Rehabilitation & Community Providers Assoc. v. DHS Office of Dev. Programs

CourtCommonwealth Court of Pennsylvania
DecidedFebruary 3, 2021
Docket543 M.D. 2019
StatusUnpublished

This text of Rehabilitation & Community Providers Assoc. v. DHS Office of Dev. Programs (Rehabilitation & Community Providers Assoc. v. DHS Office of Dev. Programs) 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
Rehabilitation & Community Providers Assoc. v. DHS Office of Dev. Programs, (Pa. Ct. App. 2021).

Opinion

IN THE COMMONWEALTH COURT OF PENNSYLVANIA

Rehabilitation and Community : Providers Association, and : Westmoreland County Blind : Association, and Associated : Production Services, Inc., and United : Cerebral Palsy of Central Pennsylvania, : Inc. and Scott Howard Schwartz by and : through Theodore A. Schwartz, Co : Guardian, and Ryan Brett by and : through His Guardian Francis Brett, : Petitioners : : v. : No. 543 M.D. 2019 : SUBMITTED: October 9, 2020 Department of Human Services : Office of Developmental Programs, : Respondents :

BEFORE: HONORABLE MARY HANNAH LEAVITT, President Judge1 HONORABLE ANNE E. COVEY, Judge HONORABLE ELLEN CEISLER, Judge

OPINION NOT REPORTED

MEMORANDUM OPINION BY JUDGE CEISLER FILED: February 3, 2021

Before this Court are Preliminary Objections filed by the Department of Human Services Office of Developmental Programs (DHS) to the First Amended Petition for Review in the Nature of a Complaint/Equity Action for Declaratory and Injunctive Relief (Petition for Review) filed by Rehabilitation and Community Providers Association, Westmoreland County Blind Association, Associated Production Services, Inc., United Cerebral Palsy of Central Pennsylvania, Inc., Scott Howard Schwartz by and through his co-guardian, Theodore A. Schwartz, and Ryan Brett by

1 This case was assigned to the opinion writer before January 4, 2021, when Judge Leavitt completed her term as President Judge. and through his guardian, Francis Brett (together, Petitioners), in this Court’s original jurisdiction. Also before this Court are Petitioners’ Preliminary Objections to DHS’s Preliminary Objections in the Form of a Motion to Strike DHS’s Preliminary Objections under Pa. R.C.P. No. 1028(a)(2) and (3). Petitioners, with the exception of Mr. Schwartz and Mr. Brett, are providers of community participation support (CPS) services to individuals with intellectual disabilities that receive reimbursement from DHS for their services. Mr. Schwartz and Mr. Brett are intellectually disabled individuals who receive CPS services from one of the provider Petitioners. Petitioners allege that in May 2019, DHS improperly implemented a new rate reimbursement system under which the provider Petitioners will no longer receive the necessary funding to keep their CPS programs operational. Petitioners seek both declaratory and injunctive relief to invalidate DHS’s new payment methodology. For the reasons that follow, we sustain DHS’s Preliminary Objection challenging Petitioners’ failure to exhaust administrative remedies, overrule Petitioners’ Preliminary Objections, and dismiss the Petition for Review. Background CPS services are services for individuals with intellectual disabilities or autism that are funded under the Consolidated Waiver, the Person/Family Directed Supports Waiver, and the Community Living Waiver (together, Waivers). The Waivers are home- and community-based waivers approved by the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services, pursuant to Section 1915(c) of the Social Security Act, 42 U.S.C. § 1396n(c). Through the Waivers, individuals who are eligible to receive services in an intermediate care facility may instead receive services in their homes and communities. The Waivers are designed to help individuals with intellectual disabilities and autism live more

2 independently. DHS is responsible for administering the Waivers and setting rates for Waiver services, including CPS services. On November 13, 2019, Petitioners filed the instant Petition for Review, alleging that on May 25, 2019, DHS published a Final Notice of Fee Schedule Rates for CPS Services (Final Notice) in the Pennsylvania Bulletin. Petitioners allege that the Final Notice instituted new reimbursement rates for Petitioners’ services that do not cover the actual costs of the services they provide. Specifically, Petitioners aver:

By publishing [the] Final Notice in the Pennsylvania Bulletin, DHS[] [has] instituted a new reimbursement system by which [CPS] services are to be provided to people with intellectual disabilities. The rates under this new system do not reflect the costs to provide [CPS] services. First quarter fiscal year [20]19-[20]20 actual costs incurred by efficient and economically run providers are between 106.87% and 153.98% of the rates set in the Final Notice. The difference between rates and actual costs is unsustainable.

....

[I]f declaratory and injunctive relief is not forthcoming, program beneficiaries will suffer irreparable harm because damage to the provider base will curtail essential services, especially in rural areas, and especially with respect to beneficiaries requiring the highest level of support. . . .

Pet. for Rev. ¶¶ 10, 12. On July 1, 2019, DHS implemented the new rate structure announced in the Final Notice. Id. ¶ 85. According to Petitioners, DHS uses a reimbursement system called a “unit of service,” and one unit equals 15 minutes of a certain type of service. Id. ¶ 17. Each type of service has a corresponding code, called a “W code,” that is used for billing and reimbursement. Id. ¶ 18. The Final Notice reduced the number of W codes from 54 to 15. Id. ¶ 19. Each new W code provides a fixed reimbursement amount per unit of

3 service. Id. ¶ 20. Petitioners allege that the new W codes fail to reflect the costs actually incurred by the providers. Id. ¶¶ 22-43. With regard to DHS’s publishing of the Final Notice, Petitioners allege:

104. The . . . Final Notice is an unpromulgated regulation insomuch as it creates a binding norm and does not comply with the Commonwealth Documents Law, [Act of July 31, 1968, P.L. 769, as amended,] 45 P.S. §§ 1102-[1602, and 45 Pa. C.S. §§ 501-907]; the Regulatory Review [A]ct, [Act of June 25, 1982, P.L. 633, as amended,] 71 P.S. §§ 745.1[-745.15]; and the Commonwealth Attorneys Act, [Act of October, 15, 1980, P.L. 950, as amended,] 71 P.S. §§ 732[-]101[ to 732-506].

105. The rate structure methodology manifested in the . . . Final Notice was not submitted to [the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services,] for approval and incorporation into the [Waivers] prior to the July 1, 2019 effective date.

106. The rate structure methodology manifested in the . . . Final Notice does not reflect costs that are reasonable, necessary, and related to the delivery of the service and sufficient to ensure access, encourage provider participation, and promote provider choice as required by federal law and the [Waivers].

Id. ¶¶ 104-06 (internal case citation omitted); see id. ¶¶ 109-11 (asserting the same averments). Petitioners seek from this Court: (1) a declaration that DHS’s Final Notice is an unpromulgated regulation and inconsistent with federally approved payment methodologies; and (2) an injunction prohibiting DHS from implementing the new rate system and requiring DHS to establish rates that are sufficient to meet reasonable provider costs. Id. at 31-32.

4 On November 14, 2019, Petitioners filed an Application for Partial Summary Relief (Application) under Pa. R.A.P. 1532(b),2 to which DHS filed an Answer on December 13, 2019. In their Application, Petitioners seek a partial judgment declaring that the Final Notice is an unpromulgated regulation. By Order dated February 14, 2020, this Court deferred the establishment of a briefing schedule for the Application until final disposition of both parties’ Preliminary Objections. On March 4, 2020, this Court also entered an Order staying discovery until further order of this Court.

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