C.F.R. » Title 45 » SUBCHAPTER A—GENERAL ADMINISTRATION › PART 95—GENERAL ADMINISTRATION—GRANT PROGRAMS (PUBLIC ASSISTANCE, MEDICAL ASSISTANCE AND STATE CHILDREN'S HEALTH INSURANCE PROGRAMS) › Subpart A—Time Limits for States To File Claims

45 C.F.R. § 95.4

Definitions

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In this subpart—

Adjustment to prior year costs means an adjustment in the amount of a particular cost item that was previously claimed under an interim rate concept and for which it is later determined that the cost is greater or less than that originally claimed.

Audit exception means a proposed adjustment by the responsible Federal agency to any expenditure claimed by a State by virtue of an audit.

Claim means a request for Federal financial participation in the manner and format required by our program regulations, and instructions or directives issued thereunder.

Court-ordered retroactive payment means either a retroactive payment the State makes to an assistance recipient or an individual, under a Federal or State court order or a retroactive payment we make to a State under a Federal court order. Although we may accept these claims as timely, this provision does not mean that we necessarily agree to be bound by a State or Federal decision when we were not a party to the action.

Federal financial participation means the Federal government's share of an expenditure made by a State agency under any of the programs listed in § 95.1.

State means the 50 States, the District of Columbia, Guam, Puerto Rico, the Virgin Islands, the Commonwealth of the Northern Mariana Islands, American Samoa and the Trust Territories of the Pacific.

State agency for the purposes of expenditures for financial assistance under title IV-A and for support enforcement services under title IV-D means any agency or organization of the State or local government which is authorized to incur matchable expenses; for purposes of expenditures under titles XIX and XXI, means any agency of the State, including the State Medicaid agency or State Child Health Agency, its fiscal agents, a State health agency, or any other State or local organization which incurs matchable expenses; for purposes of expenditures under all other titles, see the definitions in the appropriate program's regulations.

The Act means the Social Security Act, as amended.

We, our, and us refer to the HHS Centers for Medicare & Medicaid Services (CMS), and Administration for Children and Families (ACF), depending on the program involved.

[46 FR 3529, Jan. 15, 1981, as amended at 65 FR 33632, May 24, 2000; 75 FR 66336, Oct. 28, 2010]
Notes of Decisions
Cited in 6 cases, 1990–2019 · leading case: Pennsylvania, Dep't of Pub. Welfare v. Sebelius, 674 F.3d 139 (3rd Cir. 2012).
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Pennsylvania, Dep't of Pub. Welfare v. Sebelius, 674 F.3d 139 (3rd Cir. 2012). · cites it 2× “Additionally, 45 C.F.R. § 95.4 defines “claim” as follows: “In this subpart — .”
West Virginia Dep't of Health & Human Resources v. United States Dep't of Health & Human Servs., 899 F. Supp. 2d 477 (S.D.W. Va 2012). · cites it 5× “) First, it must be noted that DAB never concluded “cost item,” as it is used in 45 C.F.R. § 95.4 , means “cost component.”
Georgia Dep't of Cmty. Health v. United States Dep't of Health & Human Servs., 79 F. Supp. 3d 269 (D.D.C. 2015). “The Regulations define a “claim” as a “request for Federal financial partic- ' ipation,” 45 C.F.R. § 95.4 , where “Federal financial participation” is “the Federal government’s share of an expenditure made by a State agency.”
State of NY v. Sullivan, 802 F. Supp. 752 (N.D.N.Y. 1992). · cites it 5× “In support of this conclusion, the DAB noted the wording of 45 C.F.R. 95.4 which defines “audit exception” as “a proposed adjustment by the responsible Federal agency to any expenditure claimed by a State by virtue of an audit.”
South Carolina Health & Human Servs. Fin. Comm'n v. Sullivan, 915 F.2d 129 (4th Cir. 1990). “” 45 C.F.R. § 95.4 (1989). “Cost item” as used in this definition refers to the per diem rate and not the individual costs of particular services and the DGAB has in the past permitted state agencies to obtain reimbursement for particular cost items not included in the…”
Missouri Dep't of Soc. Servs. v. Dep't of Health & Human Servs. (D.D.C. 2019). “203 ; 45 C.F.R. § 95.4 . Missouri’s problem here arises because, as the State openly acknowledges, it made an administrative mistake almost 25 years ago.”
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