Curtis v. Child

DONALDSON, Justice.

The two cases involved in this appeal present common issues, and were consolidated for consideration of such issues by this Court. Both of the plaintiff s-respondents are elderly ladies and have been patients in the Lewiston Orchards Nursing Home for a number of years. Both of them are bedridden and unable physically or mentally to care for themselves; neither of them have any relatives upon whom they can call for assistance. The record discloses that nursing home care is essential to their subsistence. Each of the respondents has income of slightly over $200 per month derived from benefits from the Veterans Administration and from payments under the Social Security Law. It is undisputed that privately arranged nursing home care would cost far in excess of each of the respondent’s monthly income.

Nursing home care in the Lewiston Orchards Nursing Home was provided for each of the respondents, with payment for such care coming from each respondent’s Veterans Administration payments and Social Security payment, plus additional payments being made by the Department of Public Assistance (hereinafter referred to as the department or as the DPA). Social Security payments were increased by Congress, and because of such increase, each of the respondents was then receiving income in excess of that specified by the department for eligibility to receive assistance, and on April 1, 1970, the respondents’ old age assistance was terminated.

After their assistance was terminated, each of the respondents applied for and had a hearing before a department hearing officer. Following these hearings, decisions were entered affirming the termination of each of the respondent’s public assistance grant. Appeals were taken to the district court pursuant to I.C. § 67-5215. The district court ruled that the respondents were “medically needy individuals” within the meaning of I.C. § 56-209b and that the department’s regulations denying them aid were arbitrary, capricious, and unreasonable, and therefore unenforceable. The trial court in its judgments reversed the determinations of the hearing officer and ordered medical assistance to each of the respondents reinstated.

The appeals in these cases were taken following the trial court’s entry of findings of fact, conclusions of law, and judgment in favor of the individual respondents. We affirm these judgments for the reasons set out below.

The welfare program in issue is the nursing home care benefits segment of Medicaid, a medical assistance program for the poor, established by Title XIX of the Social Security Act, 42 U.S.C.A. § 1396 et seq. The program is financed through contributions from both the federal and state governments, and is administered by the states, guided by federal statutory regulations. 42 U.S.C.A. § 1396a. When a state (at its option) decides to participate in Medicaid, the state is required by § 1396a(a)(10) to provide medical assistance to those persons receiving benefits under one of the state’s federally-aided public assistance programs established for the blind, aged, totally and permanently disabled, and families with dependent children. Recipients under one of these federally assisted welfare programs are denoted “categorically needy” for purposes of eligibility for Medicaid. 45 CFR 248.10.

The federal legislation also provides for assistance programs for persons who do not qualify as “categorically needy” but can, nonetheless, be deemed “medically needy.” 42 U.S.C.A. § 1396a(a) (10), (17). Whether the federal legislation makes this phase of the program mandatory or optional with each participating state is the initial issue to be resolved in this appeal.

In addition, appellant in its assignments of error, raises two pertinent issues which must be considered in the disposition of this appeal. First, appellant contends the district court erred in concluding I.C. § 56-209b, which defines the general scope of Idaho’s medical assistance plan, makes mandatory the inclusion of “medically needy” (in addition to “categorically needy”) persons as eligible recipients of Medicaid benefits. Second, appellant rejects the district court determination that the DPA regulation discriminates against a class of needy persons, in violation of the equal protection guarantees of the United States and Idaho Constitutions.

OPTIONAL NATURE OF THE MEDICALLY NEEDY CLASSIFICATION

Respondents urge that the Social Security Act does not make optional but rather mandates that states provide Medicaid assistance to those who qualify as “medically needy.” The district court found that the import of the federal legislation was to make this aid optional. The district court properly construed the Act.

The pertinent portions of the Act are 42 U.S.C.A. § 1396a(a) subsections (10) and (17). Subsection (17) appears to support respondents’ contention. That subsection requires the state to adopt reasonable standards of eligibility for Medicaid, comparable for all groups. The subsection also contains a “flexible income” or “spend-down” provision which requires the state plan to “provide for flexibility in the application of such standards with respect to income by taking into account * * * the costs * * * incurred for medical care or for any other type of remedial care recognized under State law.” 42 U.S.C.A. § 1396a(a)(17). The inference is that since the language of subsection (17) is mandatory, its provisions require a state to consider medical needs in defining eligibility. If respondents’ necessary medical expenses were subtracted from their gross incomes, each would fall within the $152.80 cut-off.

It is undeniable that this subsection, considered by itself, lends strong support to respondents’ contention that the federal legislation precludes the DPA from declaring their ineligibility. Subsection (17) must, however, be read in light of the other subsections of the Act, specifically subsection (10). Subsection (10) plainly explains that a state plan must extend aid to the recipients of aid under the four specified categories of assistance programs. The second part details what the plan must include “if medical or remedial care and services are included for any group of individuals who are not receiving aid * * * under any such State plan [of the four specified categories] and who do not meet the income and resources requirements of [such a plan].”

Thus, a reading of subsection (10) indicates that coverage of the “medically needy” is optional with the states. Wilczynski v. Harder, 323 F.Supp. 509, 515 (D.Conn.1971); Fullington v. Shea, 320 F.Supp. 500, 505 (D.Colo.1970), aff’d mem., 404 U.S. 963, 92 S.Ct. 345, 30 L.Ed.2d 282 (1971). But when a state has adopted the optional “medically needy” phase, the “spend-down” provision contained in subsection (17) is applicable. As the court in Fullington v. Shea stated, in discussing claims under the Colorado medical assistance program:

“It is thus clear that coverage of the ‘medically needy’ is optional with the states. Colorado has not chosen to cover this group of people and the statute [1396a] does not demand that they do so. If there were such a plan, the plaintiffs’ argument that the cut-off point could only be established after medical expenses had been deducted from net income would have merit.” 320 F.Supp. at 505.

The federal regulations in 45 CFR 248.21 specifically provide that if the medically needy are included in the state medical assistance plan, the “available income” of a medically needy person must be determined in a “flexible” manner:

“§ 248.21 Financial eligibility—medical assistance programs.

(a) State plan requirements. A State plan under title XIX of the Social Security Act must:

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(2) With respect to both the categorically needy and, if they are included in the plan, the medically needy:

(i) Provide that only such income and recources as are actually available will be considered and that income and resources will be reasonably evaluated;

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(3) With respect to the medically needy, if they are included in the plan:

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(ii) Provide that there will be a flexible measurement of available income which will be applied in the following order of priority:

(a) First, for maintenance, so that any income in an amount at or below the established level will be protected for maintenance;

(b) Next, income in excess of that needed for maintenance will be applied to costs incurred for medical insurance premiums and for necessary medical or remedial care recognized under State law and not encompassed within the State plan for medical assistance. States may set reasonable limits on such medical services for which excess income may be applied.

(c) All of the remaining excess income will be applied to costs of medical assistance included in the State plan.”

CONSTRUCTION OF THE STATUTE As indicated above, states have the option, upon deciding to participate in Medicaid programs, to extend benefits to “medically needy” persons — those who, but for income in excess of the eligibility limits, could qualify as categorically needy. The district court found that the Idaho legislature, by amendment of I.C. § 56-209b in 1966, enacted this option:

“56-209b. Medical assistance. — Medical assistance shall be awarded to persons who are recipients of old-age assistance, aid to dependent children, aid to the blind, aid to the permanently and totally disabled and to such other persons as may be defined under the authority of this act to be medically needy individuals.” (Emphasis added.)

The court then determined that one who requires nursing home care and cannot pay $255.00 per month, or whatever the reasonable minimum for such care might be, is a "medically needy” person within the purview of I.C. § 56-209b.

To decide this issue, this Court must indulge in an exercise of statutory construction. Since there is no legislative history to give us insight into the Idaho legislature’s collective minds, the literal, but logical, wording of the entire statutory scheme of medical assistance (I.C. § 56-201 et seq.) must be considered. 42 U.S.C.A. § 1396a.

Appellant contends that the legislature did not intend to extend medical assistance to medically needy persons. In support of this contention appellant notes that when I.C. § 56-209b was amended, the legislature had no experience upon which to base a projection of the magnitude of the Medicaid program, since the federal Medicaid legislation, 42 U.S.C.A. § 1396 et seq., had been drafted only one year earlier. Therefore, appellant asserts the legislature only intended to include the essential categorically needy, while leaving to future legislatures the option to expand the program should experience prove it desirable. Appellant cites other sections of the Idaho Code, to be considered in pari materia with I.C. § 56-209b. I.C. § 56-201,¹ inter alia, defines medical assistance as payments for medical care made under the authority of the federal Medicaid legislation “as may be designated by the department [DPA] by rule and regidation.” Appellant also relies on I.C. § 56-202(b) ² which creates a duty on the part of the DPA to establish such rules and regulations “as may be necessary or proper to carry out the provisions of this act [State Medical Assistance Program].” I.C. § 56-203³ enumerates the powers of the DPA under the act, including the power to define medically needy individuals and to determine the scope and amount of medical care to be purchased for recipients. Appellant also faults the district court’s construction of I.C. § 56-209b, emphasizing the portion of the statute which provides for assistance to “such other persons as may be defined under the authority of this act [i.e., by the DPA] to be medically needy individuals.” The sum of appellant’s argument can be described in the alternative — either (1) the legislature did not mandate that Idaho’s Medicaid program include rendering assistance to medically needy persons or (2) defining medically needy persons is left wholly to the discretion of the DPA, which allows the department not to include any persons within this category. We find this dual reasoning unpersuasive. From a plain reading of I.C. § 56-209b, Medicaid assistance is required for medically needy individuals as well as the “categorically needy.” The medically needy are a separate and distinct category from each of the other four categories, and the mandatory language in the statute (Medical assistance shall be awarded) applies to each of the five classifications. This construction is not inconsistent with and does not infringe upon the DPA’s authority to decide to whom medical assistance should be advanced under I.C. § 56-201(e). Under I.C. § 56-202 and I.C. § 56-203, read in light of our construction of I.C. § 56-209b, the DPA is given the responsibility for defining medically needy individuals. However, the DPA’s discretion is subject to the limitation contained in I.C. § 56-203(g), which provides that the department shall have the power to “[djefine medically needy individuals in such terms as will meet requirements for federal financial participation in medical assistance payments”. The term “medically needy” is specifically defined by federal regulation, as follows:

“The term ‘medically needy’ refers to an individual whose income and resources equal or exceed the State’s standards under the appropriate financial assistance plan but are insufficient to meet his costs for medical insurance premiums and for necessary medical and remedial care and services recognized under State law but not encompassed in the State plan for medical assistance, plus his costs for medical and remedial care and services included In the State plan.” 45 CFR 248.10(a) (2).

According to this definition, the respondents are “medically needy” individuals. One of the requirements of federal financial participation is that a state, in determining the financial eligibility of medically needy individuals, must use a “flexible measurement of available income,” as delineated in 45 CFR 248.21 (a)(3)(H) (set forth above). The DPA has failed to use such a flexible measurement in determining the financial eligibility of the respondents; the DPA has, therefore, failed to follow legislative direction and failed to meet one of the requirements of federal financial participation. The DPA has defined the eligibility conditions for medically needy individuals in such terms as do not meet the requirements for federal financial participation in medical assistance payments to medically needy individuals, contrary to the legislative intent expressed in I.C. § 56-203(g).

The applicable DPA regulations provide that nursing home services are available as medical assistance to individuals who would, upon application, be eligible for inclusion in one of the categorical programs (i.e., by being old, or disabled, or blind, or having dependent children) and whose income is less than $152.80. DPA Operating Policies and Procedures ¶¶ 3161(2) and 3162.1(h). When a flexible measurement of available income is added to the existing regulations, both of the respondents qualify for medical assistance because they are elderly with insufficient available income (after it is applied to maintenance and necessary medical services) to afford the costs of nursing home services included in the state plan. Therefore, after the respondents’ available income has been applied to the costs of nursing home services in an approved nursing home (i.e., one which charges no more than $255 per month), each of them is entitled to medical assistance in an amount equal to the difference between $255 and the amount of income applicable to the costs of such care. 45 CFR 248.21.

Because of our conclusion on the statutory interpretation question, it is unnecessary to reach the constitutional issue of whether the department’s denial of medical assistance to the respondents denied them equal protection of the laws. In general, this Court will not pass on questions of constitutionality unless it is absolutely necessary to do so in order to determine the merits of the case. Swensen v. Buildings, Inc., 93 Idaho 466, 463 P.2d 932 (1970); Hill v. Schultz, 71 Idaho 145, 227 P.2d 586 (1951); Twin Falls Canal Co. v. Huff, 58 Idaho 587, 76 P.2d 923 (1938).

Judgments affirmed. Costs to respondents.

McQUADE, C. J., and COGSWELL, D. J., concur.

1 . 1.0. § 56-201 (o) : “(o) ‘Medical assistance’ shall mean payments for part or all of the cost of such care and services enumerated in section 1905(a)(1) through (15) of the Federal Social Security Act as amended by the Social Security Act amendments of 1965, Public Law 89-97, 89th congress, as may be designated by the department by rule and regulation.”

2 . I.O. § 56-202 (b) : “(b) Establish and enforce such rules and regulations and such methods of administration as may be necessary or proper to carry out the provisions of this act.”

3 .I.C. § 56-203 (g) : “(g) Define medically needy individuals in such terms as will meet requirements for federal financial participation in medical assistance' payments.”

I.C. § 56-203 (i) : “(i) Determine the amount, duration and scope of care and services to be purchased as medical assistance on behalf of needy eligible individuals.”