Genesis Health Care, Inc. v. Soura

• Decision Date: 09 December 2015
• Docket Number: C/A No. 3:14–cv–04311–CMC,C/A No. 3:14–cv–03449–CMC
• Citation: 165 F.Supp.3d 443
• Parties: Genesis Health Care, Inc., Plaintiff, v. Christian Soura, in his official capacity as Director of the South Carolina Department of Health and Human Services, Defendant. CareSouth Carolina, Inc., and Sandhills Medical Foundation, Inc., Plaintiffs, v. Christian Soura, in his official capacity as Director of the South Carolina Department of Health and Human Services, Defendant.
• Court: U.S. District Court — District of South Carolina

165 F.Supp.3d 443

Genesis Health Care, Inc., Plaintiff,

v.Christian Soura, in his official capacity as Director of the South Carolina Department of Health and Human Services, Defendant.

CareSouth Carolina, Inc., and Sandhills Medical Foundation, Inc., Plaintiffs,

v.Christian Soura, in his official capacity as Director of the South Carolina Department of Health and Human Services, Defendant.

C/A No. 3:14–cv–03449–CMC

C/A No. 3:14–cv–04311–CMC

United States District Court, D. South Carolina, Columbia Division.

Signed December 9, 2015

Gregory Brian Collins, McAngus Goudelock and Courie, Mt Pleasant, SC, James C. Cox, III, Grier Cox and Cranshaw, Columbia, SC, Edward T. Waters, Gregory M. Cumming, Feldesman Tucker Leifer Fidell, Washington, DC, for Plaintiff.

W. Allen Nickles, III, Nickles Law Firm, Richard G. Hepfer, S.C. Dept of Health and Human Services, Columbia, SC, for Defendant.

Order on Cross Motions For Summary Judgment

CAMERON MCGOWAN CURRIE, Senior United States District Judge

Through these consolidated actions, Plaintiffs, Genesis Health Care, Inc. (Genesis), CareSouth Carolina, Inc. (CareSouth), and Sandhills Medical Foundation, Inc. ( Sandhills) (collectively “Plaintiffs”), seek declaratory and injunctive relief against Defendant, Christian Soura, in his official capacity as Director of the South Carolina Department of Health and Human Services (collectively “SCDHHS”). All Plaintiffs challenge application of a specific provision of a State Plan Amendment (“SPA”) adopted in 2011, SPA 11–012, which they allege violates federal law to the extent it caps payment to Federally-qualified health centers (“FQHCs”) based on Medicare rates (“Common Claim”). Most critically, Plaintiffs allege that SPA 11–012 allows payments below the amounts mandated by 42 U.S.C. § 1396a(bb) (“Section 1396a(bb) ”). Genesis also challenges SCDHHS's failure to establish a procedure to adjust its payments under Section 1396a(bb)'s prospective payment system (“PPS”) as required by Sections 1396a(bb)(2) and (3) (“Individual Claim” or “Genesis's Individual Claim”).¹

The matter is before the court on cross motions for summary judgment. Genesis, ECF Nos. 27, 32; CareSouth, ECF Nos. 37, 41.² All parties agree that there are no genuine issues of material fact in dispute as to Plaintiffs' Common Claim. Thus, they agree application of SPA 11–012 presents only legal issues for resolution by the court and should be resolved on the parties' cross motions for summary judgment.

The parties disagree as to whether Genesis's Individual Claim is appropriate for summary judgment. Genesis argues that the issue should be resolved on motion for summary judgment. SCDHHS argues, on various grounds, that the issue is not appropriate for resolution at this time or in this proceeding. See Genesis, ECF Nos. 36 at 2–3, 39 at 2–3.

For the reasons set forth below, the court grants Plaintiffs' motions for summary judgment on their Common Claim. For the same reasons, the court denies SCDHHS's corresponding motions for summary judgment. The court denies Genesis's motion for summary judgment to the extent it seeks relief on Genesis's Individual Claim.

STANDARD

Summary judgment should be granted if “the movant shows that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law.” Fed. R. Civ. P. 56(a). It is well established that summary judgment should be granted “only when it is clear that there is no dispute concerning either the facts of the controversy or the inferences to be drawn from those facts.” Pulliam Inv. Co. v. Cameo Properties, 810 F.2d 1282, 1286 (4th Cir.1987).

The party moving for summary judgment has the burden of showing the absence of a genuine issue of material fact, and the court must view the evidence before it and the inferences to be drawn therefrom in the light most favorable to the nonmoving party. United States v. Diebold, Inc., 369 U.S. 654, 655, 82 S.Ct. 993, 8 L.Ed.2d 176 (1962).

Rule 56(c)(1) provides as follows:

(1) A party asserting that a fact cannot be or is genuinely disputed must support the assertion by:

(A) citing to particular parts of materials in the record, including depositions, documents, electronically stored information, affidavits or declarations, stipulations ..., admissions, interrogatory answers or other materials; or

(B) showing that the materials cited do not establish the absence or presence of a genuine dispute, or that an adverse party cannot produce admissible evidence to support the fact.

Fed. R. Civ. P. 56(c)(1).

A party “cannot create a genuine issue of material fact through mere speculation or the building of one inference upon another.” Beale v. Hardy, 769 F.2d 213, 214 (4th Cir.1985). Therefore, “[m]ere unsupported speculation ... is not enough to defeat a summary judgment motion.” Ennis v. National Ass'n of Bus. & Educ. Radio, Inc., 53 F.3d 55, 62 (4th Cir.1995).

BACKGROUND

The following facts and legal principles are undisputed. Plaintiffs are Federally-qualified health centers (“FQHCs”) as defined in 42 U.S.C. § 1396d(l )(2).³ This section defines FQHC to include an entity that “is receiving a grant under section 330 of the Public Health Services Act.” Id. ; see also 42 U.S.C. § 254b (codifying Section 330).

FQHCs are required to seek payment for services provided to their patients from all available sources including the federally-funded Medicare program and the jointly-funded (federal and state) Medicaid program. See 42 U.S.C § 254b(k)(3)(F). Some of Plaintiffs' patients are eligible for full coverage under both Medicare and Medicaid. These patients are referred to as “dual eligible beneficiaries.” The relief sought in this action relates specifically to reimbursement rates paid FQHCs for dual eligible beneficiaries.

State participation in the Medicaid program is voluntary; however, a state that participates must comply with “ ‘detailed federally mandated standards.’ ” Three Lower Cnties. Cmty. Health Servs., Inc. v. Maryland, 498 F.3d 294, 297 (4th Cir.2007) (quoting Antrican v. Odom, 290 F.3d 178, 183 n. 2 (4th Cir.2002) ). South Carolina was required to and did obtain approval for its plan for providing Medicaid services (the “State Plan”) from the Centers for Medicare and Medicaid Services (“CMS”), the federal agency responsible for administering the Medicaid program. See, e.g. , Pashby v. Delia, 709 F.3d 307, 314 (4th Cir.2013) (discussing CMS approval of state plans and amendments). South Carolina also received approval from CMS for the State Plan Amendment (“SPA”) at issue in this action, SPA 11–012. See Genesis, ECF No. 32–8 at 2 (CMS letter dated October 17, 2011, approving SPA 11–012 effective August 9, 2011); CareSouth, ECF No. 41–7 at 2 (same). For purposes of this order, the court assumes without deciding that CMS not only approved SPA 11–012, but intended that it be applied to FQHCs in the same manner as to non-FQHC providers and, consequently, in the manner challenged in this action.⁴

SPA 11–012 includes the following provision: “The Medicaid payment will amount to the Medicaid claim payment less the amount paid by Medicare not to exceed the sum of the Medicare co insurance and deductible. ” ECF No. 41–7 at 6 (emphasis added). This provision (“Challenged Provision”) effectively limits the total payment providers receive for services provided to dual eligible beneficiaries to no more than the rate available under Medicare. SCDHHS applies this payment limitation to Plaintiffs. Plaintiffs assert and SCDHHS does not deny that application of the Challenged Provision results in Plaintiffs receiving less than the amount they would otherwise be entitled to receive under 42 U.S.C. § 1396a(bb).

DISCUSSION

I. Application of the Challenged Provision to FQHCs (“Common Issue”)

A. Arguments of the Parties

Plaintiffs' Arguments. Plaintiffs argue that the Challenged Provision may not be applied to FQHCs because it would result in a total payment below that required by federal law, most critically 42 U.S.C. § 1396a(bb). Section 1396a(bb)(2) provides that, for services furnished during fiscal year 2001, a “State plan shall provide for payment for [covered] services in an amount (calculated on a per visit basis) that is equal to 100 percent of the average of costs of the center or clinic of furnishing such services during fiscal years 1999 and 2000 which are reasonable and related to the cost of furnishing such services, or based on such other tests of reasonableness as the Secretary prescribes in regulations[.]” 42 U.S.C. § 1396a(bb)(2). Under the prospective payment system (“PPS”), rates for services furnished after fiscal year 2001 are adjusted for changes in the scope of services and for inflation using the Medicare Economic Index (“MEI”). 42 U.S.C. § 1396a(bb)(3). States may also adopt an alternative payment methodology so long as that method is “agreed to by the State and the center or clinic” and “results in payment ... of an amount which is at least equal to the amount otherwise required to be paid ... under this section .” 42 U.S.C. § 1396a(bb)(6) (emphasis added).⁵

SCDHHS adopted an alternative methodology, which expressly provides that “[a]t yearend settlement, ... comparisons will be made to ensure that the final rate paid for a FQHC's fiscal year will provide reimbursement [of] at least the amount available under the PPS methodology.” Genesis, ECF No. 1 at ¶ 21 (quoting S.C. Medicaid Plan § 4.19–B). All Plaintiffs initially agreed to payment under SCDHHS's alternative methodology. See, e.g., Genesis , ECF No. 36 at 3 (SCDHHS memo explaining alternative methods); Genesis, ECF No. 32–5 at 9 (Contract between Genesis and SCDHHS effective July 1, 2013); CareSouth, ECF No. 41–5 at 9 (corresponding contract between Sandhills Medical Foundation, Inc. and SCDHHS). Genesis elected to receive reimbursement under the PPS methodology at some point prior to initiation of this litigation, with the election apparently becoming effective in April 2014. See Genesis, ECF No....