Opinion ID: 2052163
Heading Depth: 2
Heading Rank: 3

Heading: Suzman's Need for PCA Services

Text: [¶ 13] DHHS contracts with Alpha One, a private entity that provides managerial medical services to assess and review consumers' needs for PCA services. In September 2001, the Commissioner found that Suzman was eligible for ninety-one hours of daytime and fourteen hours of nighttime PCA services on a weekly basis. [6] In December 2001, Alpha One reassessed Suzman's needs pursuant to a DHHS rule requiring that waiver program participants be assessed on a periodic basis. See 14 C.M.R. 10 144 101-253, -254 § 22.07-1 (2001). Alpha One determined that Suzman required seventy-four hours of daytime and fourteen hours of nighttime PCA services per week. Alpha One further determined that the seventy-four daytime hours should be reduced to sixty-three hours based on the application of the 90% rule. Pursuant to Alpha One's reassessment and application of the 90% rule, DHHS reduced Suzman's daytime PCA services to sixty-three hours. [¶ 14] Suzman sought administrative review of the reduction of his PCA services. Suzman appeared with counsel at the administrative hearing. Appearing for DHHS was the Alpha One specialist, who testified about the Alpha One assessment. No documentary evidence was offered by DHHS. Suzman testified and offered several documents into evidence, including copies of letters between the Commissioner and CMS [7] concerning the Medicaid waiver program. Thereafter, the hearing officer issued a recommended decision. [8] [¶ 15] The hearing officer recommended that Suzman's daytime PCA services be reduced to sixty-three and one-half hours. The hearing officer's factual findings demonstrate the following calculations based upon the testimony of the Alpha One assessor. The hearing officer found that the average monthly cost of care in a nursing facility was $3898.50 and that 90% of that amount was $3508.65. In other words, the monthly 90% cap was $3508.65. The hearing officer found that the cost of fourteen hours of nighttime services was $624.39 per month and that the Alpha One monthly management fee was $47.38. The hearing officer then deducted the total of the nighttime care and the management fee from $3508.65 (the monthly 90% cap) and arrived at $2823.43. Next, the hearing officer divided $2823.43 by $10.30, the hourly cost of PCA services, for a total of 275 hours per month or sixty-three and one-half hours per week. [¶ 16] The DHHS Commissioner ultimately adopted the hearing officer's recommendation of sixty-three and one-half daytime PCA hours per week. Suzman appealed the Commissioner's decision to the Superior Court, which affirmed the decision.