Jackson Purchase Medical Center v. United States Department of Health & Human Services

122 F. Supp. 3d 668, 2015 U.S. Dist. LEXIS 106379, 2015 WL 4875112
CourtDistrict Court, E.D. Kentucky
DecidedAugust 12, 2015
DocketCivil Action No. 6:14-cv-1-KKC
StatusPublished
Cited by2 cases

This text of 122 F. Supp. 3d 668 (Jackson Purchase Medical Center v. United States Department of Health & Human Services) is published on Counsel Stack Legal Research, covering District Court, E.D. Kentucky primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Jackson Purchase Medical Center v. United States Department of Health & Human Services, 122 F. Supp. 3d 668, 2015 U.S. Dist. LEXIS 106379, 2015 WL 4875112 (E.D. Ky. 2015).

Opinion

OPINION AND ORDER

KAREN K. CALDWELL, Chief Judge.

Plaintiffs (“the Providers”) appeal the final administrative decision of the Secretary of Health and Human Services (“the Secretary”) to exclude certain low-income populations from the formula used to determine whether a Provider qualifies for increased Medicare reimbursement rates. Part of the Medicare formula includes patient days for individuals “eligible for medical assistance under a State plan approved under .subchapter XIX.” 42 U.S.C. § 1395ww(d)(5)(F)(vi)(II). The Providers assert that the Secretary unlawfully interpreted this statutory provision. The Court will affirm the Secretary’s interpretation because the low-income patients that the Providers seek to add in the Medicare formula are not “eligible for medical assistance” under an approved State plan.

I. BACKGROUND

A. Medicare and Medicaid

Congress created the Medicare and Medicaid programs through Titles XVIII and XIX of the. Social Security Act. Medicare is a federally funded health insurance program for older and disabled individuals. 42 U.S.C. § 1395 et seq. Medicaid is a federal grant program — unavailable to [670]*670Medicare recipients — that requires each state to create federal-state partnerships to provide certain medical services to individuals “whose income and resources are insufficient to meet the costs of necessary-medical services.” 42 U.S.C. § 13961. The design, funding, and reimbursement for these programs are distinct; however, both programs seek to improve the quality of care for vulnerable populations.

1. Medicare Reimbursement

Medicare utilizes the prospective payment system (“PPS”) to reimburse providers for inpatient hospital services. 42 U.S.C. § 1395ww(d). Generally, PPS sets a fixed reimbursement rate “for each discharge, based on the patient’s diagnosis, and regardless of actual cost.” Good Samaritan Hosp. v, Shalala, 508 U.S. 402, 406 n. 3, 113 S.Ct. 2151, 124 L.Ed.2d 368 (1993) .(citing 42 U.S.C. § 1395ww(d)). The Secretary may, however, adjust PPS reimbursement rates based on hospital-specific factors. ' 42 U.S.C. § 1395ww(d)(5). For example, “the Secretary shall provide ... for an additional payment amount for each [provider that] serves a significantly disproportionate number of low-income patients.” 42 U.S.C. § 1395ww(d)(5)(F)(i)(I). This provision is known as the Medicare disproportionate share hospital (“Medicare DSH”) adjustment.

2. Medicare DSH

Qualification for Medicare DSH — and the degree of an adjustment — depends on whether a provider meets a defined “disproportionate patient percentage.” 42 U.S.C. § 1395ww(d)(5)(F)(v). A provider’s “disproportionate patient percentage” is the sum of two fractions. 42 U.S.C. § 1395ww(d)(5)(F)(vi). The first fraction is the “Medicare fraction.” 42 U.S.C. § 1395ww(d)(5)(F)(vi)(I). The second fraction is a proxy for the percentage of a provider’s low-income, non-Medicare patients; this is the “Medicaid fraction.” The numerator of the Medicaid fraction consists of the number of patient days a provider treated “patients who (for such days) were eligible for medical assistance under a State plan approved under sub-chapter XIX of this chapter, but who were not entitled to [Medicare] benefits” and patient days a provider treated patients receiving “benefits under a demonstration project,” and the denominator of the Medicaid fraction consists of the total number of the provider’s patient days. 42 U.S.C. § 1395ww(d)(5)(F)(vi)(II). The Providers contest the Secretary’s interpretation of the patients that should be credited in the numerator of the “Medicaid fraction.”

3.Medicaid Reimbursement

Medicaid is a state-specific program where, pursuant to a federally approved “state Medicaid plan,” the federal government provides matching payments for medical assistance to eligible, low-income individuals. The “state Medicaid plan” specifies the qualifications for eligibility and establishes the nature and scope of the medical care and services covered pursuant to the state plan. 42 C.F.R. § 430.10. The Secretary must approve the state plan before federal matching payments commence, but “Considerable deference is provided to states under the [Medicaid] Act to decide ‘eligible groups, types and range of services, payment levels for services, and administrative and operating procedures.’ ” Linton by Arnold v. Comm’r of Health & Env’t, State of Tenn., 65 F.3d 508, 516 n. 10 (6th Cir.1995) (quoting 42 C.F.R. § 430.0); 42 U.S.C. §§ 1396a, 1396d(b). Federal matching payments are available for “the total amount expended ... as medical assistance under the State plan,” 42 U.S.C. § 1396b(a)(l) (emphasis added), and the states distribute these federal funds for [671]*671medical care and services described in the state Medicaid plan, 42 C.F.R. § 430.0.

4. Medicaid DSH

Medicaid also requires an upward reimbursement rate adjustment for providers serving a disproportionate share of low-income patients. All state Medicaid plans must establish a “process for determination of rates of payment under the plan ... [that] take[s] into account ... the situation, of [providers] which serve a disproportionate number of low-income patients....” 42 U.S.C. § 1396a(a)(13)(A). This provision is known as the Medicaid disproportionate share hospital (“Medicaid DSH”) adjustment.

Although both Medicare and Medicaid provide DSH adjustments, Medicare DSH and Medicaid DSH operate differently and address different objectives.

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Related

Breckinridge Health, Inc. v. Burwell
193 F. Supp. 3d 788 (W.D. Kentucky, 2016)
Owensboro Health, Inc. v. Burwell
132 F. Supp. 3d 900 (W.D. Kentucky, 2015)

Cite This Page — Counsel Stack

Bluebook (online)
122 F. Supp. 3d 668, 2015 U.S. Dist. LEXIS 106379, 2015 WL 4875112, Counsel Stack Legal Research, https://law.counselstack.com/opinion/jackson-purchase-medical-center-v-united-states-department-of-health-kyed-2015.