Kaye v. Whalen

56 A.D.2d 111, 391 N.Y.S.2d 712, 1977 N.Y. App. Div. LEXIS 10027
Appellate Division of the Supreme Court of the State of New York·Decided February 14, 1977·Published·Cited by 22 cases

Opinions

Mahoney, J.

The Medicaid Program (subchapter XIX of the Social Security Act, US Code, tit 42, § 1396 et seq.) makes available funds, to be supplemented by State contributions, to pay for the medical care of those whose means fall below certain financial standards. The Federal funds are available to those States which submit a plan for administering the funds acceptable to the Secretary of Health, Education and Welfare (US Code, tit 42, § 1396). The statute imposes myriad requirements as to what constitutes an acceptable plan (US Code, tit 42, § 1396a), but does not purport to set the specific rates at which those providing the medical services are to be reimbursed. That duty is left, within the confines of the requirements of section 1396a, to the States.

The New York State Legislature charges the respondent Commissioner of Health with the responsibility of setting the rate at which the petitioners, nursing home owners, are [113] reimbursed for the care they provide Medicaid beneficiaries. Until August, 1975 the statutory standard by which the commissioner was directed to set rates was subdivision 3 of section 2807 of the Public Health Law, which required that the rates be "reasonably related to the costs of efficient production of such service.” The subdivision goes on to impose a few specific standards, such as requiring the commissioner to consider "geographical differentials in the elements of cost” and to "exclude costs for research.” Subdivision 4 of section 2807 (L 1974, ch 682, § 1) directs the commissioner to notify each nursing home of new rates 60 days before the fiscal year for which the rates are to be effective.

The commissioner promulgated regulations, as he was required to do (Public Health Law, § 2803, subd 2, par [b]), stating in detail the criteria by which he would set the reimbursement rates (10 NYCRR Part 86). The regulations also specified that the rates would be set for calendar year periods (10 NYCRR 86-1.10). Thus, it appears from both the regulations (10 NYCRR 86-1.10) and the statute (Public Health Law, § 2807, subd 4) that new rates would be established before November 1 each year, to become effective the following January 1 and remain in effect for one year.

This case concerns the legality of two actions by the commissioner. In November, 1975 he adopted as tentative rates for 1976 the 1975 reimbursement rates, rather than generating new rates based on the criteria set forth in the then-existing department regulations. In October, 1976 he established new rates and made them retroactive to January 1, 1976, thereby supplanting the tentative rates set the previous November. Petitioners, nursing home owners, brought this article 78 proceeding in February, 1976 to invalidate the tentative rates of November, 1975 and to force the commissioner to set 1976 rates consistent with his 1975 regulations. In September, 1976 Special Term granted the requested relief and further enjoined the commissioner from changing his method of computing rates without first securing the approval of the United States Department of Health, Education and Welfare. Although the commissioner’s rate-setting action of October, 1976 occurred after Special Term’s judgment, the substance of the post-judgment rate-setting is not disputed and may be considered here without the need to remand. We accept the truth of petitioners’ uncontested allegation that both the November, 1975 and October, 1976 rates for 1976 are [114] generally lower than the 1976 rates would have been had they been set in keeping with the regulations.

Petitioners’ first ground for relief is that in each instance the commissioner acted without statutory authorization. With respect to the November, 1975 tentative rates, it is true that the then-existing regulations stated criteria, established under the standards of subdivision 3 of section 2807 of the Public Health Law whereby rates would be set for each new calendar year. Absent further legislative action before January 1, 1976, perhaps it would be fair to conclude that the commissioner was bound either to promulgate new regulations in the manner required by law (see NY Const, art IV, § 8; Executive Law, §§ 102, 103, 105) or to mechanically generate new rates conforming to the extant regulations. (But, see, State Administrative Procedure Act, § 202, subd 1, par [d] [eff Sept. 1, 1976].)* However, further legislative action had been taken, with the addition of section 2808 (L 1975, ch 649, § 7, and ch 650, § 2, eff Aug. 6, 1975), which provided, inter alia, that:

"1. a. The Commissioner shall promulgate interim regulations to expire no later than the thirty-first day of December, nineteen hundred seventy-six, that will relate the rate of payment for each residential health care facility to the operation and program management of the facility, as well as to the quality of patient care provided by the facility. Such regulations shall be consistent with regulations promulgated under the provisions of title eighteen of the federal social security act, by which payment for costs incurred by a residential health care facility for a quantity and quality of supplies or services necessary for the proper operation of a residential health care facility shall not exceed those which would be paid in the normal course of business by a prudent buyer of such supplies or services. ” (Emphasis supplied.) Paragraph b of subdivision 1 goes on to direct promulgation of interim regulations regarding real property costs. Subdivision 2 mandates that certain costs, such as political or lobbying pay[115] ments, certain types of advertising expenses, and fines should not be added in to determine 1976 rates.

Although certain aspects of section 2808, such as the provision disallowing consideration of fines paid, may have been implicitly part of the pre-existing statutory standards of subdivision 3 of section 2807 (under which the regulations existing in 1975 were promulgated), there were certainly some significant changes made by section 2808. The controlling standard for rate determination in subdivision 3 of section 2807 was that rates be "reasonably related to the costs of efficient production of such service.” The general standard added August 6, 1975 by section 2808, as noted above, was that rates "shall not exceed those which would be paid in the normal course of business by a prudent buyer of such supplies or service.” Moreover, section 2808 incorported new, detailed standards via regulations under the Federal Social Security Act.

For the commissioner to ignore the new standards of section 2808 by simply generating new rates through his old regulations would have been clearly in conflict with the Legislature’s will. Surely, the Legislature cannot be encumbered, absent constitutional constraints, by the administrative delays involved in promulgating new regulations. The purpose of regulations is to carry out statutory directives. It is true section 2808 required promulgation of interim regulations, but apparently the commissioner had insufficient time between August 6 and November 1, 1975 to do so. It was better to carry out the substantive standards of section 2808 by tentatively continuing (without interim regulations) the 1975 rate, believing it to closely approximate the rate mandated by section 2808, than to set a new rate on the basis of regulations promulgated under a statutory standard (§ 2807, subd 3) no longer in effect. Petitioners have not even attempted to prove that the interim rate set in 1975 was inconsistent with the standard of section 2808.

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Kaye v. Whalen, 56 A.D.2d 111, 391 N.Y.S.2d 712, 1977 N.Y. App. Div. LEXIS 10027 (N.Y. Ct. App. 1977).

56 A.D.2d 111 (Kaye v. Whalen) — published by Counsel Stack Legal Research, free access to 12M+ legal documents.

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