Dougherty v. Department of Human Services , 91 N.J. 1 ( 1982 )

The opinion of the Court was delivered by

O’HERN, J.

This case concerns judicial waiver of an agency regulation denying Medicaid reimbursement for certain classes of medical services. Specifically, we must decide the validity, as applied to the facts of this case, of a state regulation that prohibits payment for an air cleaner medically needed to stabilize the asthmatic condition of a young patient.

I.

Michael Dougherty is a nine-year-old boy who is eligible for Aid to Families with Dependent Children (AFDC) medical assistance and therefore eligible for Medicaid benefits. He suffers from asthma and allergic rhinitis. Treatment with medication and injections was attempted without success. He was twice hospitalized for several days of care. Twice monthly he required emergency room treatment. In the fall of 1979, after four trips to the emergency room in eight weeks, Michael’s allergist prescribed that an “HEPA Cleaner” be installed in Michael’s room. This air cleaner removes very small particles of household dust, molds and pollens from the air. Michael’s mother bought the equipment in October 1979 and applied for reimbursement of the purchase price of $269. The Middlesex County local unit of the Division of Medical Assistance and Health Services of the State Department of Human Services denied reimbursement because according to N.J.A.C. 10:59-1.6, the air cleaner was included in a class of environmental control equipment whose primary and customary use is non-medical. The Doughertys requested a fair hearing in accordance with N.J.A.C. 10:49-5.3. At the hearing in February 1980 the evidence showed that Michael’s condition had improved since he had been using the air cleaner and that he had had no further hospitalization or emergency room treatment. The Administrative Law Judge reversed the local agency, found the item to be medically necessary and not environmental equipment as defined by the regulation, and recommended reimbursement. On appeal to the Department of Human Services, the Commissioner’s designee reversed on the basis that the equipment purchased was an electrostatic air filter, an item for which payment was specifically prohibited by the regulation. The Appellate Division reversed, holding that under the unique circumstances of this case the regulation should be waived to achieve the broader purposes of the New Jersey Medical Assistance and Health Services Act, N.J.S.A. 30:4D-1 et seq. We granted the Department’s petition for certification, 88 N.J. 495 (1981).

II.

Title XIX of the Social Security Act established the Medicaid program under which participating states may provide federally funded medical assistance to certain eligible needy persons. 42 U.S.C. § 1396. We have described the program as follows:

Medicaid is a program whose principal aim is that of “enabling each State, as far as practicable under the conditions in such State, to furnish * * 4 medical assistance [to] individuals whose income and resources are insufficient to meet the costs of necessary medical services * * *,” 42 U.S.C. § 1396. In order to achieve this goal, a complex cost-sharing mechanism has been constructed providing for partial federal funding of medical services rendered to the indigent.

The Medicaid Act represents an exercise in what has been termed “cooperative federalism.” Note, “State Restrictions on Medicaid Coverage of Medically Necessary Services,” 78 Colum. L. Rev. 1491, 1491 (1978). The program is primarily administered by the State, subject to federal guidelines and constraints. Each participating State is required to adopt a plan, which must be approved by the Secretary of the Department of Health, Education & Welfare (HEW), covering in detail the services to be rendered. 42 U.S.C. §§ 1396, 1396a(a). The plan must provide for five general categories of medical assistance and may include others. 42 U.S.C. § 1396a(a)(13)(B). [Monmouth Medical Center v. State, 80 N.J. 299, 302-03 (1979)].

The New Jersey Medical Assistance and Health Services Act, N.J.S.A. 30:4D-1 et seq., was enacted to enable the State to obtain the benefits provided by the federal law. The Division of Medical Assistance and Health Services in the Department of Human Services has been charged with implementing and administering a program of medical assistance and directed to do whatever is “necessary to secure for the State of New Jersey the maximum Federal participation that is available with respect to a program of medical assistance, consistent with fiscal responsibility and within the limits of funds available for any fiscal year.... ” N.J.S.A. 30:4D-7. New Jersey may typically receive a reimbursement from the federal government of 50 percent of the program costs. The Division is authorized to promulgate rules and regulations to carry out that intent, N.J. S.A. 30:4D-7, as well as to provide the Secretary of HEW with the State’s plan, N.J.S.A. 30:4D-7(a). Monmouth Medical Center, supra, 80 N.J. at 316.

Although Title XIX does not require states to provide funding for all medical treatment falling within the five general categories, it does require that “State medical plans establish ‘reasonable standards... for determining... the extent of medical assistance under the plan which... are consistent with objectives of [Title XIX],’ 42 U.S.C., § 1396a(a)(17)...” Beal v. Doe, 432 U.S. 438, 441, 97 S.Ct. 2366, 2369, 53 L.Ed.2d 464, 470 (1977). We have never held that our statutory program requires state reimbursement for all medically necessary services for every patient. Monmouth Medical Center, supra, 80 N.J. at 309.¹

There are two questions, then, in this case. Is the agency regulation valid, and was it correctly applied as to this claimant, i.e., was the order of waiver proper?

III.

A.

In Texter v. Dept. of Human Services, 88 N.J. 376 (1982), we recently restated the principles governing review of agency regulations. We held there that “[administrative agencies have wide discretion in selecting the means to fulfill the duties that the Legislature delegated to them.” Id. at 383. N.J.S.A. 30:4D-5 and 4D-7 authorize the agency and the Commissioner to adopt rules and regulations to implement the policies of the act. On review, courts presume that an administrative regulation is valid. The burden is on the challenger to demonstrate that the regulation is arbitrary, capricious or unreasonable. New Jersey Guild of Hearing Aid Dispensers v. Long, 75 N.J. 544, 562-63 (1978); Cole Nat’l Corp. v. State Board of Examiners, 57 N.J. 227, 231 (1970). A court will not substitute its judgment for the expertise of the agency. New Jersey Guild, supra, 75 N.J. at 562.

In fulfilling its statutory mandate, the Division has adopted a comprehensive manual for the administration of the program, N.J.A.C. 10:49-1.1 et seq. Its several hundred pages give detailed descriptions of eligible items such as orthotic appliances, N.J.A.C. 10:55-1.1 et seq., coverage for physical therapy, N.J.A.C. 10:53-1.6, and payment allowed for prescription drugs. N.J.A.C. 10:51-6.18. In the subchapter entitled “Medical Supplier Manual,” the agency specified certain non-covered items including personal incidentals, gauze, bandages, and orthopedic mattresses. N.J.A.C. 10:59-1.6. In subsection (a)(6) the following items were excluded from coverage:

Environmental control equipment and supplies (for example, air conditioners, humidifiers, dehumidifiers, electrostatic filters and so forth: 1. exceptions are vaporizers and cool mist humidifiers.)

The record does not disclose the reason for each such exclusion. The agency argues that environmental equipment was excluded from coverage because it not only serves the medical needs of the patient but also aids the comfort and convenience of all of the members of the household. No one would deny that surgical gauze is necessary for medical treatment of a wound or that other appliances may be necessary for medical treatment, but an agency administering so vast and complex a program can well determine that such choices must be made and that certain items deserve different treatment. Judicial supervision of such classifications would be unwise.² Establishment of priorities is best left to the legislative branch and executive agencies. Since the standards adopted were reasonable and consistent with the objectives of the Medicaid Act, the Appellate Division found the regulation to be valid. We agree.

B.

A more difficult question is whether the regulation should be ordered waived in the circumstances of this case. Prior to the installation of the air cleaner the young boy had been hospitalized twice at a cost of approximately $1,000 per hospitalization, and had been to the emergency room twice a month at an average cost of $40 per visit, exclusive of the cost of drugs. All of these fees were paid with public funds. The price of the air cleaner was $269 and it seems to have eliminated the problem. In addition to the public economic benefit, the boy has been spared the continuing suffering of illness and the trauma of hospitalization.

To achieve what it called a sensible and humane result, the Appellate Division ordered the regulation waived. It is an appealing solution, satisfies our sense of personal justice and settles the matter, but it may not serve the public interest. In our view, the matter must be remanded to the agency to make the decision on waiver itself.

The manual of procedures for administration of the Medicaid program permits the administrative flexibility to deal with the practicalities of the situation highlighted by the circumstances of this case. N.J.A.C. 10:49-5.3(b)(4), in effect at the time of the Dougherty hearing, provides that the fair hearing shall include consideration of

... the reasonableness and equitableness [sic] of the policies promulgated under law if the claimant is aggrieved by their application to his situation.³

The inevitable adversarial clash of litigation focused attention at the agency level on whether the particular device was “environmental equipment.” The administrative law judge found that it was not. The agency found that it was. The agency’s deliberations did not resolve the necessary question of whether the rule is reasonable or equitable as applied to Michael Dougherty’s situation.

Waiver would require focusing the administration of the program on an individual basis, a process perhaps well suited to disputes between individual litigants, but not necessarily productive of the general good. No great sense of justice is required to realize that the claimant in this case would be better off with the filter' and that the cost would be minimal. The entire Court joins the dissent in this observation. But it is not fair to the administrators of the program to assume that they too are not fully aware of these matters. In our view the dissent does not fully take into account the fact that uniformly administrable rules may best enforce the policies underlying regulatory statutes. Even at the agency level, waiver would require a case-by-case determination of whether the facts of a particular situation merit waiver and, thus, might hamper efficient rule application. Much more troubling is the concept of judicial waiver.⁴ Applying this concept of waiver to dictate the scope of coverage for assistance programs obviously displaces the agency’s discretion and decision-making function.

Because the Legislature has delegated to the agencies the authority to adopt, revise and enforce implementing regulations, we believe it would be wrong for us as judges to substitute our judgments in individual cases for those of agency heads. The increasing social demands for limited public resources will strain our delivery systems to the utmost. Under current federal legislation, 95 Stat. 535, the funds for many social service programs have been rolled into block grants to the states. State agencies must make the hard choices about how to expend these funds. We hold no franchise to allocate these diminishing resources. The institution of the judiciary, having no power to raise revenues of its own or to exert the police power beyond the reach of its writ, can only make an arbitrary reshuffling of available revenues without consideration of those who will be taken out at the other end of the shuffle. We have no monopoly on justice. We share it with many, and not just the Legislature and the Executive. We share it also with administrators whose task is often a lot more difficult than ours.

As noted in Texter, supra, 88 N.J. at 389, “the economic costs of [such a] regulation are relevant .... ” The agency may well conclude that although waiver may serve the individual needs of the patient, in the long run the overall statutory purposes of equitably and reasonably serving the medically needy are better served by drawing certain fixed lines in administration of the program.

Moreover, in many cases there will be no increased cost to the public, since the applicant will obtain the needed equipment through his or her own funds. The other cost, not acknowledged by the dissent, however, is the expenditure of administrative energy, time and personnel in adjudicating what seems to be the rule of the dissent, namely, in every case where the regulation prohibits reimbursement, there is to be a trial to see whether or not the cost-benefit analysis of the particular item favors the claimant. Judges may be attuned to trials, but their proliferation is hardly a hallmark of sound administration. Exactly what the cost is in added personnel is something this Court does not know, but we may safely assume that the administrators do know. It may very well be that the cost of such case-by-case determinations will require an offsetting decrease in reimbursable medical services, thereby depriving not simply the claimant in this case of the filter, but many other citizens of medical services now allowed under the regulations. Obviously the administrators knew that an air cleaner can be used for medical purposes — otherwise the exception would never have been inserted in the regulation. They also knew that it was equally adaptable to non-medical uses. Presumably they may have concluded that given the overall cost of the Medicaid program, the costs of case-by-case determinations in this and other cases, and the likelihood that in the majority of cases the benefits were predominantly environmental rather than medical, it would be unwise to provide for reimbursement in any case. The reasoning may also have included the observation that in most cases there will be members of the family who benefit from the filter and who might therefore be regarded as probable contributors to its purchase. The decision is hardly irrational and our remand is not meant to suggest any suspicion that it is. It is simply to make sure that the agency, which apparently did not consider its power to waive the regulation in a “fair hearing,” will focus on that issue.

We therefore conclude that the Commissioner must make the determination as to whether, in the circumstances of this case, waiver of the regulation serves the purposes of the New Jersey Medical Assistance and Health Services Act. A just limit on public responsibility may further the legislative policy and serve to inform a society that may in the future have to face even more difficult decisions but which might otherwise be unprepared for the analysis and unable to accept it. Obviously, the agency’s consideration of alternate forms of treatment that, although not strictly allowed, are medically necessary, remedy the patient’s problem and simultaneously save tax dollars, would be. not only practical but also humane. But a basic tenet of judicial review is that courts are not free to substitute their judgment as to the wisdom of a particular administrative action for that of the agency so long as that action is statutorily authorized and not otherwise defective because arbitrary or unreasonable. New Jersey Guild of Hearing Aid Dispensers v. Long, 75 N.J. 544, 562-63 (1978).

We modify the Appellate Division judgment in part and remand to the Department of Human Services in accordance with this opinion.

1 ln Monmouth Medical Center, supra, 80 N.J. at 309, this Court expressly declined “to join the fray” of split opinion as to whether a State must fund all necessary medical services for which federal matching funds are available. The original Act required participating states to move toward, and eventually to furnish, “comprehensive care and services to substantially all individuals who meet the plan’s eligibility standards with respect to income and resources,” Social Security Amendments of 1965, Title XIX, § 1903(e), 79 Stat. 350. In response to the rapidly inflating cost of medical services, this section was repealed in 1972, Social Security Amendments of 1972, Title II, § 230, 86 Stat. 1410. The legislative history demonstrates concern for the substantial burden placed on limited state resources by the rapid increases in the cost of Medicaid. See also Virginia Hospital Ass’n v. Kenley, 427 F.Supp. 781 (D.C.F.D.Va.1977).

2 We do not deal here with the exclusion of a specific medical condition. The Code of Federal Regulations provides, for example, that a State may not arbitrarily deny or reduce the amount, duration, or scope of a required service under § 440.220 to an otherwise eligible recipient solely because of the diagnosis, type of illness or condition. [42 C.F.R. § 440.230(c)(1)].

3 Although applicable at the time of the hearing in February 1980, N.J.A.C. 10:49-5.3(b)(4)(ii), requiring agency consideration of the “reasonableness and equitableness” [sic] of the departmental policies, has since been repealed. 12 N.J.R. 561, 581 (1980); 13 N.J.R. 1, 17 (1981). The requirement that agency hearings and determinations be fair and reasonable is mandated by case law, Texter, supra, 88 N.J. at 382-83, and such hearings must include consideration of particular circumstances. Worthington v. Fauver, 88 N.J. 183, 204 (1982), citing Bayshore Sewerage Co. v. Dept. Environ. Protection, 122 N.J. Super. 184, 199 (Ch.Div.1973).

Shortly before oral argument, the claimant submitted an article on filtration devices as a supplement to the administrative record pursuant to R. 2:5-5. The article was submitted to counter the assumption made below that the HEPA air cleaner is an electrostatic air filter, and thus specifically excluded by the rule as an ineligible item. The item points out that the HEPA air cleaner is not an electrostatic air filtration system, but rather is a system developed by the Atomic Energy Commission during World War II and whose existence has remained almost completely unknown to the public. We have not considered the material. See Pomanowski v. Monmouth County Bd. of Realtors, 87 N.J. 426 (1981). The Commissioner will have the benefit of this new evidence on the remand.

4 We need not debate the question of judicial power to order waiver. The requirement that rules make provision for exceptions has been described as “withering.” Diver, “Policymaking Paradigms in Administrative Law,” 95 Harv.L.Rev. 393, 419 (1981). The Supreme Court has confirmed that the validity of a rule does not depend on its inclusion of a waiver clause. FCC v. WNCN Listeners Guild, 450 U.S. 582, 601 n. 44, 101 S.Ct. 1266, 1278 n. 44, 67 L.Ed.2d 521, 538 n. 44 (1981); Iuppo v. Burke, 162 N.J.Super. 538 (App.Div.1978) (State agency may not suspend regulation without formal amendment and compliance with the Administrative Procedure Act); but see WAIT Radio v. FCC, 418 F.2d 1153, 1157-60 (D.C.Cir.1969) (agency must give meaningful consideration to waiver applications); In re Fair Hearing, 138 N.J.Super. 417 (App.Div.1975) (six month limitation period ordered waived). Suffice it to say that the major purpose of regulatory reform, to bring higher levels of fairness and consistency in administrative adjudications, Unemployed-Employed Council of N.J., Inc. v. Horn, 85 N.J. 646, 650 (1981), will not be advanced by ad hoc judicial selection of benefit recipients.