DEPARTMENTAL APPEALS BOARD
Department of Health and Human Services
SUBJECT: New York State
DATE: January 24, 1990
Department of Social Services Docket No. 89-252
Decision No. 1128
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
$2,664,557 claimed under title XIX of the Social Security Act for the
quarter ended September 30, 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. 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. Some of the cases involved individuals who were eligible for
Medicaid on the basis of disability, while other cases involved
individuals who were eligible for Medicaid on some other basis.
Proceedings concerning the non- disability-based claims are currently
pending before the Board. However, the State requested a summary
decision upholding the disallowance of the 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. 1052 (1989); New York State
Dept. of Social Services, DAB No. 1102 (1989); and New York State Dept.
of Social Services, DAB No. 1114 (1989).
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
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 Settle dated 1/17/90.
Conclusion
Accordingly, based on the analysis in DAB No. 1012, we uphold the
disallowance 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.
________________________ Donald F. Garrett
________________________ Alexander G. Teitz
________________________ Norval D. (John)
Settle Presiding Board Member
1. In some related cases now pending before the Board, 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