Department of Health and Human Services
DEPARTMENTAL APPEALS BOARD
Appellate Division
SUBJECT: New York
State DATE:
September 30, 1993
Department of Social Services
Docket No.
A-93-229 Decision No. 1440
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
$11,932,475 claimed under title XIX of the Social Security Act for
the
quarter ended June 30, 1991. 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. The State used statistical sampling procedures to
estimate
the amount paid to individuals who were eligible for Medicaid on
the
basis of disability.
In its notice of appeal, the State requested a summary decision
upholding
the disallowance of this amount based on New York State Dept.
of Social
Services, DAB No. 1012 (1989). Similar summary decisions have
already
been issued by the Board. See New York State Dept. of Social
Services,
DAB No. 1420 (1993), and decision cited therein.
In DAB No. 1012, 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. The Board found that sampling
was
impermissible because it was used in lieu of making the
disability
determinations which the regulations, reasonably interpreted,
require in
each case for which payment is made. 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 Healy to Settle dated September 23, 1993.
Conclusion
Accordingly, based on the analysis in DAB No. 1012, we uphold
the
disallowance of the amount remaining in dispute to the extent that
it
represents disability-based claims calculated by extrapolation from
a
statistical sample. As in that decision, we remand to the Agency
that
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.
____________________________ Cecilia Sparks Ford
____________________________ Donald F. Garrett
____________________________ Norval D. (John) Settle
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
6/1/89, p. 5. If the same is true here, there would of course be
no
need for further Agency