Franklin County Nursing Home v. Commonwealth

559 A.2d 1002, 126 Pa. Commw. 375, 1989 Pa. Commw. LEXIS 402
CourtCommonwealth Court of Pennsylvania
DecidedJune 6, 1989
Docket1563 C.D. 1985
StatusPublished
Cited by7 cases

This text of 559 A.2d 1002 (Franklin County Nursing Home v. Commonwealth) is published on Counsel Stack Legal Research, covering Commonwealth Court of Pennsylvania primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Franklin County Nursing Home v. Commonwealth, 559 A.2d 1002, 126 Pa. Commw. 375, 1989 Pa. Commw. LEXIS 402 (Pa. Ct. App. 1989).

Opinions

SMITH, Judge.

Franklin County Nursing Home (Franklin) appeals from an order of the Executive Deputy Secretary of the Department of Public Welfare (DPW) denying Franklin reimbursement of costs under Pennsylvania’s medical assistance program, Section 443.1 of the Public Welfare Code.1 This Court reverses DPW.2

The issue before this Court is whether Section 201 of the General Appropriations Act of 1980 (Act)3 required DPW to [377]*377reimburse Franklin for the period October 1, 1980 to June 30, 1981 at a rate not less than its immediately preceding rate, and whether the Act further required DPW to utilize Franklin’s final audited rate in determining the rate of reimbursement as opposed to Franklin’s interim rate for the period October 1, 1980 to June 30, 1981.

I

Franklin is a county skilled nursing and intermediate care facility providing services to Medicaid patients pursuant to the medical assistance program. In Section 201 of the Act, signed into law on June 18, 1980, the General Assembly directed DPW to replace the existing statewide ceiling system of reimbursement rates for county nursing homes with a new group-based ceiling system which involved the calculation of separate reimbursement ceilings for county homes within each of the five standard metropolitan statistical areas (SMSA) in the Commonwealth. Section 201 further provided that no public nursing home would have a ceiling below its reimbursement rate in effect prior to implementation of the new ceilings and that a change in the method of reimbursement must receive prior approval by the United States Department of Health and Human Services (HHS).

On July 26, 1980, DPW published a notice in the Pennsylvania Bulletin (10 Pa.B. 3122) stating its intention to amend the current statewide ceilings in accordance with requirements of the Act. Subsequently, on September 30, 1980, DPW submitted a request to HHS for approval of a proposed amendment to the Pennsylvania State Plan for Medical Assistance (state plan) noting on the HHS transmittal form that such amendment was being sought to comply with Section 201 of the Act. HHS disapproved the request in a letter dated December 24, 1980 for reasons set forth in an attached memorandum which stated the following with reference to the “no loss” clause of the Act:

Additionally, we observe that the language in the Pennsylvania appropriations bill concerning the subject amend[378]*378ment includes a ‘no loss’ clause for affected facilities. That is, the appropriations language provides that no public nursing home shall have a ceiling below its rate that was in effect prior to the imposition of the ceilings. The ‘no loss’ clause appears acceptable, but this provision should be included in the plan.

Although the state plan was approved by HHS in March of 1981,4 the final plan did not include the “no loss” clause referred to in the Act, nor was this clause included in the subsequent DPW regulations which implemented the Act.5

After publication of DPW’s proposed rules at 10 Pa.B. 4963-4973 (1980), but prior to approval of the state plan by HHS, Franklin wrote DPW to inquire about the proposed changes in reimbursement to county homes. DPW responded by letter dated January 29, 1981 that if a county home’s SMSA ceiling is less than the reimbursement rate which the home received on December 30, 1980, reimbursement at the higher rate would continue.

The SMSA based ceilings became effective October 1, 1980 and Franklin was assigned to the non-SMSA Group III. The skilled nursing facility ceiling for Group III was $39.24 for the period October 1, 1980 through December 31, 1980 and the intermediate care facility ceiling for this period was $29.14. Franklin’s final audited rates for this same three month period were $42.37 for skilled nursing facility and $29.23 for intermediate care facility.

DPW revised the county nursing home SMSA ceilings effective July 1, 1981, increasing the non-SMSA Group III skilled nursing facility ceiling by $9.11 per day and the intermediate care facility ceiling by $7.44 per day. For the first six months of 1981, however, the 1980 ceilings were still in effect. Franklin’s final audited rates for January 1, 1981 through June 30, 1981 were $42.29 for skilled nursing facility and $31.65 for intermediate care facility.

[379]*379For both of these periods (October 1 through December 31, 1980 and January 1 through June 30, 1981), DPW determined that Franklin’s final audited rates had been capped by the SMSA ceilings. The practical effect of this determination was that Franklin failed to recoup its actual costs for these periods as follows:

Franklin Date SMSA ceiling final audit Loss per Patient Day
Skilled Nursing Facility
10-1-80 to 12-31-80 $39.24 $42.37 $2.05
1-1-81 to 6-30-81 $39.24 $42.29 $3.05
Intermediate Care Facility
10-1-80 to 12-31-80 $29.14 $29.23 $ .09
1-1-81 to 6-30-81 $29.14 $31.65 $2.51

Franklin appealed from DPW’s 1980 audit report, and on January 20, 1983, the Office of Hearings and Appeals (OHA) adopted the hearing officer’s recommendation that Franklin’s reimbursement for the period October 1, 1980 through December 31, 1980 be increased to the level of its final audited rates. DPW petitioned for reconsideration of this order on February 4, 1983, and thereafter, Franklin appealed the 1981 audit report. Both appeals were consolidated. On May 9, 1985, the Executive Deputy Secretary entered an order reversing the OHA. Hence, Franklin’s petition for review to this Court.6

II

Franklin first contends that DPW’s argument that the “no loss” clause of the Act is unenforceable, because it was not included in the final state plan approved by HHS and DPW regulations implementing the plan, constitutes a [380]*380deliberate defiance of the legislative mandate. Franklin notes that the Act clearly mandated that county nursing homes shall sustain no loss as a result of the implementation of the statewide ceilings. Franklin argues that despite DPW’s failure to incorporate the “no loss” provision in the state plan or its regulations, this Court should find that the provision was approved by HHS by virtue of DPW’s initial submission (September 30, 1980) which sought approval to comply with Section 201 of the Act; the HHS response to the initial submission that the “no loss” clause appeared to be acceptable; DPW’s published notice of intent to amend the ceilings in accordance with the Act; and DPW’s letter to Franklin (January 29, 1981) affirming that county nursing homes would continue to be reimbursed at the higher rate.

The Court is persuaded by Franklin’s argument. Although DPW argues strenuously that it had no intent to adopt a “no loss” clause, this Court finds it telling that subsequent to DPW’s publication of the notice of intent (July 25, 1980) and proposed rules (December 27, 1980) which failed to mention the “no loss” clause, DPW wrote to Franklin by letter of January 29, 1981 stating:

The Appropriations Act requires

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Bluebook (online)
559 A.2d 1002, 126 Pa. Commw. 375, 1989 Pa. Commw. LEXIS 402, Counsel Stack Legal Research, https://law.counselstack.com/opinion/franklin-county-nursing-home-v-commonwealth-pacommwct-1989.