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From Health Law Daily, April 18, 2018

Medicaid benefits court order is not one-size-fits-all

By Rebecca Mayo, J.D.

A court order relating to an individual’s rights to benefits under one Medicaid program does not necessarily apply to the individual’s rights to benefits under a separate Medicaid program. An appeals court held that an individual could not use a court order relating to standard Medicaid income limit calculations to force HHS to use the same income limit calculations for his subsequent enrollment in an additional Medicaid benefits program. The appeals court found that the court lacked jurisdiction to review the legal and factual issues surrounding the additional Medicaid benefits program until they reach the court through exhaustion of the administrative review process (Pachas v. North Carolina Department of Health and Human Services, April 17, 2018, Dietz, R.).

Medicaid coverage. A patient began receiving Medicaid coverage after a stroke and brain tumor left him confined to a wheelchair and in need of nursing care. The following year the patient began receiving Social Security disability benefits. The Department of Social Security (DSS) then determined that with the disability income, the patient’s income was above the federal poverty level for an individual and he therefore needed to pay a deductible on his Medicaid benefits. The patient, however, was the primary provider for his wife, two minor children, and his wife’s elderly parents. He argued that his deductible should have been based on the federal poverty level for a family of four or six, instead of that of an individual.

The patient appealed through the administrative process but did not prevail. He then petitioned for judicial review in superior court. The court held that the agency improperly applied the income limit and reversed the agency decision and ordered the agency to reinstate the patient’s Medicaid benefits.

CAP/DA coverage. Due to changes in the patient’s health condition, he then enrolled in the Community Alternative Program for Disabled Adults (CAP/DA) Medicaid program. The CAP/DA program is governed by a separate statute from the standard Medicaid program and the state may request a waiver of the State Plan requirements for income and resource rules from the federal government. Based on this purported waiver, the patient’s income limit was again calculated using the individual federal poverty level, not the family poverty level, and again he was asked to pay a deductible. The patient filed a motion in superior court to enforce the court’s previous order and a petition for writ of mandamus.

Jurisdiction. When a trial court on judicial review orders an agency to take action, the court retains jurisdiction to ensure its order is carried out. However, this authority to supervise the agency’s actions extends only to issues actually presented and necessarily involved in determining the case. The trial court held that its initial order on judicial review did not apply to the patient’s Medicaid eligibility under the CAP/DA program because the CAP/DA program nor the factual and legal issues concerning the State’s request for a waiver of various Medicaid provisions through CAP/DA were not an issue and were never addressed. The trial court dismissed the motion and petition for lack of jurisdiction and held that the patient must resort to the administrative process. The patient appealed.

Decision. The appeals court found that the trial court properly concluded that the agency’s determination of the patient’s CAP/DA program eligibility involved different facts and legal issues than the traditional Medicaid benefits at issue in the first order. Therefore, the trial court’s order dismissing the motion and petition for lack of jurisdiction is affirmed.

The case is No. COA17-710.

Attorneys: Madison Hardee (Legal Services of Southern Piedmont) for Carlos Pachas. Joshua H. Stein, Office of the Attorney General, for North Carolina Department of Health and Human Services.

Companies: North Carolina Department of Health and Human Services

MainStory: TopStory CaseDecisions CMSNews MedicaidNews EligibilityNews MedicaidPaymentNews NorthCarolinaNews

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