DEPARTMENTAL APPEALS BOARD
Department of Health and Human Services
SUBJECT: California Department of
DATE: April 23, 1990
Health Services Docket No. 89-156
Decision No. 1149
DECISION
The California Department of Health Services (California, DHS) appealed
a determination by the Health Care Financing Administration (HCFA)
disallowing $1,417,831 in federal financial participation (FFP) claimed
under Title XIX of the Social Security Act (Medicaid). HCFA's
disallowance was based on a review of administrative costs under four
interagency agreements between DHS and the California Department of
Social Services (DSS) for the fiscal year ending June 30, 1986. The
dispute concerns whether certain expenditures under the agreements were
properly claimed at the enhanced FFP rate of 75 percent available for
compensation and training of skilled professional medical personnel
(SPMP) or supporting staff or at the 50 percent rate available generally
for administrative costs. At issue here is HCFA's disallowance of the
portion of California's claim which exceeded the 50 percent rate. 1/
For the reasons explained more fully below, we conclude that California
is entitled to FFP only at the 50 percent rate for the disputed
expenditures. The State agency staff at issue were analysts and
clerical staff in the offices responsible for Medicaid disability
determi- nations. We find both that the analysts, who worked in
conjunction with SPMP, were professional adjudicators, not SPMP, and
that the clerical staff were not supporting staff for SPMP since their
functions did not have the requisite direct nexus with SPMP functions.
We also find that California is not entitled to enhanced reimbursement
for expenditures associated with disability determinations but which
were not for compensation, travel, or training of SPMP. Accordingly, we
uphold the disallowance in full.
Applicable law, regulations, and guidelines
Section 1903(a) of the Social Security Act (the Act) provides for
payment of:
(2) . . . 75 per centum of so much of the sums expended . . . (as
found necessary by the Secretary for the proper and efficient
administration of the State plan) as are attributable to
compensation or training of skilled professional medical personnel,
and staff directly supporting such personnel, of the State agency
or any other public agency . . . .
* * * *
(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. 2/
HCFA's implementing regulations, 42 C.F.R. 432.50(b)(1) and
433.15(b)(5), provide 75 percent FFP for SPMP and support staff.
Sections 432.50(b)(6) and 433.15(b)(7) implement the 50 percent matching
provision generally applicable to FFP claims for costs of
administration. 3/ Section 432.50(a) states generally for staffing and
training costs that:
FFP is available in expenditures for salary or other compensation,
fringe benefits, travel, per diem, and training, at rates
determined on the basis of the individual's position as specified
in paragraph (b) . . . .
Section 432.50(c)(1) provides that rates of FFP higher than 50 percent
"are applicable only to those portions of the individual's working time
that are devoted to the kinds of positions or duties that qualify for
those rates."
The terms "skilled professional medical personnel" and "staff
directly
supporting such personnel" are not defined in the Act. HCFA regulations
contain the following definitions at 42 C.F.R. 432.2:
"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 Medical
Assistance Manual (Manual), issued to state Medicaid agencies in an
Action Transmittal by the Social and Rehabilitation Service (predecessor
agency to HCFA) in July 1975, SRS-AT-75-50.
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 profes-
sional 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 responsibili- ty in the
administration of the title XIX medical assistance
program requiring medical subject area expertise.
"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 admin- istrative 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.
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.
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 "[j]ob announcements emphasizing requirements at or
above the college level in medical care and medical care
administration." Further, its listing in an "appropriate medical
classification" in a dictionary or handbook of occupational titles is a
secondary indicator that a position is a skilled medical position.
The determination of whether a 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.
Background
In a final report issued in March 1988, HCFA determined that California
had improperly made claims under some of the four interagency agreements
covered by the review. California Ex. 4 (Final Review Report). After
the final report was issued, HCFA modified the amount recommended for
disallowance based on follow-up action by California as well as later
expenditure data. California Ex. 9; see also California Exs. 5, 6, and
8 (these exhibits detail the follow-up action by California). Based on
these modified findings, HCFA disallowed $1,417,831. This amount is
broken out as follows: (1) $1,013,867 FFP-- the difference between
California's claim at 75 percent for SPMP and supporting staff and the
50 percent found allowable for certain state agency personnel costs; (2)
$381,449 FFP--the difference between California's claim at 75 percent
for expenditures for "consultative examinations," "medical evidence,"
and "claimant transportation" and the 50 percent found allowable on
the
basis that the expenditures were not for compensation, travel, or
training of SPMP or supporting staff; and (3) $22,515 FFP--an amount
claimed at 50 percent for expenditures not supported by accounting
records (as noted above, this amount is uncontested and therefore this
portion of the disallowance is upheld without discussion).
Under the interagency agreements, DSS was to provide disability
evaluation services, respond to program inquiries, conduct fair
hearings, and administer the Child Health and Disability
Prevention/Early and Periodic Screening, Diagnosis, and Treatment
(CHDP/EPSDT) programs for Medi-Cal recipients. HCFA found that "[t]he
DSS personnel who were designated as SPMP or support staff under the
Disability Evaluation Services and CHDP/EPSDT Administration contracts
generally did not meet Federal requirements for FFP at the 75 percent
rate." California Ex. 4, p. 10.
California's appeal concerned only personnel in the two State Programs
Bureaus (Oakland and Los Angeles) within the Disability Evaluation
Division. See California Notice of Appeal and Brief. Accordingly, the
disal- lowance of amounts pertaining to other personnel is upheld
without further discussion. See California Ex. 4, pp. 10-13, and Ex.
10, pp. 5-8. The disputed positions are Disability Evaluation Analysts
(DEA) and clerical staff in the support units of the State Programs
Bureaus. 4/
Also under the Disability Evaluation Services contract, HCFA determined
that California improperly claimed enhanced reimbursement for
expenditures for consultative examinations, medical evidence, and
claimant transportation ($381,449 of the amount disallowed). These
expenditures were related to obtaining data in connection with the State
Programs Bureaus' disability determination function.
Discussion
Before proceeding to consider whether the disputed expenditures
qualified for 75 percent reimbursement, we first briefly discuss the
nature of the question presented by this case. As the Board has noted
in prior cases, whether federal funding is available at all is not an
issue. Rather, the question presented is whether federal matching is
available at the 75 percent rate as opposed to the 50 percent rate
generally available for expenditures necessary for administration under
section 1903(a)(7) of the Act. The Act provides for enhanced FFP only
for expenditures for compensation, travel, and training for SPMP. In
this regard, where the record does not show that the Manual provisions
clearly include a disputed position's functions as SPMP, they are
excluded and appropriately matched only at 50 percent. As California
recognized here, the Board has held in analogous circumstances that
where a state is claiming reimbursement of costs at a rate higher than
50 percent, the State has the burden to show that the costs claimed are
entitled to the higher rate of reimbursement. California Brief, p. 5,
and cases cited therein. Below, we describe each category of disputed
expenditures and examine whether 75 percent FFP is available.
I. Expenditures for State Programs Bureau Personnel
A. Disability Evaluation Analysts
DSS described its disability determination function for purposes of this
appeal. California Ex. 11. State Programs Bureaus in the Oakland and
Los Angeles field offices of the Disability Evaluation Division process
cases referred from counties in order to determine eligibility under the
Medi-Cal Medically Needy Program. California explained that:
Disability determinations are made by an adjudicative team composed
of a specially trained disability evaluation analyst and duly
qualified medical consultant. Medical information and other data
is obtained for each claim. Determinations are made in accordance
with strict regulations.
* * * *
[DEAs] require the skill to understand, evaluate and apply medical
principles and information in making disability decisions. These
functions require the DEA to work closely with staff physicians
(medical consultants). California Ex. 11.
Both parties based their arguments on California's description of the
major responsibilities of the DEA:
1. Review the application and determine what medical evidence is
required to document the existence of a medical impairment.
Obtain medical evidence of record by way of letter request or
phone contact. The DEAs are required to discuss medical
conditions and issues with the treating physician in order to
get the required information.
2. In mental impairment cases, DEAs must obtain a description of
activities and behavior in support of medical reports to
evaluate these impairments. This requires direct contact with
the applicant.
3. Obtain vocation information from the applicant.
4. Initiate requests for consultant medical examinations when the
evidence of record is insufficient. Staff physicians review
and co-sign the requests.
5. Consult with staff physicians to resolve medical issues in a
claim and for evidence interpretation in complex claims.
6. Determine when the claim has adequate medical documentation and
is ready for staff physician review.
7. Use an outline of physical capacities (Residual Functional
Capacities) provided by the staff physician to prepare a
disability decision based on medical/vocational considerations.
8. As an evaluation team, the DEA and staff physician both sign
the decision document.
California Ex. 2 (same as HCFA Ex. 3); see also California Ex. 11. DEA
applicants must have a college degree and/or certain experience in the
disability evaluation process (or technical experience with "the medical
evaluation of . . . physical or mental functioning"--HCFA Ex. 2). See
California Ex. 11. The State itself provided a 13-19 week training
program. The record includes the agenda from a training program in the
Oakland Bureau given in 1985. The training included a lengthy reading
list and covered all body systems as well as the disability
determination process.
Both parties also relied on the descriptions of a DEA-type position
(called DDS Examiner) and of a Medical Consultant in sections 24501.001
and 24501.010 of the Program Operations Manual (a Social Security
Administration document). The Program Operations Manual described the
analyst as responsible for "case processing activities" and the medical
consultant as responsible for "professional medical activities."
California Ex. 11; HCFA Ex. 4.
The record contains a job description for the DEA series showing
positions at varying levels of responsibility and supervisory duties.
HCFA Ex. 2. 5/ The DEA position was described as follows:
Positions in these classes are involved in obtaining and analyzing
medical, personal and vocational information in the adjudication of
claims for disability . . . .
The "Knowledges and Abilities" section of the specification emphasizes,
depending upon the level of the position, skills or knowledge in
gathering and analyzing data, medical terminology, adjudication
techniques, administration, and supervision.
The organization charts in the record for the Oakland and Los Angeles
Bureaus both show a DEA bureau chief, two DEA specialists who work
directly for the bureau chiefs, and four adjudication units, primarily
comprised of DEAs. 6/ HCFA Exs. 6 and 7.
1. The DEA positions are not SPMP.
California contended that the DEA personnel were SPMP performing
"medically related" functions in a "medically oriented program,"
the
State Programs Bureau. California Brief, pp. 8 and 10. California
relied on the nature of the training provided to the DEAs and asserted
that the DEAs were required to be "familiar with medical terminology,
treatment, and effects of all types of medical conditions. . . . [and]
able to read medical reports and evaluate and analyze the information
contained therein." California Brief, p. 7. California also relied on
the "team" nature of the work with the medical consultants (staff
physicians), who were accepted as SPMP by HCFA, to make disability
determinations. California asserted that the DEAs were properly
classified as SPMP since they "apply administrative practices and
procedures related to the field of medicine working in conjunction with
staff physicians to make medical/vocational decisions on applicants
claiming medical disabilities." California Brief, p. 9. 7/
We look to the regulations and to the implementing Manual provisions in
order to determine whether 75 percent matching is available. The
definition of SPMP at 42 C.F.R. 432.2 specifically mentions personnel
such as physicians, nurses, and nursing home administrators. The
definition includes "other specialized personnel in the field of medical
care." Neither this regulation nor the Manual specifically mentions
positions responsible for adjudicating disability claims. The question
then is whether these positions would qualify for 75 percent matching
based on the general principles set forth in the Manual for the
assessment of SPMP status.
The positions require a college degree or its equivalent and clearly
require the exercise of judgment in a non- routine aspect of program
administration, so that there is no question that the DEAs are
professional as that term is used by the Manual. Furthermore, the DEA
personnel may have extensive knowledge of medical terminology and
conditions rendering applicants disabled for Medicaid purposes.
Nevertheless, there is no basis here for concluding that the DEAs are
personnel specialized in medical care. The weight of the evidence here
supports a conclusion that the positions are administrative only,
requiring the adjudication not medical evaluation of disability status.
The medical consultants' responsibilities include "[e]valuating medical
evidence," "[a]ssessing the severity of impairments," and "describing
the functional capacities or limitations imposed by impairments."
California Ex. 11, section 24501.010 of The Program Operations Manual.
The medical consultants, who are recognized as SPMP, clearly are the
team members who exercise the medical judgment involved in the
disability determination process. The DEA position is not properly
classified as SPMP simply due to a relationship to skilled professional
medical activities. As illustrated by the DEA job specification and the
description of the DDS examiner position (in California Exhibit 11), the
DEAs handle the case processing and adjudicative aspects of disability
determinations. Their exercise of judgment relies on the medical
expertise of the medical consultants.
California described these positions as "medically related." California
Brief, p. 10. What is required, however, is that a position require
"medical subject area expertise." Manual section 2-41-20(B)(2)(a).
SPMP
functions require "knowledge and skills gained from professional
training in a health science or allied field." Id. The DEA positions
do not require this. While the State relied on the extensive training
it provided to the personnel, what this training accomplished was an
understanding of how to use the determinations of the SPMP in making
disability determinations. The DEAs do not by virtue of this training
acquire the requisite medical expertise for SPMP status. Rather, the
record shows that the positions utilize medical data and evaluations in
an administra- tive, adjudicatory capacity. The DEAs do not themselves
make medical judgments; rather, they evaluate the status of an
individual in light of criteria for disability, based on medical
judgments made by others.
Under the Manual provisions, the function of a position determines its
status. Evidence that a position is properly classified as SPMP can be
obtained from job descriptions and organization charts. The DEA job
specification illustrates why these are not SPMP positions. HCFA Ex. 2.
As we described above, neither the education nor the skills referenced
in the job specification are medical as required by the Manual.
The organization charts for the State Program Bureaus show only that the
professional units of the bureaus are only DEAs and medical consultants.
HCFA Exs. 6 and 7. There is no reason from the organization charts to
accord SPMP status to the DEAs. In fact, these charts only undercut
California's position to some extent since, when a state claims an
entire office as SPMP, that claim is inherently suspect. See California
Dept. of Health Services, DAB No. 646 (1985). 8/ Also, the record does
not reference any listing for this type of position in a dictionary or
handbook of occupational titles under "an appropriate medical
classification." Manual section 2-41-20(B)(2)(b).
In concluding that the positions are not SPMP, we do not diminish their
importance. It is clear under the Manual provisions, however, that
professional, administrative positions in the Medicaid program are not,
in general, SPMP. The DEAs function as professional adjudicators, not
SPMP. Accordingly, these positions are properly matched at 50 percent
as opposed to 75 percent FFP.
2. The DEA positions are not support staff for SPMP.
California argued in the alternative that the DEA positions would
qualify for 75 percent reimbursement as supporting staff for the medical
consultants. California relied on section 432.2 of 42 C.F.R. and argued
that the DEAs were supporting staff "whose activities were directly
necessary to the carrying out of the functions which are the
responsibility of SPMP." California argued that without the DEAs it
would have to hire more medical doctors to perform the disability
determination functions of the DEAs. California Brief, pp. 10 and 11.
As HCFA argued here, and as the Board held in Oregon Dept. of Human
Resources, DAB No. 729 (1986), professional positions are per se
precluded from being categorized as SPMP support positions. The
regulation on which the State relied defined supporting staff as
"secretarial, stenographic, clerical and other subprofessional staff."
42 C.F.R. 432.2 (1985). "Subprofessional staff" are "persons
performing
tasks that demand little or no formal education; a high school diploma;
or less than 4 years of college." Id. Since, as we found above, these
DEA positions are clearly professional, performing non-routine tasks in
the administration of the Medicaid program, they cannot qualify for 75
percent FFP as support personnel.
Accordingly, we conclude that there is absolutely no merit to
California's contention that the DEA positions qualify for enhanced
reimbursement as supporting staff.
B. Clerical Staff
HCFA found in its review report that the clerical unit staff in the Los
Angeles and Oakland State Programs Bureaus did not qualify for 75
percent FFP as supporting staff for SPMP. Each bureau has an Office
Services Supervisor responsible for four clerical units. Each unit is
also under the direct supervision of another clerical supervisor,
generally a lower level Office Services Supervisor (one unit in each
bureau is supervised by a Senior Word Processing Technician). Most
clerical personnel are either Office Assistants or Word Processing
Technicians. Relying on the organization charts, the review report
stated that:
The Clerical staff in the various support staff units described
above were not supervised by and did not function in direct support
of, the Medical Consultants [the only positions in the State
Programs Bureau HCFA found to be SPMP]. As a result, those
positions . . . did not qualify for enhanced FFP . . . .
California Ex. 4, p. 11. California described the functions of the
clerical units as follows:
Consultative Exam Unit Personnel--This unit prepares authorizations
and schedules consultative medical examinations per the requests of
staff physicians and DEAs.
Word Processing Unit--This unit prepares all letters to medical
treating sources requesting medical evidence of record. The unit
also prepares and types medical/vocational rationales and
decisions. Medical Transcribers transcribe medical reports that
are phoned in over a remote telephone diction [sic] system.
Case Processing Unit--This unit provides direct clerical support to
staff physicians and DEAs.
Administrative Services Unit--This unit performs functions in
direct support of Bureau operations. Functions include consultative
exam auditing, personnel control, and transactions, mailing
disability cases and letters and administrative clerical support.
California Ex. 2 and HCFA Ex. 3.
The record contains a California State Personnel Board job specification
for the Office Services Supervisor (various classes) position. HCFA Ex.
8. The specification states:
This consolidated series specification describes three levels of
classes that train, plan, organize, and direct a staff of clerical
employees who perform a variety of general office and related
clerical support tasks, including functions as typing, stenography,
filing, accounting, cashiering, statistics and others.
The State did not assert that the units in question were supervised by
SPMP and did not indicate that this specification was not accurate for
these positions.
California asserted only that these clerical units were necessary for
the SPMP to carry out their functions and reiterated its view that the
DEAs were also SPMP. In asserting that the clerical staff units
qualified for enhanced reimbursement, California simply relied on the
general requirements for 75 percent reimbursement applicable during the
period at issue. California Brief, p. 12.
We note at the outset that California's blanket claim that its entire
clerical staff in the State Programs Bureaus were "directly supporting
staff" is subject to close scrutiny. Manual section 2-41-20(B)(1)(b);
California Dept. of Health Services, DAB No. 646 (1985). Entitlement to
enhanced reimbursement for supporting staff depends on a direct nexus
with SPMP functions. California has presented only the most brief and
general descriptions of the personnel at issue. As we explain below,
there is no basis in this record to substantiate enhanced reimbursement
for all the clerical personnel in the two bureaus.
The regulations define "supporting staff" as staff "whose activities
are
directly necessary to the carrying out of the functions" of SPMP. 42
C.F.R. 432.2. The Manual states that such staff are in positions whose
work assignments are related in an immediate way to the direct
completion of SPMP work. Manual section 2-41-20(B)(2)(c). In that
regard, supporting staff positions report to and are supervised directly
by SPMP. While supporting staff can be supervised in a personnel
reporting sense by someone other than an SPMP, supporting staff must
nevertheless perform work, under the substantive direction of SPMP,
which directly supports SPMP functions. See New Jersey Dept. of Human
Services, DAB No. 845 (1987).
California clearly recognized that it had the burden to establish that
the disputed positions qualified for enhanced reimbursement. The meager
descriptions provided for the clerical units are simply inadequate to
meet this burden. While the Case Processing Unit is described as
providing direct clerical support, there is nothing in the record to
show what that conclusory statement means. Neither the organization
charts nor the California job specification for the clerical supervisor
provides evidence linking specific clerical functions to SPMP functions.
Review of the organization charts shows that the clerical units are
wholly separate from the adjudication units where the medical
consultants are located.
The record contains no information about specific work assignments
initiated by SPMP in an SPMP role the completion of which SPMP directly
supervised. This is the standard which must be met. As the Board
previously observed:
To use a lesser standard would lead to the conclusion that almost
any function performed by an employee . . . would qualify for 75%
FFP, and the limited exception to the routine 50% FFP for
administrative expenditures would be rendered meaningless.
DAB No. 646, p. 5.
Here, we can only speculate that the medical consultants (SPMP) might
require some supporting staff functions. Speculation is not sufficient.
California has provided no basis in this record for a finding about the
extent to which clerical costs might be allocable to any support staff
functions with the "immediate" and "direct" nexus that is
required for
75 percent FFP. Accordingly, we conclude that there is no basis for FFP
at the enhanced 75 percent rate for the State Programs Bureaus' clerical
staff.
II. Expenditures for Consultative Examinations, Medical Evidence, and
Claimant Transportation
California claimed 75 percent FFP for expenditures for consultative
examinations, medical evidence, and claimant transportation. These
expenditures were incurred in connection with the disability
determination function of the State Programs Bureaus. HCFA found that
California had erroneously claimed 75 percent FFP by improperly
combining these expenditures with its expenditures for personal
services, travel, and training. California Ex. 4, p. 14.
Consultative examinations are professional assessments of an applicant's
condition and health based on a current physical examination by a
licensed specialist. 9/ Expenditures for medical evidence were for
professional assessments of the applicant's condition and health based
on current and historical treatment records. California claimed that
whether medical evidence is obtained from a hospital, physician, or
other medical practitioner, an "SPMP" provides an assessment of
diagnosis, etc. California further stated that transportation costs for
applicants or those providing the medical examinations are integral to
performance of necessary medical examinations. California Ex. 3;
California Brief, pp. 12 and 13.
In support of its claim for these expenditures at the enhanced 75
percent rate, California asserted that "the 42 C.F.R. 432.50(b)(1)
syntax (placement of the comma) enables this provision to be interpreted
to include all services performed by SPMP to support the evaluation of
the applicant's disability." California Brief, p. 13. California also
argued that there is no requirement that SPMPs be employees of the
Medicaid Agency.
Suffice it to say that there is absolutely no basis for California's
claim for enhanced reimbursement for the expenditures in question here.
California has misapplied the regulations and shown a woeful lack of
understanding of the overall purpose for the enhanced SPMP rate. The
enhanced rate was intended to encourage the states to "retain and
augment" skilled professional medical staff to administer the Medicaid
program. Manual section 2-41-20(A). The statute is implemented in the
part of the regulation setting requirements for state personnel
administration. 42 C.F.R. Part 432. These regulations pertain to
direct staff of a state's Medicaid agency (here DHS) or staff employed
by other public agencies (such as DSS) "whose duties are directly
related to administration of the Medicaid program" (42 C.F.R. 432.2).
SPMP is a term of art which by statute describes specialized personnel
engaged in administering the medical aspects of the Medicaid program.
Those providing medical assessments were not staff of the Medicaid
agency or of another public agency engaged in Medicaid program
administration, which SPMP must be. 42 C.F.R. 432.50(b)(1). A
physician, hospital, or other practitioner that provides a medical
assessment of a disability applicant is not a SPMP engaged in the
administration of the California Medicaid plan. The mere fact that
these individuals provide information that is integral to program
administration does not mean that their activities constitute program
administration.
Moreover, California does not specify what about the comma placement in
the regulation supports its position. California cited 42 C.F.R.
432.50(b)(1) as follows:
(b) Rates of FFP. (1) for skilled professional medical
personnel and supporting, [sic] staff of the Medicaid agency . . .,
the rate is 75 percent.
California Brief, p. 3. We find no basis in the syntax of the
regulation at 42 C.F.R. 432.50(b)(1) to support enhanced reimbursement
for expenditures other than those for salary or other compensation,
fringe benefits, travel, per diem, or training for SPMP or supporting
staff engaged in the administration of the Medicaid program. 42 C.F.R.
432.50(a) and (b)(1).
Accordingly, we conclude that expenditures for medical assessments and
transportation related to medical examinations for applicants do not
qualify for 75 percent FFP.
Conclusion
For the reasons explained above, we uphold the disallowance in full.
_____________________________ Judith A.
Ballard
_____________________________ Norval D. (John)
Settle
_____________________________ Cecilia Sparks
Ford Presiding Board Member
1. The record reflects that $22,515 of the FFP disallowed was claimed
at the 50 percent rate but found by HCFA not to be supported by
accounting records. California Exhibits (Exs.) 9 and 10. California did
not provide documentation to dispute HCFA's finding. Accordingly, we
uphold this portion of the disallowance without further discussion.
2. 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.
3. The applicable regulations are set forth in the 1985 C.F.R.
codification. Final regulations amending the requirements for SPMP at
the 75 percent rate were published at 50 Fed. Reg. 46663 (1985) and
effective on February 10, 1986. The amendments substantially narrowed
the availability of FFP for SPMP positions. See Montana Dept. of Social
and Rehabilitation Services, DAB No. 1024 (1989), p. 12; Oregon Dept. of
Human Resources, DAB No. 729 (1986), pp. 9-10. HCFA chose to deem
these amended requirements effective as of July 1, 1986. HCFA Ex. 1.
The prior regulations and implementing Manual provisions cited in this
decision thus apply to govern the FFP rate properly paid for the
expenditures at issue.
4. HCFA had examined 141 positions and found that 128 did not qualify
for enhanced reimbursement as SPMP or supporting staff. Based on data
from the State, HCFA allowed a portion of the FFP claimed at 75 percent
for each of the 13 SPMP positions; this is reflected in the final
disallowance amount of $1,013,867. HCFA Ex. 9; see also 42 C.F.R.
432.50(c)(1).
5. This exhibit is a California State Personnel Board job
specification for DEAs performing disability determinations under Titles
II and XVI of the Social Security Act. California did not assert that
the specification was different for the actual positions at issue.
6. In the Oakland bureau, one adjudication unit has seven medical
consultants and the other three have none. In the Los Angeles bureau,
each adjudication unit has at least one medical consultant. California
did not assert that this made a difference in assessing the SPMP status
of the DEAs.
7. California did not allege that distinctions ought to be made based
on whether a DEA position was at an analyst, specialist, or supervisory
level. Thus, we treat the position functions generally, not
distinguishing based on type within the job series.
8. We regard these positions as somewhat analogous to the positions
considered in New Jersey Dept. of Human Services, DAB No. 688 (1985).
There we found that positions responsible for third-party liability
recoveries, exclusion of providers from the program, and recovery of
overpayments or statutory penalties were not SPMP. The positions at
issue in DAB No. 688 also required knowledge of medical terminology and
involved interaction with medical consultants.
9. California erroneously described the examining physicians as SPMP,
but, as explained below, they could not so qualify.