State of Delaware Department of Health and Social Services, Division of Medicaid & Medical Assistance v. United States Department of Health and Human Services

272 F. Supp. 3d 103
CourtDistrict Court, District of Columbia
DecidedAugust 8, 2017
DocketCivil Action No. 2016-1734
StatusPublished
Cited by3 cases

This text of 272 F. Supp. 3d 103 (State of Delaware Department of Health and Social Services, Division of Medicaid & Medical Assistance v. United States Department of Health and Human Services) is published on Counsel Stack Legal Research, covering District Court, District of Columbia primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
State of Delaware Department of Health and Social Services, Division of Medicaid & Medical Assistance v. United States Department of Health and Human Services, 272 F. Supp. 3d 103 (D.D.C. 2017).

Opinion

MEMORANDUM OPINION AND ORDER

COLLEEN KOLLAR-KOTELLY, United States Distinct Judge

The pending case raises a thicket of regulatory and jurisdictional issues. Plaintiff is the entity charged with administering Delaware’s Medicaid program. Due to a technological limitation, Delaware’s computer systems were unable to separately report certain collections that the State made from third-parties. Part of these collections were owed to the federal government. Plaintiff addressed this technological limitation by simply netting these collections from its Medicaid expenditures, and only seeking federal funding based on the net amount. The federal government issued two reports warning Delaware that this approach was unacceptable, principally because there was insufficient evidence that the relevant collections were actually being netted, and that the federal government was receiving due credit. Not long after the second report was issued, the federal government “disallowed” $10,080,378 in federal funding, equal to what it viewed as the amount that Delaware had failed to credit the federal government from third-party collections. Delaware sees this is a manifest injustice, believing that it has already credited the federal government with this amount, and must now double pay.

Despite this indignation, however, Delaware missed the deadline to seek administrative review of the disallowance determination by two weeks. After a lengthy period during which Delaware allegedly sought a retroactive extension of the filing deadline, Delaware filed an appeal with the Departmental Appeals Board (the “Board”), which summarily rejected the appeal for untimeliness. Plaintiff sought review of the rejection before this Court, and Defendants moved to dismiss, principally on the basis that judicial review was unavailable. Upon consideration of the pleadings, 1 the relevant legal authorities, and the record as a whole, the Court shall GRANT-IN-PART and DENY-IN-PART the motion to dismiss.

The Court finds that it has subject-matter jurisdiction under 42 U.S.C. § 1316(e)(2)(C) to exert judicial review over the Board’s decision to reject Plaintiffs appeal, and that under a standard of review set by the Administrative Procedure Act (“APA”), Plaintiff has stated a plausible claim that the Board’s decision was arbitrary, capricious, an abuse of discretion, or otherwise not in accordance with law. Given the availability of an adequate remedy at law, however, Plaintiffs common law claims for unjust enrichment and for money had and received are dismissed without prejudice because they sound in equity, among other considerations.

Finally, the alleged APA violations were pled only against Defendants United States Department of Health and Human Services (“HHS”) and the Secretary of the United States Department of Health and Human Services (the “Secretary”). See Compl., Counts I — III. Only the common law claims were brought against the other *106 two Defendants, the Centers for Medicare and Medicaid Services (“CMS”), and the Administrator for the Centers for Medicare and Medicaid Services (the “Administrator”). Id., Counts IV-V. Accordingly, CMS and the Administrator are dismissed from this lawsuit without prejudice.

I. BACKGROUND

A. Statutory and Regulatory Background

1. Medicaid

Medicaid ,is a cooperative federal-state program through which the federal government provides financial assistance for. States to furnish medical care to low-income families and individuals. Wilder v. Virginia Hosp. Ass’n, 496 U.S. 498, 502, 110 S.Ct. 2510, 110 L.Ed.2d 455 (1990). In order to participate in Medicaid, a State must first develop a Medicaid plan “describing, conditions of eligibility and covered services.” Bowen v. Massachusetts, 487 U.S. 879, 883, 108 S.Ct. 2722, 101 L.Ed.2d 749 (1988). That plan must then be approved by CMS. 42 U.S.C. § 1396a.

Once approved, the federal government pays the State on a quarterly basis for a specified pei-centage of the State’s Medicaid expenditures. Id. § 1396b. This financial contribution is called the “federal financial participation” (“FFP”). The quarterly federal .contribution is made as an advance payment “based on the State’s estimate of its anticipated future expenditures.” Bowen, 487 U.S. at 883-84, 108 S.Ct. 2722. Then, within 30 days after the end of the-quarter, the State must submit a Form CMS-64, entitled the Quarterly Medicaid Statement of Expenditures for the Medical Assistancé Program (“QSE”), on which the State reports its actual expenditures for the quarter. See 42 C.F.R. §§ 430.30(c)(1)-(2).

Because the Medicaid program is a pay- or of last resort, the State is responsible for recovering payments from third-parties that were legally obligated to cover medical care that was ultimately paid for the by the State. 42 U.S.C. § 1396a(a)(25)(A). If the State receives federal funds for services for which it later recovers monies from third-parties, the corresponding federal contributions are considered “over-payments” and' the State must refund those amounts to the federal government. 42 U.S.C. § 1396b(d)(2)(B). The State must report and refund overpayments through a credit to the federal government on its quarterly QSE. 42 C.F.R. § 433.320(a)(1). If a State does not credit the federal government with overpay-ments, then CMS “will disallow expenditures equal to the determined overpayment amount.” Compl. ¶ 20; see 42 U.S.C. § 1316(d); 42 C.F.R. § 430.42(a) (describing disallowance procedure).

2. Reconsideration and Appeals Process

Section 1316(e) and accompanying regulations set forth two routes for the State to contest a disallowance determination. The first route is the reconsideration process, which allows the State to request “reconsideration of the disallowance, provided that such request is made during the 60-day period that begins on the date the State receives1 notice of the disallowance.” 42 U.S.C. § 1316(e)(1). Within 60 days of receiving the request for reconsideration, the Administrator “shall ...' issue a written decision or a request for additional information ,Id. § 430.42(c)(2).

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Bluebook (online)
272 F. Supp. 3d 103, Counsel Stack Legal Research, https://law.counselstack.com/opinion/state-of-delaware-department-of-health-and-social-services-division-of-dcd-2017.