Opinion ID: 4514777
Heading Depth: 3
Heading Rank: 1

Heading: Attachment 4.19-A, Section IV, Subsection G

Text: ¶53. The Plan, in Attachment 4.19-A, Section IV, subsection G, entitled “Request for Rate Change-For Rate Years Prior to October 1, 2005,” reads, A hospital may at times offer to the public new or expanded services, purchase equipment, drop such services, or retire equipment which requires Certificate of Need (CON) approval. Within thirty (30) days of implementing a CON approved change, the hospital must submit to the Division an allocation of the approved amount to the Medicaid Program. This amount must be separated as applicable between capital costs, educational costs and operating costs. An estimate of any increase or decrease in operating costs applicable to the Medicaid Program due to the change, as well as the effective date of the change will also be submitted. Such amounts will be subject to desk review and audit by the Division. Allowance for such changes shall be made to the hospital’s Medicaid Prospective rate as provided elsewhere in this plan. Failure to submit such required information within thirty (30) days will be a basis for disallowance of all expenses associated with the change. Overpayments as a result of the difference between estimates and actual costs shall be refunded to the Division of Medicaid. (Emphasis added.) 25 ¶54. At the hearing, CMMC offered evidence that the DOM had expressly agreed that, “in accordance with” this provision, the DOM required CMMC “to provide DOM with an Amended [Medicaid] Cost Report.” The DOM further acknowledged that the “DOM accepted the Amended [Medicaid] Cost Report with this approach [exclusion of North Campus costs and patient days] for the estimate required by Section G.” Despite this provision and this admission, the DOM now claims that it is bound by the Medicare NPR, which was a review of CMMC’s Medicare—not Medicaid—cost report. This was contradicted by the DOM’s concession that CMMC’s prospective rate was in fact set based upon the amended Medicaid cost report as required by Section IV, subsection G, of Attachment 4.19-A. ¶55. In addition, subsection G does not require CMMC to appeal the Medicare NPR as a prerequisite to appeal an erroneous rate calculation by the DOM. Instead, subsection G establishes that the DOM is responsible for preparing the “estimate of any increase or decrease in operating costs applicable to the Medicaid Program due to the change,” with “[s]uch amounts . . . subject to desk review and audit by the Division.” This provision establishes that the DOM, not Medicare, is responsible for correctly setting CMMC’s Medicaid reimbursement rate. Subsection G does not transfer this authority to the federal Medicare agency, CMS, or its intermediary.