GAB Decision 773
August 14, 1986
Michigan Department of Social Services;
Docket No. 85-215
Garrett, Donald F.; Stratton, Charles E. Ford, Cecilia S.
(1) The Michigan Department of Social Services (MDSS or State)
appealed a determination by the Health Care Financing Administration
(HCFA or Agency) disallowing $153,725 in federal financial participation
(FFP) under Title XIX (Medicaid) of the Social Security Act. HCFA
generally provides FFP at a rate of 50% for administrative costs of a
Medicaid program. At issue here is FFP claimed by MDSS for the period
of October 1, 1982 to March 31, 1984 based on an enhanced rate of 75%
available for compensation and training of personnel qualifying as
skilled professional medical personnel (SPMP) or support staff to such
personnel. The positions in dispute were all part of the State's
Crippled Children's program, a program within the Michigan Department of
Public Health. The Crippled Children's program received Medicaid
funding under an agreement with MDSS, the State Medicaid agency.
As explained more fully below, we have concluded that, based
on
regulations in effect during 1982-1984 and the Medical Assistance
Manual
(Manual), the Agency's disallowance for all the SPMP and support
staff
positions in dispute was proper. Regarding the position which the
State
claimed for SPMP status (i.e., the Regional Office
Administrator
position), we conclude that the position did not fulfill both
the
professional and the medical components of the applicable definitions
of
an SPMP. For the four positions which the State claimed were
support
staff to SPMP's (i.e., the Office Managers, Handicapper
Children's
Representatives, Case Records Coordinators, and office clerks),
we
conclude that the State did not demonstrate a sufficient nexus
between
the duties of staff claimed as support and those of the SPMP's.
I. Applicable law, regulations, and guidelines
Section 1903(a) of the Act provides for payment of:
(2) . . . 75 per centum of the sums expended . . . (as
found
necessary by the Secretary for the proper and efficient
administration
of the State plan) as are (2) attributable to compensation or
training
of skilled professional medical personnel, and staff directly
supporting
such personnel. . . .
* * * *
(7) . . . 50 per centum of the remainder of the amounts expended
. .
. as found necessary by the Secretary for the proper and
efficient
administration of the State plan. /1/
The terms "skilled professional medical personnel" and "staff
directly
supporting such personnel" are not defined in the Act.
Agency
regulations contain the following definitions at 42 CFR 432.2
/2:/:
"Skilled professional medical personnel" means physicians,
dentists,
and other health practitioners; nurses; medical and
psychiatric social
workers; medical, hospital, and public health
administrators, and
licensed nursing home administrators; and other
specialized personnel
in the field of medical care.
"Supporting staff" means secretarial, stenographic, clerical,
and
other subprofessional staff whose activities are directly necessary
to
the carrying out of the functions which are the responsibility
of
skilled professional medical personnel. . . .
"Subprofessional staff" means persons performing tasks that
demand
little or no formal education; a high school diploma; or
less than 4
years of college.
The regulations are supplemented by Part 2-41-20 of the Manual.
This
Part was issued in an Action Transmittal by the Social
and
Rehabilitation Service (predecessor agency to HCFA) in July
1975,
SRS-AT-75-50. The Action Transmittal describes Part 2-41-20 as
an
"(implementation) and interpretation of the regulation on
Federal
financial participation in State expenditures for staffing of
the
medical assistance program."(3) The Manual contains the
following
"principles" which are used to assess claims for 75% FFP:
B. Principles
1. General
* * * *
a. The function of a "skilled professional medical"
position whether
at the State or local level, is the principal basis for
determining
eligibility for increased Federal matching. The title of a
position or
its organizational placement in the Medical Assistance
Unit
administering title XIX will be used as subsidiary evidence to
confirm
that a staff function is eligible for 75 percent matching.
Support positions derive their eligibility for increased
Federal
matching from their direct association with and supervision by
skilled
professional medical personnel whether at the State or local
level.
b. Staffing will normally include some employees engaged
in
functions which are neither skilled professional medical functions
nor
supportive of such functions.
Therefore, salaries and related costs of the total cadre of
personnel
involved in the administration of the title XIX program are
not
reimbursable at the 75 percent rate.
* * * *
2. Specific
a. The function, rather than the title, of a position is
the
significant factor. Staff classified as skilled professional
medical
personnel must be in functions at a professional level of
responsibility
in the administration of the title XIX medical assistance
program
requiring medical subject area expertise.(4) "Professional"
and
"medical" functions are defined as follows:
Professional -- the function is at a level which requires
college
education or equivalent and it relates directly to non-routine
aspects
of the program requiring the exercise of judgment.
Medical -- the function is peculiar to medical programs and
requires
expertise in medical services care delivered, studying and
evaluating
the economics of medical care, planning the program's scope,
or
maintaining liaison on the medical aspects of the program with
providers
of service and other agencies which provide health care.
As a class, these functions require knowledge and skills gained
from
professional training in a health science or allied scientific
field.
They involve overseeing the delivery of medical care and services.
Staff positions in which the primary function is the application
of
administrative practices and procedures unrelated to the
specialized
field of medical care management are eligible for 50 percent
matching.
For example, a physician in charge of an accounting operation would
be
eligible for staff reimbursement only at 50 percent FFP.
* * * *
c. Support positions claimed at 75 percent matching must
directly
support skilled professional medical personnel functions.
Support staff must be in work assignments related in an
immediate way
to the direct completion of the work of such professional
medical
personnel (e.g., secretaries, statistical clerks,
administrative
assistants).
To be eligible for 75 percent matching all such support
personnel
must report directly to the skilled professional medical staff and
be
supervised by such skilled staff members. Support functions not
related
in such direct manner to skilled medical functions are eligible only
for
50 percent matching.
(5) Functional flow charts can provide documentation that
support
positions claimed at 75 percent matching are in direct support
of
skilled professional medical staff.
d. Where staff time is split among functions at different
levels of
Federal matching, the portion of time in each function must
be
documented.
C. Examples of Organizational Functions
Following are examples of functions needed to operate State
title XIX
programs and the expected level of Federal matching. . . .
* * * *
5. Audit Staff - 50 or 75 percent FFP
Personnel engaged in routine claims review, such as auditing
whether
the codes correctly coincide with billed charges, are matched at
50
percent. Matching at 75 percent would apply to those
skilled
professional medical personnel (and directly supporting staff)
whose
function involves assessing the necessity for and adequacy of
the
medical care and services provided, as in utilization review.
6. Other Skilled Professional Medical Personnel - 75 percent FFP
Staff includes personnel such as physicians, dentists,
pharmacists,
hospital administrators, medical economists, medical and
psychiatric
social workers, and registered nurses who are responsible for
activities
such as: providing liaison on professional medical matters,
medical
services program development, medical care assessments, and research
and
evaluation concerning all aspects of the delivery and economics
of
medical services. Included would be members of medical review
and
independent professional review teams.
* * * *
Section 2-41-20(B)(2)(b) of the Manual provides that the official
position
descriptions are the "basic substantiation" for a position's
professional
medical status. This section also provides for
consideration of "(job)
announcements emphasizing requirements at or
above the college level in
medical care and medical care
administration." Further, its listing (6) in an
"appropriate medical
classification" in a dictionary or handbook of
occupational titles is a
secondary indication that a position is a skilled
medical position.
As we commented in another decision, the determination of whether
a
personnel position is a skilled professional medical one or
support
staff is not an exact science. Rather, the determination is
based upon
the examination of information about the actual tasks performed
by
questioned personnel and a reasonable application of the guidelines
set
out in the Manual, implementing the statute and regulations. We
note
that the Manual, at 2-41-20(B)(1)(b), states that "(staffing)
will
normally include some employees engaged in functions which are
neither
skilled professional medical functions nor supportive of
such
functions."
II. Use of Improper Standards
The State argued that the Agency in issuing its disallowance
improperly
relied upon a document entitled "Title XIX Financial Management
Review
Guide for Identification of Skilled Professional Medical
Personnel"
(Review Guide), which the State maintained was inconsistent with
both
the applicable regulations and the policy interpretations as
contained
in the Medical Assistance Manual. The State also maintained
that the
Agency relied upon proposed regulations pertaining to SPMP that were
not
promulgated in final form until after the period in dispute. (The
final
regulations were published on November 12, 1985, effective February
10,
1986. 50 Fed. Reg. 46652). The State argued that the
Agency made at
least two errors in its review because of this improper
reliance on the
Review Guide and proposed regulations: (1) the Agency
restricted
eligibility for support staff to only "secretarial and
stenographic
personnel," a requirement not contained in the regulations then
in
effect or in the Manual; and (2) the Agency failed to accept
"public
administrators" as SPMP's thus precluding 75% reimbursement for
the
Regional Office Administrators. See State's Reply Brief, pp.
3-4.
In a decision issued after the present appeal was instituted, the
Board
concluded that the Agency may have improperly relied upon the
Review
Guide and regulations not yet in effect. Oregon Department of
Human
Services, Decision No. 729, March 20, 1986, pp. 9-11. We agreed
in that
appeal with Oregon's argument that the Review Guide was
inconsistent
with the then current regulations and Manual provisions, which
are also
applicable here. Without deciding to what extent HCFA may have
also
improperly relied upon these sources in the present appeal, we
repeat
our conclusion in Oregon that the statute and the regulations and
Manual
provisions in effect fr the time period at issue are the only
relevant
sources in(7) evaluating whether the State is eligible for 75%
enhanced
reimbursement. Here, when reviewing the Agency's determination
that the
positions did not qualify for 75% FFP, the Board has based its
findings
and conclusions solely upon these standards.
III. The State's Program
The Crippled Children's program entered into a contract with MDSS,
the
"single state agency" for Medicaid purposes, to administer
medical
services for certain handicapped children who were eligible for
or
receiving Medicaid assistance. See State's Attachment 1 to July
17,
1986 submission, esp. Schedule E (the contract). The
functions of the
Crippled Children's program, according to the contract, were
to:
1. Determine which children in, or eligible for, the
Medical
Assistance Program qualify as crippled children under
legislative
mandate and Public Health's rules and procedures.
2. Provide case management including approval of
physicians,
hospitals and other providers for the provision of services, to
those
determined to be eligible for Crippled Children Program benefits.
This
management will be provided by physicians, nurses, and other
health
professionals in the central and regional offices that serve
crippled
children.
3. Utilize the same method of payment for services rendered
to
crippled children (including rates of reimbursement) used by
Social
Services to pay for services rendered to Medical Assistance
recipients.
4. Provide to Social Services, on a timely basis, all
information
relating to eligibility, authorization and other information
as
required, which would enable invoices for services rendered to
be
processed for prompt payment.
5. Certify to Social Services hospitals and nursing-care
facilities
approved for the inpatient care of children eligible for
Medical
Assistance benefits.
6. Certify to Social Services the speech and hearing
centers
approved for the evaluation of recipients suspected of being hard
of
hearing.
7. Prior authorize those selected services for Social
Services
program recipients which may from time to time be mutually agreed
upon.
(8) 8. Provide to Social Services, on a timely basis, all
reports
necessary to fulfill federal reporting requirements.
9. Designate appropriate personnel to work on a Public
Health/
Social Services task force to examine issues of reimbursement,
claims
processing, cost-accounting and systems development.
State's Attachment 1 to July 17, 1986 submission, pp. 13-14.
The Crippled Children's program was administered through five
"regional
offices" of the State, located in the areas of Detroit,
Marquette,
Pontiac, Grand Rapids, and Lansing. The State's
organizational
structure called for each regional office to be headed by a
physician
and to have a "consultant team" composed of a nurse, medical
social
worker, nutritionist, audiologist, and vision consultant. (At
varying
times during the period at issue some positions were vacant in some
of
the regional offices) It is undisputed that all of these personnel
were
SPMP's. The physician's tasks, as described for one of the
regional
offices, were to:
1. Coordinate the CC (Crippled Children's) Program
regional office
activities. Interpret program philosophy and implement
DSCC policies
and procedures.
2. Approve diagnostic examination requests and review
reports of
same and determine future action.
3. Determine medical eligibility from medical information
coming
from a variety of sources.
4. Review and suggest revision to the lists of conditions
that
determine medical eligibility.
5. Review and supervise hospital admission forms for case finding.
6. Supervise and make decisions on prior authorizations
for durable
goods for all patients under the age of 21 years of age for
Crippled
Children and Medicaid Programs.
7. Ascertain the necessity for out-of-state care for a patient.
8. Upon request or by one's initiative, set up field
clinic or
appraise hospitals and hospital clinic for delivery of care.
Monitor
same periodically.
9. Consult with and advise providers, local health
departments,
county offices of social work, local or district school systems,
private
agencies, Bureau of(9) Personal Health Services and other
services
regarding Crippled Children Program; need to add mental health
agencies
(we have considerable involvement at all levels in this area).
10. Recruit new medical specialists for Crippled Children
Program.
Advise and monitor their role in delivery of care.
11. Assist with the decision to refer patients to Grand
Valley
Nursing Centre.
12. Evaluate adult nursing home placement for patients
under the age
of 15 years.
13. Update medical, educational and social knowledge by
reading and
attending conferences and continuing medical educational
programs.
14. Keep abreast of all laws referable to handicapped
children or
related to public health issues and the handicapped child.
Agency's Ex. B, item 17.
Several secretaries, who were undisputed as SPMP support staff,
reported
directly to the physicians or other consultants in each of the
regional
offices. Agency's Brief, p. 6. The State has claimed 75%
reimbursement
for all the remaining positions within the regional
offices. For each
of the offices, the State claimed as SPMP status a
"Regional Office
Administrator," who also reported to the physician
administrator. The
State claimed as support staff an "Office Manager"
position, the
predecessor position to the Regional Office Administrators, for
some of
the period in dispute for some of the offices (the change
in
classification of this position is discussed below). The State has
also
claimed as support staff within each regional office several
"case
records coordinators," "handicapper children's representatives,"
and
general clerical positions. We consider the State's claim for each
of
these positions in turn below.
IV. Regional Office Administrator positions
The State claimed as SPMP's one "Regional Office Administrator" for
each
of the five regions for part or all of the period in dispute. /3/ Two
of
the positions,(10) in the Marquette and Pontiac regional offices,
were
originally classified as an admittedly less responsible position
of
"Office Manager" but were "upgraded" to Regional Office
Administrators
at some point during the period in dispute. The State
claimed support
staff status for these two positions during the period when
they were
classified as Office Managers, but claimed SPMP status for the
remainder
of the period when they were classified as Regional
Office
Administrators. We discuss the State's claims for 75%
reimbursement for
the Officer Manager positions in a separate section (on pp.
21-22
below).
The Agency based its disallowance for the Regional Office
Administrator
positions on both the educational prerequisites for the
positions and
the functions of the positions as described in the incumbents'
official
position descriptions (PD's). We first consider below the
issue of
educational requirements for the positions and next address
the
functions of the positions as described in the PD's and by one of
the
Regional Office Administrators.
A. The Educational Requirements for the Regional Office
Administrator
position
The Agency argued that one reason the Regional Office
Administrator
positions were not SPMP's was that, for two of the positions
(in the
Marquette and Pontiac regional offices), the minimal qualifications
for
the jobs were listed as a high school education with two
years
experience. See Agency's Exs. C, D. The Agency maintained
that the
positions could not be considered SPMP with such minimal
educational
qualifications. The State responded to this argument by
explaining in
detail the history of the positions and arguing that they were
unique.
The positions in Marquette and Pontiac were originally classified
as
"Office Managers," an admittedly non-professional position
requiring
only a high school education. As the educational requirements
for this
slot in the other regions were made more stringent, the individuals
in
the Marquette and Pontiac offices were upgraded from their former
(11)
Office Manager positions to the Regional Office Administrator
job.
According to the State, the incumbents were qualified for the
Regional
Office Administrator positions by having over twenty years
experience on
the job. The two positions were thus "grandfathered into"
the
professional slot by the State Civil Service Commission. See
State's
Opening Brief, p. 5.
The State appeared to maintain that, in reviewing the
qualifications
required for the Regional Office Administrator positions in
the five
regions, the Agency should have reviewed the positions where
the
incumbents were hired directly for the position of Regional
Office
Administrator, rather than where the incumbents were grandfathered
into
the positions. In those regions where the incumbents were
hired
directly, the educational requirements were listed as a
"bachelor's
degree in public health management or a health related field" and
"four
years of professional level experience in public health, health
care,
community organization, program development or an area of
administration
such as budgeting or administrative analysis." See Agency's
Exs. G, H;
State's Attachment 17-A.
While the educational prerequisites for a position are not per
se
determinative of whether or not a position is an SPMP, we conclude
that
the State's assertions regarding the Regional Office Administrators
is
weakened by the fact that two of the positions required only a
high
school education and two years experience. Leaving aside the issue
of
whether the Regional Office Administrators performed
"medical"
functions, the State has a heavy burden to demonstrate that a
position
is "professional" when it could be performed by an individual with
no
formal college training.
The Medical Assistance Manual defines "professional" to be where
"the
function is at a level which requires college education or
equivalent.
. . ." Part 2-41-20(B)(2)(a), quoted in full on page 4,
above. The
Manual thus recognizes the possibility of situations in
which someone
with less than a college degree would qualify as "professional"
because
of "equivalent" training or experience. However, we find that
the State
has not demonstrated this circumstance here. The record
contains only
general allegation that the incumbents initially hired for
positions not
requiring a college education received sufficient on-the-job
training to
qualify them for positions requiring at least a college
degree.
In seeking to demonstrate that the two Office Managers were upgraded
into
"professional" positions, the State made two points:
* Both of these individuals had over ten years of experience in
the
programs giving them the opportunity to acquire experience and skills
to
upgrade their role.
(12) * There were three years where these individuals
functioned
alongside professional administrators of other offices. They
attended
the same staff meetings and received the same directives from the
State
Office.
State's Reply Brief, p. 14. The State also noted that the
"executive
leadership" of the program was able to compare the performance of
the
upgraded Regional Office Administrators to the other three. See
id.
With regard to the incumbents' having "over ten years of experience,"
the
significance of this fact is refuted by the PD's for both
individuals which
list the minimal experience for the Regional Office
Administrator position as
only "(two) years' experience in
administrative analysis or as an office
manager." Agency's Exs. C, D,
item 30(B). In any event, we would still
seriously question whether ten
years' experience in a position asserted by
the State to be a
subprofessional support position would per se qualify one
as having the
"equivalent" of a college degree.
With regard to the State's second point, the State did not demonstrate
how
the two incumbents operated "alongside professional administrators
of other
offices" (emphasis added). The offices were in different
regions of the State
and there is no indication that the two Office
Managers were temporarily
transferred to the other regions to receive
instruction from other
administrators. Nor do we find especially
significant that the Office
Managers attended the same staff meetings,
whose frequency was not specified,
or received the same directives. In
any event, as we explain elsewhere
in this decision, we conclude that
the State has not demonstrated that the
other three Regional Office
Administrators functioned at a "professional"
level in the sense
intended by the Manual, i.e., that their job "(related)
directly to
non-routine aspects of the program requiring the exercise of
judgment."
We are likewise unpersuaded by the State's point that the
"executive
leadership" of the program had the ability to compare the
performance of
the upgraded Office Managers to the other three Regional
Office
Administrators. The State presented no evidence obtained from
such a
comparison nor has the State actually maintained that such a
comparison
was even made.
B. The functions of the Regional Office Administrator positions
The State emphasized that, whatever the stated qualifications of
the
Regional Office Administrators, all of the incumbents
performed
functions that should be classified as SPMP. The(13) record
contains
the PD's for each of the incumbents. One of the incumbents, in
the
Grand Rapids regional office, /4/ participated in a telephone
conference
call. We evaluate the information he provided about his
duties below.
We find that the record does not demonstrate that the functions
of the
positions are both "medical" and "professional" as those terms
are
defined in the Manual.
As summarized by the State, the Regional Office Administrators had
three
major areas of responsibility:
(1) administration (of the regional offices);
(2) overseeing case management provided by staff and
relationships
with health care consultants; and
(3) outreach and communication with the medical community,
health
care providers (including public health agencies), and other
community
agencies.
State's Opening Brief, p. 4. The position descriptions for the
three
Regional Office Administrators other than in Marquette and
Pontiac
(where the incumbents were upgraded from the Office Manager
position)
track these three descriptions. See Agency's Exs. G, H;
State's
Attachment 17-A.
The first area of responsibility is a purely supervisory one that
does
not, on its face, require either medical functions or
professional
functions related to "non-routine aspects of the program
requiring the
exercise of judgment." Manual, part 2-41-20(B)(2)(a). The
PD of the
incumbents at the three regional offices other than Marquette
and
Pontiac listed this function first, including as tasks under
this
category "to supervise administrative regional office staff,"
"to
maximize office efficiency," "to maintain liaison with the
(central
office)" and "to prepare the budget for the regional office." See,
e.
g., Agency's Ex. H.
The second task, captioned in the PD's "Coordination with
Consultants,"
might arguably require a greater degree of medical knowledge
or
professional judgment. However, as explained below, neither the
PD's
nor the information provided (14) by the Grand Rapids
incumbent
demonstrate to us that the position is an SPMP. The
position
descriptions for the three regional offices provide:
Coordination with Consultants
A. To assure professional consultant input in CC case management
- to establish and maintain cooperative working relationships
with
administration professional consultants, including social work,
medical,
nursing, hearing and speech, vision and nutrition
- to work with individual consultants in the establishment
of
criteria for identifying cases requiring professional consultation
B. To coordinate case conferences
Agency's Exs. G, H; State's Attachment 17-A, item 17. We find
that the
"coordination with consultants" function as described in the PD's
does
not involve either professional or medical-related tasks as intended
by
the regulations and Manual. The Administrators' job here appears to
be
ministerial, creating the arrangements whereby the "consultants" in
the
regional offices (who were SPMP's) can express their judgments on
cases.
In the telephone conference call, the Regional Office Administrator
for
the Grand Rapids regional office explained his duties. /5/ See Tape
of
April 30, 1986 Telephone Conference Call. In response to a
question
from the Board as to whether he evaluated the care a client was
getting,
the Administrator indicated that in some cases, where it was( 5)
within
his expertise, he would make some sort of initial evaluation, but
will
then refer the cases on to the medical consultants. A
State
representative then asked:
Would you describe your function as dealing with many of the
routine
service determinations in that you would determine, look at, quality
of
care and appropriateness of care from specific providers and that
when
situations become extremely unusual and complex and outside of any
prior
experience or training, that that would go to the medical
coordinator?
The Administrator responded:
Yes, I would say that's a fair assumption. Probably 50% of them
are
fairly cut-and-dried. They may go to specialty care. In
this
particular city there's only one provider for that; he's up on
our
program, the child is naturally referred to that provider.
There's
other ones where the care is more complex. The child may have
had one,
two, or three diagnoses and the provider is going to be more than
one.
Then the medical coordinator gets involved or the nurse gets
involved.
Who would be the best to handle this type of child? And I'll
make that
particular decision, but I make sure the medical coordinator gets
that
particular case and he makes that particular decision.
As described by this Administrator, the "coordination" function
appeared
to involve some greater degree of responsibility than as explicated
in
the PD's, but we still do not find that his duties were that of an
SPMP.
We find that the primary "judgment" which the Administrator makes
is
that of deciding which of the specialized SPMP consultants in
the
regional office should be assigned to a particular case. The
State's
representative asked whether the Administrator "(looked) at quality
of
care and appropriateness of care from specific providers." The
incumbent
testified that he may make a preliminary assessment as to
the
appropriateness of care, citing at another point the decision of
whether
a client should see an opthalmologist rather than an
optometrist. The
Administrator admitted, however, that the final
judgment regarding
appropriateness of care is always made by the SPMP
consultant. We found
the Administrator's statements somewhat confusing
with regard to his
precise function within the office, but it appeared that
the preliminary
assessments he makes regarding appropriateness of care are
made in the
context of referring the case to a specialist.
(16) The third task performed by the Regional Office Administrators
was
described in the position descriptions as follows:
Community Outreach
A. To create and increase CC (Crippled Children's)
Program
visibility in the region, through outreach to the medical
community,
school systems, volunteer and charitable organizations, public
and
private agencies and the general public
B. To make arrangements with area health care
providers,
particularly hospitals, to assure transmittal of medical
information
necessary for casefinding and case management, i.e., inpatient
admission
notices and medical reports
C. To establish working relationships with local health departments
- establish channels of communication between the regional
office and
local health departments providing services to crippled children
. . .
- to support and oversee the activities of the local
health
department CC Representatives. Includes visiting the local
health
department administrator to arrange for time, office
accommodations,
etc., adequate for the fulfillment of the CC Representatives'
duties;
providing training and consultation for the representatives.
Agency's Exs. G, H; State's Attachment 17-A, item 17. In the
telephone
conference call, the Board asked the Administrator to explain how
the
community outreach functions of the position "entailed an
understanding
of the public health system." Tape of April 30, 1986
Telephone
Conference Call. The Administrator responded:
It's not unusual for myself to do an in-service at some of
the
hospitals, particularly with the new nurses, explaining not only
what
the Crippled Children program is but what we cover, . . . what they
can
expect from us. We put these on not only for nurses but some
physicians
attend. There's peer groups; the cancer group we just
got done doing
an in-service with. There's professional associations, .
. . other
health departments which we are constantly talking to,
educating them,
explaining to them our program. The in-service is
really limited.
Since I've been involved with special ed., I do a lot of work
with
schools. I get a lot of calls from special ed. teachers.
They have a
problem with one of their handicapped children: You know,
is this going
to be covered(17) by our service? They explain to me the
situation, so
I says make sure they get a medical here, but it sounds like
this kid
would be eligible for our services. . . .
There are many ways of doing outreach in our particular
region. The
outreach is only limited by the time we have to spend on
that.
We conclude from the PD and the Administrator's statements that the
State
did not demonstrate that the community outreach portion of the job
met the
Manual's definition of what an SPMP does. The position
description does
not indicate that the Administrators made professional
judgments or needed a
particular knowledge of medicine or public health,
but rather appears to
describe what the Agency characterized as
"performing pubic relation work in
the community and with area health
care providers." Agency's Brief, pp.
10-11. The Administrator is "to
create and increase . . . Program
visibility, . . . to make arrangements
with . . . providers . . . to assure
transmittal of medical information,
. . . and to establish . . .
relationships with local health
departments." E.g., Agency's Ex. H (Position
description).
When specifically asked how this job function requires a knowledge
of
public health, the Administrator only described examples of
activities,
such as "in-service training," which he described as "explaining
. . .
our program." In answering inquiries about eligibility, the
witness
explained that he would need "to get a medical (person) here (to
make
the actual determination)," but he could express some
preliminary
assessment such as "it sounds like this kid would be eligible for
our
services." By the Administrator's own description, his function
clearly
does not require "knowledge and skills gained from professional
training
in a health science or allied scientific field." Manual, part
2-41-20(B)
(2) (b).
One factor that is significant in evaluating the functions of the
Regional
Office Administrators is that each of the regional offices was
headed by a
physician administrator, who had final responsibility for
the substantive
work of the office (see the listing of the physician's
tasks on pages
8-9). The purpose of the Regional Office Administrator
position was
apparently not to "administer" the office in terms of the
substantive public
health work of the office, but appears rather to
serve a more purely
supervisory function that at times touched upon
medical or public health
issues. The title Regional Office
Administrator is in this sense a
misleading label. The physician
administrator was in fact the top
"administrator" of the offices; the
Regional Office Administrator was
an intermediate-level position that
fulfilled more limited "administrative"
purposes. This factor(18) does
not itself preclude the Administrators
from being SPMP's under the
applicable standards, but it provides in our view
a context in which a
greater burden is placed upon the State to demonstrate
both the
professional and medical nature of the Regional Office
Administrators'
work.
The State relied upon the applicable regulation's reference to
"public
health administrators" as one example of the types of positions that
may
be SPMP's. See 42 CFR 432.2. The State made the point that a
public
health administrator would, by definition, "administer" and that
the
Agency improperly concentrated on the administrative functions of
the
Regional Office Administrators when issuing its disallowance. If
the
Regional Office Administrators were the only or the
primary
administrators of the offices, we might agree with the State.
However,
the physician administrators appear to us in this case as the
public
health administrators to which the regulations properly refer.
The
purely administrative functions of the Regional Office
Administrators
are indeed relevant in determining whether the positions are
SPMP's.
The Board asked the parties to define the term "public
health
administrators" using the "Dictionary of Occupational Titles" or
other
works specified by the Manual (part 2-41-20(B) (2) (b)) and to
compare
and contrast these definitions with the duties of the positions
which
the State claims are SPMP's. The State quoted the definitions
of
"public health" and of "administrator" from Webster's Third
New
International Dictionary, as well as describing the requirements for
a
master's degree in public Health from the University of Michigan
School
of Public Health. After some further discussion, the State then
argued
that "there is a very good fit between the duties of the regional
office
administrator and any reasonable definition of public
health
administrator." State's Supplementary Material of July 17, 1986, p.
8.
We do not find the definitions of "public health" and "administrator"
or
the requirements for a master's degree in public health to
demonstrate
that the Regional Office Administrators qualify as "public
health
administrators" as used in the SPMP regulations. We do not
question
that the Regional Office Administrators were "administrators," nor
do we
question that they operated in an office whose function involved
public
health. We find, however, that the regulations did not
contemplate
providing enhanced reimbursement to any individual providing some
type
of administrative services to a public health office. The
reference to
"public health administrator" is a general reference to the type
of
position which would qualify for SPMP status and cannot supersede
the
obvious requirements that such an individual operate in a
"professional"
capacity and that his or her actual tasks be related to
medicine or
public health.
(19) The State's description of the requirements for a degree in
public
health actually reinforces for us the Agency's position that anyone
who
administers in an office involved with public health is not per se
an
SPMP. Those achieving a master's degree in public health from
the
program described by the State would presumably be qualified to fill
a
SPMP position. However, this was not the training which the
Regional
Office Administrators possessed. As we have discussed above,
two of the
incumbents had only a high school degree and the one individual
from the
Grand Rapids region which the State chose to participate in
the
telephone conference call had a bachelor's degree in business and
a
master's degree in "blind rehabilitation" (which was apparently
not
directly used in his present position /6)/). Tape of April 30,
1986
Telephone Conference Call. In comparing the training and
expected
employment of a candidate for a master's degree in public health
with
the training and job functions of the Regional Office
Administrators,
the conclusion becomes even clearer that the Regional
Office
Administrators were not public health administrators as intended by
the
regulations and the Manual. As we have found above, the
substantive
administration of the regional offices which required a knowledge
of
public health was performed by the physician administrators, so
that
other duties not requiring specialized knowledge were, quite
logically,
delegated to the intermediate-level Regional Office
Administrators.
Although not specifically argued by the State, we note that the
Michigan
Civil Service Commission classified two of the Regional
Office
Administrators (in the Detroit and Lansing regions) as "Public
Health
Administrators" on the PD's. While this classification may
appear on
the surface supportive of the State's position, we are not
persuaded
that it should alter our analysis. First, the State Civil
Service
Commission was inconsistent in so classifying the positions:
the
incumbents in the Marquette and Pontiac regions were classified
as
"Department Supervisor," while the incumbent in the Grand Rapids
region
(who spoke in the telephone conference before the Board) was
classified
as "Department Analyst." No explanation was offered for
this
inconsistency, which appears particularly significant in light of
the
State's insistence that the work of the Regional Office
Administrators
was at a (20) similar level in all five regions.
Furthermore, while
there may arguably be some basis for distinguishing the
incumbents in
the Marquette and Pontiac regions (who were "upgraded" from the
former
Office Manager positions) from those in the other three regions,
no
apparent basis would explain the fact that the Grand Rapids
Regional
Office Administrator, whom the State chose to speak before the
Board
(and therefore whom one might perhaps expect to be more qualified
than
the incumbents at Detroit and Lansing) was not classified as a
Public
Health Administrator. This lack of consistency indicates to us
that the
Civil Service Commission's classification system is not significant
with
regard to the application of the principles governing SPMP status.
Secondly, the State presented no evidence to explain how a
particular
classification is chosen by the State Civil Service Commission
and
whether the Commission itself attaches any importance to the label.
/7/
Given the inconsistency of classification we have described above,
the
official status of the classifications is called into question.
For
instance, from the little that has been presented in the record,
it
seems conceivable that the incumbent's supervisor or even the
incumbent
himself may select the label applied to the PD.
Third, even if the classification label used by the State Civil
Service
Commission were entitled to some type of presumptive validity (which
is
not specifically required by any authority of which we are aware),
any
such presumption could certainly be rebutted by evidence to the
contrary
that the classification is inappropriate or inaccurate for our
purposes
here. We have concluded above that the Agency has presented
such
evidence, demonstrating to us that both the educational requirements
and
functions of the Regional Office Administrator positions do not
fulfill
the intent and purpose of the SPMP regulations and
policy
interpretations. /8/
(21) V. Office Manager positions
The State claimed 75% reimbursement for three Office Manager
positions.
For the Grand Rapids regional office, the Office Manager retired
and was
replaced by a Regional Office Administrator. For the Marquette
and
Pontiac regional offices, the Office Managers were upgraded to
Regional
Office Administrator positions at some point during the period
in
dispute because of their job experience. /9/ While the State at
first
appeared to claim SPMP status for all the Office Manager positions,
it
clarified during the course of the appeal that the positions were
not
SPMP's in its view, but rather should be claimed as support staff
to
SPMP's. See Tape of April 30, 1986 Telephone Conference Call;
Agency's
Supplemental Memorandum of May 21, 1986, pp. 1-2.
The State made no attempt to justify why the Office Managers should
be
viewed as support staff to SPMP's, nor did the State even explain
what
specific SPMP positions the Office Managers allegedly supported.
As we
have found in other decisions, a grantee has the burden to justify
all
costs and a State must specifically explain why a position should
be
classified as an SPMP or support staff. The State emphasized
generally
that(22) the regional offices operated on a "team" basis;
presumably,
the State would maintain that the Office Managers were support
staff in
the sense that they provided support to all the SPMP's in the
office.
As we also explain below in the discussion of the State's claim for
other
support staff positions, we conclude that the general support of
all the work
of an office, including that of SPMP's, does not fulfill
the regulations' and
Manual's intent in defining support staff to SPMP.
The enhanced rate of FFP
for SPMP and support staff was intended for
exceptional circumstances and
there must be some "immediate" and
"direct" nexus between the work of support
staff and a particular SPMP.
California Department of Health Services,
Decision No. 646, May 7, 1985,
p. 5. The State's claim of support staff
status for the Office Managers
especially lacks credibility since for the
upgraded Regional Office
Administrator positions, which were at least similar
to the former
Office Manager positions, the State has not claimed them to be
support
positions at all, but instead are claimed to be managerial
positions
supported by other personnel in the offices. Thus, we find
the State's
position to be inherently contradictory and are unable to accept
the
Office Managers as support staff.
VI. Case Records Coordinators
The State described the Case Records Coordinators (CRC's) as "managers
of
records for a group of Crippled Children Program Cases." State's
Opening
Brief, p. 7. the CRC's duties involved four areas of
activity,
according to the State: (1) case finding, (2)
eligibility
determination, (3) case management, and (4)
liaison/consultant. The
State further submitted:
These functions are an extension of the physician, nurse
consultant,
and other health care professionals on staff. Examples of
these
activities are review of diagnoses on hospital admission
notices,
authorizing or denying services requiring prior approval,
performing
case management by reviewing medical reports/recommendations,
and
relating to families, local health departments, and health
care
providers, especially physicians.
Id.
As explained below, we conclude that the Case Records Coordinators
were
not support staff to SPMP's under the applicable regulations and
the
Manual. We base this conclusion on two findings: first, that
the State
did not demonstrate how the CRC's provided support to any
particular
SPMP in the regional offices, and, secondly, that the CRC's
had
essentially independent duties which by their nature may
have(23)
furthered the overall work of the regional office but were not
related
in a direct or immediate way to the specific duties of any SPMP.
In its opening brief, the State submitted that the CRC's were
"extensions"
of the "physician, nurse consultant, and other health care
professionals on
staff." State's Opening Brief, p. 7. In its reply
brief, in response to
the Agency's argument that the State's concept of
"direct support" was too
"loosely construed," Agency's Brief, pp.
21-22, the State then clarified that
the CRC's provide support to the
Regional Office Administrators, as well as
to the physician
administrators of the regional offices. The State thus
argued that
"(this) establishes the connection between the CRC's and SPMP
staff,
specifically the (regional office) administrator and the
medical
coordinator. The working relationship with other SPMP staff,
namely the
nurse, social worker, hearing consultant, etc. is a joint
cooperative
effort which is facilitated by the administrator." State's Reply
Brief,
p. 21.
The Medical Assistance Manual provides that "(support) staff must be
in
work assignments related in an immediate way to the direct completion
of
the work of . . . professional medical personnel (e.g.,
secretaries,
statistical clerks, administrative assistants)." Manual,
section
2-41-20(B)(2)(c). The State has claimed that the CRC's provide
"direct
support" to several, perhaps all, the SPMP's in the regional
offices.
/10/
While it may be possible for the CRC's duties to 'relate in an
immediate
way to the direct completion of the work" of each and every SPMP in
the
Office, the State would need to articulate how this is so; in our
view,
the State would need to explain how the duties of the CRC's were
divided
in order to provide direct support to each particular SPMP.
The Manual further provides that to be eligible as support staff
the
"support personnel must report directly to the skilled
professional
medical staff. . . ." Manual, part (24) 2-41-20(B)(2)(c). /11/
In order
to "report directly" to an SPMP, the support staff must, in our
view,
perform discrete tasks necessarily incident to specific duties
performed
by identifiable SPMP(s). /12/ To conclude otherwise would
render
meaningless the Manual's emphasis on "direct" and "immediate"
support.
In response to a specific written question from the Board on this issue
of
direct support to a particular SPMP, see question 6 of Board's March
27, 1986
letter, the State never sought to explain any particular
"division of duties"
in the tasks of the CRC's in order to demonstrate
immediate support to the
SPMP's. Instead, the State appeared to
emphasize the "team concept" of
the offices and the importance of the
program of the function of the
CRC's. See Tape of April 30, 196
Telephone Conference Call. We do
not question the significance of the
CRC's work or of any of the other staff
in the State's offices, nor do
we question that the offices were organized in
a logical manner.
However, the provision for 75% FFP for support staff to
SPMP's is
specifically limited by the regulations and Manual and the State
must
demonstrate how the staff in its offices provided "immediate"
and
"direct" support to the SPMP's.
The functions of the CRC's, as explicated in a position description of
an
incumbent /13/ and by other explanations by the State, provides
additional
support for our conclusion that the CRC's do not qualify as
SPMP support
staff. The State described the CRC's as
"paraprofessionals" who were
trained by the physician administrators and
nurse consultants to "perform(25)
the more routine aspects of medical
eligibility and case management." State's
Opening Brief, p. 8. The
"paraprofessional" nature of their work is
corroborated by the position
description submitted by the State, which
describes in extensive detail
the case management and eligibility
determination functions of the
position. /14/ See State's Attachment 17-B,
esp. attached pp. 1-6. The
case records coordinator summarized
her job as follows:
Under prescribed parameters and criteria, I review and monitor
all
incoming documents, correspondence, telephone child patients within
this
assigned area (of three counties). I determine need for further
action
and perform accordingly. The purpose and result of my work
management
of all documents and personal contacts met in the performance of
my
daily duties, to locate and service the crippled children of the
state
of Michigan.
State's Attachment 17-B, item 16.
We find the duties of the duties of the CRC to be essentially
independent,
as highlighted by the State's characterization of the
position as
"paraprofessional." In response to the question, "Who
reviews or checks your
work?," the CRC answered on the position
description, "It is reviewed by me."
State's Attachment 17-B, item 20(
a). In response to the question,
"what happens when an error is
found?," the incumbent further answered that
"(when) an error is found
it is reviewed by me." Id., item 21(a).
The State has provided no evidence that the CRC's received
continuing
substantive supervision from SPMP's in the offices, nor that the
CRC's
functions were related in an immediate and direct way to the
completion
of the SPMP's work.
In California Department of Health Services, Decision No. 646, May
7,
1985, the Board considered a similar situation where California
sought
SPMP support staff status for personnel of its Child Health
Information
Claiming Unit (CHIC). The Board rejected California's
arguments:
In the Agency's view, uncontradicted by the State, the work done
by
CHIC was the routine claims processing functions such as routine
error
identification,(26) maintenance of a file listing Medicaid
providers,
general data collection, and flagging of claims that might require
fee
adjustments or might indicate overutilization. While these tasks
were
helpful, and maybe even an essential first step, in identifying
claims
and providers that a SPMP may later choose to examine further, they
lack
the "immediate" and "direct" nexus that is required for 75% FFP.
These
functions were performed prior to the SPMPs' involvement in a
SPMP
capacity. The organizational chart submitted by the State
implies
through the use of arrows that there was some sort of direct
association
between the employees and the SPMP. But it does not
indicate that the
specific work assignments were initiated by the SPMP in an
SPMP role and
that the SPMP directly supervised the employee in the work
performed.
To use a lesser standard would lead to the conclusion that almost
any
function performed by an employee of the State Medicaid agency
would
qualify for 75% FFP, and the limited exception to the routine 50%
FFP
for administrative expenditures would be rendered meaningless.
Id., p. 5 (emphasis added). We actually find Michigan's arguments
less
convincing than we did California's because, in the present case,
the
CRC's work was not preliminary to the work of the SPMP's, but
rather
appeared to be entirely independent of the functions of the
SPMP's.
/15/
VII. Regional Office Clerks
The clerical staff of the regional offices provided general support
for
the regional offices. The State submitted:
The staff qualify as direct support by the nature of the
functions
that they perform. They handle the mail (which is
voluminous), answer
phones, type correspondence, pull and file cases, and
manage outgoing
mailings. These duties support all of the regional
office staff
including especially the health professionals and case
records
coordinators.
State's Opening Brief, p. 8.
(27) We conclude that the regional office clerks do not qualify as
support
staff to SPMP's. First, as we also concluded above with regard
to the
Case Records Coordinators, there is no evidence of direct support
to any
particular SPMP in the office. A general "pool" of clerical
worker
performing general office duties does not fulfill the definition
of support
staff to SPMP. The Manual clearly requires a "direct" and
"immediate"
relationship between the SPMP and particular support
personnel. (See
our discussion above on pp. 22-24.) As with the Case
Records Coordinators,
the State never attempted to explain how each of
the clerical staff supported
in a direct and immediate way the work of
one or more identifiable
SPMP's.
One factor which we find significant is that the Agency has
already
granted support staff status to the secretaries who worked directly
for
the physician administrators and SPMP consultants. The clerical
staff
in the offices appears to be a separate group who by their
nature
provided generalized services and thus did not provide "direct"
and
"immediate" support to the SPMP's.
The second flaw in the State's arguments regarding the clerical staff
was
that many of those whom the staff supported were not SPMP's. In
fact,
the only instance we could find in which a clerical staff member
appeared to
provide direct support to some particular group of personnel
was for the Case
Records Coordinators, whom the State argued were
support staff themselves,
rather than SPMP's. See State's Attachment
17-C, items 24, 27.
The State appeared to argue that, although the regional office
clerks
supported other personnel whom the State claimed to be support
staff
themselves, the clerks whould still be considered support staff
to
SPMP's since the "functional relationship is direct" to the
eventual
support of the SPMP's. State's Supplementary Material of July
17, 1986,
p. 10 (emphasis in original). First, insofar as the clerks
supported
the Case Records Coordinators and the Handicapper
Children's
Representatives, we have elsewhere in this decision concluded that
these
other positions were not support staff to SPMP's so we must reject
this
part of the State's argument.
Second, insofar as the clerks supported personnel properly
considered
support staff to SPMP's (such as the secretaries who worked
directly for
the specialist consultants), we conclude that such an indirect
line of
support to an SPMP is by its nature not "direct" and "immediate"
support
of an SPMP.
(28) The State cited Oregon Department of Human Resources, Decision
No.
729, March 20, 1986, for the proposition that personnel could
be
considered support staff even if they supported other personnel
who
themselves were support staff to SPMP's. The case does not stand
for
the proposition cited. Rather, in Oregon, the Board in
essence
concluded that the existence of a non-SPMP supervisor did not
preclude a
finding that clerical staff provided the type of direct and
immediate
support to SPMP's that qualified for 75% FFP. Id., pp.
31-32. The
Board then remanded the matter to determine what portion of
the
personnel costs for word processors, secretaries, and
clerical
specialists were allowable at 75%.
In the present case, for those situations in which the clerks
allegedly
supported a person who was support staff itself, the State made
no
allegation that there was simultaneous support to a particular
SPMP.
The State here has only alleged general support from the regional
office
clerks to the other personnel in the office.
VIII. Handicapper Children's Representatives
According to the State, the "prime responsibility" of the
Handicapper
Children's Representatives was to conduct the interview of
applicants
for program benefits. State's Opening Brief, p. 9.
When appropriate,
the Representatives will refer cases to the SPMP
consultants in the
offices for "appropriate follow through," State's
Attachment 17-D, item
17(2), presumably as an immediate follow-up to the
application
interview. The Representatives also appeared to provide a
miscellany of
functions other than the application interview; the PD
listed 19
particular functions performed in the position. State's
Attachment
17-D, item 17. The State described broadly the purpose of
the position
to "act as the program's eyes and ears in relating to the
families and
children the program serves." State's Opening Brief, p. 9.
Our major reason for rejecting the State's claim that the
Representatives
were support staff to SPMP's is again that the State was
unable to articulate
the particular SPMP or group of SPMP's the
Representatives allegedly
supported. On page 25 of its reply brief, the
State submitted that
"these positions perform functions supportive of
the SPMP team" (third
paragraph), that they "report to (Regional Office)
(Administrators)," and
that they are "obviously functional extensions of
the medical social work
consultants." (Fourth paragraph). /16/
(29) The State provided no further explanation of how
the
Representatives provided direct and immediate support to any of
these
positions, despite a specific question on this subject from the
Board.
See question 7 of Board's March 27, 1986 letter; Tape of April
30, 1986
Telephone Conference Call.
The lack of direct and immediate support to the SPMP's in the office
is
explained for us, as with the Case Records Coordinators discussed
above,
by the essentially independent duties of the Representatives.
The
Representatives appeared to provide "support" to the program only in
the
abstract sense of supporting the efforts of the whole program. As
we
concluded above with regard to the Case Records Coordinators, for
the
Board to accept the State's argument that such positions are
SPMP
support staff would render meaningless the regulations's and
Manual's
clear limitations in defining what personnel qualify for
enhanced
reimbursement. See discussion above on pp. 22-26. A
state could always
maintain that some position supports the SPMP's of an
office because the
efforts of the position benefit the functioning of an
office as a whole.
The State relied in its arguments upon West Virginia Department
of
Welfare, Decision No. 372, December 30, 1982, pp. 10-11, in which
the
Board found support staff status for "Social Service Worker
I"
positions. The State argued that the functions of the Social
Service
Worker I positions were similar to the Handicapper
Children's
Representatives in this case, in that both "(interacted) directly
with
clients in gathering medical information and (interacted) with
local
medical service providers." State's Reply Brief, p. 26.
However, we find that West Virginia is not precedent for the
present
appeal because of the procedural posture in that case. In
West
Virginia, the Agency specifically conceded that the Social
Service
Worker I position would qualify as support staff. As the State
has
recognized, the Board in its decision only "described generally"
the
functions of the Social Service Worker I positions, id., p. 26, and
did
not independently analyze whether these positions should be
considered
support staff, since this was admitted by the Agency. In the
present
appeal, by contract, the Agency has contested the categorization
of
Handicapper Children's Representatives as support staff and has
provided
strong arguments in support of its position.
IX. An Additional Argument of the State
The State argued that the Agency was being inconsistent in
the
disallowance action which led to this appeal, since the Agency
had
approved 75% reimbursement for all personnel in the(30)
Crippled
Children's program regional offices for the period 1973-1975.
See
State's Opening Brief, pp. 1-2; Reply Brief, pp. 4-7;
State's
Attachment 16, esp. p. 7.
We conclude that HCFA's determination regarding the Crippled
Children's
program in 1973-1975 should not affect our analysis. The
Manual
provisions we have relied upon here were issued in July 1975.
Even
assuming that HCFA was applying similar regulations and guidelines
in
the review of the program in 1982-1984 as it was in 1973-1975,
the
record does not demonstrate that the interrelationship of the
particular
positions and their functions in the program were identical for
the two
periods. The first Regional Office Administrator position was
only
created in 1979, see State's Reply Brief, p. 6, so the set-up of
the
offices could not have been identical. The State also submitted
that
"the responsibilities performed by the (program in the 1980's)
are
essentially the same as in the early 1970's." State's Reply Brief,
p.
5. Even so, this does not establish that all the personnel working
in
the regional offices responsible for administration of the program
were
SPMP or support.
In any event, based on a comprehensive record concerning the positions
at
issue, we have applied the regulations and Manual provisions which
govern 75%
reimbursement and have determined that the positions do not
qualify for
enhanced reimbursement. The State has not demonstrated as a
matter of
law why we should decide to the contrary simply because the
Agency may have
permitted 75% reimbursement for the regional offices ten
years earlier.
CONCLUSION
For the foregoing reasons, we uphold the Agency's disallowance in
full.
/1/ In paragraphs (1), (3),
(4), (5) and (6), section 1903(a)
sets the rate of FFP for other types of
expenditures for the
Medicaid
program. /2/
Regulations also repeat the statute's provision of
75% FFP for skilled
professional medical personnel and support staff to
such personnel and the
provision of 50% FFP for other general costs.
See (respectively) 42 CFR
432.50(b)(1), 42 CFR 433.15(b)(5); 42 CFR
432.50(b)(6), 42 CFR
433.15(b)(7). /3/ The State also
appeared
to initially claim SPMP status for an Office Manager in the Grand
Rapids
regional office (who was replaced during the period in dispute by one
of
the Regional Office Administrators referred to above), but the
State
clarified, during the course of the appeal, that it only claimed
support
staff status for this individual. See Tape of April 30, 1986
Telephone
Conference Call.
/4/ Grand Rapids was one of the offices for
which the incumbent was hired
directly to the Regional Office
Administrator position which required a
bachelor's degree. /5/ The
Agency objected during the telephone conference call that the
duties of this
Administrator may not be representative of those in the
other four regional
offices. The Agency's objection may be well-founded
insofar as the
State would logically choose an incumbent whose
qualifications and job duties
might be more professional and
medical-related than those in other regions.
However, since we uphold
the disallowance in this part of the decision based
on the assumption
that this Administrator was representative, we do not
consider whether
the Administrator who participated in the conference call
was in fact
more highly qualified than those in the other regions. /6/
The
incumbent in the Grand Rapids
office had previously worked for
the same office as a vision consultant, an
SPMP position which
apparently called for the incumbent's particular graduate
training. The
State did not argue that the training was a prerequisite for
the work as
a Regional Office Administrator. See Tape of April 30, 1986
Telephone
Conference Call.
/7/ The Medical Assistance Manual provides,
"State manuals of job
classifications are (a secondary) means for
substantiating that a position is
normal to the medical care field."
Part 2-41-20(B)(2)(b). The State did not
present any such manual to the
Board nor did the State claim that a State
manual explained the job
classifications listed on the PD's in the record of
this appeal.
/8/ The State also mentioned during the telephone conference
call that
the State "believed" the Regional Office Administrators who
were
upgraded from Office Managers were considered to be "professional"
by
the State Civil Service Commission since they were classified with
the
designation "VI" or "VII" on the PD's. (One of the incumbents
was
classified as "Department Supervisor" VI or VII (the copy is
difficult
to read) and the other as "Department Supervisor VII"). As we
also
discussed above, the significance of this alleged fact is called
into
question by the fact that the PD's are entirely inconsistent in
this
labeling: two of the other Regional Office Administrators are
labeled
"Public Health Administrator 12" and the other is labeled
"Department
Analyst VII." Furthermore, the written record presented by the
State
provides no corroboration that the State Civil Service
Commission
attached special significance to the symbols "VI" and "VII" on the
PD's,
despite the fact that the record includes extensive
documentation
explaining the upgrade of positions by the State Civil
Service
Commission. See State's Attachments III-VIII to its June 6,
1986
submission to Board. /9/
The State presented documentation to
verify when during the period in dispute
the Office Managers in the
Marquette and Pontiac regional offices were
upgraded to Regional Office
Administrator status. Since we conclude
that the Agency's disallowance
pertaining to both the Office Managers and the
Regional Office
Administrators should be upheld, we do not decide when the
upgrading
specifically
occurred. /10/ One of the
positions which the State
claims that the CRC's support is the Regional
Office Administrator,
which we have concluded above was not an SPMP.
While this may weaken
the State's claim of support staff status for the CRC's
we nonetheless
consider the State's arguments that the CRC's are support
staff to the
other personnel in the regional offices who are SPMP's and
conclude on
this basis that we would uphold the Agency's determination that
CRC's
are not eligible for 75% reimbursement. /11/ The Manual goes on
to
state a requirement that
support staff "be supervised by" SPMP.
The importance of a supervisory
relationship was downplayed in Action
Transmittal SRS-AT-76-66 (April 20,
1976) and our determinations here
are not based on the existence of a
supervisory relationship in the
typical
sense. /12/ Of course, if a
state were able to document
that a part of a person's duties were in support
of SPMP's and another
part of his other duties were not, the State would be
entitled to
enhanced reimbursement on that basis. See Manual,
part
2-41-20(B)(2)(d). /13/
The State provided a position description
of one incumbent for each of the
CRC, clerical staff, and Handicapper
Children's Representative
positions. See State's Attachments 17-B,
17-C, and 17-D. During
the April 30, 1986 telephone conference call,
both parties stipulated that
the Board could consider the position
descriptions as representative for each
of the three positions.
/14/ According to the State, the eligibility
determination functions of
the CRC's are not applicable for the "Title XIX
clients" (which are the
only relevant clients for our purposes), since these
clients are
automatically eligible for benefits. State's Opening Brief,
p. 8.
/15/ Furthermore, the functional flow charts for the regional offices
of
the Michigan Crippled Children's program do not demonstrate to us
any
direct association between the work of the CRC's and the duties of
any
particular SPMP. See Agency's Ex.
A. /16/ We have of
course
concluded above that the Regional Office Administrators were not
SPMP's.
APRIL 25, 1987