Social services – Reimbursement rates – Medicaid

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Where a petitioner has challenged the rates of reimbursement for health care services established by the Executive Office of Health and Human Services, the petitioner has not met its burden of showing unreasonableness, so EOHHS’s motion for summary decision should be allowed.

“Petitioner MI Nursing/Restorative Center, Inc. (MI Nursing) appeals from rates of reimbursement established by respondent the Executive Office of Health and Human Services (EOHHS). EOHHS moves for summary decision. The motion is meritorious. …

“The interpretive dispute revolves around the passage of the regulations that says: ‘EOHHS will not adjust any High Medicaid Adjustment solely because a facility under-reported Massachusetts Medicaid days in its quarterly User Fee Assessment Form.’ 101 C.M.R. §206.06(14)(d). …

“MI Nursing’s interpretive theory is as follows. The situations that §206.06(14)(d) describes as inadequate bases for changes to a facility’s rates are ‘solely’ those in which a facility ‘under-reported’ its Medicaid days. MI Nursing reads the word ‘under-reported’ as denoting an erroneously low count by the reporting facility. In this case, MI Nursing says, there was no error: the facility accurately reported its Medicaid days based on MassHealth’s then-current approvals. MI Nursing extrapolates from the modifier ‘solely’ that the regulation does allow facilities to update such non-erroneous data.

“EOHHS reads §206.06(14)(d) more expansively. In its view, the bar on updates to ‘under-reported’ data covers any case in which a newer set of numbers is higher than those originally reported. By extension, EOHHS does not envision any circumstances in which new data would justify an updated high-Medicaid adjustment. …

“Although the question is close, §206.06(14)(d) is best viewed as ambiguous. The parties have identified no case law analyzing the precise meaning of the word ‘under-report.’ …

“In terms of the reasonableness of EOHHS’s interpretation (on scores other than ordinary language), MI Nursing questions whether EOHHS attributes any meaning to the word ‘solely’ (‘EOHHS will not adjust … solely because a facility under-reported’). … On balance, the answer is yes. …

“It is important to reiterate that the playing field is tilted. In order to prevail, EOHHS’s interpretive position does not need to be superior to the alternatives. The non-agency party bears a ‘formidable’ burden to refute the ‘reasonableness’ of the agency’s view. …

“In the end, MI Nursing does not carry that burden. The upshot of its arguments is that a skilled and vigilant draftsperson might have had good reason to rewrite 101 C.M.R. §206.06(14)(d) by replacing the word ‘under-reported,’ omitting the word ‘solely,’ or both. But it is not quite unreasonable to believe that the regulation as written intends to communicate the message the EOHHS discerns there, namely that ‘[EOHHS] will rely on the data reported in the facility’s original quarterly User Fee Assessment Form.’ …

“On the facts established beyond genuine dispute, the claim presented by MI Nursing is incapable of entitling the facility to relief. Accordingly, EOHHS’s motion for summary decision is allowed. Summary decision is hereby entered to the effect that the rates of reimbursement challenged in this appeal are affirmed.”

MI Nursing/Restorative Center, Inc. v. Executive Office of Health and Human Services (Lawyers Weekly No. 27-034-26) (8 pages) (Malkiel, Administrative Magistrate) (Division of Administrative Law Appeals) (Docket No. RS-24-0647) (March 24, 2026).

Click here to read the full text of the opinion.