Jewish Memorial Hospital v. Whalen

391 N.E.2d 1296, 47 N.Y.2d 331, 418 N.Y.S.2d 318, 1979 N.Y. LEXIS 2079
CourtNew York Court of Appeals
DecidedJune 7, 1979
StatusPublished
Cited by40 cases

This text of 391 N.E.2d 1296 (Jewish Memorial Hospital v. Whalen) is published on Counsel Stack Legal Research, covering New York Court of Appeals primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Jewish Memorial Hospital v. Whalen, 391 N.E.2d 1296, 47 N.Y.2d 331, 418 N.Y.S.2d 318, 1979 N.Y. LEXIS 2079 (N.Y. 1979).

Opinion

OPINION OF THE COURT

Jones, J.

The regulations governing the formulas and rates of reimbursement by Blue Cross for hospital care and services adopted by the Commissioner of Health on May 28, 1976 (and the individual reimbursement rates thereafter promulgated thereunder) were validly made applicable to all care and services rendered after January 1, 1976. Additionally no warrant has been shown to set aside in particular the specific regulation that imposed a limit on the individual hospital’s base-year expenses (used for computing reimbursement rate) of 100% of the average base-year expenses of all the hospitals in the same grouping. We conclude, however, at variance with the courts below, that no adequate predicate has been shown for the adoption of the regulation directing elimination for reimbursement purposes of 10% of the compensation of interns and residents as attributable to their educational costs. Accordingly, we declare this particular regulation invalid. Finally, we agree that the present proceeding by the petitioning hospitals is not barred by the four-month Statute of Limitations of CPLR 217.

In conformity with the Public Health Law, rates at which hospitals are reimbursed by Blue Cross for services rendered to its subscribers are determined in the following manner. Respondent Commissioner of the Department of Health issues regulations defining the characteristics of reimbursement formulas, two of which must ultimately be implemented — one for the metropolitan New York Blue Cross-Blue Shield Plan (the downstate formula), the other for the remaining seven Blue Cross-Blue Shield Plans in the State (the upstate formula). Based on those regulations (Part 86 of title 10 of the New York Code of Rules and Regulations; 10 NYCRR Part 86), Blue Cross submits proposed reimbursement formulas and individual rate schedules to the Commissioner of Health, who thereafter is required to certify to the Superintendent of [337]*337Insurance rate schedules which he finds to be reasonably related to the cost of efficient production of hospital services. After the schedules so certified have been approved by the Superintendent of Insurance, each individual hospital is advised of the rate of reimbursement applicable to it.

In early fall, 1975 the Blue Cross Plans submitted to the Commissioner of Health proposed reimbursement formulas for 1976. Conscious of the growing concern over escalating hospital costs and anticipating legislation and revision of the regulations governing reimbursement rates, the commissioner did not certify the formulas submitted but instead notified the Superintendent of Insurance on October 28, 1975 that the calculation of new rates, i.e., for 1976, would have to await the revised regulations and that the 1975 rates would be continued on an interim basis. The hospital industry was notified of this action. On December 4, 1975 the Superintendent of Insurance approved the continued use of the 1975 rates pending promulgation of the final rates for 1976.

New regulations effecting significant changes in reimbursement formulas were thereafter adopted by the commissioner and promulgated by him on May 28, 1976, and on June 1, 1976 he directed the Blue Cross Plans to prepare new reimbursement formulas in accordance with the revised regulations, such formulas to be effective as of January 1, 1976 and to control reimbursement with respect to care and services rendered after that date. After the proposals had been received from the plans, in the fall of 1976 the commissioner certified reimbursement formulas and rates and the Superintendent of Insurance granted his approval in late October and November. Commencing in mid-November individual hospitals were advised of their respective reimbursement rates which would be effective for services rendered on and after January 1 of that year.

On February 25, 1977 petitioners* voluntary hospitals who claim that their 1976 reimbursement rates are lower than the 1975 rates, instituted this article 78 proceeding as a class action on behalf of themselves and all other hospitals similarly situated for a judgment enjoining the Commissioner of the Department of Health, the Superintendent of Insurance and Blue Cross Plans throughout the State from applying the revised Part 86 regulations and the reimbursement rates certified and approved in accordance therewith in fixing reimbursements to hospitals by Blue Cross Plans for services [338]*338provided in 1976. Following the Appellate Division’s reversal of an order of Special Term which had dismissed the proceeding as barred by the four-month Statute of Limitations of CPLR 217, the matter was remitted to Special Term for further proceedings (60 AD2d 804). Thereafter, petitioners’ motion for partial summary judgment was denied and the petition was dismissed on the merits. That determination was unanimously affirmed by the Appellate Division, which granted leave to appeal to our court. The order of affirmance should be modified.

In addition to attacks on the substantive provisions of the regulations which describe the characteristics of the reimbursement formulas, petitioners assert that the regulations, promulgated in May, 1976, and the resulting formulas and rates, assigned in November, 1976, could not be made retroactive to January 1, 1976, with the result, it is argued, that 1975 reimbursement rates must be regarded as having continued to prevail during 1976. Because this challenge, if successful, would be determinative of the appeal in petitioners’ favor, we turn first to this aspect of the litigation.

For their assault on retroactivity petitioners rely on two statutory provisions (Public Health Law, § 2807, subds 3, 4), two regulations of the Department of Health (10 NYCRR 86-1.15 [a], 86-1.16) and an assertion of a denial of due process. Insofar as reliance is placed on subdivision 3 of section 2807 of the Public Health Law, they point to no language in that subdivision, however, that requires prospective approval of reimbursement rates for the year 1976, given the legislative intent that may be inferred from what transpired at the 1976 legislative session with respect to subdivision 4 of section 2807, the other statutory provision on which they rely.

At the outset it should be observed that the legislative expression with respect to prospectivity is found in subdivision 4 of section 2807 of the Public Health Law and that there have been two subdivisions numbered 4 pertinent to our present considerations.1 The first of these, which indeed contemplated only prospective rate-fixing, was enacted effective September 1, 1974 by chapter 682 of the Laws of 1974 and directed the Commissioner of Health to notify each hospital of its approved reimbursement rate at least 60 days prior to the [339]*339"fiscal year” for which the rate was to become effective. However, chapter 76 of the Laws of 1976 provided that this subdivision 4 of section 2807 of the Public Health Law was to be suspended as of November 1, 1975 for the period through March 31, 1977, thus relieving the commissioner of observance of its command at least with respect to 1976 reimbursement rates. The same chapter enacted an alternative subdivision 4, to be effective from March 30, 1976 through March 31, 1977, covering only a portion of the period of suspension of the original subdivision 4 — a portion which commenced well after the calendar year 1976 had begun. This second subdivision 4 required hospital notification of rate approval 60 days prior to the beginning of an "established rate period” for which the rate was to become effective.

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Bluebook (online)
391 N.E.2d 1296, 47 N.Y.2d 331, 418 N.Y.S.2d 318, 1979 N.Y. LEXIS 2079, Counsel Stack Legal Research, https://law.counselstack.com/opinion/jewish-memorial-hospital-v-whalen-ny-1979.