Department of Health and Human Services
DEPARTMENTAL APPEALS BOARD
Appellate Division
SUBJECT: Missouri Department of
DATE: August 29, 1990
Social Services Docket No. 89-263
Decision No. 1189
DECISION
I. Introduction
The Missouri Department of Social Services (State) appealed a
disallowance by the Health Care Financing Administration (HCFA) of
$347,307 in federal funding claimed for Medicaid services under Title
XIX of the Social Security Act (Act). The disallowance was for the
federal share of amounts paid to Maple Lawn Nursing Home (Maple Lawn)
for long-term care during the period July 1, 1984 through June 30, 1989.
HCFA determined that Missouri had violated its state plan by granting
Maple Lawn two different types of rate increases. First, during Maple
Lawn's first year of operation, the State granted it negotiated trend
factor increases to compensate it for inflation. Second, after Maple
Lawn's first year, the State granted it a rate increase to compensate it
for its costs as a newly built facility.
The State argued that the trend factor increase did not violate the
state plan and was consistent with its practice in administering the
state plan. In addition, the State argued that the rate increase at the
end of Maple Lawn's first year also did not violate the state plan and
constituted a reasonable settlement of a disputed claim.
Our conclusion is in two parts. We conclude that the State was entitled
to grant Maple Lawn negotiated trend factor increases during its first
year of operation and therefore we reverse this portion of the
disallowance. Additionally, we conclude that State was not entitled to
grant Maple Lawn a rate increase at the end of its first year of
operation and we therefore uphold this portion of the disallowance.
II. Summary of Case
A. Summary of the Law
In order to qualify for federal funding, a state's claim for the cost of
medical services must be in accordance with an approved Medicaid state
plan. Section 1903 of the Act. The plan must fulfill certain statutory
and regulatory requirements, and be approved by the Secretary.
Prior to 1980, states were required under section 1902(a)(13) of the Act
to reimburse long-term care facility services at rates determined on a
"reasonable cost-related" basis, using methods and standards approved
by
the Secretary. In 1980, Congress amended this section to require that
state plans provide for payment of such services
through the use of rates (determined in accordance with methods and
standards developed by the State . . . ) which the State finds,
and makes assurances satisfactory to the Secretary, are reasonable
and adequate to meet the costs which must be incurred by
efficiently and economically operated facilities. . . .
Section 962 of Public Law 96-499, the Omnibus Reconciliation Act of
1980. This provision, known as the "Boren Amendment," was intended
to
provide the states greater flexibility in developing methods of provider
reimbursement. 1/ The legislative history indicates that Congress
intended to keep requirements on states to the minimum level necessary
to assure accountability, and not to burden state with unnecessary
paperwork requirements. 48 Fed. Reg. 56047 (1983), citing S.REP. No.
96-471.
Under the Boren Amendment, states have flexibility to develop
reimbursement methods and state plans will be approved so long as the
state provides the requisite assurances. While the Boren Amendment did
not give states flexibility to ignore the methods set out in a state
plan, the shift in emphasis under the Boren Amendment requires that
greater weight be given to what the state intended, since HCFA will
approve a state's proposed methods as long as a state has made the
requisite assurances. See South Dakota Dept. of Social Services, DAB
No. 934 (1988).
Pursuant to the Boren Amendment, Missouri restructured its reimbursement
system from a retrospective basis to a prospective basis. 2/ See
AGI-Bloomfield, supra, 299. Under the retrospective system, a facility
received payments during a fiscal year on the basis of an estimated
per-diem rate. At the conclusion of the year, costs were reported to
the Department and the rate could be increased retroactively to reflect
all allowable costs incurred throughout the preceding year. Id. at 298.
Under the prospective system, a facility is assigned a rate and receives
"negotiated trend factor" increases to compensate it for inflation.
13
CSR 40-81.081(4)(A)1. At the end of the year, if the facility's
allowable costs have exceeded its per-diem rate, there is no provision
for rate adjustment and the facility does not receive retrospective
payments or a prospective rate increase. The facility may obtain a rate
increase only under certain delineated conditions. 13 CSR
40-81.081(4)(A)2 and (7)(B)1.
Under Missouri's prospective system, a facility's current rate is its
rate on June 30 of the preceding state fiscal year adjusted by a
negotiated trend factor. 13 CSR 40- 81.081(4)(A)1.A. This dispute
involves calculation of rates for Maple Lawn, a newly constructed
facility which had no historical data on which to base the rate in its
first year of operation.
B. Summary of Facts
Maple Lawn was certified as a Medicaid provider on May 9, 1984. Ex. 1,
p 2. Maple Lawn was assigned a tentative per diem rate of $37.05. Id.
Based on its projected budgeted cost report for the eight-month period
April 1, 1984 through December 31, 1984, it was subsequently assigned an
initial prospective rate of $37.29 to be effective May 9, 1984. Id. As
of July 1, 1984, it received a $1.00 trend factor increase (Id.) and as
of January 1, 1985 it received an additional $.35 trend factor increase.
Ex. 2. Consequently, at the end of its first year, Maple Lawn's
per-diem rate was $38.64 ($37.29 + $1.00 + $.35). In July 1985 it
received a trend factor increase of $1.56 bringing the rate to $40.20.
HCFA disallowed the trend factors awarded to Maple Lawn during its first
year of operation. Disallowance Letter, p. 3.
In March of 1986, the State compared Maple Lawn's "initial prospective
rate" to its actual historical costs for its initial year of operation
(May 1984 through April 1985). Ex. D. The rate reconsideration work
sheet shows that Maple Lawn had "reported cost" of $48.19. The State
disallowed some of these costs and determined that Maple Lawn had an
adjusted allowable cost of $42.63. 3/ Id. Since its adjusted allowable
cost exceeded its per-diem rate, the State decided that Maple Lawn's
1985-1986 rate should remain at $40.20. Id.; Ex. C, p. 3.
Maple Lawn filed a complaint before the Missouri Administrative Hearing
Commission challenging the State's refusal to increase its prospective
Medicaid rate. Ex. E. In November 1986, Maple Lawn and the State
entered into a settlement by adopting the following rate schedule:
May 9, 1985 to June 30, 1985 $42.63 July 1, 1985 to June
30, 1986 $44.27 July 1, 1986 to present $45.09
The settlement agreement states that the rates would "reimburse the
facility for its costs as a newly built facility and result in
reasonable prospective reimbursement to allow operation of the facility
in an efficient and economic manner." Ex. F, p. 1. The Agency
disallowed the additional amount added by the settlement agreement to
Maple Lawn's rate.
III. Analysis
This case presents two issues. The first issue involves whether the
State was entitled under the state plan to grant negotiated trend factor
increases during Maple Lawn's first year of operation. The second issue
involves whether the State was entitled under the state plan to increase
Maple Lawn's initial prospective rate after its first year of operation.
A. Trend Factor Increases During the First Year of Operation
HCFA argued that the language of the plan precluded trend factor
increases to Maple Lawn, a newly constructed provider, and that awarding
such increases to Maple Lawn compensated it twice for inflation. The
State argued that the plan authorized trend increases for all providers
and that it had consistently provided such increase to all providers.
Further, the State asserted that in reviewing new providers' budgets and
setting initial prospective rates, it was aware that the new providers
would also receive trend increases during their first year. Ex. J, pp.
71-72.
In South Dakota Dept. of Social Services, supra, the Board set forth the
principles it uses in determining whether to defer to a state's
interpretation of its plan. First the Board looks to the language of the
plan. If the language is ambiguous, it looks to whether the state's
interpretation gives reasonable effect to the language of the plan as a
whole. In considering the state's explanation of intent, the Board
considers whether it is reasonable in light of the purpose of the
provision and program requirements. The Board may also consider
consistent administrative practice as evidence of intent.
While the language of Missouri's plan is complex and susceptible to more
than one interpretation, we find that Missouri's interpretation is
entitled to deference for the following reasons:
o Missouri's interpretation is reasonable in light of both the
language and the organization of the plan.
o Missouri's interpretation is supported by its contemporaneous
administrative practice.
o There is no evidence that Missouri's interpretation and practice
resulted in providers' receiving a double inflationary factor for
this period.
o Missouri's interpretation is consistent with the purpose of its
prospective reimbursement methodology.
Below we discuss each of these factors.
1. The Language of the Plan
Missouri's interpretation is supported by the language of the 1983 plan.
The primary portions of the plan involved in this dispute are sections
(4) and (7). Section (4) dealt with prospective rates for existing
providers and provided negotiated trend factors as part of the rate
setting methodology. Section (7) dealt with prospective rates for newly
constructed providers. HCFA argued that section (7) did not authorize
trend factors, and that section (4), which did authorize trend factors,
did not apply to newly constructed providers.
We disagree. We find that while section (7) did not specifically set
forth trend factor formulas for newly constructed providers, it
implicitly recognized that such providers would receive trend increases.
Section (7) required a newly constructed provider to submit a budget and
other documentation justifying its rate request to the medical services
section of the Department which forwarded the information to its
Advisory Committee. 13 CSR 40-81.081(7)(F)1.A. The Committee made a
recommendation to the Director, who set the initial prospective rate.
13 CSR 40-81.081(7)(E). Section 40- 81.081(7)(F)1.A implicitly
recognized that a newly constructed provider would receive an allowance
for inflation such as a trend factor increase. It read:
New Construction must apply for rate adjustment to the department
for consideration by the advisory committee. . . . Until such time
as the final decision is rendered, the per-diem rate shall be that
rate granted to the new construction by the medical services
section for that period less any allowance for inflation and in no
case greater than the class ceiling in effect on June 1, 1981,
adjusted by the negotiated trend factor. (Emphasis Supplied.)
While a new provider would not receive trend increases pending its
initial prospective rate, the quoted provision contemplated that a newly
constructed provider would be entitled to trend increases once its
initial prospective rate was set, and that this entitlement included
increases which came due while it was waiting for its initial
prospective rate. Further, the reference in Section 40-81.081(7)(F)1.A
to a class ceiling adjusted by the negotiated trend factors further
supports the conclusion that trend factors were contemplated. The
initial prospective rate provided by section (7) for newly constructed
facilities could remain in synchrony with a ceiling routinely adjusted
by trend factors only if the rate itself were adjusted by trend factors
over time. Moreover, as we discuss below, an inflation allowance is an
essential element of the State's prospective rate system, and it would
be unreasonable to read the State plan as a whole, and section (7) in
particular, as never authorizing an allowance for inflation for newly
constructed providers. 4/
HCFA relied on section (4) as primary support for its position that
trend factor increases were not authorized for newly constructed
providers. Section (4) sets out the specific methodology for
prospective reimbursement rate computation and includes, among other
things, the formula for negotiated trend factors. An introductory
provision in section (4) states that the section applies to providers
participating in the program prior to June 30, 1982. Even though
section (4) as a whole applies to the pre-existing providers, the
section does not preclude the use of elements of the rate methodology
set out in the section for newly constructed providers if other sections
authorize use of those elements. Since, as we found above, section (7)
implicitly authorized the use of an inflation allowance for newly
constructed providers, we conclude that section (4) need not be viewed
as an outright bar for such allowances as HCFA argued. 5/
The primary problem with HCFA's restrictive construction of section (4)
is that it precludes trend factor increases for all post-1982 providers
even after their first year, and thereby makes Missouri's plan
dysfunctional. Absent grounds for an extraordinary rate increase,
post-1982 providers would be stuck in perpetuity at their original rate.
This in turn would make it unfeasible for new providers to ever join the
program. HCFA implicitly recognized the unreasonable effects of its
construction because it did not contest Maple Lawn's entitlement to
trend factors after its first year. Ex. J, p. 69. There is simply no
basis in the language of the plan, however, for finding that the plan
authorized trend factors for subsequent rate years for newly constructed
providers, but not for the initial rate year.
In summary, we find that sections (4) and (7) of the plan recognize two
different methods of setting the original rate for pre-1982 and
post-1982 providers and the State reasonably interpreted the language of
these two sections to apply trend factors as the mechanism to compensate
both types of providers for inflation. 6/
2. Consistent Contemporaneous Practice
We also defer to Missouri's interpretation here because it was supported
by the State's consistent contemporaneous practice. In its comments to
the audit, the State represented that it "had consistently interpreted
the Plan to require that the trend factor be applied to adjust the rates
of new facilities." 7/ Ex. 8, p. 7. The record demonstrates that the
State routinely awarded trend factors to new providers in their first
year and that Maple Lawn's trend factor increases reflected state policy
and not a rate calculation anomaly. See Ex. C. 8/
3. No Evidence of Double Compensation
Further, there is no evidence that Missouri's interpretation and
practice resulted in newly constructed providers' receiving a double
inflationary factor during their first year. HCFA had assumed that both
the providers' proposed budgets and the initial prospective rates based
on the budgets included "anticipated cost increases," and therefore
found that the addition of a trend factor constituted double
compensation. Disallowance Letter, p. 3. Missouri argued that in view
of its consistent practice of providing trend factor increases to
initial per diem rates, providers estimated their costs in the
expectation of receiving the increases. Ex. 8, p. 7. Further, it is
significant that the State engaged in an extensive review process in
setting the initial rate for newly constructed providers which included
submission of projected budgets and other documentation to support
costs. That review presumably would uncover double or excessive
inflation for newly constructed providers. 9/
In any event, the circumstances applicable to Maple Lawn provide further
assurance that its rate did not include a double inflation factor.
Maple Lawn's initial rate was based on its submission of an eight-month
budget. Ex. 8, p. 3. Since the budget was for less than a year, the
provider could not have been using the budget to project annual
inflation. This fact corroborates the State's position that it assessed
the annual impact of inflation by use of trend factors and not the
provider's budget. Maple Lawn's rate, even when increased by trend
factors, remained significantly lower than its actual allowable cost.
When the State conducted its review to establish Maple Lawn's 1985-1986
rate, it found Maple Lawn's allowable cost to be $42.63, but the rate,
even with trend factor increases for the period under review, was just
$38.64. 10/ Ex. 4, p. 2.
4. Reasonableness in Light of Methodology
Finally, the State's interpretation is reasonable in light of its
prospective reimbursement methodology and is consistent with program
requirements. The purpose of the plan's prospective rate system is to
establish rates which "are reasonable and adequate to assure an
efficient and economically operated facility . . . ." 13 CSR 40-
81.081(1). Since a provider's costs are not retroactively adjusted, a
prospective system must include a mechanism for compensating the
provider for inflation. While this could be done for first year
providers through a budget projection, a trend factor is an equally
acceptable mechanism to achieve this goal.
In fact, use of trend factors could achieve greater equity in the
implementation of the plan for at least two reasons. First, uniform use
of trend factors compensates all providers consistently for the effects
of inflation. Second, other limitations in the plan were determined by
trend factor formulas. For example, a provider's rate could not exceed
the level of care ceiling in effect on June 30, 1981, as adjusted by the
negotiated trend factor. 13 CSR 40-81.081(2)(C). Uniform use of trend
factors maintains appropriate correlations between providers' rates and
rate ceilings.
For the foregoing reasons, we find that Missouri was entitled to
increase Maple Lawn's rate by negotiated trend factors during its first
year of operation. Therefore, HCFA should recalculate the disallowance
by giving the State credit for the trend factor increases of July 1984
and January 1985 in this respect.
B. Rate Increases After Maple Lawn's First Year of Operation
At the conclusion of Maple Lawn's first year of operation, the State
conducted a twelve month review and found that Maple Lawn had a reported
per-diem cost of $48.19 but an allowable cost of $42.63. Ex. 4. Since
the allowable cost exceeded Maple Lawn's rate, the State did not adjust
the rate and it remained $40.20. Id.; Ex. C, p. 3. Maple Lawn filed an
administrative complaint and the State settled the case by increasing
Maple Lawn's rate pursuant to a schedule. Ex. F.
HCFA argued that the State was not authorized by the state plan to
increase the rate in this manner. It based its position on the 1983
plan, the State's administrative practice under 1983 plan, and the
representations the State made in its 1986 amendments about the meaning
of its 1983 plan.
Section 40-81.081(7)(F)1.C of the 1983 state plan provided for
retroactive and prospective decrease of an initial rate if the rate
exceeded allowable cost. However, the 1983 plan did not provide for a
rate increase if, as in Maple Lawn's situation, the allowable cost
exceeded the initial rate. In his correspondence with HCFA concerning
the 1986 plan amendment, the Director represented to HCFA that the State
interpreted its 1983 plan as not providing for such increases and that
it was the State's practice to not allow increases in these
circumstances. He wrote:
(7)(B)(5). clarifies an existing ambiguity in the State plan. The
plan required rate reductions at the twelve month review stage for
facilities which had initial rates higher than actual per-diem
costs for the first twelve months of operation. There was,
however, no provision for rate increases at the twelve month review
stage and no rate increases have therefore been granted. This
addition clarifies that no rate increases are to be allowed after
review of a newly constructed facility's twelve- month cost report.
Ex. 5, p. 3.
Not only does the record contain this representation by the Director,
but the summary of the Rate Advisory Committee's meeting also
demonstrates that it was the State's practice not to grant such
increases. Ex. C., p. 3.
The State argued that it was at a disadvantage in litigation with Maple
Lawn because the 1983 plan had no express language prohibiting the
increase Maple Lawn sought. It asserted that the departmental policy of
denying such increases would be construed as an invalid, unpromulgated
policy under Missouri law. Further, it argued that its and HCFA's
exposure in this case was significantly greater than the amount for
which it settled. It therefore maintained that the settlement was a
prudent and rational decision within the discretionary authority of the
State.
We have previously held that HCFA is not bound by a state's settlement
agreement with a provider and is entitled to determine whether a
settlement complies with Medicaid and state plan requirements.
California Dept. of Health Services, DAB No. 1015 (1989); Missouri
Dept. of Social Services, DAB No. 1035 (1989).
Because the State's rate increase settlement with Maple Lawn violated
the state plan, we find that HCFA acted reasonably in refusing to
recognize it. Since the plan expressly provided for a rate decrease if
the per-diem rate exceeded allowable cost, it would have been a simple
matter for the plan to provide for the opposite result. The fact that it
did not authorize an increase when it expressly provided for a decrease
indicates that an increase was not allowed. This conclusion is further
supported by the following considerations:
o The State did not identify any section of this plan which would
provide a basis for Maple Lawn's increase.
o The essence of a prospective reimbursement system, such as the
one set forth in Missouri's 1983 plan, is that per-diem rates are
not routinely increased to compensate a provider for its actual
per-diem cost experienced during the preceding year. Missouri,
supra, 5; AGI-Bloomfield, supra, 299. This is one of the principal
means by which prospective rate structures encourage economic
efficiency and discourage rate inflation.
o Such a system necessarily recognizes certain conditions under
which providers should receive additional compensation and
expressly provides for increases to meet such conditions. In the
1983 Missouri plan, negotiated trend factor increases, which
compensated providers for inflation, were an example of exactly
this phenomenon. Other examples in the 1983 plan included changes
in level of care, unusual labor market conditions, and
extraordinary circumstances including an act of God. The plan
therefore set forth definitive and limited grounds which entitled a
provider to a rate increase. See 13 CSR 40-81.081(4)(A)2 and
(7)(B)1.
o In defending the settlement, Missouri argued that its plan was
ambiguous and that its interpretation was entitled to controlling
weight. In fact, we are giving the State's interpretation
controlling weight. Missouri expressly interpreted the 1983 plan
to not authorize such rate increases (Ex. 5) and denied such
increases on a routine basis. Ex. C, p. 3.
o In defending the settlement, the State argued that its
administrative practice of denying such rate increases would be
regarded as an invalid unpromulgated policy. We do not agree that
the basis for the State's initial denial of Maple Lawn's rate
increase was unpromulgated. As explained above, the State was
operating a prospective rate plan in which rates could be adjusted
on certain articulated grounds. The plan did not authorize an
increase on the grounds that a new provider's first year cost
exceeded its initial prospective rate. The 1986 amendment expressly
precluding such an increase clarifies the State's plan. However,
the fact that the State adopted this amendment does not change the
fact that such increases were not authorized by the 1983 plan.
We therefore uphold HCFA's disallowance of the rate increase set forth
in Missouri's settlement with Maple Lawn.
IV. Conclusion
For the reasons set forth above, we conclude that Missouri is entitled
to federal funding for the July 1984 and January 1985 negotiated trend
factor increases to Maple Lawn Nursing Home. We conclude that Missouri
is not entitled to federal funding for the rate increases contained in
its November 3, 1986 settlement with Maple Lawn. HCFA should recompute
the disallowance accordingly.
Judith A. Ballard
Norval D. (John) Settle
Donald F. Garrett Presiding Board Member
1. The Boren Amendment reflected Congressional displeasure at the
cost ineffectiveness of the reasonable cost-related basis.
AGI-Bloomfield Convalescent Center v. Toan, 679 S.W.2d 294, 298 (Mo.
App. 1984).
2. Missouri's provisions for setting Medicaid long- term care rates
are contained in Attachment 4.19-D of its state plan. The attachment is
a copy of the Missouri Medicaid long-term care rate regulations which
are set forth in Title 13 of the Missouri Code of State Regulations.
The initial version of Missouri's prospective rate regulations and
related state plan was effective October 1, 1981. AGI-Bloomfield,
supra, 298. That plan and regulations were amended in 1982 and 1983.
Missouri Dept. of Social Services, DAB No. 1035 (1989). In its
disallowance letter and report on which the disallowance was based (Ex.
J, pp. 66-67), HCFA relied on the language of the 1986 state plan. In
responding to the report, the State also cited the language of the 1986
plan. However, the parties ultimately relied on the 1983 plan as the
controlling version for purposes of this dispute and cited the 1986 plan
as illustrative of the meaning of the 1983 plan.
3. The State reduced Maple Lawn's reported costs for minimum
utilization, capital cost adjustments, direct billed Medicaid/Medicare
services and auction proceeds. Ex. D.
4. The other parts of section (7) do not undercut this reading of
section (7). HCFA argued that trend factors were not authorized because
section 40-81.081(7)(F)2.A-S set forth allowable cost areas for new
construction and did not include trend factors. This subsection
contained categories of cost areas such as compensation to owners,
covered services and supplies, depreciation, and interest and finance
costs. These were the cost categories which were used to set a rate.
This subsection was not designed to deal with the question of how a
provider was compensated for inflation after that rate was set.
Therefore, it is not surprising or dispositive that trend factors were
not enumerated there.
5. For the same reasons, we conclude that section (2) need not serve
as an outright bar to the use of an inflation allowance in the form of
negotiated trend factors. Section (2) sets out the general principles
for establishing payment rates. Although it refers to negotiated trend
factors in the context of the rate for pre-existing providers, it
authorizes the newly constructed providers to receive a rate in
accordance with "applicable provisions," i.e., the provisions of
section (7), which also may be viewed as authorizing trend factor
increases.
6. We further find that the State's construction of its plan is
supported by the State statutory provisions on the per-diem rate.
Section 208.169.1(5), RSMo., provides that a negotiated trend factor
"shall be applied to each facility's Title XIX per diem reimbursement
rate." This provision on its face seems to provide trend factors for
both existing and newly constructed facilities. Moreover, we are not
convinced, as HCFA argued, that subsection (2) of the statute precluded
trend factor increases for newly constructed providers in their first
year. Subsection (2) can reasonably be read to be limited to the issue
of how a newly constructed provider's rate is set, not whether a newly
constructed provider is entitled to receive trend factors. The
Department's consistent practice has been to grant subsection (5) trend
factors to newly constructed providers. This statute was enacted in
1983 and amended in 1987. If the Missouri legislature disagreed with
the Department's implementation of the legislation, it presumably would
have amended the statute to expressly preclude trend factors for newly
constructed providers.
7. HCFA argued that in his April 2, 1987 letter discussing the 1986
plan amendments, the Director had recognized that newly constructed
providers were not entitled to trend factors. We find, however, that
the Director's discussion was limited to the preclusion of rate
increases at the conclusion of a new provider's first year.
8. The sequence of events in this case was consistent with 13 CSR
40-81.081(7)(F)1. Maple Lawn was awarded a "tentative rate" of $37.05
in May 1984 by medical services. Ex. 1, p. 2. In August 1984 it was
notified that it had been awarded a prospective rate of $37.29 effective
May 9, 1984 and a trend increase as of July 1, 1984. Id., p. 1. Until
August, it received its tentative rate of $37.05, but it was then
retroactively reimbursed pursuant to the increased rates. Id.
9. Missouri's rate-setting process for newly constructed providers
involved review by three different entities in the State system: the
Division of Medical Services of the Department of Social Services, the
Department's Advisory Committee, and the Director of the Department of
Social Services.
10. Additionally, Maple Lawn's rate and allowable costs were well
below the applicable rate ceiling. The plan set forth a level of care
ceiling of one hundred twenty-five percent of the weighted mean rate
paid for each level of long-term care. 13 CSR 40-81.081(3)(H). In March
1986, when Maple Lawn was notified of its prospective rate, the attached
work sheet described a class ceiling rate of $49.93. Ex. 4. Maple
Lawn's rate, even with the trend factor increases, was only $40.20,
which placed it at the lower end of rates of providers of its