New York State Department of Social Services, DAB No. 1361 (1992)

Department of Health and Human Services

DEPARTMENTAL APPEALS BOARD

Appellate Division

SUBJECT:  New York State Department of Social Services

DATE:  October 6, 1992
Docket No. A-92-252
Decision No. 1361

   DECISION

The New York State Department of Social Services (State) appealed a
determination by the Health Care Financing Administration (Agency)
disallowing federal financial participation (FFP) in the amount of
$3,216,710 claimed under title XIX of the Social Security Act for the
quarter ended June 30, 1990.  The costs claimed represented amounts
originally paid under the State-funded medical assistance program which
the State later claimed as payments for individuals eligible for
Medicaid.  The State used statistical sampling procedures to estimate
the amount paid to individuals who were eligible for Medicaid on the
basis of disability.

The State requested a summary decision upholding the disallowance based
on New York State Dept. of Social Services, DAB No. 1012 (1989).
Similar summary decisions have already been issued by the Board.  See
New York State Dept. of Social Services, DAB No. 1342 (1992), and
decision cited therein.

In DAB No. 1012, the Board held that the State was not authorized to use
statistical sampling as a basis for claiming Medicaid funds payable on
behalf of disabled individuals.  The Board found that sampling was
impermissible because it was used in lieu of making the disability
determinations which the regulations, reasonably interpreted, require in
each case for which payment is made.  Accordingly, the Board sustained
the  disallowances to the extent that they represented extrapolations
from cases in the sample involving individuals eligible for Medicaid
based on disability.  The Board remanded that part of the disallowances
pertaining to the cases in the sample to determine whether the
disability determination in each case was properly made.

The Agency agreed to the issuance of a summary decision here based on
DAB No. 1012.  Letter from Healy to Settle dated October 1, 1992.

Conclusion

Accordingly, based on the analysis in DAB No. 1012, we uphold the
disallowance to the extent that it represents disability-based claims
calculated by extrapolation from a statistical sample.  As in that
decision, we remand to the Agency that part of the disallowance which
pertains to the cases in the sample to determine whether the disability
determination in each case was properly made so that FFP is allowable.
1/  The State may appeal the Agency's determination in the sample cases
pursuant to 45 C.F.R. Part 16.

 

 ________________________ Cecilia Sparks Ford

 

 ________________________ Donald F. Garrett

 

 ________________________ Norval D. (John) Settle Presiding Board
 Member

1.  In some related appeals, the Agency asserted, and the State did not
dispute, that claims for the expenditures made on behalf of the
individuals in the sample cases were not included in the amounts in
dispute.  Docket Nos. 89-51, 89-86 and 89-87, Agency's brief dated
6/1/89, p. 5.  If the same is true here, there would of course be no
need for further Agency