James Ex Rel. James v. Richman

465 F. Supp. 2d 395, 2006 U.S. Dist. LEXIS 84846, 2006 WL 3387183
CourtDistrict Court, M.D. Pennsylvania
DecidedNovember 21, 2006
DocketCivil Action 3:05-CV-2647
StatusPublished
Cited by8 cases

This text of 465 F. Supp. 2d 395 (James Ex Rel. James v. Richman) is published on Counsel Stack Legal Research, covering District Court, M.D. Pennsylvania primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
James Ex Rel. James v. Richman, 465 F. Supp. 2d 395, 2006 U.S. Dist. LEXIS 84846, 2006 WL 3387183 (M.D. Pa. 2006).

Opinion

MEMORANDUM

CAPUTO, District Judge.

Presently before the Court are cross motions for summary judgment filed by Plaintiff Robert A. James and Defendant Estelle B. Richman, Secretary of the Commonwealth of Pennsylvania, Department of Public Welfare. (Docs. 30 and 32.) For the reasons stated below, Plaintiffs motion for summary judgment, as to his request for a permanent injunction, will be granted. Plaintiffs request for a declaratory judgment will be denied. Defendant’s motion for summary judgment will be denied. The Court has jurisdiction over this matter pursuant to 28 U.S.C. § 1331.

STATUTORY BACKGROUND

Pennsylvania participates in the Federal Medicaid Program established by Title XIX of the Social Security Act, also known as the Medicaid Act, 42 U.S.C. § 1396 et seq. Under the Act, the states are granted federal funding to establish plans to dispense assistance to qualified needy individuals. The federal funding is conditioned upon the state’s adoption of a plan which complies with the requirements imposed by the Act and by the Secretary of the United States Department of Health and Human Services, who administers the Medicaid program through the Health Care Financing Administration (“HCFA”). The Department of Public Welfare is the regulatory body charged with administering Medicaid assistance throughout the Commonwealth of Pennsylvania. See 62 Pa. Stat. Ann. § 403. The Medicare Catastrophic Coverage Act of 1988 (“MCCA”), 42 U.S.C. § 1396r-5, amended the Medicaid Act, adding spousal impoverishment provisions which “permit a spouse living at home (called the ‘community spouse’) to reserve certain income and assets to meet the minimum monthly maintenance needs he or she will have when the other spouse (the ‘institutionalized spouse’) is institutionalized, usually in a nursing home, and becomes eligible for Medicaid.” Wis. Dep’t of Health & Family Servs. v. Blumer, 534 U.S. 473, 478, 122 S.Ct. 962, 151 L.Ed.2d 935 (2002). In adopting the MCCA, Congress sought to protect community spouses from becoming impoverished, yet, at the same time, preclude financially secure couples from receiving Medicaid assistance. Id. at 480, 122 S.Ct. 962.

The MCCA provides that “no income of the community spouse shall be deemed available to the institutionalized spouse.” 42 U.S.C. § 1396r-5(b)(l). “The community spouse’s income is thus preserved for that spouse and does not affect the determination whether the institutionalized spouse qualifies for Medicaid.” Blumer, 534 U.S. at 480-81,122 S.Ct. 962.

The MCCA, however, treats assets differently. The MCCA shelters a standard amount of assets called the “community spouse resource allowance” or “CSRA.” Id. at 477, 122 S.Ct. 962. To determine the CSRA, the total of all the couple’s resources, whether owned jointly or severally, is calculated as of the time one spouse is institutionalized; half of that total is then allocated to each spouse. 42 U.S.C. § 1396r-5(c)(l)(A). That amount is the CSRA and is subject to a ceiling. 42 U.S.C. § 1396r-5(c)(2)(B), (f)(2)(A), (g). In determining eligibility, the CSRA is not considered available to the institutionalized *399 spouse, but all resources above the CSRA must be spent in order for the institutionalized spouse to be eligible for Medicaid. Blumer, 534 U.S. at 482-83, 122 S.Ct. 962.

FACTUAL BACKGROUND

The undisputed material facts, as stipu-. lated to by the parties, are as follows. Plaintiff Robert A. James is a seventy-eight (78) year old resident of Summit Health Care nursing facility in Wilkes-Barre, Pennsylvania. (Doc. 28 ¶ 1.) Plaintiff has at all relevant times been married to Josephine A. James, who is seventy-six (76) years of age. (Doc. 28 ¶ 5.)

On August 10, 2005, Plaintiff, then seventy-seven (77) years of age, was admitted into Summit Health Care nursing facility, where he has since resided. (Doc. 28 ¶¶ 3-4.) On September 20, 2005, Plaintiff filed a Resource Assessment with the Department of Public Welfare at the Luzerne County Assistance Office. (Doc. 28 ¶ 6.) Therein, Plaintiff stated that he and his wife’s available resources, as of the date of Plaintiffs admission to Summit Health Care nursing facility, totaled $381,443.00. Id. After allowing for the CSRA, and the institutionalized spouse’s allowance, Plaintiff and his wife had available resources totaling $278,343.00. (Doc. 28 ¶ 7.)

In order to reduce their assets to the required level of spousal impoverishment, on September 12, 2005, Mrs. James purchased a single premium immediate irrevocable annuity from General Electric Assurance Company, a commercial insurance company licensed to sell in the Commonwealth of Pennsylvania, for $250,000.00. (Doc. 28 ¶ 8.) This annuity was payable to Mrs. James in monthly amounts of $2,937.71, beginning October 1, 2005 and ending on September 1, 2013, an eight (8) year period. Id. The terms of the endorsement to the annuity provide “[t]his Contract may not be surrendered, transferred, collaterally assigned, or returned for a return of the premium paid. This Contract is irrevocable and has no cash surrender value. An Owner may not amend this Contract or change any designation under this Contract.” (Doc. 28 ¶ 9.) The parties agree that this annuity is actu-arially sound.

On September 15, 2005, Plaintiff purchased a new vehicle for $28,550.00. (Doc. 28 ¶ 10.) At this point, all resources beyond those permitted by the CSRA and the institutionalized spouse’s allowance had been spent or converted to the annuity. Id.

Thereafter, on September 20, 2005, Plaintiff filed an application for Medicaid coverage to assist with the payment of Plaintiffs nursing facility bill, seeking eligibility for September 15, 2005. (Doc. 28 ¶ 11.)

On November 22, 2005, the Luzerne County Assistance Office determined that Plaintiff was not eligible for Medicaid assistance because he did not receive fair consideration for resources used to purchase the annuity. (Ex. D.)

On December 12, 2005, the Department of Public Welfare issued a new PA 162 Notice to Plaintiff, advising him that the notice he had previously received, on November 22, 2005, was rescinded,’ and that he was “ineligible for nursing home payment at this time. Excess resources exist due to the availability of the $250,000 annuity. You may reapply when resources are within eligibility limits.” (Doc. 28 ¶ 12.) The reason for the rejection for Medicaid assistance is that, in the view of Defendant, the annuity has a value of $185,000.00 and therefore represents assets that are beyond the CSRA, and are therefore available for payment for nursing care.

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Bluebook (online)
465 F. Supp. 2d 395, 2006 U.S. Dist. LEXIS 84846, 2006 WL 3387183, Counsel Stack Legal Research, https://law.counselstack.com/opinion/james-ex-rel-james-v-richman-pamd-2006.