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1
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OPINION
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EXTRACTED KEY WORDS
PROVIDERS REIMBURSEMENT STATUTE REGULATION CARE ENROLLED PROVIDERS ELIGIBILITY RECIPIENTS RETROACTIVE REIMBURSEMENT DSS COURT PLAN YORK COSTS ASSISTANCE PROVISION NY2D RENDERING MEDICAID RATE APPELLATE EXPENSES ADMINISTRATOR LAW SEITTELMAN POCKET COSTS PLAINTIFFS PAYMENT SUPREME COURT MATTER |
ESTELLE SEITTELMAN, &C., ET AL., RESPONDENTS, AND LEAH SILVERMAN, ET AL.,
INTERVENORS-RESPONDENTS, v. BARBARA J. SABOL, &C., ET AL., APPELLANTS.
91 N.Y.2d 618, 697 N.E.2d 154, 674 N.Y.S.2d 253 (1998).
April 2, 1998
1 No. 26
(98 NY Int. 0027)
Decided April 2, 1998
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This opinion is uncorrected and subject to revision before publication
in the New York Reports.
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John W. McConnell, for appellant State commissioner.
Cheryl Payer, for city appellant.
Scott A. Rosenberg, for respondents/intervenors-
respondents.
SMITH, J.:
The primary issue presented by this appeal is whether defendants by
regulation may limit Medicaid reimbursement for expenses incurred by
eligible individuals during the three month period preceding the
application for Medicaid to only those services rendered by Medicaid
enrolled providers. We hold that such a State regulatory limitation is
unsupported by the language or policy of the Federal statute. It is
neither rational nor reasonable and is thus unenforceable. We also
hold that the recipient may be reimbursed only at the Medicaid rate in
existence at the time the service was rendered and may not be
reimbursed for all out of pocket costs.
Plaintiff Estelle Seittelman, as Administrator of the Estate of Ida
Zichlinsky, commenced this combined declaratory judgment and article
78 proceeding against the Department of Social Services and the
Commissioner of the New York City Human Resources Administration
challenging the Department's refusal to reimburse Ms. Zichlinsky for
monies expended for home care services she required during the three
month pre-application period. Pursuant to a promulgated regulation,
DSS denied payment on the ground that Ms. Zichlinsky's medical
services were obtained from a non-Medicaid enrolled provider. Three
other individuals were allowed to intervene as plaintiffs. Sayde Bass
and Leah Silverman sought reimbursement for private home care
services, and Marguerite Holohan sought reimbursement for nursing care
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