Concourse Rehabilitation & Nursing Center Inc. v. Whalen

249 F.3d 136, 2001 WL 473721
CourtCourt of Appeals for the Second Circuit
DecidedMay 4, 2001
DocketDocket No. 00-9394
StatusPublished
Cited by5 cases

This text of 249 F.3d 136 (Concourse Rehabilitation & Nursing Center Inc. v. Whalen) is published on Counsel Stack Legal Research, covering Court of Appeals for the Second Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Concourse Rehabilitation & Nursing Center Inc. v. Whalen, 249 F.3d 136, 2001 WL 473721 (2d Cir. 2001).

Opinion

KATZMANN, Circuit Judge:

Plaintiffs, the operators of a nursing facility that receives reimbursement for services under the New York State Medicaid plan, appeal from a judgment entered on October 20, 2000, in the Southern District of New York (Conti, Judge), following a grant of summary judgment in favor of the New York State Department of Health (“Department”) on plaintiffs’ claims that the facility was inadequately compensated by the Department for certain rehabilitative services provided to its patients and that such undercompensation constitutes a violation of federal Medicaid law. We affirm.

Background

Plaintiffs, Concourse Rehabilitation & Nursing Center, Inc., and Concourse [139]*139Nursing Home (collectively “Concourse”)1, operate a 240-bed residential health care facility in the Bronx. As we explained in our previous opinion, Concourse Rehabilitation & Nursing Center, Inc. v. DeBuono, 179 F.3d 38, 42-43 (2d Cir.1999) (hereinafter “DeBuono”), this case arises from an audit conducted by the Department in 1996 and 1997, which concerned claims submitted by Concourse in May 1995. As a result of this audit, the Department determined that Concourse had misclassified the type of therapy provided to a number of its patients and had, as a result, been overcompensated for their care. See id. at 43. Concourse contends that the criteria used by the Department for making this determination violate the federal Medicaid Act (Title XIX of the Social Security Act), 42 U.S.C. §§ 1396, 1396a-u (1993 & Supp. IV 1998).

Although our previous opinion provides a thorough description of the statutory and regulatory scheme governing this case, see DeBuono, 179 F.3d at 40-42, it is useful to review that framework briefly here, before moving on to the arguments presented by the parties on appeal.

A. The Medicaid Program

The Medicaid Program, which covers the costs of medical care for the indigent, is jointly funded by the federal government and the governments of participating States. See DeBuono, 179 F.3d at 41. Although States are not required to participate in the program, those electing to do so “must submit a plan to the U.S. Secretary of Health and Human Services (Secretary) for approval.” Id. As we explained in DeBuono:

The plan must be in writing and must comprehensively describe the nature and scope of the State’s Medicaid program. Upon approval of the plan by the Secretary, the State becomes entitled to receive reimbursement from the federal government for a percentage of the monies it pays to residential health care facilities for their care of Medicaid patients. The balance of the costs for such care is furnished by State and local governments.

Id. Administration of the program is governed by the Medicaid Act, and the distribution of federal funds to the States for care provided in accordance with the individual State plans “must be approved by the Health Care Financing Administration [ (“HCFA”) ], a division of the Department of Health and Human Services, according to standards contained in 42 U.S.C. § 1396a(a).” Id. When the dispute over the Department’s audit of Concourse’s submissions arose, HCFA’s approval of federal funding was governed in part by a provision called the “Boren Amendment,” 42 U.S.C. § 1396a(a)(13) (1994), which has since been repealed, see id.; Balanced Budget Act of 1997, Pub.L. No. 105-33, § 4711(a)(1), 111 Stat. 251, 507-08 (repealing the Boren Amendment for services provided after Oct. 1, 1997); note 2, infra. At that time, the Boren Amendment provided, in pertinent part, that:

A State plan for medical assistance must—
provide ... for payment ... of the ... nursing facility services ... provided under the plan ... through the use of rates (determined in accordance with methods and standards developed by the State which, in the case of nursing facilities, take into account the costs (includ[140]*140ing the costs of services required to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident eligible for benefits under this subchapter) of complying with subsections (b) (other than paragraph (3)(F) thereof), (c), and (d) of section 1396r of this title ...) which the State finds, and makes assurances satisfactory to the Secretary, 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 ....

42 U.S.C. § 1396a(a)(13)(A) (1994). Thus, under the then-existing Boren Amendment, States were required to assure the Secretary that their plans provided “reasonable and adequate” payment for costs incurred by “efficiently and economically operated facilities” in order to be eligible for federal funds. In Wilder v. Virginia Hospital Ass’n, 496 U.S. 498, 509-10, 110 S.Ct. 2510, 110 L.Ed.2d 455 (1990), the Supreme Court held that the Boren Amendment afforded health care providers a substantive right — enforceable under 42 U.S.C. § 1983 — to reasonable and adequate rates, in addition to a procedural right to have a State make the requisite findings.2

The Boren, Amendment’s reference to “services required to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident eligible for benefits” has its origin in certain revisions made to the Medicaid and Medicare Acts as part of the Omnibus Budget Reconciliation Act of 1987, Pub.L. No. 100-203, § 4211, 101 Stat. 1330-183 to -207 (1987) (“OBRA '87”). See generally Indiana Ass’n of Homes for the Aging, Inc. v. Indiana Office of Medicaid Policy & Planning, 60 F.3d 262, 265 (7th Cir.1995) (describing the effect of OBRA '87 on the Medicaid program); Valdivia v. California Dep’t of Health Servs., No. S-90-1226EJG EM, 1991 WL 80896, at *2 (same) (E.D.Cal. Feb. 25, 1991). Under 42 U.S.C. § 1396r(b)(2) — one of the provisions added to the Medicaid Act by OBRA '87 — “[a] nursing facility must provide services and activities to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care.... ”

HCFA regulations expand upon this requirement, providing that if “specialized rehabilitative services ... are required in [141]*141the resident’s comprehensive plan of care,” the facility must either provide those services or obtain those services from an outside source. 42 C.F.R.

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249 F.3d 136, 2001 WL 473721, Counsel Stack Legal Research, https://law.counselstack.com/opinion/concourse-rehabilitation-nursing-center-inc-v-whalen-ca2-2001.