Colorado Health Care Ass'n v. Colorado Department of Social Services

842 F.2d 1158, 1988 U.S. App. LEXIS 2008
CourtCourt of Appeals for the Tenth Circuit
DecidedFebruary 22, 1988
DocketNo. 85-1016
StatusPublished
Cited by71 cases

This text of 842 F.2d 1158 (Colorado Health Care Ass'n v. Colorado Department of Social Services) is published on Counsel Stack Legal Research, covering Court of Appeals for the Tenth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Colorado Health Care Ass'n v. Colorado Department of Social Services, 842 F.2d 1158, 1988 U.S. App. LEXIS 2008 (10th Cir. 1988).

Opinion

HOLLOWAY, Chief Judge.

The plaintiff-appellant Colorado Health Care Association appeals from the dismissal of its complaint which challenged a reduction in reimbursement paid by the State of Colorado (State) to providers of long term nursing services to Medicaid pa[1161]*1161tients. The services are provided as authorized by Title XIX of the Social Security Act, 42 U.S.C. §§ 1396 to 1396p and the Colorado Medical Assistance Act (Medicaid), Colo.Rev.Stat. §§ 26-4-101 et seq.

The association is a not-for-profit corporation comprised of operators of long-term nursing facilities; other appellants are entities who either own, lease, operate or manage such facilities and are certified to provide services under the Colorado Medicaid program (hereinafter “appellants” or “providers”). The appellants challenged the repeated suspension or elimination of the “incentive allowance” component of the daily rate paid by the State to nursing homes which provide services to Medicaid patients. The district court dismissed their complaint. Colorado Health Care Association v. Colorado Dept. of Social Services, 598 F.Supp. 1400 (D.Colo.1984). This timely appeal followed. We find the district court’s opinion persuasive and affirm.

I.

A. Colorado Medicaid Reimbursement Plan

The central issue is whether the State’s decision to amend its Medicaid plan so as to eliminate the payment of the incentive allowance resulted in violation of the Medicaid standards mandated by the Boren Amendment. Codified within 42 U.S.C. 13-96a(a)(13)(A)(1982), the Boren Amendment of 1980 requires that a state reimburse service providers under rates which are reasonable and adequate to meet the costs which must be incurred by efficiently and economically operated facilities in order to provide care and services in conformity with applicable state and Federal laws, regulations and quality and safety standards. Id. (Effective October 1, 1980).1

Under the Colorado Medicaid plan, the State pays certified nursing homes for their services to qualified Medicaid patients on a daily rate, paid per patient per day (PPD). The Colorado Department of Social Services (DSS) is the State agency which administers the Medicaid program. DSS establishes a PPD rate for individual nursing homes. The rate is prospective and based on historical costs for all certified and participating nursing homes for the preceding reporting period of six months. The reimbursement rate is adjusted every six months.

The overall PPD rate for each participant provider is calculated and determined by two components: administration costs and health care costs. Administration costs which are reimbursable or allowable under state law include the expenses incurred with the administration of the nursing home, property, and room and board. Health care costs are not included in the calculation of the incentive allowance at issue. Colo.Rev.Stat. § 26-4-103(4.5).

The administrative costs are the basis for the incentive allowance and are subject to a maximum reimbursement formula or ceiling.2 This ceiling is statutorily defined within “Reasonable cost of services” as “the actual costs of ... administration, property and room and board costs excluding food costs, to the ninetieth percentile of medicaid patients” residing in participating facilities. Id. The reasonable cost or ninetieth percentile is based on the reported costs of medicaid patients in all participating nursing homes in the State. These costs are audited and reviewed in the six-[1162]*1162months period being used to establish a new rate.

During the times material to this case, the incentive allowance was calculated on the difference between the ceiling rate of 90% and the nursing home's administration cost rate. This incentive factor was further limited in that it could not exceed twelve percent of the ceiling rate, that is, the ninetieth percentile. Added to this incentive allowance is the inflation allowance, based on the consumer price index, which takes into account the increases in costs that occur between the time the costs are incurred and the time the rate is paid. IV R. TR 103-104. The historical costs for administration and health care are subject to the statutory limits on components which will be recognized as reimbursable elements.3

As to the administration cost, the calculation of that PPD rate can be stated as:

actual costs limited by statute patient days
+ incentive allowance (if costs below ninetieth percentile)
+ inflation factor (based on consumer price index)
= PPD
(Per Patient rate paid Daily to service provider)

If a nursing home’s costs exceed the ninetieth percentile costs, then the DSS calculates the rate based upon the ninetieth percentile or reasonable costs rather than the nursing home’s actual allowable costs. Colo.Rev.Stat. § 26-4-103(4.5), and § 26-4-110(5)(a). If a nursing home’s actual allowable costs are below the ninetieth percentile, the department will increase the nursing home’s rate by adding an incentive allowance to their actual costs. At the times in question here, the incentive allowance was initially calculated as 50 percent and after 1984 as 25 percent4 of the difference between the ninetieth percentile and the nursing home’s actual costs. IV R. TR 51-104-106.

B. Administrative and Procedural History

The DSS has at five times adopted a rule which temporarily suspended the payment of the incentive allowance to those nursing homes whose administrative costs were below the ninetieth percentile. Initially, the decision or informal rule suspending this payment was made by the Colorado Board of Social Services (CBSS) within the DSS. After public hearings on January 7, 1983 and February 4, 1983, at its regular meeting on February 4, the CBSS adopted, on an “emergency basis” an amendment to its long-term care reimbursement regulations. This change eliminated payment of the incentive for services rendered from April 1, 1983 to May 30, 1983 and from May 30, 1983 until June 30, 1983 because of a projected $24 million shortage in Medicaid funds. Plaintiffs’ Exh. 1. The State stipulated that the denial of this component of the PPD was “due strictly to a ‘lack of available appropriations.’ ” I R. 127, If 4.

The appellants filed this suit in state court and the case was removed to federal court on the appellees’ petition; jurisdiction arises from the federal question, pursuant to 28 U.S.C. §§ 1331, 1441. I R. 1-23. Subsequently, the Governor of Colorado approved a supplemental appropriation act which made funds available to pay the incentive allowance. Plaintiffs’ Exh. 3, S.B. 273. In S.B. 273, $755,662 was appropriat[1163]*1163ed from general funds with the purpose as stated: “Restores one-half of the nursing home incentive payment for the last half of the year [1982-1983, the 1983 fiscal year].” Plaintiffs’ Exh. 4 at line 22.

After the Governor’s signing of S.B.

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842 F.2d 1158, 1988 U.S. App. LEXIS 2008, Counsel Stack Legal Research, https://law.counselstack.com/opinion/colorado-health-care-assn-v-colorado-department-of-social-services-ca10-1988.