Camacho v. Perales

786 F.2d 32, 1986 U.S. App. LEXIS 21596
CourtCourt of Appeals for the Second Circuit
DecidedJanuary 24, 1986
DocketNo. 1163, Docket 85-7139
StatusPublished
Cited by16 cases

This text of 786 F.2d 32 (Camacho v. Perales) is published on Counsel Stack Legal Research, covering Court of Appeals for the Second Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Camacho v. Perales, 786 F.2d 32, 1986 U.S. App. LEXIS 21596 (2d Cir. 1986).

Opinion

KEARSE, Circuit Judge:

Intervenors-plaintiffs Aida Figueroa and William Boyd (“intervenors”) appeal from a final judgment of the United States District Court for the Southern District of New York, John E. Sprizzo, Judge, dismissing their class action complaints challenging the method by which defendants Commissioner of the New York State Department of Social Services, et al. (collectively the “State”), calculate the Medicaid eligibility of aged, blind, or disabled persons who are not entitled, because of their financial status, to receive Supplemental Security Income (“SSI”) benefits and who live with spouses who are not aged, blind, or disabled within the meaning of the SSI program, 42 U.S.C. §§ 1381-1383c (1982) (“ineligible spouses”). Intervenors contended that the State’s method violates 42 U.S.C. § 1396a(a) (1982), which requires that states choosing to provide Medicaid to medically needy aged, blind, or disabled persons must employ the “same methodology” in calculating Medicaid eligibility that the federal government employs in determining SSI eligibility. They sought principally (A) a judgment declaring (1) that the State’s inclusion of certain income of the ineligible spouse in the computation of the applicant’s financial eligibility violates the same-methodology requirement, and (2) that the State must base all of its income allowance calculations on the number of family members in the household; and (B) an order requiring defendants to reimburse all members of the class for unpaid Medicaid benefits that would have been payable if the requested methodology had been used. We conclude (1) that the State’s present methodology fails to conform to the SSI methodology in at least two respects, including the respect challenged by intervenors and the respect that intervenors seek to perpetuate. Since we decline to order the perpetuation of a methodology that in any respect violates the same-methodology requirement of federal law, we affirm in part, reverse in part, and remand for further proceedings.

I. BACKGROUND

Under Medicaid, which is a federal and state cost-sharing program through which participating states provide medical assistance to persons whose income and resources are insufficient to cover the costs of necessary medical care, there are two classes of eligible persons: the “categorically needy” and the “medically needy.” The categorically needy, see 42 C.F.R. § 435.1(b)(ii) (1984), are those persons eligible for cash assistance under either the Aid to Families with Dependent Children (“AFDC”) program, 42 U.S.C. § 601 et seq. (1982), or the SSI program for persons who have reached the age of 65 or who are blind or disabled, id. § 1381 et seq. The medically needy, see 42 C.F.R. § 435.-l(b)(3)(i), are those persons who (a) meet the nonfinancial eligibility requirements for cash assistance under AFDC or SSI, and (b) [34]*34have income or resources that exceed the financial eligibility standards of the relevant program but that are considered insufficient to pay for necessary medical care. In a state that has elected to provide Medicaid to medically needy persons, such a person becomes eligible for Medicaid if, during a given period, he incurs medical expenses in an amount equal to or greater than the amount by which his income exceeds the “medically needy income standard” set by the state (termed a “spend-down”). See 42 U.S.C. § 1396a(a)(17); 42 C.F.R. §§ 435.831(c) and (d) (1984); N.Y. Admin.Code tit. 18, § 360.5(d) (1985).

Intervenor Boyd is a disabled Medicaid applicant who met all of the requirements for SSI except those as to level of income or resources. Intervenor Figueroa is administratrix of the estate of her late husband, William Figueroa, who was, like Boyd, an SSI-related medically needy Medicaid applicant. New York State provides Medicaid to persons who fall within the definition of medically needy and who “spend down” to the State’s medically needy income level. Both intervenors challenge the methodology used by State and local officials to calculate, with respect to the SSI-related medically needy, the level of their income or resources for Medicaid eligibility purposes when they live with spouses who are not eligible for SSL

A. The Statutory and Regulatory Background of SSI and Medicaid

States that choose to participate in the Medicaid program are required to provide Medicaid to the categorically needy, 42 U.S.C. § 1396a(a)(10)(A)(i), and may, in addition, elect to provide Medicaid to the medically needy, id. § 1396a(a)(10)(C). As a state that has chosen to provide Medicaid to the medically needy, New York is required to include in its Medicaid plan “reasonable standards (which shall be comparable for all-groups ...) for determining eligibility for ... medical assistance under the plan____” Id. § 1396a(a)(17). A regulation promulgated by the Secretary of the Department of Health and Human Services (“Secretary”, “Department”) in 1981 provides that the income standard to be used must, in addition, be “(a) [b]ased on family size; [and] (b) [u]niform for all individuals in a covered group.” 42 C.F.R. § 435.811 (1984). The statutory section principally at issue here, 42 U.S.C. § 1396a(a)(10)(C)(i) (I — II), requires the State to use, in determining the Medicaid eligibility of the medically needy aged, blind, or disabled, the “same methodology” that is used to determine financial eligibility in the SSI program. That section provides, insofar as is pertinent to this case, as follows:

the [State’s] plan must include a description of ... (Ill) the single standard to be employed in determining income and resource eligibility [for the SSI-related medically needy] and the methodology to be employed in determining such eligibility, which shall be the same methodology which would be employed under the supplemental security income program in the case of groups consisting of aged, blind, or disabled individuals in a State in which such program is in effect____
1. The SSI Methodology

Under the federal statutory scheme, the maximum benefits payable to an SSI-eligible individual are set at a certain rate; if both husband and wife are SSI-eligible and are living together, the maximum benefits payable to the couple are set at a higher rate. At the time this action was commenced, the Federal benefit rates for eligible individuals and eligible couples were, respectively, $284.30 and $426.40 per month. If the SSI applicant is aged, blind, or disabled and the spouse is not, the following methodology is used to determine the financial eligibility of the applicant.

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Camacho v. Perales
786 F.2d 32 (Second Circuit, 1986)

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Bluebook (online)
786 F.2d 32, 1986 U.S. App. LEXIS 21596, Counsel Stack Legal Research, https://law.counselstack.com/opinion/camacho-v-perales-ca2-1986.