Ward v. Ohio Dept. of Job & Family Servs. ( 2020 )

[Cite as Ward v. Ohio Dept. of Job & Family Servs., 2020-Ohio-3551.]
IN THE COURT OF APPEALS OF OHIO
SIXTH APPELLATE DISTRICT
ERIE COUNTY
Jeremy Ward, et al. Court of Appeals No. E-19-055
Appellee Trial Court No. 2018-CV-0274
v.
Ohio Department of Job &
Family Services DECISION AND JUDGMENT
Appellant Decided: June 30, 2020
*****
Linda R. Van Tine, for appellee.
Dave Yost, Ohio Attorney General, and Rebecca L. Thomas,
Assistant Attorney General, for appellant.
*****
ZMUDA, P.J.
{¶ 1} This matter is before the court on appeal from the judgment of the Erie
County Court of Common Pleas, reversing an administrative decision issued by the Ohio
Department of Job and Family Services (“ODJFS”) and awarding attorney fees to Jeremy
Ward (“Ward”). For the reasons that follow, we affirm, in part, and reverse, in part.
{¶ 2} Appellee Ward has received Medicaid-funded services, including private-
duty nursing (“PDN”), for over 18 years. Ward was born with numerous, significant,
medical conditions, and he sought to continue receiving PDN services through the
individual options (“IO’) waiver program for the one-year period beginning February 15,
2018, and ending February 14, 2019. State and federal law requires an annual
reassessment for individuals participating in the IO Waiver program. Pursuant to Ohio
Adm.Code 5160-40-01(E)(5):
An individual’s continued enrollment in the individual options waiver
program shall be redetermined no less frequently than every twelve months
beginning with the individual’s initial enrollment date or subsequent
redetermination date. Individuals must continue to meet the eligibility
criteria specified in paragraph (D) of this rule to continue enrollment in the
waiver program.
Likewise, 42 C.F.R. 441.302(c)(2) mandates:
Reevaluations, at least annually, of each beneficiary receiving home or
community-based services to determine if the beneficiary continues to need
the level of care provided and would, but for the provision of waiver
2.
services, otherwise be institutionalized in * * * [a] hospital, a NF, or an
ICF/IID.1
{¶ 3} In the course of Ward’s annual reassessment, the Erie County Board of
Developmental Disabilities conducted an assessment, and forwarded its findings to the
Ohio Department of Developmental Disabilities (“DODD”). Based on its review, the
DODD concluded that Ward’s needs could be met with less costly homemaker personal
care (“HPC”) services by HPC providers with medication certification and nursing-task
delegation, with nursing services provided on an intermittent basis when appropriate.
{¶ 4} Ward requested a hearing with the ODJFS, as provided by R.C. 5101.35(B),
to challenge the change in services. The ODJFS issued a decision, providing for the
substitution of HPC providers for PDN services. The agency noted Ward’s “multiple
health issues,” but determined Ward’s request for PDN services was not medically
necessary, and found appropriately trained and certified HPC providers could meet his
needs. Ward appealed this decision to the ODJFS Director, and the director dismissed the
appeal.
{¶ 5} Ward then appealed the decision to the trial court, arguing the agency’s
decision lacked evidentiary support, and was, instead, the result of a policy change that
prioritized cost reductions. After its review, the trial court reversed the decision of the
1
As provided at 42 C.F.R. 400.202 and 400.203, “NF” means a “skilled nursing facility.”
As provided at 42 C.F.R. 400.200, “ICF/IID” stands for “intermediate care facility for
individuals with intellectual disabilities.”
3.
ODJFS, finding the evidence of medical necessity in support of PDN “overwhelming and
very persuasive.” In overruling the decision of the ODJFS, the trial court determined that
Ward “is entitled to receive and continue to receive private duty nursing services as he
clearly meets the definition of medical necessity pursuant to [Ohio Adm.Code]
5160-1-01.” Additionally, the trial court ordered ODJFS to pay Ward’s attorney fees “in
accordance with” R.C. 119.092.
{¶ 6} The ODJFS appeals this judgment, asserting the following assignments of
error:
1. The lower court erred in awarding attorney fees to Mr. Ward
under R.C. 119.092, as neither that statute nor any other statute authorizes a
fee award in this type of appeal.
2. The lower court erred to the extent that it concluded that Mr.
Ward is entitled to private duty nursing services on a long-term or
permanent basis. Under federal and state Medicaid law, eligibility for such
services must be redetermined at least annually, and the services cannot be
provided if the eligibility requirements are not met.
{¶ 7} Our review of the matter is limited, compared to the review undertaken by
the trial court. While the trial court considers the evidence in determining whether
reliable, probative, and substantial evidence supports the agency’s decision, we review
the trial court’s decision for an abuse of discretion. Mocznianski v. Ohio Dept. of Job &
Family Servs., 6th Dist. Lucas No. L-19-1076, 2020-Ohio-1161, ¶ 21-22. ”Where,
4.
however, questions of law are raised on appeal from an administrative agency, ‘both the
common pleas court and the court of appeals exercise plenary powers of review.’”
Mocznianski at ¶ 23, quoting Cameron v. Ohio Dept. of Transp., 108 Ohio App. 3d 20, 23,
669 N.E.2d 874 (6th Dist.1995).
{¶ 8} Here, the parties present us with very little to review. Both Ward and the
ODJFS reached agreement regarding PDN services for the service year at issue, with the
ODJFS opting not to appeal the reversal of the agency’s decision for that period
regarding PDN services. Both Ward and the ODJFS also agree that R.C. 119.092
provides no basis to award Ward his attorney fees in the administrative appeal, brought
pursuant to R.C. 5101.35(E). The law, on this issue, is clear.
{¶ 9} Pursuant to R.C. 119.092(F)(2), the provisions of R.C. 119.092 do not apply
if hearing “was conducted for the purpose of determining the eligibility or entitlement of
any individual to benefits.” As the hearing under R.C. 5101.35 sought adjudication to
determine Ward’s eligibility for PDN services, and the parties agree that attorney fees
may not be awarded, we find the first assignment of error well-taken, and vacate the
award of attorney fees.
{¶ 10} The parties’ remaining dispute exists outside the scope of this appeal. In its
second assignment of error, the ODJFS challenges only the language chosen by the trial
court, referencing PDN services on “a long-term or permanent basis,” and not the
reversal of the agency’s determination. This challenge reads more into the wording of
the trial court’s entry than is included in the judgment, and is more aptly considered as a
5.
reaction to Ward’s reliance on the language in preventing future “medical necessity”
review. The challenged language reads:
The Court overrules the decision of the [ODJFS] and ORDERS that
[Ward] is entitled to receive and continue to receive private duty nursing
services as he clearly meets the definition of medical necessity pursuant to
O.A.C. 5160-1-01.
***
To keep him safe and given the best change to live, [Ward] meets all
the statutory criteria as a medical necessity pursuant to O.A.C. 5160 and
must have nursing services continue.
While the assignment of error suggests a challenge to the trial court’s judgment, the
ODJFS otherwise emphasized in its argument that it is not challenging the finding of the
court, the reversal of the ODJFS decision regarding PDN services for the period on
review. The only challenge raised seeks a rewrite of the trial court’s analysis in reaction
to Ward’s stated intention to use this analysis as “settled law.”
{¶ 11} Ward, in response to the ODJFS assignment of error, seeks to preserve the
trial court’s analysis as a “finding” regarding medical necessity, arguing policy
considerations and not the law. Ward argues that the trial court’s analysis of medical
necessity should be declared as binding on the ODJFS, because demonstration of medical
necessity for PDN each year is overly burdensome and a waste of Ward’s limited
resources. While acknowledging that Medicaid requires annual eligibility determinations,
6.
Ward argues he should be able to meet the definition of “medical necessity” based solely
on the trial court’s choice of language regarding his diagnosis and his treatment plan, as it
related to the 2018-2019 service year.
{¶ 12} The parties argue an issue that is not before us on appeal. We may review
the trial court’s judgment in reversing the agency decision, but neither party has
requested this review. Instead, the ODJFS asks us to strike part of the trial court’s
analysis, as having potential suggestive effect for future eligibility determinations. Ward,
on the other hand, argues policy considerations in seeking a legal declaration that he
satisfies the definition of “medical necessity” for purposes of future eligibility
determinations. Neither party cites to any provision within federal or state law that
supports their respective positions.
{¶ 13} The issues raised under the guise of the ODJFS’s second assignment of
error pertain to matters beyond the scope of the present appeal, which is limited to the
decision regarding the 2018-2019 service period. Both Ward and the ODJFS seek a
factual determination, regarding medical necessity, for purposes of future, annual
reevaluations. As previously stated, however, we are limited to reviewing the trial
court’s judgment for an abuse of discretion, with no authority to conduct our own review
of the facts. See Mocznianski, 6th Dist. Lucas No. L-19-1076, 2020-Ohio-1161at ¶ 21-
22. Accordingly, we find the second assignment of error not well-taken.
7.
{¶ 14} Based on the forgoing, we affirm the judgment of the Erie County Court of
Common Plea, reversing the agency decision regarding eligibility for DPN services, but
reverse and vacate the judgment awarding attorney fees. Ward and the ODJFS are
ordered to split the costs of this appeal pursuant to App.R. 24.
Judgment affirmed, in part,
and reversed, in part.
A certified copy of this entry shall constitute the mandate pursuant to App.R. 27.
See also 6th Dist.Loc.App.R. 4.
Mark L. Pietrykowski, J. _______________________________
JUDGE
Christine E. Mayle, J.
_______________________________
Gene A. Zmuda, P.J. JUDGE
CONCUR.
_______________________________
JUDGE
This decision is subject to further editing by the Supreme Court of
Ohio’s Reporter of Decisions. Parties interested in viewing the final reported
version are advised to visit the Ohio Supreme Court’s web site at:
http://www.supremecourt.ohio.gov/ROD/docs/.
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