L.Douglasv.IndependentLivingCenterand
FederalMedicaidPaymentRequirements
CharlesLuband
SNRDentonUSLLP
Introduction
I.
TheMedicaidprogramisastateprogramoperatedwithintheconfinesoffederal
law.Thus,eventhoughtheprogramisadministeredbythestates,federallaw
restrictsastate’sactionsinadministeringtheMedicaidprogram.
Thepurposeofthisoutlineistodiscusstheseoverlappingauthoritiesinthecontext
ofMedicaidpaymentrequirements.ThecurrentcontroversyregardingMedicaid
paymentrequirementsdatestotheearly1980s,whenMedicaidrateswere
decoupledfromMedicareratesforbothhospitalsandnursinghomes.Fromthis
pointforward,providersoftenaccusedstatesofviolatingoffederallawwhen
providerrateswerenolongersufficient.However,whetherindividualdisputes
weresuccessfulhasdependednotjustonthemeritsofthecasesbutalsoonchanges
infederallaw,changesincaselaw,andonchangingtheoriesregardingtheabilityof
providerstoactuallyevenmaintainanaction.Inthemeantime,therehasbeen
scantregulationfromthefederalagency.
TheDouglascasesariseinthecontextofthathistory.HowtheSupremeCourtrules
maysubstantiallyshapethefutureofproviderlawsuitsagainststateswithrespect
toMedicaidproviderrates.Atthesametime,andinresponsetoDouglas,the
CentersforMedicareandMedicaidServices(“CMS”)haspromulgatedaproposed
rulewhichcouldalsoinfluencefutureconversationsbetweenprovidersandstates
regardingpaymentrates.Furthermore,despitethependencyoftheDouglascases
beforetheSupremeCourt,providersinCaliforniahavecontinuedtolaunch
successfullawsuitsagainstthestateofCaliforniatotrytoforestalladditionalcutsin
reimbursement.
Thisoutlinewillfirstbrieflydescribethehistoryofcaselawconcerningprovider
enforcementoffederalMedicaidpaymentrequirements,thendescribetheDouglas
casesandthemostrecentprovidercasesinCalifornia.IwillalsodescribetheCMS
proposedregulation.FinallyIwilldiscusssomeadditionalissuesforthefuture.
II.
AHistoryofProviderEnforcementofFederalMedicaidPayment
Requirements.
Incontestingwhetherstatesetproviderratescomplywithfederallaw,providers
sincetheearly1980shavegenerallyreliedontwoprovisionsoffederallaw:First,
theBorenAmendmentrequirementinSection1902(a)(13)oftheSocialSecurity
Actthatpaymentsbe“reasonableandadequatetomeetthecostswhichmustbe
incurredbyefficientlyandeconomicallyoperatedfacilities.”Second,theEqual
AccessrequirementinSection1902(a)(30)(A)oftheSocialSecurityActthat
paymentbe“consistentwitheconomy,efficiencyandqualityofcareand…sufficient
toenlistenoughproviders….”SincetherepealoftheBorenAmendmentin1997,
theEqualAccessprovisionhasbeenthefocusofproviderlawsuitsregardingthe
adequacyofrates.
Itisimportanttonotethatprovidersneednotallegeaviolationoffederallawin
ordertochallengestateproviderrates.Providersoftencanlaunchachallenge
basedonstatelawprovisionsorevenbasedontheMedicaidprovideragreement
betweentheproviderandthestateMedicaidprogram.
A.
TheBorenAmendment
Priorto1980,MedicaidratesweregenerallytiedtoMedicarerates,whichweretied
tocosts.Statesthushadlittleflexibilityinsettingpaymentrates.Intheearly1980s,
variousactsofCongress(inparticular,theOmnibusBudgetReconciliationActs
(OBRAs)of1980and1981)brokethelinktoMedicareratesandprovidedstates
withenhancedflexibilityinsettingpaymentrates.
AkeyaspectofthischangewasadoptionoftheBorenAmendment,whichallowed
statestoprovidepaymentbasedonmethodsandstandardsdevelopedbythestate,
solongastherateswere“reasonableandadequatetomeetthecostswhichmustbe
incurredbyefficientlyandeconomicallyoperatedfacilities.”Pub.L.No.96‐499,94
Stat.2650,§962(a)(amendingSection1902(a)(13)(E)oftheSocialSecurityAct).As
discussedbelow,thisprovisionledtoscoresofproviderclaimingthatrateswerenot
reasonableoradequate.
CongressrepealedtheBorenAmendmentaspartoftheBalancedBudgetActof
1997andlargelyreplacedtherequirementsinSection1902(a)(13)withprocedural
requirements.
B.
TheEqualAccessProvision
SinceveryearlyintheimplementationoftheMedicaidprogram,theprogramhas
includedtherequirementthatpaymentsbesufficienttoensureaccess,quality,and
efficiency.Theserequirementswerelatercodifiedinregulation.SeeS.Rosenbaum,
IssueBrief:MedicaidPaymentRateLawsuits,CaliforniaHealthCareFoundation
(hereinafter“IssueBrief”)3(Oct.2009)(citinga1966Handbook).
In1989,CongressincorporatedtheserequirementsintotheMedicaidActdirectly,
thusrequiringthatstates“assurethatpaymentsareconsistentwithefficiency,
economy,andqualityofcareandaresufficienttoenlistenoughproviderssothat
careandservicesareavailableundertheplanatleasttotheextentthatsuchcare
andservicesareavailabletothegeneralpopulationinthegeographicarea.”Section
1902(a)(30)(A).
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C.
LawsuitsandIssues
FollowingthepassageoftheBorenAmendment,therewerenumeroussuitsby
providersandprovidergroupsallegingstateviolationsoftheBorenAmendment
requirementthatratesbe“reasonableandadequate”tomeetthecostsof“efficiently
andeconomicallyoperatedfacilities.See,e.g.,AMISUB(PSL)Inc.v.ColoradoDept.of
SocialServices,879F.2d789(10thCir.1989);WestVirginiaUniversityHospitals,Inc.
v.Casey,885F.2d11(3rdCir.1989).Incertaincases,notablyOrthopaedicHospitalv
Bleshe,103F.3d1491(9thCir.1997),providersalsoclaimedviolationsoftheEqual
AccessProvision.InOrthopaedicHospital,theNinthCircuitdeterminedthatthe
EqualAccessProvisionrequiredthatfor“paymentratestobeconsistentwith
efficiency,economy,qualityofcareandaccess,theymustnearareasonable
relationshiptoprovidercosts.”ThecourtfurtherrequiredthattheCalifornia
Medicaidagencybeartheburdenofjustifyinganypaymentratethatsubstantially
deviatesfromcosts.
Asapreconditiontodeterminingwhetherthestatehadviolatedthefederal
requirements,aquestionthatincreasinglyaroseinthecontextoftheselawsuitswas
whethertheprivatepartybringingthelawsuithadarightthatcouldbeenforcedin
thefederalcourts.Manyofthelawsuitsinfederalcourtwerebroughtunderthe
auspicesof42U.S.C.§1983,aCivilWarerastatutethatpermitsprivateplaintiffsto
suestatesthatviolaterightssecuredunderfederalstatutes.Section1983offered
certainadvantages,inparticularthepotentialtoobtainrecoveryofattorneysfees.
SomeothercaseswerenotasclearlybroughtundertheauthorityofSection1983.
BecauseSection1983requiresthattheprivatepartyhavearightsecuredundera
federalstatute,aninitialdefenseofmanystateswasthattheBorenAmendmentdid
notprovidesucharighttoproviders.InthecontextoftheBorenAmendment,this
issuewasresolvedbytheU.S.SupremeCourtinfavorofprovidersbyWilderv.
VirginiaHosp.Ass’n,496U.S.498(1990),whichheldthattheBorenAmendment
wasenforceableunderSection1983.WhethertheEqualAccessProvisionincluded
anenforceablerighthasneverbeendefinitivelydeterminedbytheSupremeCourt
(althoughundercurrentprecedent,discussedbelow,itseemsdoubtful).
Additionalareasofconstitutionallawandfederallawhavealsoshapedpayment
ratelawsuitsagainststates.Forexample,becauseoftheconceptsoffederalism
rootedinthe11thAmendmenttotheU.S.Constitution,statesareimmunefrom
lawsuitsfordamagesinfederalcourt.Asaresult,casesbroughtbyprovidersare
framedaslawsuitsagainstspecificstateofficialsforprospectiveinjunctiverelief.
Thisissueisimportant,butnotessentialtothependingDouglascases.
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D.
TheImpactofGonzaga
AlthoughthequestionofwhethertheBorenAmendmentwasenforceablewas
decidedbytheWilderdecision,thecontinuedabilityofproviderstobringlawsuits
againststateswithrespecttoproviderrateswasundercutsignificantlybytwo
differentissues.Mostobviously(andwhichwasalreadymentionedabove)wasthe
repealoftheBorenAmendment,whichwasadirectpoliticalresultofthestates’
upsetregardingproviderlawsuits.Thesecondwasasignificantshiftincaselaw
regardingtheabilityofplaintifftobringactionsunderSection1983.Most
significantly,inGonzagaUniversityv.Doe,576U.S.273(2002),theSupremeCourt
heldthat,inordertobringanactionunderSection1983,theremustbean
“unambiguouslyconferredrighttosupportacauseofaction.”TheGonzagacase
hadnothingtodowithMedicaid‐‐theunderlyingactiondealtwiththeFederal
EducationRecordsPrivacyAct‐‐buttheimpactonMedicaidcaseswasprofound.
PriortoGonzaga,therewasadevelopingsplitintheCircuitswithrespectto
whetherproviderscouldbringactionsunderSection1983withrespecttotheEqual
AccessProvision.(Inaddition,therewasasignificantsplitwithrespecttothe
natureoftherequirementsimposedbytheEqualAccessProvision.)AfterGonzaga,
thecourtsmoreuniformlyfoundthattheprovidershadnoenforceablerightof
actionanddidnotevenreachthemeritsofwhattheEqualAccessProvision
requiredofstates.SeeS.Rosenbaum,IssueBrief,Appendix.
III.
TheDouglascases
ThebackgroundconcerningMedicaidproviderrateappealsisessentialto
understandingtheDouglascases.TheDouglascasesarereallythreecases‐‐
Douglasv.IndependentLivingCenterofSouthernCalifornia,Douglasv.California
PharmacistsAss’n,andDouglasv.SantaRoseMemorialHospital‐‐thatwere
consolidatedbytheSupremeCourt.ThequestionbeforetheCourtinthesecasesall
raisethesameissue,whichiswhetherMedicaidbeneficiariescanchallengeastate
lawinfederalcourtbasedontheclaimthatthestatelawconflictswithfederallaw
andisthusinvalidbasedontheSupremacyClauseoftheUnitedStatesConstitution.
(Anotherwayofsayingthesamethingistosaythatthestatelawis“preempted”by
theconflictingfederallaw.)
Asdiscussedabove,priortoGonzaga,mostplaintiffsallegingthatstateprovider
rateswereinconsistentwithfederalMedicaidlawwouldbringanactionunder
Section1983,particularlybecauseofthepotentialtoobtainattorneysfees.The
DouglasplaintiffsdidnotbringanactionunderSection1983butratherallegeda
directconstitutionalviolationviatheSupremacyClause.
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A.
HistoryPriortotheSupremeCourt
TheDouglasdisputesbeganin2008,whentheCaliforniastatelegislaturepasseda
seriesoflawsreducingratesundertheMedi‐Cal(CaliforniaMedicaid)fee‐for‐
serviceprogram.Theinitialcuts,imposedbyAssemblyBillX35(“AB5”)were
enactedinFebruary2008withaneffectivedateofJuly1,2008.Thelegislation
providedfortenpercentcutstoMedicaidpaymentratesforphysicians,dentists,
pharmacies,adultdayhealthcenters,clinics,hospitalsandotherproviders.The
CalifornialegislaturelatersupersededtheAB5cutsandimposed,effective
February28,2009,adifferentsetofcutsthatrangedfrom1percentto10percent.
Allofthesereductionswereenactedfortheexpresspurposeofaddressingthe
CaliforniabudgetdeficitandneitherthelegislaturenorthestateMedicaidagency
studiedtheimpactthattheratereductionswouldhavepriortotheenactmentofthe
cuts.
Providerandbeneficiaryorganizationsbroughtfiveseparatelawsuitsinstateand
federalcourtsinCalifornia.Thefirstfederaldistrictcourttohearthecasedenied
theplaintiffs’motionforinjunctiverelief,statingthattheEqualAccessProvisiondid
notcreateanenforceablerightofaction.TheNinthCircuitreversedthedistrict
courtandremanded.Thefederaldistrictcourteventuallydidenjointhestatefrom
implementingtheratereductionsinallofthecases.TheNinthCircuitupheldthe
districtcourtdecisions,statingthatthereductionswereinconsistentwiththeEqual
AccessProvisionandrelyingontherequirementsonstatesthattheNinthCircuit
hadimposedinOrthopaedicHospital.TheNinthCircuitstatedthattheclaimswere
properlybroughtinfederalcourtdirectlyundertheSupremacyClause,without
regardtowhethertheymightalsobebroughtunderSection1983orthroughan
impliedrightofaction.
CaliforniatwicerequestedreviewbytheSupremeCourt,firstwhentheNinth
Circuitinitiallyreversedthedistrictcourtandremanded,IndependentLivingCenter
v.Shewry,543F.3d1050(9thCir.2008),cert.denied,129S.Ct.2828(2009),and
thenagainwhenthecasecameupagainonappeal.ThesecondpetitiontotheCourt
containedtwoquestionsthattheyhopedtohavetheCourtconsider:(1)whether
Medicaidrecipientsandprovidersmaymaintainacauseofactionunderthe
SupremacyClausetoenforcetheEqualAccessProvision,and(2)whetherastate
lawthatcouldresultinreducedMedicaidreimbursementtoprovidersmaybe
preemptedbytheEqualAccessProvisionbasedonrequirementsthatdonotappear
inthetextofthestatute(i.e.therequirementof“responsiblecoststudies”foundby
theNinthCircuit).TheCaliforniaprovidersopposedanySupremeCourtreview.
InMay2010,theCourtrequestedthattheSolicitorGeneralprovideguidanceasto
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whethertheCourtshouldgrantreview.TheSolicitorGeneral’sviewswereseenby
allsidesasbeingcritical.Afterextensivelobbyingbyoutsidegroups,theSolicitor
GeneralrecommendedthattheCourtnotgrantreview,amongotherthings,noting
thatCMSwouldbeshortlyissuingregulationsthatwouldassistindefiningthe
substanceoftheEqualAccessProvisionandwhatrequirementsmustbefollowed
bystates..TheCourtneverthelessgrantedcertiorariinJanuary2011,butonlywith
respecttothequestionofwhethertheSupremacyClauseallowedanaction.
Akeyissueinthecontextofthebriefingin2011wasthequestionofwhichsidethe
SolicitorGeneralwouldtakewithrespecttothequestionbeforetheCourt.The
SolicitorGeneral’slettertotheSupremeCourtin2010hadnotbeenasstrongin
oppositiontoCourtreviewasnationalprovidergroupshadhoped.Infact,whenthe
SolicitorGeneralfinallyfiledabrief,theSolicitorGeneralsidedwithCaliforniain
urgingthattheCourtfindthattheSupremacyClausedidnotprovidetheCalifornia
plaintiffswiththeabilitytogointofederalcourt.Briefingwascompletedinthe
summerof2011,andthecasewasthefirstheardbytheCourtinthe2011‐12Term.
B.
ArgumentsBeforetheCourt
TheStatesbasicargumentbeforetheCourtwasthatithasbeenfairlywell
establishedthattheMedicaidActdoesnotincludeanexplicitrightforaprovideror
beneficiarytocontestastateviolationoftheEqualAccessProvision.The
SupremacyClausemaynotbeusedtobasicallyrunaroundtheabsenceofa
statutorilyestablishedrightofaction.
Theprovidersandbeneficiariescounteredthatthecourts,andtheSupremeCourt,
havelongallowedSupremacyClauseactionsbyaggrievedparties,bothinsideand
outsideoftheMedicaidcontext,withoutregardtowhetherornottheunderlying
statuteprovidesarightofaction.Infact,theabilityofaggrievedpartiestobring
suchactionsactuallyfurthersratherthanfrustratesCongress’sintent.
TheCourtheardoralargumentsinOctober.TheCourt’sdecisionisexpected
shortly.
C.
TheRegulatoryProcessandFurtherRateReductions
StatesaregenerallyrequiredtoamendtheirMedicaidstateplanwheneverastate
makesasignificantchangetotheirMedicaidprogram.Althoughthestateof
Californiahadsubmittedstateplanamendmentstoimplementthecutscontainedin
thelegislationunderlyingtheDouglasdisputes,thestatedidsolate,firstsubmitting
stateplanamendmentstotheCMSinSeptember2008.Thestatealsodidnotreply
toCMSrequestsforadditionalinformation,andinNovember18,2010,CMS
eventuallynotifiedthestatethatitwasdenyingthestateplanamendments.The
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statenotifiedCMSthatitwasrequestingreconsiderationofthestateplan
amendmentdenial.
Eventually,inthecontextofstateplanamendmentapprovalprocesseswithrespect
toratereductionsin2011,Californiadroppeditsrequestforreconsiderationwith
respecttoanytimeperiodpriorto2011,whereithadbeenenjoinedfromreducing
rates.OnOctober27,2011,CMSapprovedtheratereductionsthatwouldoccur
beginningJanuary1,2011.BecausetheCaliforniaratereductionsrequestedfor
2011werepiledontopofthereductionsthestatehadpreviouslysought,CMSin
essenceapprovedreductionsevengreaterthanthereductionsthathadbeensought
inthelegislationthatunderlietheDouglascases.
Asaresult,thespecificratereductionsatissueinthelegislationthatunderliethe
DouglascaseswerenolongerbeingsoughtbythestateofCaliforniafortimeperiods
beforeJanuary1,2011,andCMShadprovidedspecificapprovalforratereductions
afterJanuary1,2011,basedonlegislationandstateplanamendmentsthatwere
differentfromthosethatunderlaytheDouglascases.OnOctober28,2011,the
SolicitorGeneralnotifiedtheSupremeCourtofthesedevelopments,andon
November4,2011,theSupremeCourtrequestedthatthepartiesaddresswhether
andhowthesedevelopmentsshouldimpacttheCourt’sconsiderationofthecase.In
essence,thequestionwaswhethertheunderlyingquestionwasnowmootandthe
caseshouldbedismissed.
InresponsetotheCourt’srequest,allpartiesagreedthatthecasewasnotmoot.
CaliforniaandtheSolicitorGeneraleachurgedthattheCourtproceedtodecidethe
questionthathadbeenbriefedregardingtheSupremacyClause.Theproviders
urgedthatthechangedcircumstancesindicatethattheCourtcoulddismissthe
writsofcertiorariashavingbeenimprovidentlygranted.Thiswouldinessence
sendthecasesbacktothedistrictcourts.Notethatitwassomewhatsurprisingthat
theSolicitorGeneraldidnoturgethattheCourtdismiss,sincetheSolicitorGeneral
hadurgedin2010thattheCourtnottakethecases.Thecasescontinuetobe
pendingbeforetheSupremeCourt.
Inthemeantime,theCaliforniaprovidersandbeneficiariesthatoriginallybrought
theactionsinfederaldistrictcourtthatunderlaytheDouglascaseswentbackinto
federaldistrictcourttochallengethenewratereductionsandseekaninjunction
preventingthoseratereductionsfromgoingintoeffect.Inadditiontoclaimingthat
thestatehadviolatedtheSupremacyClause,thenewlawsuitsaddedthefederal
DepartmentofHealthandHumanServices(“HHS”)asaDefendantandclaimedthat
theapprovaloftheratereductionsbyHHSwasaviolationoftheAdministrative
ProceduresAct(“APA”).
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Thusfar,thenewlawsuitsbyprovidersandbeneficiariestostopthenewrate
reductionshavebeensuccessful.ThedistrictcourtshavefoundthattheCMS
approvalofthecutslikelyviolatedtheMedicaidActandtheAPA.Thecourtshave
statedthatbecausetheCMSletterthatapprovedtheratecutsprovidednorationale
orexplanationanddidnotresultfrom,orprovidefor,third‐partyrevieworinput,
anddidnotinvolveanadministrativeadjudication,CMS’spositionisnotgrantedthe
substantialamountofdeferencethatwouldotherwiseberequiredbyChevronU.S.A.
v.NRDC,467U.S.837(1984).ThreecasesarecurrentlybeingappealedtotheNinth
CircuitwithopeningbriefsbythestatescheduledtobefiledtheweekofFebruary
21.
IV.
FederalRegulationsRegardingtheEqualAccessProvision
Requirements
Asnotedabove,in2010,theSolicitorGeneral,aspartofitsbrieftotheSupreme
CourturgingtheCourtnottograntreviewoftheDouglascases,notedthatCMSwas
intendingtoissueregulationsregardingtheEqualAccessProvision.CMSissueda
proposedruleonMay6,2011.
A.
SummaryoftheProposedRule
Theproposedrulewouldrequirethatstatesperformananalysisofaccessto
Medicaidservicesatleastonceeveryfiveyears.Ifthestate’sanalysisdetermines
thataccessisinsufficient,thestatemustsubmitacorrectiveactionplantocorrect
theaccessproblemwithinoneyear.Intermsofmeasuringaccess,CMSdidnot
proposeaspecificstandardbutratherproposedguidelinesforstatesto
demonstrateconsistencywiththeaccessrequirements.CMSdidnotproposeto
requirethatproviderrateshaveaspecificrelationshiptoprovidercosts,whichwas
whattheNinthCircuitrequiredinOrthopaedicHospital.
CMSwouldrequirethatstatesconsiderinputfrombeneficiariesandstakeholders
regardingaccessbeforesubmittingastateplanamendment.
B.
CriticismoftheProposedRule
ManyorganizationscommentedontheProposedRule.Providerorganizationsin
particularcommentedthattheaccessframeworkmustmoredirectlylinkprovider
paymentratestobeneficiaryaccess.Further,manyproviderorganizationsurged
thatamechanismbeestablishedthatwouldallowbeneficiariesandstakeholders
(i.e.providers)toraiseconcernsandissuesregardingaccessandproviderpayments
directlywithCMS.Theproposedrule’sexclusionofmanagedcarerateswasalso
criticized.Theproposedrulehasnotyetbeenfinalized.
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V.
WhatdoesallofthismeanforMedicaidandMedicaidproviders?
A.
TheSupremeCourtDecision
IftheSupremeCourtallowscasestoproceedundertheSupremacyClause,there
mightbeasubstantialresurgenceinprovidersbringingactionsagainststatesto
challengeratereductions.Therearealreadysomesignsofsucharesurgence.
TherearecurrentchallengesinatleastArizonaandWashingtonStateintheNinth
CircuitandintheEleventhCircuit.
However,theabilitytobringanactiondoesnotnecessarilydeterminethesubstance
oftheEqualAccessProvisionandwhetherornotacourtwillbedeterminedtohave
violatedtheEqualAccessProvision.AnimportantfactorregardingtheNinth
Circuit’sdecisionsinCalifornia(andthereasonwhysimilarlawsuitsarebeing
broughtspecificallyintheNinthCircuit)isthelong‐lastingandprescriptive
precedentialvalueofOrthopaedicHospitalindefiningwhattheEqualAccess
Provisionrequires,atleastintheNinthCircuit.Althoughthefederaldistrictcourt
fortheDistrictofConnecticutdidnotdismissaclaimregardingtheEqualAccess
ProvisionbroughtundertheSupremacyClause,thecourtheldthattheEqualAccess
ProvisiondidnotincludetheproceduralrequirementsthattheNinthCircuithas
requiredandrefusedtograntapreliminaryinjunction,statingthattheplaintiff
associationhadnotshownalikelihoodofsuccesswithrespecttothesubstantive
issuesandgivingdeferencetoCMS’sapprovalofthestate’splansubmission.The
districtcourt’sdecisionwassummarilyupheldbytheSecondCircuitinan
unpublisheddecision.
Ontheotherhand,thesuccessoftheprovidersandbeneficiariesinCalifornia
bringingactionsinfederaldistrictcourtwithrespecttotheAPAmightbeyet
anotherrouteforproviderandbeneficiaries.Inthemostrecentcasesreferencedin
SectionIII.Cabove,providersandbeneficiarieshavesuccessfullyenjoinedrate
reductionsbychallengingCMS’approvalofthestateplanamendmentsthatwould
haveimplementedtheratereductions.However,thesecasesmayalsorelyonthe
proeceduralrequirementsthattheNinthCircuithasheldexistintheEqualAccess
Provision.
B.
TheProposedRegulation
Anothersignificantquestioniswhethertheproposedregulationregardingthe
EqualAccessProvisionwillhaveanyimpactontheabilityofprovidersand
beneficiariestochallengeratereductions.IfCMS’regulationisviewedasproviding
theagency’sviewsregardingthesolesubstantiveandproceduralrequirements
imposedbytheEqualAccessProvision,thatcouldwellundercutproviderand
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beneficiarylawsuitsthathavereliedonmorethanwasincludedintheproposed
rule.Forexample,therequirementsinOrthopaedicHospitalarenotpresentinthe
proposedrule.
Ontheotherhand,ifthefinalruleaddsmoretotheEqualAccessProvisionor
providessomeotheravenueforimpactedprovidersorbeneficiariestochallenge
ratereductions,thefinalregulationcouldresultinanadditionaladministrative
avenueforpaymentratereductionchallenges.
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