Department of Health and Human Services
DEPARTMENTAL APPEALS BOARD
Appellate Division
SUBJECT: New York State
DATE: April 17, 1990
Department of Social Services Docket No. 90-65
Decision No. 1147
PARTIAL DECISION
The New York State Department of Social Services (State) appealed a
determination by the Health Care Financing Administration (Agency)
disallowing federal financial participation (FFP) in the amount of
$5,661,758 claimed under title XIX of the Social Security Act for the
quarter ended December 31, 1987. The costs claimed represented amounts
originally paid under the State- funded medical assistance program which
the State later claimed as payments for individuals eligible for
Medicaid. Of the amount disallowed, $5,634,249 was claimed for
individuals who were eligible for Medicaid based on disability and
$27,509 was claimed for individuals who were Medicaid-eligible on some
other basis.
The State requested a summary decision upholding the part of the
disallowance which involves disability-based claims based on New York
State Dept. of Social Services, DAB No. 1012 (1989). Similar summary
decisions have already been issued by the Board. New York State Dept.
of Social Services, DAB No. 1128 (1990); New York State Dept. of Social
Services, DAB No. 1114 (1989); New York State Dept. of Social Services,
DAB No. 1102 (1989); and New York State Dept. of Social Services, DAB
No. 1052 (1989). The part of the disallowance involving non-
disability-based claims ($27,509) is currently pending before the Board.
In DAB No. 1012, the State's claim was made using statistical sampling
procedures, that is, the State estimated the amount paid to Medicaid
eligibles based on its review of the case records for a sample of
recipients of State-funded medical assistance during the period in
question. The Board held that the State was not authorized to use
statistical sampling as a basis for claiming Medicaid funds payable on
behalf of disabled individuals because the State had not made the
disability determinations which the regulations require in each case for
which FFP is available. Accordingly, the Board sustained the
disallowances to the extent that they represented extrapolations from
cases in the sample involving individuals eligible for Medicaid based on
disability. The Board remanded that part of the disallowances
pertaining to the cases in the sample to determine whether the
disability determination in each case was properly made.
The Agency agreed to the issuance of a summary decision here based on
DAB No. 1012. Letter from Novinski to Ballard dated 4/9/90.
Conclusion
Accordingly, based on the analysis in DAB No. 1012, we uphold that part
of the $5,634,249 disallowance which represents disability-based claims
calculated by extrapolation from a statistical sample. As in that
decision, however, we remand to the Agency the part of the disallowance
which pertains to the cases in the sample to determine whether the
disability determination in each case was properly made so that FFP is
allowable. 1/ The State may appeal the Agency's determination in the
sample cases pursuant to 45 C.F.R. Part 16.
________________________ Alexander G. Teitz
________________________ Norval D. (John)
Settle
________________________ Judith A. Ballard
Presiding Board Member
1. In some related appeals, the Agency asserted, and the State did
not dispute, that claims for the expenditures made on behalf of the
individuals in the sample cases were not included in the amounts in
dispute. Docket Nos. 89-51, 89-86 and 89-87, Agency's brief dated June
1, 1989, p. 5. If the same is true here, there would of course be no
need for further Agency