Colby v. Commissioner

18 Mass. App. Ct. 767
CourtMassachusetts Appeals Court
DecidedNovember 15, 1984
StatusPublished
Cited by1 cases

This text of 18 Mass. App. Ct. 767 (Colby v. Commissioner) is published on Counsel Stack Legal Research, covering Massachusetts Appeals Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Colby v. Commissioner, 18 Mass. App. Ct. 767 (Mass. Ct. App. 1984).

Opinion

Greaney, C.J.

To resolve this appeal, we are required to explore the complexities of medicaid regulations, State and Federal. In particular, we examine “deeming” procedures. We conclude: (1) that a decision by a referee of the Department of Public Welfare (department) denying Lila Colby and her two children medicaid eligibility for the period between April 1, 1983, and September 30, 1983, until they had incurred medical expenses in excess of $1,722.96, was correct, and (2) that the department’s deeming policy as expressed in 106 Code Mass. Regs. § 505.460 (1983), and as applied to the Colby family, is in compliance with Federal law.

1. Background: the operation of the medicaid program. Title XIX of the Social Security Act of 1965, 42 U.S.C. §§ 1396 et seq. (Supp. V 1975), creates a cooperative Federal-State medical assistance program to enable States to furnish medical assistance to families with dependent children and to aged, blind or disabled individuals who have insufficient income and resources to meet the costs of necessary medical services. 42 U.S.C. § 1396(1) (1982). If a State chooses to participate in the medicaid program, it must meet all the requirements of the Social Security Act and of regulations promulgated by the Federal Department of Health and Human Services (HHS). 42 U.S.C. §§ 1396, 1396a (1982). 42 C.F.R. § 435.10 (1983).

With respect to these requirements, the Federal program distinguishes two groups of medicaid recipients. A participating State must provide medical assistance to the “categorically needy” (42 C.F.R. § 435.4 [1983]), namely those individuals and families whose level of income and resources are low enough to qualify them for cash assistance under the Supplemental Security Income (SSI) Program or under the Aid to Families with Dependent Children (AFDC) Program. 42 U.S.C. § 1396a(a)(10)(A) (1982). Pursuant to 42 U.S.C. [769]*769§ 1396a(a)(10)(C) (1982), a State may also provide medical assistance to the “medically needy” (42 C.F.R. § 435.4 [1983]), namely those individuals or families whose levels of income are too low to cover all the costs of medical care but too high to qualify them for cash grants under the SSI or AFDC programs (the SSI medically needy and the AFDC medically needy).

Under the Massachusetts medicaid program, administered by the department, medical assistance is furnished to the categorically needy (as required) and the medically needy (as permitted). To obtain medicaid, a medically needy person must have income and resources within the limits of the State’s medical assistance plan. 42 C.F.R. § 435.4 (1983). Those who have income greater than the allowable level may nonetheless become eligible when they incur medical bills equal to the amount of income that exceeds the medicaid level. 42 C.F.R. § 435.831(d) (1983). The amount of medical bills that must be incurred prior to attaining eligibility is known as a “spend-down.”

In determining eligibility for medicaid, the Social Security Act requires States to base assessments of financial need only on “such income and resources as are, as determined in accordance with standards prescribed by the Secretary, available to the applicant or recipient.” 42 U.S.C. § 1396a(a)(17)(B) (1982). The State agency administering the program locally must employ reasonable standards and methodologies to evaluate income. 42 U.S.C. § 1396a(a)(17)(C) (1982). Eligibility decisions may not take into account the financial responsibility of any individual for any applicant or recipient of assistance unless the applicant or recipient is the individual’s spouse or child. 42 U.S.C. § 1396a(a)(17)(D) (1982).

Federal regulations also permit the State to consider income and resources of spouse or parents as available to a medically needy applicant or recipient even if they are not actually contributed. 42 C.F.R. §§ 435.821(c), 435.822(b)(2) (1983). The department has promulgated regulations which provide that, when a child under eighteen resides with a parent, the assets and income of the parent are considered available to the child [770]*770irrespective of whether they are actually contributed to the child’s support. 106 Code Mass. Regs. § 505.410(A)(1) (1983). Additionally, each spouse has financial responsibility for the other, and when spouses reside together, the assets and income of each spouse are considered mutually available, whether or not actually contributed. 106 Code Mass. Regs. § 505.450(A)(1) (1983). Consideration of one individual’s income as available to another is referred to as “deeming.”

If a medically needy individual is eligible for medicaid under more than one category, Federal and State law permit the individual to have his eligibility determined under the category he selects. 42 C.F.R. § 435.404 (1983). 106 Code Mass. Regs. § 505.460 (1983).2 Until 1983, when an individual who was eligible as either SSI or AFDC medically needy chose to have his eligibility determined under the SSI category, the department split the family’s income between the two separate assistance units and compared the total income of each unit to the medicaid income standard without “deeming.”

In March, 1983, however, the department amended § 505.460, the “choice of category” regulation, to provide that “assets and income shall be considered in accordance with the regulations for financial responsibility.” Pursuant to the amended regulation, the department now “deems” the income of an SSI medically needy applicant to his AFDC medically needy family if the applicant and his family reside in the same household, even if both apply as separate assistance units. It is the application of the department’s “deeming” regulations to the plaintiffs’ February, 1983, medicaid eligibility redetermination which is at issue here.

2. The Colby s’ situation. Harry Colby is a disabled veteran who resides with his wife, Lila Colby, and their two minor [771]*771children. The family’s sole source of income is a Veterans’ Administration disability pension which Mr. Colby receives in the amount of $732.16 per month. Mr.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Boston Police Patrolmen's Ass'n v. Menino
22 Mass. L. Rptr. 72 (Massachusetts Superior Court, 2006)

Cite This Page — Counsel Stack

Bluebook (online)
18 Mass. App. Ct. 767, Counsel Stack Legal Research, https://law.counselstack.com/opinion/colby-v-commissioner-massappct-1984.