determine whether DOH claimed Federal Medicaid reimbursement for CDT services provided by nonhospital providers in the State in accordance with Federal and State requirements.