Arbor Court Healthcare, LLC v. Iowa Department of Health and Human Services

Court of Appeals of Iowa·Decided February 5, 2025·No. 24-0697·Published

Opinion

IN THE COURT OF APPEALS OF IOWA

No. 24-0697

Filed February 5, 2025

ARBOR COURT HEALTHCARE, LLC, Plaintiff-Appellant,

vs.

IOWA DEPARTMENT OF HEALTH AND HUMAN SERVICES, Defendant-Appellee.

Appeal from the Iowa District Court for Polk County, Jeanie Vaudt, Judge.

Arbor Court Healthcare, LLC appeals the district court’s order affirming the final decision in its administrative appeal before the Iowa Department of Health and Human Services. AFFIRMED.

Rebecca A. Brommel and Joshua D. Hughes of Dorsey & Whitney LLP, Des Moines, for appellant.

Brenna Bird, Attorney General, and Breanne A. Stoltze, Assistant Solicitor General, and Tyler Grimm and Patrick Valencia, Assistant Attorneys General, for appellee.

Heard by Greer, P.J., and Langholz and Sandy, JJ.

SANDY, Judge.

This appeal arises from the district court’s judicial review of an administrative agency action under Iowa Code section 17A.19 (2023). Arbor Court Healthcare, LLC (Arbor Court) appeals the district court’s order affirming the final decision of the Iowa Department of Health and Human Services (HHS). HHS denied Arbor Court’s request to use the “short period cost report”1 process in relation to the setting of Arbor Court’s Medicaid reimbursement rates following its acquisition of an existing Medicaid-certified nursing facility. Arbor Court administratively appealed the denied request and in a contested case proceeding, HHS affirmed the initial denial. Arbor Court then requested judicial review. The district court determined that HHS acted as required by law and that Arbor Court established no right to relief. Arbor Court contends that HHS’s determination should be reversed under the Iowa Administrative Procedure Act (IAPA). We affirm the district court’s order.

I. Background Facts and Proceedings A. Legal Background on Medicaid Cost Reporting To provide some context for the facts here, we must first examine how HHS reimburses Medicaid-eligible nursing facilities in Iowa and the ways in which H.F. 891 affects that process. See H.F. 891, 89th G.A. 1st sess., § 31(1)(a)(1)(a); 2021 Iowa Acts ch. 182, § 31(1)(a)(1)(a). Iowa nursing facilities often contract with HHS

1 The parties use this term to refer to HHS’s practice of implementing an informal

policy of permitting Medicaid-certified nursing facilities to submit a cost report documenting three months of operation costs following a change of ownership. Those “short period cost reports” serve as the basis for HHS’s recalculation of a facility’s Medicaid reimbursement rates following a change of ownership. Further explanation will follow below.

to receive payment for the care they provide to such facility’s Medicaid-eligible residents. HHS sets a per diem rate that determines that compensation. See Iowa Admin. Code r. 441-81.6(4). HHS calculates the per diem rate, in part, through an assessment of the facility’s operating costs. HHS assesses the facility’s operating costs through the costs reported in the facility’s required annual cost report. See id. r. 441-81.6(3). For most facilities, that report is due by the end of the fifth month following the end of the facility’s fiscal year. Id. In July of every odd-numbered year, HHS uses those reports to update the per diem compensation rates for most facilities—a process referred to as “rebasing.” See id. r. 441-81.6(4).

In order to adjust to changes in the Medicaid average case-mix index, rate are adjustments are conducted each quarter. See id. A case-mix index is “a numeric score within a specific range that identifies the relative resources used by similar residents and represents the average resource consumption across a population or sample.”2 Id. r. 441-81.1. These new rates are provided to the facilities through quarterly rate letters which describe the updated per diem compensation rate and how that rate was calculated.

When a nursing facility is sold to a new owner, that “new owner shall continue to be reimbursed using the previous owner's per diem rate adjusted quarterly for changes in the Medicaid average case-mix index.” Id. r. 441-81.6(15). But often the facility’s costs will increase because of costs associated with the acquisition.

2 The “Medicaid average case-mix index” is “the simple average, carried to four

decimal places, of all resident case-mix indices where Medicaid is known to be the per diem payor source on the last day of the calendar quarter.” Iowa Admin. Code r. 441-81.1.

As a result, HHS had adopted an informal policy of permitting such facilities to submit a “short period cost report” documenting three months of operation costs following the change of ownership. HHS would subsequently rebase rates using only the costs incurred under new ownership. The record does not contain explicit authority for that practice, but the administrative law judge cited rule 441-81.6(13) as a possible source of authorization. See id. r. 441-81.6(13) (“The department, in its sole discretion, may reopen a review of a financial and statistical report at any time.”). He reasoned that “HHS’s action could be rationalized into permissibility by viewing it as HHS amending the cost report of an existing facility.”

B. Iowa House File 891 H.F. 891 was signed by the governor on June 16, 2021. The relevant provisions were intended to stabilize payments to nursing facilities following COVID-19 due to the financial effects the pandemic had on those facilities. The law amended Medicaid compensation rate setting and prohibited rebasing rates in 2021:

Notwithstanding any provision of law to the contrary, for the fiscal year beginning July 1, 2021, the department shall not rebase case-

mix nursing facility rates, but shall instead reimburse case-mix nursing facilities by adjusting the nursing facility case-mix adjusted rates that were effective July 1, 2019, using the mid-points of each of the most recent cost reports submitted by the nursing facility for the period ending on or before December 31, 2018, and inflating these costs forward applying the inflation factor as determined using the latest available quarterly publication of the HCFA/SNF index, to the extent possible within the state funding, including the $19,080,860 provided for this purpose.

H.F. 891, § 31(1)(a)(1)(a). As a result, rates were not rebased in 2021 using 2020 cost reports.

Following H.F. 891’s enactment, HHS published notice of the session law, announced a public comment period, and mailed notices about the change to affected facilities. And HHS’s quarterly notices sent to facilities also included language about the change and advised facilities of their right to appeal compensation rates within ninety days. See Iowa Admin. Code r. 441-7.4(3).

C. Arbor Court’s 2020 Cost Reporting Arbor Court operates a nursing facility in Mount Pleasant. The company acquired the facility from a prior owner on October 1, 2020. Arbor Court received compensation from HHS for the services the facility provided to Medicaid-eligible residents.

To receive such compensation from HHS, Arbor Court was required to submit its annual cost report by July 31, 2021,3 which it timely filed on that date. Although it had the option to file a short period cost report, Arbor Court chose to file its required regular annual cost report without also filing a short period cost report because both reports would have covered the same period: October 1, 2020 through December 31, 2020. Because it believed the reports would have been duplicitous and H.F. 891 had not yet been enacted, Arbor Court would have received no financial benefit from simultaneously filing a short period cost report alongside its annual cost report.

But H.F. 891 became effective on July 1, 2021. As required by H.F. 891 and consistent with the prior notice HHS provided to nursing facilities, HHS did not use 2020 annual cost reports to rebase Arbor Court’s rates effective July 1, 2021.

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