NOT FOR PUBLICATION WITHOUT THE
APPROVAL OF THE APPELLATE DIVISION
SUPERIOR COURT OF NEW JERSEY
APPELLATE DIVISION
A-5153-98T2
HOSPITAL CENTER AT ORANGE,
ST. FRANCIS MEDICAL CENTER,
ST. MARY HOSPITAL (PASSAIC),
DEBORAH HEART AND LUNG CENTER,
CATHEDRAL HEALTH CARE SYSTEM, INC.,
ST. FRANCIS HOSPITAL (JERSEY CITY),
MOUNTAINSIDE HOSPITAL, PALISADES
GENERAL HOSPITAL, RANCOCAS HOSPITAL,
ST. MARY HOSPITAL (HOBOKEN), and
HACKETTSTOWN COMMUNITY HOSPITAL,
Plaintiffs-Appellants,
v.
MICHELE K. GUHL, Commissioner of
the Department of Human Services,
and MARGARET MURRAY, Director of the
Division of Medical Assistance and
Health Services,
Defendants-Respondents.
_________________________________________________________________
Argued January 11, 2000 - Decided June 1, 2000
Before Judges Skillman, D'Annunzio and
Newman.
On appeal from Division of Medical Assistance
and Health Services, Department of Human
Services.
Calvin A. Jones argued the cause for
appellants (Reed, Smith, Shaw & McClay,
attorneys; Murray J. Klein, of counsel; Mr.
Jones and Steven M. Ziolkowski, on the
brief).
Rhonda S. Berliner-Gold, Deputy Attorney
General, argued the cause for respondents
(John J. Farmer, Jr., Attorney General,
attorney; Mary C. Jacobson, Assistant
Attorney General, of counsel; Ms. Berliner
Gold and Barbara Pryor Waugh, Deputy Attorney
General, on the brief).
The opinion of the court was delivered by
SKILLMAN, P.J.A.D.
This case deals with the obligation of the Division of
Medical Assistance and Health Services (Division) to provide
prompt review of hospitals' appeals from administrative
determinations of Medicaid reimbursement rates.
On February 17, 1999, appellants, which are twelve non
profit acute care hospitals that participate in the Medicaid
program, initiated this action in lieu of prerogative writs in
the Law Division. The named defendants were Margaret Murray, the
Director of the Division, and Michele K. Guhl, the Commissioner
of the Department of Human Services. Appellants alleged that
they had filed administrative appeals with the Division
challenging the Medicaid reimbursement rates established in
January 1996, October 1996, January 1997 and January 1998, but
that the Division had "continually and consistently failed to
make any determination or issue any decision with respect to any
of the . . . rate appeals." Appellants sought an order directing
the Division to decide all their pending rate appeals within
thirty days. Appellants also sought an order directing the
Division to decide any future rate appeals within 120 days. In
addition, appellants sought an order requiring "defendants to pay
. . . all costs and fees, including attorneys fees, incurred in
prosecuting this action."
Appellants' claims were based on principles of state
administrative law as well as Title XIX of the Federal Social
Security Act, commonly known as the Medicaid Act,
42 U.S.C.A.
§§1396-1396v, and the regulations adopted thereunder. In addition,
appellants contended that the Division's failure to promptly
decide their Medicaid rate appeals violates the Due Process
Clause of the Fourteenth Amendment. Appellants asserted that
their federal claims were maintainable under
42 U.S.C.A.
§1983.
Respondents filed a motion to dismiss appellant's complaint
or, in the alternative, to transfer the case to this court. On
May 13, 1999, the Law Division transferred the case, concluding
that this court has exclusive jurisdiction because appellants
seek review of the inaction of a state administrative agency.
On June 29, 1999, appellants filed a motion for the summary
entry of an order compelling the Division to immediately decide
their pending Medicaid rate appeals.
On July 9, 1999, while appellants' motion was pending, the
Division issued final decisions in all of appellants' pending
Medicaid rate appeals except for four filed by Deborah Heart and
Lung Center.See footnote 11 Twenty-nine of these decisions consisted of
identical form letters that denied the hospitals' Medicaid rate
appeals on the ground that the "hospital did not sustain a
marginal loss in providing inpatient services to Medicaid
beneficiaries at the rates under appeal." The other two were
form letters that dismissed the hospitals' rate appeals on the
ground that they had been filed beyond the twenty-day period
allowed under N.J.A.C. 10:52-9.1(b)(1).
Following these decisions, respondents filed a motion to
dismiss this appeal on the ground that appellants' claim that the
Division had failed to decide their rate appeals within a
reasonable period of time was moot because the Division had
issued decisions. Appellants opposed the motion on the ground
that their claims were not limited to a demand for issuance of
decisions in the pending rate appeals. We denied respondents'
motion.
Appellants now ask this court to grant declaratory and
injunctive relief that would require the Division to decide
future Medicaid rate appeals in a timely manner. Specifically,
appellants seek an order that would require the Division "to
issue written determinations of hospitals' rate appeals within
120 days." Appellants also seek a determination that the
decisions issued by the Division on July 9, 1999 were
"incomplete" and an order directing the Division to issue
"complete" decisions in their rate appeals. In addition,
appellants seek an award of attorney's fees under
42 U.S.C.A.
§1988.
We conclude that the Division has an obligation to decide
Medicaid rate appeals within a reasonable period of time, and
that the Division failed to satisfy that obligation in processing
the appeals that precipitated this action. However, neither
federal nor state law obligates the Division to decide Medicaid
rate appeals within 120 days or any other fixed time period, and
we do not believe it would be appropriate for this court to
impose such an obligation. Therefore, we deny appellants'
request for injunctive relief compelling the Division to decide
future Medicaid rate appeals within a specified time period. We
also reject appellants' demand for a declaration that the
decisions in the rate appeals issued on July 9, 1999, are
"incomplete." We reject appellants' claim for attorney's fees
under
42 U.S.C.A.
§1988.
I
Preliminarily, we note that the Law Division properly
transferred the case to this court.
Rules 2:2-3(a)(2) and 2:2-4 "contemplate[] that 'every
proceeding to review the action or inaction of a
state
administrative agency [shall] be by appeal to the Appellate
Division.'"
Pascucci v. Vagott,
71 N.J. 40, 52 (1976) (quoting
Central R.R. v. Neeld,
26 N.J. 172, 185,
cert. denied, 357
U.S.
928,
78 S. Ct. 1373,
2 L. Ed.2d 1371 (1958)). "The term
'action,' found in [
Rules 2:2-3(a) and 2:2-4], includes
inaction."
Mathews v. Finley,
46 N.J. Super. 175, 177 (App.
Div.),
certif. denied,
25 N.J. 283 (1957). Therefore, the
Appellate Division has exclusive jurisdiction to consider a claim
of state administrative agency inaction.
Pascucci v. Vagott,
supra, 71
N.J. at 52;
Johnson v. New Jersey State Parole Bd.,
131 N.J. Super. 513, 517-21 (App. Div. 1974),
certif. denied,
67 N.J. 94 (1975);
see also Toll Bros., Inc. v. State of New Jersey,
Dept. of Envtl. Protection,
242 N.J. Super. 519, 525-26 n.3 (App.
Div. 1990);
Equitable Life Mortgage & Realty Investors v. New
Jersey Div. of Taxation,
151 N.J. Super. 232, 237-38 (App. Div.),
certif. denied,
75 N.J. 535 (1977);
but cf. Township of Montclair
v. Hughey,
222 N.J. Super. 441, 446-48 (App. Div.),
modified on
other grounds,
108 N.J. 587 (1987).See footnote 22 If our determination of
such a claim requires the development of a factual record, "we
can remand to the agency for a statement of reasons, for further
action by the agency, or can permit the Law Division to create a
record and make fact-finding."
Trantino v. New Jersey State
Parole Bd.,
296 N.J. Super. 437, 460 (App. Div. 1997),
modified
on other grounds,
154 N.J. 19 (1998).
Accordingly, under our appellate rules, the appropriate
procedural route for a party claiming to be adversely affected by
the inaction of a state administrative agency is to file a notice
of appeal and motion for summary disposition accompanied by a
supporting brief, certification and other relevant factual
materials. The agency's response to such a motion affords this
court an opportunity to determine whether there is any dispute
concerning the factual allegations upon which an inaction claim
is grounded. If there is no dispute, this court can proceed to a
prompt disposition of the claim. If there is a dispute, the
matter can be remanded to the agency, an Administrative Law Judge
or the Law Division to develop a record and make appropriate
factual findings.
In this case, appellants' motion for the summary entry of an
order compelling the Division to immediately decide their pending
Medicaid rate appeals was mooted when the Division decided those
appeals while the motion was still pending. Insofar as the
certifications submitted in connection with that motion relate to
appellants' other claims, the parties consented to
supplementation of the record to include their respective
certifications. Moreover, we are satisfied from our review of
the certifications that there is no dispute concerning any
factual allegations material to a disposition of appellants'
remaining claims. Therefore, this appeal is ripe for a final
decision without the need for a remand.
II
Respondents renew their argument that this appeal should be
dismissed as moot because the Division has now rendered decisions
in the rate appeals that appellants sought to compel the Division
to decide. Appellants respond that we have already rejected this
argument by denying respondents' motion to dismiss the appeal.
Because our order denying respondents' motion to dismiss was
interlocutory, it is subject to reconsideration.
See State v.
Reldan,
100 N.J. 187, 205 (1985);
Johnson v. Cyklop Strapping
Corp.,
220 N.J. Super. 250, 257-64 (App. Div. 1987),
certif.
denied,
110 N.J. 196 (1988). However, we remain satisfied that
this appeal is not moot.
Although the Division's failure to issue timely decisions in
appellants' then pending Medicaid rate appeals precipitated this
action, appellants sought not only an order compelling the
Division to decide the pending appeals within thirty days, but
also a directive that the Division decide any future Medicaid
rate appeal within 120 days. In addition, after the Division
decided the pending rate appeals, appellants asserted a claim
that those decisions were "incomplete" and sought an order
directing the Division to issue "complete" decisions. Appellants
also seek an award of attorney's fees. These claims were not
mooted by the issuance of decisions in the rate appeals that were
pending when the action was initiated,
cf. Galloway Township Bd.
of Educ. v. Galloway Educ. Ass'n,
78 N.J. 25, 37-47 (1978), and
must now be addressed.
III
Appellants argue that the Division's failure to issue timely
decisions in their Medicaid rate appeals violated the statutes
and regulatory provisions governing the Medicaid program, the Due
Process Clause of the Fourteenth Amendment and the State law
requirement of fundamental fairness in the administrative
process. To prevent such delay in future Medicaid rate appeals,
appellants seek an order directing the Division to decide future
Medicaid rate appeals within 120 days.
Preliminarily, it is appropriate to describe briefly the
regulatory framework under which Medicaid rate appeals are
brought before the Division. The Medicaid program is a joint
federal-state program established by Title XIX of the Social
Security Act to provide medical care for indigent, disabled and
elderly persons.
42 U.S.C.A.
§1396. Although states are not
required to participate, a state that chooses to participate must
operate its program in compliance with the federal statute and
regulations.
Harris v. McRae,
448 U.S. 297, 301,
100 S. Ct. 2671, 2680,
65 L. Ed.2d 784, 794 (1980).
The Division is the state agency responsible for
administering the New Jersey Medicaid program.
N.J.S.A. 30:4D-4,
5. Under the present regulatory system, the Division issues an
individual rate schedule at least once a year to each hospital
participating in the Medicaid program.
N.J.A.C. 10:52-5.1 to
5.17. If a hospital disputes its rate schedule, it may file an
appeal with the Division.
N.J.A.C. 10:52-9.1. Such an appeal
may involve a claim either that the Division has made calculation
errors or that the rates do not provide adequate compensation for
the hospital's costs in caring for Medicaid recipients.
N.J.A.C.
10:52-9.1(a),(b).
Appellants' rate appeals all involved claims that the
Medicaid reimbursement rates established by the Division did not
provide the hospitals with adequate compensation for the care of
Medicaid recipients. Such an appeal must be filed within twenty
days after publication of the rates, and the documentation
supporting the appeal must be filed within an additional sixty
day period.
N.J.A.C. 10:52-9.1(b)(1). After the Division
reviews the hospital's submission, it must issue a written
decision regarding the hospital's rate appeal. If a hospital
disagrees with the Division's decision, it may request a hearing
before an Administrative Law Judge, whose initial decision is
then adopted, modified or rejected by the Director of the
Division.
N.J.A.C. 10:52-9.1(d).
In January 1996, October 1996, January 1997 and January
1998, the Division issued rate schedules to all New Jersey
hospitals then participating in the Medicaid program. On each
occasion, appellants filed administrative appeals alleging that
their reimbursement rates were inadequate. When appellants filed
this action in February 1999, the Division had not decided any of
appellants' rate appeals, even though some of them had been
pending for a full three years.
It is firmly established in this State that administrative
agencies' procedures are subject to judicial review and
supervision to assure fairness in the administrative process.
See,
e.g.,
In re Arndt,
67 N.J. 432, 436 (1975);
In re Senior
Appeals Examiners,
60 N.J. 356, 363 (1972). As Justice Jacobs
observed in
Monks v. New Jersey State Parole Bd.,
58 N.J. 238,
248-49 (1971)
:
Our Judicial system has historically been
vested with the comprehensive prerogative
writ jurisdiction which it inherited from the
King's Bench; that jurisdiction has been
frequently exercised in the supervision of
inferior governmental tribunals including
administrative agencies. . . . When our 1947
Constitution was prepared, pains were taken
to insure not only that the court's
prerogative writ jurisdiction would remain
intact, but also that the manner of its
exercise would be greatly simplified ([N.J.
Const.] art. VI, sec. 5, ¶ 4). The
implementing court rules now provide an easy
mode of review designed to insure procedural
fairness in the administrative process and to
curb administrative abuses.
Furthermore, our courts have held that undue delay in the
administrative process may result in a denial of "fundamental
procedural fairness."
Arndt,
supra, 67
N.J. at 436;
see also
Johnson v. New Jersey State Parole Bd.,
supra, 131
N.J. Super. at
517-21.
In
Arndt, the Court observed that a delay of nearly three
years between a motorist's arrest on suspicion of driving while
under the influence of alcohol and the Division of Motor
Vehicle's final decision suspending his license for refusing to
submit to a breathalyzer test "evince[d] an entire lack of that
acute appreciation of justice which should characterize a
tribunal charged with [such a] delicate and important duty." 67
N.J. at 437 (quoting
Smith v. Illinois Bell Tel. Co.,
270 U.S. 587, 591,
46 S. Ct. 408, 409,
70 L. Ed. 747, 749 (1926)). The
Court concluded that because the suspension proceedings had not
been conducted "within a reasonable time and . . . the
proceedings as a whole were conducted with seriously unfair
disregard of [the motorist's] rights, . . . the order of
suspension should be vacated."
Ibid.
The Division's delay in issuing decisions regarding
appellant's Medicaid rate appeals was as clearly unjustifiable as
the administrative delay that the Court
found to violate
"fundamental procedural fairness" in
Arndt.
Id. at 436.
Appellant hospitals are quasi-public entities that are entitled
to a timely determination of any claim that they are not being
adequately compensated for the care of Medicaid recipients.
The Division's only explanation for its long delay in
deciding appellants' rate appeals was presented through the
certification of its "Administrator of Provider Rate Setting,"
which states in pertinent part:
14. The typical packet received from a
hospital requesting a rate appeal contains
documentation between 3 inches and 12 inches
thick. . . . Each of these packets must be
individually reviewed and considered.
15. The first step in the review
process is to determine whether the hospital
has submitted documentation in support of
each of the three categories. If the hospital
has not submitted the required information,
the rate appeal is denied.
16. If the hospital has submitted
documentation in support of each category,
the documents are examined closely and the
proposed calculations are considered. In
addition, based upon the documentation
submitted, in some instances [the Division]
creates its own new calculations and/or
requests additional information from the
hospital.
17. There are only 2 people, including
myself, within my department capable of
performing this intensive review and this is
not our only job function.
. . . .
22. A strict 120 day deadline is not
feasible given the amount of documentation
submitted, that all hospitals submit their
documentation on approximately the same day,
the intensive examination of those documents
and the complex calculations involved in
determining rate appeals, and the need, in
some cases, for obtaining further
documentation from the hospital.
If the Division had received an unexpectedly large number of
rate appeals in a particular year, which created a backlog that
prevented every appeal from being decided in a timely manner, the
Division's explanation might provide a reasonable excuse for some
delay in the administrative process. However, the record
indicates that the Division has received approximately the same
number of appeals each time it has established new rates,See footnote 33 and
that it did not decide any hospital rate appeals between February
16, 1996 and July 9, 1999. Furthermore, when the Division
finally did take action, apparently under the pressure of this
litigation, it issued decisions on the same day in all seventy
four of the pending rate appeals that had been filed by hospitals
between January 26, 1996 and January 26, 1998. The simultaneous
issuance of so many decisions indicates that the Division has the
capacity to decide a substantial number of rate appeals within a
short period of time. Moreover, two of the Division's decisions
simply dismissed appeals that hospitals had filed three years
earlier on the ground that the appeals were untimely, even though
such a determination could have been made in just a few minutes,
without undertaking the "intensive examination of documents" or
"complex calculations" that the Division claims are required to
decide a Medicaid rate appeal. Therefore, the Division's failure
to decide even those rate appeals that it eventually concluded
had been filed out-of-time provides added support for our
conclusion that the agency violated its statutory
responsibilities.
Nevertheless, we find no basis for requiring the Division to
decide Medicaid rate appeals within 120 days or any other fixed
time period. When the Legislature has concluded that an agency
should be required to take action within a fixed time period, it
has incorporated a specific provision in the applicable
legislation establishing a deadline for agency action. See,
e.g., N.J.S.A. 52:14B-10(c) (Administrative Procedure Act);
N.J.S.A. 40:55D-73 (Municipal Land Use Law). The Medicaid Act
does not contain a comparable provision. Although the federal
regulations that govern the Medicaid program require "prompt
administrative review" of a rate appeal, 42 C.F.R. § 447.253(e),
neither the federal Medicaid statute nor the implementing
regulations require a state Medicaid agency to issue a decision
within a fixed period of time. In the absence of any federal
mandate or state legislative directive that the Division issue
its decision in a rate appeal within a specific time, we do not
believe it would be appropriate to impose such a requirement by
judicial fiat. Instead, we limit the relief in this case to a
declaration that the Division has an obligation to decide
Medicaid rate appeals within a reasonable period of time.
The Division suggested at oral argument that, except in
extraordinary circumstances, it should be able to decide a
Medicaid rate appeal within six months after a hospital submits
the documentation supporting its appeal. We assume the Division
will undertake to decide future Medicaid rate appeals within this
time period, and that if any individual appeal cannot be decided
within six months, the Division will notify the hospital of the
reason for the delay and the additional time it anticipates will
be required to complete its review and issue a decision. If the
Division fails to issue a decision within a reasonable period of
time, a hospital may seek appropriate relief from this court
under the procedures described in section I of this opinion.
IV
Appellants also seek a declaration that the Division's
decisions in the rate appeals issued on July 9, 1999 are
"incomplete" and a direction to the agency to issue "complete"
decisions.
N.J.A.C. 10:52-9.1(b)(2) provides that:
The Division will not approve an increase in
a hospital's rates unless the hospital
demonstrates that it would sustain a marginal
loss in providing inpatient services to
Medicaid recipients at the rates under appeal
even if it were an economically and
efficiently operated hospital. . . . Any
hospital seeking a rate increase must
demonstrate the cost it must incur in
providing services to Medicaid beneficiaries
and the extent to which it has taken all
reasonable steps to contain or reduce the
costs of providing inpatient hospital
services.
In denying appellants' rate appeals, except for the two that
were dismissed as untimely, the Division stated:
Because [the Division] determined that your
hospital did not sustain a marginal loss for
the rate period under appeal, it did not
address the issues of whether the hospital
was efficiently or economically operated or
whether it had taken reasonable steps to
reduce or contain its costs.
Appellants contend that by the terms of
N.J.A.C. 10:52
9.1(b)(2), the Division must make four separate determinations in
deciding a rate appeal:
(1) the Division must first determine
whether the hospital is efficiently operated;
if not,
(2) the Division must adjust for efficiency
in determining whether the hospital would
suffer a marginal loss;
(3) the Division must determine if the
hospital has demonstrated the cost it must
incur in providing services to Medicaid
beneficiaries; and
(4) the Division must determine if the
hospital has taken all reasonable steps to
contain or reduce that cost of providing
inpatient services.
Appellants contend that because the Division only decided that
they did not suffer marginal losses for the rate periods in
question, the Division created the potential for "piecemeal
decisionmaking," which could result in additional delay.
However, there is no statute or administrative regulation
that requires the Division to consider every issue that may be
pertinent to a rate appeal even if it concludes that a hospital's
failure to satisfy one requirement of the regulation is
dispositive of the appeal. Moreover, it is not uncommon for an
administrative agency or a court to pass upon only those issues
that need to be addressed in order to reach a final decision in a
matter. For example, a court may grant summary judgment
dismissing a complaint based upon a single affirmative defense,
without considering other possible grounds for dismissal.
Although this form of disposition may result in additional
litigation if an appellate court concludes that the trial court
erred in granting summary judgment on that ground, this does not
mean that a trial court is required to consider not only the
defense that it finds to be dispositive of the case, but also all
other possible defenses simply to avoid the possibility of a
remand.
The same principle applies to administrative agency
adjudication. Although an agency may decide in its discretion to
consider all issues presented in an administrative proceeding, in
order to assure that a hearing will produce a final decision, it
is not required to do so. Consequently, the Division's decision
to consider only a single issue, which the Division found to be
dispositive of appellants' rate appeals, did not violate any of
the statutory or regulatory provisions governing the Medicaid
program or constitute an abuse of discretion. Any alleged error
in those decisions is not properly before us in this appeal, but
should instead be raised within the framework of appellants'
pending administrative appeals from those decisions.
V
Finally, we consider appellants' attorney's fee claim. This
claim is based on
42 U.S.C.A.
§1988, which provides that "[i]n
any action or proceeding to enforce a provision of section[] . .
. 1983 . . ., the court, in its discretion, may allow the
prevailing party, other than the United States, a reasonable
attorney's fee as part of the costs." Section 1983 (
42 U.S.C.A.
§1983) provides in relevant part:
Every person who, under color of any statute,
. . . subjects, or causes to be subjected,
any . . . person . . . to the deprivation of
any rights, privileges, or immunities secured
by the Constitution and laws, shall be liable
to the party injured in an action at law,
suit in equity, or other proper proceeding
for redress. . . .
Although our decision rests solely on state grounds, this
does not foreclose appellants from seeking an award of attorney's
fees under
42 U.S.C.A.
§1988, because a party who prevails
solely on state grounds, without the court reaching its federal
claims, may be entitled to such fees.
See Maher v. Gagne,
448 U.S. 122, 132-33,
100 S. Ct. 2570, 2576-77,
65 L. Ed.2d 653, 663
(1980);
Williams v. Hanover Housing Auth.,
113 F.3d 1294, 1297-99
(1st Cir. 1997);
see also Urban League of Greater New Brunswick
v. Mayor & Council of Carteret,
115 N.J. 536, 542-46 (1989).
Attorney's fees are recoverable in a § 1983 action if the
plaintiffs prevail on a state law issue arising from the same
nucleus of common facts as the federal claims, provided the
federal claims are substantial enough to support federal
jurisdiction.
Maher v. Gagne,
supra, 448
U.S. at 133 n.15, 100
S. Ct. at 2576, 65
L. Ed.
2d at 663;
see Williams v. Hanover
Housing Auth.,
supra, 113
F.
3d at 1298. A federal claim is
considered insubstantial only if it is obviously without merit or
its unsoundness "so clearly results from the previous decisions
of this court as to foreclose the subject and leave no room for
the inference that the question sought to be raised can be the
subject of controversy."
Hagans v. Lavine,
415 U.S. 528, 537-38,
94 S. Ct. 1372, 1379,
39 L. Ed.2d 577, 587-88 (1974).
Appellants asserted two federal claims. First, appellants
claimed that the Division's delays in deciding their rate appeals
violated the Due Process Clause of the Fourteenth Amendment. In
support of this claim, appellants relied solely upon four cases
that involved administrative delays in processing claims for
governmental benefits:
Fusari v. Steinberg,
419 U.S. 379,
95 S.
Ct. 533,
42 L. Ed.2d 521 (1975) (unemployment compensation);
Perez v. Lavine,
378 F. Supp. 1390 (S.D.N.Y. 1974) (welfare);
Nelson v. Sugarman,
361 F. Supp. 1132 (S.D.N.Y. 1972) (same);
Viglietta v. Blum,
437 N.Y. Supp.2d 625 (N.Y. Sup. Ct. 1981)
(medical assistance). However, this case does not involve an
individual's claim for governmental benefits but rather a
determination of the reimbursement rates to be paid to providers
of government funded services. In determining whether a party
has presented a viable procedural due process claim, two
fundamental considerations are the nature of the private interest
involved and the risk that the challenged administrative practice
will result in a deprivation of that interest.
See Mathews v.
Eldridge,
424 U.S. 319, 339-43,
96 S. Ct. 893, 905-07,
47 L. Ed.2d 18, 36-38 (1976). A Medicaid provider's interest in a prompt
determination of a dispute over the level of its reimbursement
rates is not at all comparable to an individual's need for a
speedy determination of his or her entitlement to welfare
benefits or other government assistance necessary to provide
food, shelter and other essentials of life, such as was involved
in the cases upon which appellants rely.
Compare Goldberg v.
Kelly,
397 U.S. 254, 260-66,
90 S. Ct. 1011, 1016-20,
25 L. Ed.2d 287, 295-98 (1970)
with Ritter v. Cohen,
797 F.2d 119, 124 (3d
Cir. 1986),
and Cassim v. Bowen,
824 F.2d 791, 797-98 (9th Cir.
1987).
Furthermore, appellants had a readily available remedy to
prevent undue delay in the issuance of decisions in their rate
appeals. As discussed in section I of this opinion, appellants
could have filed a notice of appeal and motion for summary
disposition to compel the Division to decide their appeals. The
availability of such an expeditious judicial remedy may negate
any claim that a party has been deprived of a constitutionally
protected interest as a result of agency inaction.
See Anastasio
v. Planning Bd. of Township of West Orange,
209 N.J. Super. 499,
519-22 (App. Div.),
certif. denied,
107 N.J. 46 (1986);
see also
Rivken v. Dover Township Rent Leveling Bd.,
143 N.J. 352, 378-79,
cert. denied,
519 U.S. 911,
117 S. Ct. 275,
136 L. Ed.2d 198
(1996).
In
Anastasio, a developer obtained a judgment under
42 U.S.C.A.
§§1983 and 1988 against members of a planning board on
the theory that their delay in reviewing and approving a site
plan application violated the Due Process Clause of the
Fourteenth Amendment and the Takings Clause of the Fifth
Amendment. In reversing, we noted that plaintiff was "free at
any time to bring an action in lieu of prerogative writs under
state law to challenge the action of the board" and concluded
that "as a matter of law plaintiff could suffer no violation of
any constitutional right by reason of delay in approval of its
site plan." 209
N.J. Super. at 520. The Third Circuit reached
the same conclusion in rejecting a developer's claim that a
municipality's delay in issuing a building permit constituted a
denial of procedural due process.
Bello v. Walker,
840 F.2d 1124, 1127-28 (3d Cir.),
cert. denied,
488 U.S. 851,
109 S. Ct. 134,
102 L. Ed.2d 107 (1988);
see also DeBlasio v. Zoning Bd. of
Adjustment of West Amwell,
53 F.3d 592, 597 (3d Cir.),
cert.
denied,
516 U.S. 937,
116 S. Ct. 352,
133 L. Ed.2d 247 (1995)
("[W]hen a state affords a full judicial mechanism with which to
challenge the administrative decision in question, the state
provides adequate procedural due process, . . . whether or not
the plaintiff avails himself or herself of the provided appeal
mechanism.") (quoting
Bello,
supra, 840
F.
2d at 1128).
Similarly, appellants' own deliberate decision not to avail
themselves of the readily available judicial remedy for
administrative inaction precluded them from asserting a claim
under the Due Process Clause.
Appellants' second federal claim was predicated upon a
regulation of the Department of Health and Human Services (DHHS),
which provides in relevant part:
The Medicaid agency must provide an appeals
or exception procedure that allows individual
providers an opportunity to submit additional
evidence and receive prompt administrative
review, with respect to such issues as the
agency determines appropriate, of payment
rates.
[42
C.F.R. § 447.253(e)(2000)]
This regulation was adopted to implement the so-called "Boren
Amendment," under which states were required to establish
Medicaid rates that were "reasonable and adequate to meet the
costs which must be incurred by efficiently and economically
operated facilities."
42 U.S.C.A.
§1396a(a)(13)(A). The
Balanced Budget Act of 1997, Pub. L. No. 105-33,
111 Stat. 251, §
471, repealed the Boren Amendment and replaced the requirement of
"reasonable and adequate" rates with a requirement of a "public
process for determination of rates of payment."
42 U.S.C.A.
§1396a(a)(13)(A). However, because some of appellants' rate
appeals were filed prior to the repeal of the Boren Amendment, it
is arguable that this legislation and the regulations adopted
thereunder, including 42 C.F.R. § 447.253(e), apply to this
case.See footnote 44 See Children's Hosp. & Health Ctr. v. Belshe,
188 F.3d 1090, 1095 (9th Cir. 1999).
There is a conflict among the federal circuit courts of
appeals as to whether an administrative regulation constitutes a
"law" within the intent of
42 U.S.C.A.
§1983. Compare Harris v.
James,
127 F.3d 993, 1005-09 (11th Cir. 1997), with Boatman v.
Hammons,
164 F.3d 286, 289 (6th Cir. 1998). If an administrative
regulation by itself cannot provide the foundation for a § 1983
claim, appellants' claim that the Division violated 47 C.F.R. §
447.253(e) would not be maintainable under
42 U.S.C.A.
§§1983
and 1988. However, we do not need to decide this issue, because
we conclude that 47 C.F.R. § 447.253(e) did not create a
privately enforceable right.
It is now firmly established that "to seek redress through §
1983, . . . a plaintiff must assert the violation of a federal
right, not merely a violation of a federal law." Blessing v.
Freestone,
520 U.S. 329, 340,
117 S. Ct. 1353, 1359,
137 L. Ed.2d 569, 582 (1997). Three factors determine whether a statutory
provision creates an individual federal right:
First, Congress must have intended that the
provision in question benefit the plaintiff.
Second, the plaintiff must demonstrate that
the right assertedly protected by the statute
is not so "vague and amorphous" that its
enforcement would strain judicial competence.
Third, the statute must unambiguously impose
a binding obligation on the States. In other
words, the provision giving rise to the
asserted right must be couched in mandatory
rather than precatory terms.
[Id. at 340-41, 117 S. Ct. at 1359, 137 L.
Ed.
2d at 582.]
In determining whether a statutory provision satisfies these
criteria, a court should not consider a statute "as an
undifferentiated whole," but should instead determine whether the
specific provision relied upon by the plaintiff creates privately
enforceable rights. Id. at 342, 117 S. Ct. at 1360, 137 L. Ed.
2d at 583. Consequently, even though the Supreme Court concluded
that the Boren Amendment's mandate that states establish Medicaid
rates that are "adequate to meet the costs that must be incurred
by efficiently and economically operated facilities,"
42 U.S.C.A.
§1396a(a)(13)(A), created a privately enforceable right, Wilder
v. Virginia Hosp. Ass'n,
496 U.S. 498,
110 S. Ct. 2510,
110 L.
Ed.2d 455 (1990), this does not mean that every other obligation
imposed under authority of the Boren Amendment also gave rise to
privately enforceable rights.
We conclude that 47 C.F.R. § 447.253(e) did not create
privately enforceable rights because it was couched in
"precatory" rather than "mandatory" terms. Blessing, supra, 520
U.S. at 340, 117 S. Ct. at 1359, 137 L. Ed.
2d at 582. The
essentially "precatory" nature of the obligation imposed by 42
C.F.R. § 447.253(e) is evidenced by the statement issued by DHHS
when it adopted the regulation:
With regard to the comment on establishing
time periods, we believe that a greater
degree of specificity in the appeals
provision would not be in the interests of
State flexibility nor would it necessarily
result in any substantial benefit to the
Medicaid program. We do agree that State
appeal procedures should be consistent with
the intent of the Federal provision regarding
prompt administrative review as currently
reflected in the regulation. Therefore, we
are not revising the regulations to specify a
given time period, for the State to act on
appeal requests.
[
48 Fed. Reg. 56,046, 56,052 (1983).]
In view of the fact that DHHS made a deliberate policy decision
not to require state Medicaid agencies to decide rate appeals
within a specific period of time, we do not believe that 47
C.F.R. § 447.253(e) can be reasonably read to "unambiguously
impose a binding obligation on the States." Blessing, supra, 520
U.S. at 340, 117 S. Ct. at 1359, 137 L. Ed.
2d at 582.
Moreover, even if a plaintiff demonstrates by application of
the three factors identified in Blessing that a statutory
provision was intended to confer an individual right, this only
establishes "a rebuttable presumption that the right is
enforceable under § 1983." Blessing, supra, 520 U.S. at 341, 117
S. Ct. at 1360, 137 L. Ed.
2d at 582. Congress may foreclose
relief under § 1983 either "expressly, by forbidding recourse to
§ 1983 in the statute itself, or impliedly, by creating a
comprehensive enforcement scheme that is incompatible with
individual enforcement under § 1983." Ibid. Appellants' claim
was grounded solely upon 47 C.F.R. § 447.253(e), not any
statutory provision. Consequently, the question is not one of
congressional intent but rather whether DHHS intended to confer
an individual right when it adopted 47 C.F.R. § 447.253(e). We
are satisfied based on the language of this regulation and the
previously quoted accompanying statement that DHHS did not intend
to authorize an action under
42 U.S.C.A.
§1983 whenever a
Medicaid agency failed to issue a timely decision in a rate
appeal. See Suter v. Artist M.,
503 U.S. 347, 357-64,
112 S. Ct. 1360, 1366-70,
118 L. Ed.2d 1, 12-16 (1992); Harris v. James,
supra, 127 F.
3d at 1008-10.
In sum, appellants failed to present a substantial question
under the Due Process Clause or other federal law, and therefore
are not entitled to attorney's fees under
42 U.S.C.A.
§1988.
Accordingly, the Division of Medical Assistance and Health
Services is directed to decide future appeals of hospitals'
Medicaid reimbursement rates within a reasonable period of time.
Appellants' other claims for relief are denied.
Footnote: 1 1 Appellants' counsel advised the court at oral argument
that Deborah's rate appeals have been the subject of settlement
discussions, and that Deborah is not pursuing any claim regarding
the Division's failure to decide those appeals during the period
following July 9, 1999.
Footnote: 2 2 There is some authority for the view that the Law
Division has jurisdiction to entertain an action to compel a
state agency to perform a ministerial duty. See Pfleger v. State
Highway Dep't,
104 N.J. Super. 289 (App. Div. 1968); Colon v.
Tedesco,
125 N.J. Super. 446 (Law Div. 1973). However, the
Division's determinations concerning the allocation of staff and
other resources to review and issue decisions in Medicaid rate
appeals clearly involves a discretionary rather than a
ministerial duty.
Footnote: 3 3 The Division indicates that it received seventeen
appeals of the January 1996 rates, twenty appeals of the October
1996 rates, seventeen appeals of the January 1997 rates and
twenty appeals of the January 1998 rates.
Footnote: 4 4 In view of the repeal of the Boren Amendment, DHHS
announced the proposed repeal of 42 C.F.R. § 447.253(e) on
October 6, 1999. 64 Fed. Reg. §§ 54,263, 54,266 (1999).