In re Estate of Tomeck

872 N.E.2d 236, 8 N.Y.3d 724
CourtNew York Court of Appeals
DecidedJune 28, 2007
StatusPublished
Cited by15 cases

This text of 872 N.E.2d 236 (In re Estate of Tomeck) is published on Counsel Stack Legal Research, covering New York Court of Appeals primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
In re Estate of Tomeck, 872 N.E.2d 236, 8 N.Y.3d 724 (N.Y. 2007).

Opinion

OPINION OF THE COURT

Read, J.

The Commissioner of the Saratoga County Department of Social Services (the County DSS) seeks to recoup Medicaid payments made on behalf of John M. Tomeck (the husband) from the estate of Margaret M. Tomeck (the wife) and a trust that she created. To resolve this appeal, we must consider the spousal impoverishment provisions of the Medicaid Act (42 USC § 1396r-5) and its state counterpart (Social Services Law § 366-c), the income-first policy adopted by New York to carry out these provisions (Social Services Law § 366-c [8] [c]), and the anti-alienation provision of the Social Security Act (42 USC § 407 [a]). In particular, we are called upon to decide whether New York’s income-first policy, which takes Social Security benefits into account, violates the federal anti-alienation provision. We hold that it does not.

I.

Medicaid’s Spousal Impoverishment Provisions

Medicaid, a joint federal-state program established pursuant to title XIX of the Social Security Act (42 USC § 1396 et seq.), [728]*728pays for medical care for those unable to afford it, including nursing home care for medically needy older people who become eligible by incurring medical expenses that reduce their monthly income and assets below prescribed levels. Ordinarily, a local Medicaid agency employee calculates an applicant’s income and resources to figure out how much must be reduced or “spent down” in order for the applicant to meet the financial criteria to qualify for Medicaid benefits (see 42 USC § 1396r-5 [c] [1] [B]; Social Services Law § 366-c [7]; 18 NYCRR 360-4.8 [c]).

“Because spouses typically possess assets and income jointly and bear financial responsibility for each other, Medicaid eligibility determinations for married applicants have resisted simple solutions” (Wisconsin Dept. of Health & Family Servs. v Blumer, 534 US 473, 479 [2002]). Thus, as part of the Medicare Catastrophic Coverage Act of 1988 (MCCA) (42 USC § 1396r-5), Congress adopted the spousal impoverishment provisions, a complex set of standards governing the allocation of resources between the spouse residing in a nursing home (the institutionalized spouse) and the spouse residing in the community (the community spouse). In general, these provisions are designed to insure that the community spouse retains necessary, but not excessive, income and assets, which do not need to be depleted to make the institutionalized spouse eligible for Medicaid. “In the MCCA, Congress sought to protect community spouses from ‘pauperization’ while preventing financially secure couples from obtaining Medicaid assistance” (Blumer, 534 US at 480; see also Matter of Schachner v Perales, 85 NY2d 316, 319 [1995] [discussing prior law]).

The spousal impoverishment provisions include rules for assigning income to spouses, and for determining the community spouse’s “minimum monthly maintenance needs allowance” (MMMNA), an amount deemed sufficient for the community spouse to live at a modest level after the institutionalized spouse becomes eligible for Medicaid, subject to a statutory floor and ceiling (see 42 USC § 1396r-5 [b], [d] [3]; Social Services Law § 366-c [2] [h], Q]; [3]). Any shortfall between the MMMNA and the income allotted to the community spouse is denominated the “community spouse monthly income allowance” (CSMIA), which is one of the allowances or amounts “deducted” when determining the institutionalized spouse’s monthly income available to pay for nursing home care (see 42 USC § 1396r-5 [d] [1], [2]; Social Services Law § 366-c [2] [g]; [4]).

“The provision for [the CSMIA] ensures that income [729]*729transferred from the institutionalized spouse to the community spouse to meet the latter’s basic needs is not also considered available for the former’s care. As a result, Medicaid [pays] a greater portion of the institutionalized spouse’s medical expenses than it would absent the CSMIA provision” (Blumer, 534 US at 482).

The spousal impoverishment provisions also encompass rules for computing and apportioning a married couple’s combined jointly and separately owned resources in order to protect the community spouse’s share, called the “community spouse resource allowance” (CSRA) (see 42 USC § 1396r-5 [f] [2]; Social Services Law § 366-c [2] [d]). The CSRA is generally equal to one half of the couple’s total countable (i.e., nonexempt) resources, subject to a statutory floor and ceiling (see 42 USC § 1396r-5 [c] [1], [5]; [f] [2]; Social Services Law § 366-c [2] [c], [d], [e]; see also Blumer, 534 US at 482 n 5). All of the institutionalized spouse’s countable resources and the community spouse’s countable resources exceeding the CSRA may be used to pay for nursing home care, and must be spent down in order for the institutionalized spouse to qualify for Medicaid (see 42 USC § 1396r-5 [c] [2]; Social Services Law § 366-c [5] [a]). Once Medicaid eligibility is established, however, “no resources of the community spouse shall be deemed available” to support the institutionalized spouse (see 42 USC § 1396r-5 [c] [4]; Social Services Law § 366-c [5] [c]).

Either spouse has the right to a fair hearing to challenge the adequacy of the MMMNA or the CSRA calculated by the state Medicaid agency (see 42 USC § 1396r-5 [e]; Social Services Law § 366-c [8]). A hearing examiner may raise the MMMNA when exceptional circumstances exist, and may increase the CSRA to generate additional income as necessary to meet the MMMNA (see 42 USC § 1396r-5 [e] [2] [B], [C]; Social Services Law § 366-c [8] [b], [c]).

Finally, Medicaid benefits may not be withheld from the institutionalized spouse in the event the community spouse declines to make spousal resources available to pay for medical expenses (see 42 USC § 1396r-5 [c] [3]; Social Services Law § 366 [3] [a]; see also § 366-c [5] [b]). Specifically, section 366 (3) (a) of the Social Services Law mandates that Medicaid

“shall be furnished to applicants in cases where, although such applicant has a responsible relative [730]*730with sufficient income and resources to provide medical assistance as determined by the regulations of the department, the income and resources of the responsible relative are not available to such applicant because of . . . the refusal or failure of such relative to provide the necessary care and assistance. In such cases, however, the furnishing of such assistance shall create an implied contract with such relative, and the cost thereof may be recovered from such relative in accordance with title six of article three [‘Powers to Enforce Support’] and other applicable provisions of law.”

As we have explained, this “ ‘spousal refusal’ rule indicates that Medicaid must be provided to the institutionalized spouse who meets eligibility requirements even if the community spouse has income or resources in excess of the [CSRA], as long as the State may seek recovery of the cost of medical assistance from the community spouse” (Matter of Shah v DeBuono, 95 NY2d 148, 161 [2000], citing 42 USC § 1396r-5 [c] [3] and Social Services Law § 366 [3] [a]; see also 18 NYCRR 360-4.10 [c] [4]; Morenz v Wilson-Coker, 415 F3d 230 [2d Cir 2005] [institutionalized spouse who executed valid assignment of spousal support rights to state could not be deemed ineligible for Medicaid on account of community spouse’s assets]).

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Bluebook (online)
872 N.E.2d 236, 8 N.Y.3d 724, Counsel Stack Legal Research, https://law.counselstack.com/opinion/in-re-estate-of-tomeck-ny-2007.