DocketNumber: No. 08-P-2052
Citation Numbers: 75 Mass. App. Ct. 636
Judges: Grasso
Filed Date: 10/30/2009
Status: Precedential
Modified Date: 6/25/2022
Mary Shelales appeals from a judgment of the Superior Court affirming the decision of the Office of Medicaid (department) board of hearings that Shelales was ineligible for Massachusetts Medicaid program (MassHealth) long-term care benefits for a period of 164 days, commencing on June 28, 2007, due to a disqualifying transfer of assets. On appeal, Shelales argues that (1) the department incorrectly calculated the commencement date for the penalty period of ineligibility as beginning on June 28 rather than on January 12, 2007, and (2) the department’s interpretation of its applicable regulation is inconsistent with governing Federal Medicaid law. We affirm.
On April 30, 2007, Shelales applied for MassHealth benefits to cover her nursing home expenses and requested coverage retroactive to January 11, 2007. The department denied Shela-les’s application, concluding that her January 11 transfer of $41,993 to her children rendered her ineligible for long-term care benefits for a period of 164 days commencing on June 28, 2007, the first day after her prepayment of expenses was exhausted.
Shelales requested a hearing, and a hearing officer affirmed the denial of benefits. Shelales sought judicial review in the Superior Court pursuant to G. L. c. 30A, § 14. A Superior Court judge affirmed, and this appeal ensued.
2. Discussion. MassHealth is a cooperative Federal and State undertaking that provides payment for medical services to eligible individuals and families who are unable to pay for their own medical care. See G. L. c. 118E, § 9; Haley v. Commissioner of Pub. Welfare, 394 Mass. 466, 467 (1985). “[Ejstab-lished[] pursuant to and in conformity with” the Federal Medicaid program, MassHealth must meet the requirements of Federal law in order to receive Federal financial reimbursement. G. L. c. 118E, § 9, inserted by St. 1993, c. 161, § 17. See Youville Hosp. v. Commonwealth, 416 Mass. 142, 146 (1993).
The payment of long-term care expenses for individuals in nursing homes (“nursing-facility services”) is among the covered medical services of MassHealth. 130 Code Mass. Regs. § 519.006(A)(2) (2004). To be eligible for MassHealth long-term care coverage, an individual must meet a number of criteria including having $2,000 or less in countable assets.
The parties do not dispute that Shelales made a disqualifying transfer of assets to her children on January 11, 2007. Nor do they dispute that, under the governing formula, the period of ineligibility for long-term care benefits resulting from that transfer is 164 days. What is disputed is the date on which the penalty period commences to run. The department maintains that the penalty period did not commence until June 28, 2007, the day after Shelales’s prepayment of medical services was exhausted. Shelales maintains that the penalty period began to run on January 12, 2007, the day following the transfer of her assets to her children.
“For transfers occurring on or after February 8, 2006, the period of ineligibility begins on the first day of the month in which resources were transferred for less than fair-market value or the date on which the individual is otherwise eligible for MassHealth payment of long-term care services, whichever is later,,6 (emphasis added).
Their dispute centers on the regulatory language “the date on which the individual is otherwise eligible for MassHealth payment of long-term care services.” Ibid. Under the department’s interpretation of that language, the penalty period for Shelales’s application did not commence until June 28, 2007.
Focusing on the words “otherwise eligible,” Shelales contends that she was otherwise eligible for payment of MassHealth long-term care services on January 12, 2007, because, aside from the disqualifying transfer to her children the previous day, she met all other criteria for payment on that date.
Even were we to assume that Shelales’s suggested interpretation of the regulation, read broadly, is reasonable, that interpretation is not the only reasonable way to construe the regulation and the governing Federal law. Where ambiguities exist, a reviewing court must show deference to the experience, technical competence, specialized knowledge, and discretionary authority conferred upon the regulatory agency. See Athol Daily News v. Board of Review of the Div. of Employment & Training, 439 Mass. 171, 174 (2003); G. L. c. 30A, § 14(7). When an agency’s interpretation is reasonable, we afford the agency “considerable leeway” in interpreting a statute it is charged with enforcing, unless the statute unambiguously bars the agency’s approach. Goldberg v. Board of Health of Granby, 444 Mass. 627, 633 (2005) (citation omitted). We will not overturn an agency’s interpretation of its own regulation and statutory mandate unless that “interpretation is patently wrong, unreasonable, arbitrary, whimsical, or capricious.” Box Pond Assn. v. Energy Facilities Siting Bd., 435 Mass. 408, 416 (2001) (citation omitted). Especially is this so when the case involves interpretation of a complex statutory and regulatory framework such as Medicaid. See Kozloski v. Contributory Retirement Appeal Bd., 61 Mass. App. Ct. 783, 786 (2004) (great deference afforded to agency’s expertise when it is charged with applying difficult and complex set of regulations).
We discern no unreasonableness in the department’s interpretation of its regulation. Indeed, its interpretation more reasonably comports with the Federal and State legislative and regulatory
We also discern no conflict between the department’s interpretation of its regulation and the Deficit Reduction Act of 2005, RL. 109-171, 120 Stat. 4 (2006). Congress recognized that most penalty periods for disqualifying transfers of assets would be rendered meaningless if the disqualification period were to expire before long-term care was ever needed. See H.R. Rep. No. 109-276, at 387, 505 (2005). To close this loophole, the “eligible for medical assistance under the State plan” language was added to the Federal statute to offer a later date for commencement of the penalty period.
Judgment affirmed.
Although Shelales estimated that her payment would last until July 2, for reasons not clear in the record, her prepayment only lasted until June 27, 2007.
The 164-day ineligibility period commenced on June 28 and ended on December 9, 2007.
Additional factors for eligibility include whether the individual is over
MassHealth standard medical assistance encompasses a wide range of benefits, including nursing-facility services. See 130 Code Mass. Regs. § 520.019(A) (2006). Denial of eligibility for nursing facility services does not affect an individual’s eligibility for other MassHealth benefits. See 130 Code Mass. Regs. § 520.018(C) (2006).
Under Shelales’s proffered interpretation, the 164-day ineligibility period
The department’s regulation tracks the governing Federal law, which provides that the ineligibility period starts “the first day of a month during or after which assets have been transferred for less than fair market value, or the date on which the individual is eligible for medical assistance under the State plan . . . , whichever is later.” 42 U.S.C. § 1396p(c)(l)(D)(ii).
The parties agree that, aside from the disqualifying transfer, Shelales was eligible for payment of benefits on January 12, 2007, as her countable assets were less than $2,000, and she met other eligibility criteria. See note 3, supra.
The motion judge considered, but did not resolve, the issue whether Shelales’s prepayment to the nursing home remained a “countable asset” until consumed, whether on a weekly or monthly basis. We also need not address that issue.
Prior to enactment of the Deficit Reduction Act, the commencement date of Shelales’s penalty period of ineligibility would have been January 1, 2007, because Federal law and implementing Massachusetts regulations then in existence established the starting date for the penalty period only by reference to the first day of the month during or after the assets have been transferred for less than fair market value.