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Kuppersmith v. Dowling, 1999 N.Y. Int. 0033 (Mar. 25 1999).




Whether 18 N.Y.C.R.R. §505.14(b)(3)(i)(a)(3), the regulation governing a treating physician's ability to order home care services under the Medicaid program, is arbitrary and capricious in refusing to establish a presumption in favor of the treating physician's recommendation as to the number of hours of home care services the patient should be authorized to receive.


No. The regulation is reasonable and within the Medicaid Act's broad grant of authority to New York to chose the proper scope and duration of benefits, while meeting the needs of recipients.


Title XIX of the Social Security Act, 42 USC §§ 1396 et seq. (the "Medicaid Act"), gives federal grants to states to provide medical and rehabilitative services to the poor, elderly and disabled. Although federal regulations provide that "personal care services" will be prescribed by a physician, the Medicaid Act broadly authorizes states to establish plans for implementing such services, so long as the state standards are reasonable and consistent with the Medicaid Act.

New York's implementing regulations include six requirements for the authorization of home care services. See, 18 N.Y.C.R.R. 505.14 et seq. Under these regulations the treating physician must submit a form to the local social services district describing the patient's medical condition and the tasks for which the patient requires assistance. Physicians are proscribed, however, from recommending the number of hours that the patient should be authorized to receive. The final determination of what services and how many hours will be provided is made by the local social services district after conducting a multi-faceted review of the case, including an assessment of the social, home care, and nursing needs, as well as an inquiry into the appropriateness and cost-effectiveness of the contemplated services.

Petitioners, a certified class of Medicaid recipients, challenged the implementation of 18 N.Y.C.R.R. 505.14(b)(3)(i)(a)(3), that portion of the regulations circumscribing the role of the treating physician. They argued that greater weight should be given to the treating physician's assessment of what personal care services should be provided. The Supreme Court and Appellate Division rejected these claims, finding that the regulation was not "arbitrary, capricious, or manifestly contrary to the statute," and rejecting a "treating physician's rule" that would establish a presumption that the treating physician's recommended number of personal care services should be granted.

The Court of Appeals affirmed the Appellate Division. The Court found that the New York standards for determining the extent of Medicaid home health assistance were within the Medicaid Act's broad grant of authority, indicating that such standards need only be reasonable and consistent with the objectives of the act. See Beal v. Doe, 432 U.S. 438, 444 (1977). The New York home health program properly takes into consideration multiple factors relevant to providing services to persons in need. Since the program involves more than a single medical determination, the state determination to not defer to a treating physician's opinion was reasonable and consistent with the objectives of the Medicaid Act.

Prepared by the liibulletin-ny Editorial Board.