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PETITIONER CARE FACILITY WAS ENTITLED TO THE UNDERLYING DATA USED BY THE OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES TO CALCULATE MEDICAID REIMBURSEMENT RATES; MATTER REMITTED FOR RECALCULATION WITH AN EXPLANATION OF THE FACTORS CONSIDERED (THIRD DEPT). ​

The Third Department, reversing the Office for People with Developmental Disabilities, determined petitioner care facility was entitled to the underlying data used by the respondent to calculate the Medicaid reimbursement rate:

… [P]etitioner contends that the acuity factor utilized by respondents in calculating its rate determination is not transparent or verifiable, and that respondents’ refusal to disclose the data necessary to identify the factors in the regression analysis render the rate determination arbitrary and capricious. We agree. * * * The statutes demand empirical data in order to confirm the mathematical validity of the formula produced by the regression analysis in determining these rates, not simply blind reliance on an unknowable formula … .

Moreover, respondents’ wholehearted reliance on the consultant’s regression analysis, without confirmation of empirical data supporting the analysis, is inconsistent with the statutory scheme pertaining to state and federal statutes which require that the methodologies underlying the establishment of the rates and the justification for the rates be provided to petitioner (see 42 USC § 1396a [a] [13] [A]; Public Health Law § 2807 [3]). * * *

[R]espondents are directed to recalculate petitioner’s 2017-2018 and 2020-2021 reimbursement rates with appropriate explanation of the factors considered. Matter of Richmond Children’s Ctr., Inc. v Delaney, 2024 NY Slip Op 06406, Third Dept 12-19-24

Practice Point: Care facilities paid by Medicaid through the Office for People with Developmental Disabilities are entitled to an explanation of the factors considered in calculating the Medicaid reimbursement rate.

 

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