Stratford Nursing & Convalescent Center, Inc. v. Kilstein

802 F. Supp. 1158, 1991 U.S. Dist. LEXIS 20716, 1991 WL 417854
CourtDistrict Court, D. New Jersey
DecidedNovember 15, 1991
DocketCiv. No. 88-359
StatusPublished
Cited by1 cases

This text of 802 F. Supp. 1158 (Stratford Nursing & Convalescent Center, Inc. v. Kilstein) is published on Counsel Stack Legal Research, covering District Court, D. New Jersey primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Stratford Nursing & Convalescent Center, Inc. v. Kilstein, 802 F. Supp. 1158, 1991 U.S. Dist. LEXIS 20716, 1991 WL 417854 (D.N.J. 1991).

Opinion

OPINION

DEBEVOISE, District Judge.

This matter comes before the court on Defendants’ motion for summary judgment pursuant to Fed.R.Civ.P. 59 on all counts of Plaintiffs complaint. In addition, Plaintiff cross-moves for summary judgment on all counts of its Complaint. For the reasons set forth below, Defendants’ motion will be granted and the complaint will be dismissed.

STATEMENT OF FACTS AND PROCEDURAL HISTORY

Plaintiff, Stratford Nursing and Convalescent Center is a licensed nursing home that has participated in the New Jersey Medicaid program since the inception of that program in 1970. Defendant, Thomas Russo is the former Director of the Division of Medical Assistance and Health Services (“DMAHS”), which is the agency of the State that administers its Medicaid program. Defendant Russo served as Director of DMAHS from 1978 to 1989, when he resigned and was succeeded by Defendant, Saul Kilstein. Defendant Melissa Hager is a Deputy Attorney General (“DAG”) employed by the New Jersey Division of Law. She joined the Division of Law in December 1983 and was thereafter assigned to represent DMAHS. She provided legal representation for DMAHS until September 1988, when she was transferred to a new assignment.

New Jersey’s Medicaid Rate-Setting Procedures

Medicaid is a federally-created, state-implemented program designed to ensure that people who cannot afford necessary medical care are able to obtain it, see 42 U.S.C. § 1396 et seq. The program is jointly funded by the state and federal governments, and has been described as an exercise in “cooperative federalism.” Harris v. McRae, 448 U.S. 297, 308, 100 S.Ct. 2671, 2683, 65 L.Ed.2d 784 (1980). States have broad discretion under federal statutes to adopt their own standards for determining the extent of medical assistance to be provided, but to qualify for federal funds, participating states must submit a state plan to the federal Department of Health and Human Services for approval. 42 U.S.C. § 1396a(a); 42 C.F.R. § 430.10. Among other things, the state plan must “provide for the establishment or designation of a single state agency to administer or supervise the administration of the plan.” 42 U.S.C. § 1396a(a)(5). DMAHS is the designated “single state agency” vested with authority to “determine the amounts to be paid medical providers” under Medicaid. N.J.S.A. 30:4D-5; 30:4D-7(b).

Under DMAHS’s regulations, long-term care facilities like Stratford that provide care to Medicaid-eligible patients are reimbursed on the basis of rates established annually for each participating facility. N.J.A.C. 10:63-3.1(A). DMAHS does not itself perform the initial calculation of a facility’s reimbursement rate, but rather has contracted with the Health Facilities Rate-Setting (“HFRS”) Unit of the New Jersey Department of- Health (the agency of the state that is generally responsible for hospital rate-making under New Jersey’s health care statutes, see N.J.S.A. 26:2H-1 et seq.) to perform that initial calculation. For each participating facility, HFRS calculates an annual rate from financial information filed by the facility,1 and then forwards its calculation to DMAHS for review and approval.

After being notified of its annual rate, a facility has 30 days to decide if it wishes to appeal. N.J.A.C. 10:63-3.20(a)(l). If it chooses to appeal, the first step in the process is to request a “Level I” review, [1161]*1161which may be accomplished by an informal hearing or by document submission. After the facility has presented any evidence or arguments it wishes to present regarding the rate determination, a Level I decision, which must be approved by both the Director of HFRS and DMAHS’s Chief of Long Term Care Reimbursement, is issued to the facility. See e.g. Defendants’ Brief, Appendix (“App.”) Volume II (“Vol. II”), Exhibit (“Exh.”) 26.

If the facility is not satisfied with the Level I decision, it may, within 20 days of receiving that decision, request a more formal hearing, known as a “Level II” appeal. N.J.A.C. 10:63-3.20(A)(2). Level II appeals are referred by DMAHS to the New Jersey Office of Administrative Law for formal hearing before an Administrative Law Judge (“AU”) under New Jersey’s Administrative Procedure Act. N.J.S.A. 52:14B-1 et seq. After a full adversarial trial, the AU issues an Initial Decision recommending a disposition of the dispute to DMAHS. The Initial Decision is then reviewed by the Director of DMAHS, who has 45 days to accept or reject the AU’s recommendations, and to issue a Final Agency Decision. N.J.S.A. 52:14B-10(c). If a facility is still not satisfied with its reimbursement rate, it may appeal that decision to the Superior Court of New Jersey, Appellate Division. N.J.Ct.R. 2:2-3(a)(2). Review of any Appellate Division decision would be in the Supreme Court of New Jersey. N.J.Ct.R. 2:2-l(a)(2); N.J.Ct.R. 2:12-1.

Rate-Setting Methodology and Property Cost Reimbursement

Effective December 29, 1977, DMAHS promulgated regulations, known as “Cost Accounting and Rate Evaluation” (“CARE”) guidelines, describing “the methodology to be used by the State of New Jersey to establish prospective per diem rates for the providing of routine care to patients under the State’s Medicaid program.” Foreword, N.J.A.C. 10:63-3.1. In general terms, the CARE regulations provide for reimbursement of facilities based on a “screened rate” system, under which rates are calculated by applying regulatory “screens,” or reasonableness limits, to the actual costs reported by the facility for-each of the twelve “cost centers” (e.g., food, patient care, property). As to each cost center, a facility will generally be reimbursed for actual costs up to the screened limit, which, for most cost centers, is determined by a statewide averaging process.

In the area of property costs, however, the regulatory “screen” used to limit a facility’s reimbursement rate is somewhat different. Rather than a statewide-average type of screen, DMAHS uses a facility-specific screen known as a Capital Facilities Allowance (‘‘CFA”) to set the limit to property costs.2 Before January 1986, the property cost component of a facility's rate was calculated by using either its actual property costs or its “screened,” CFA-derived limit, whichever was lower. Effective January 21, 1986, DMAHS amended its CARE guidelines to make the CFA method of calculating a facility’s property cost reimbursement the sole method of reimbursement. see 17 N.J.Reg. 2331 (Oct. 7, 1985).'

While the CARE guidelines specify the standard rate-setting methodology for determining reimbursement rates for nursing homes, the guidelines also recognize, as federal law does, the need for some discretion in order to address exceptional situations in which “the strict application of the CARE regulations might result in some inequity.” see Foreward, N.J.A.C.

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802 F. Supp. 1158, 1991 U.S. Dist. LEXIS 20716, 1991 WL 417854, Counsel Stack Legal Research, https://law.counselstack.com/opinion/stratford-nursing-convalescent-center-inc-v-kilstein-njd-1991.