New York Improperly Paid $1.4 Billion for Long-Term Care Plans

The state of New York improperly claimed reimbursements for a significant amount of Medicaid Long-Term Care (MLTC) plans, resulting in $1.4 billion in overpayments in fiscal year 2014, according to a report from the Office of Inspector General (OIG). MLTC plans include fixed monthly capitation payments to provide long-term care services to beneficiaries who are chronically ill or disabled and who wish to remain in their homes and communities.

During 2014, New York claimed $4.8 billion in total Medicaid reimbursements for capitation payments made to MLTC plans.

OIG reviewed a random sample of 100 payments New York made to MLTC plans in 2014 and consulted with CMS physicians to determine whether the beneficiaries associated with these payment received adequate service planning and care management.


Of the 100, 36 were improperly claimed for reimbursement. CMS physicians also found that some MTLC plans did not comply with New York’s contract requirements for providing adequate patient-centered service planning and care management for 71 of the the beneficiaries associated with the payments.

“As a result, there could have been health and safety risks to these beneficiaries,” the report reads.

Of the 36 samples that were out of compliance, plans associated with 19 payments did not conduct the beneficiary’s eligibility assessment or reassessment in a timely manner, document the assessment, or document that it was performed by a registered nurse. In addition, 14 did not provide a written care plan for the beneficiary that covered the payment period; 10 did not provide the beneficiary with any community-based services during the payment period; and one associated beneficiary should have been disenrolled from the MTC plan at least one month before the payment period. Eight of the payments contained more than one deficiency.


OIG stated it reviews Medicaid home- and community-based services in New York that are identified as being at high risk for improper payments. The review covered more than 1 million payments totaling just under $4 billion that the state agency made to 29 MLTC plans in 2014.

Written by Amy Baxter

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