Federal Reports

For the period January 1 through December 31, 2013, the Delaware Department of Health and Social Services, Division of Medicaid and Medical Assistance (State agency) did not fully comply with Federal Medicaid requirements for billing manufacturers for some rebates for physician-administered drugs dispensed to enrollees of managed-care organizations (MCOs). The State agency properly billed for most rebates for MCO drug utilization in our judgmental sample. However, the State agency did not have valid National Drug Codes (NDCs) for other drug utilization data submitted by MCOs for physician-administered drugs, and the State agency did not bill manufacturers for rebates for these drugs. We estimate that the State agency did not bill manufacturers for rebates totaling $230,000 ($127,000 Federal share). We did not have enough information to determine an estimate for some of the utilization.

Most of the New Jersey Department of Human Services' (State agency) claims for Federal Medicaid reimbursement for partial care services did not comply with Federal and State requirements. The partial care services program provides individualized outpatient clinic services (e.g., group and individual therapy, prevocational services, and medication management) to beneficiaries with mental illness to reduce unnecessary hospitalization. On the basis of our sample results, we estimated that the State agency improperly claimed at least $94.8 million in Federal Medicaid reimbursement for partial care services that did not meet Federal and State requirements.