Review of Medicaid Payments for Services Provided Under New Yorks Section 1915(c) Traumatic Brain Injury Waiver at Belvedere of Albany, LLC, from January 1, 2005, through December 31, 2007

摘要

The State agency's Office of Long-Term Care administers the traumatic brain injury (TBI) waiver program through 10 contracted regional resource development centers (not-for-profit organizations) that serve specific counties throughout the State. Under the TBI waiver program, each beneficiary is required to have an individualized plan of care that, every 6 months, is reviewed by a regional resource development specialist. As part of the plan-of-care review, the regional resource development specialist must ensure that the beneficiary is assessed to need a nursing home level of care by a State agency-certified assessor. The regional resource development specialist must maintain documentation of each plan of care and assessment for at least 3 years. During calendar years 2005 through 2007, the State agency claimed Federal reimbursement totaling $131 million for services provided by 212 providers under the TBI waiver program. During this period, Belvedere of Albany, LLC (Belvedere), a TBI service provider, received Medicaid reimbursement for 2,434 beneficiary-months totaling $11.9 million ($5.9 million Federal share). A beneficiary-month includes all HCBS for a beneficiary for 1 month. Belvedere provided TBI waiver program services in areas covered by regional resource development centers in Schenectady and Queensbury, New York. (We refer collectively to these organizations as the centers.) Our objective was to determine whether the State agency's claim for Medicaid reimbursement for TBI waiver program services provided by Belvedere complied with certain Federal and State requirements.