Law v. DEPARTMENT OF HEALTH & HOSPITALS

989 So. 2d 871, 2008 WL 3401950
CourtLouisiana Court of Appeal
DecidedAugust 13, 2008
Docket43,417-CA
StatusPublished
Cited by1 cases

This text of 989 So. 2d 871 (Law v. DEPARTMENT OF HEALTH & HOSPITALS) is published on Counsel Stack Legal Research, covering Louisiana Court of Appeal primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Law v. DEPARTMENT OF HEALTH & HOSPITALS, 989 So. 2d 871, 2008 WL 3401950 (La. Ct. App. 2008).

Opinion

989 So.2d 871 (2008)

Leola LAW, Plaintiff-Appellant,
v.
DEPARTMENT OF HEALTH & HOSPITALS, Office of the Secretary, Defendants-Appellees.

No. 43,417-CA.

Court of Appeal of Louisiana, Second Circuit.

August 13, 2008.

Lee Brian Aronson, for Appellant.

*872 Neal Risley Elliott, Jr., Baton Rouge, for Appellees.

Before PEATROSS, MOORE and LOLLEY, JJ.

LOLLEY, J.

Plaintiff, Leola Law, appeals a judgment from the First Judicial District, Parish of Caddo, State of Louisiana, which upheld an Administrative Law Judge's ("ALJ") denial of Law's application for dentures based on statutory interpretation. For the following reasons, we reverse.

FACTS

This case concerns an application by plaintiff, Leola Law, for Medicaid benefits filed on August 16, 2006. Law's application was specifically for prosthetic dentures that she is in need of as a result of tooth decay and other dental issues. After reviewing her application, Louisiana Department of Health and Hospitals ("LDHH") found that Law was only eligible for the Pure Qualified Medicare Beneficiary program ("Pure QMB") which does not cover dentures. Since Law receives $691.00 a month in Social Security benefits, she exceeded the state benefit rate of $603.00 which would have made her eligible for a different status—"Dual QMB." With Dual QMB status, Law may have been provided coverage for dentures. Both categories are found under Title XIX of the Social Security Act.

Law's application was denied. Law then filed a Petition for Judicial Review of Medicaid's refusal to pay. The trial court held a hearing and found it was unable to make a determination of the appropriateness of granting or denying Law's Petition for Judicial Review because the record was incomplete. The trial court asked that the ALJ hold a hearing "within 90 days." The ALJ held a rehearing, and the record was supplemented with a transcript along with a summary of proceedings. The trial court then reviewed the record in its entirety, affirmed the findings of the LDHH, and subsequently upheld the denial of Law's application for dentures. It is from this judgment Law now appeals.

LAW AND DISCUSSION

Standard of Review

When reviewing an administrative final decision in an adjudication proceeding, the trial court functions as an appellate court. Once a final judgment is rendered by the trial court, an aggrieved party may seek review by appeal to the appropriate appellate court. On review of the trial court's judgment, no deference is owed by the court of appeal to the factual findings or legal conclusions of the trial court, just as no deference is owed by the Louisiana Supreme Court to factual findings or legal conclusions of the court of appeal. Thus, an appellate court sitting in review of an administrative agency reviews the findings and decision of the administrative agency and not the decision of the trial court. King v. Sec'y, Department of Health and Hospitals, 42,071 (La.App. 2d Cir.04/04/07), 956 So.2d 666, writ denied, XXXX-XXXX (La.09/14/07), 963 So.2d 1001.

The applicable standard of review is set forth in La. R.S. 49:964. The trial court and the court of appeal have the authority to reverse or modify the decision of the agency if substantial rights of the party seeking review have been prejudiced because the administrative findings, inferences, conclusions, or decisions are: (1) in violation of constitutional or statutory provisions; (2) in excess of the agency's statutory authority; (3) made upon unlawful procedures; (4) affected by other error of law; (5) arbitrary or capricious or characterized by abuse of discretion or clearly unwarranted exercise of discretion; or (6) *873 manifestly erroneous in view of the reliable, probative and substantial evidence in the record. See King, supra.

At the outset we note that there is no merit to Law's argument that the state policies LDHH relied on should not have been introduced into evidence. Law argues that she was not made aware of the state policies at the time her application was denied. However, after reviewing the record we believe LDHH followed 42 C.F.R. § 435.912 and notice was adequate.

Medicaid/Medicare Background

Medicare, enacted in 1965 under Title XVIII of the Social Security Act, 42 U.S.C. §§ 1395-1395ccc, is a federally run program to provide financing for medical procedures for certain disabled individuals and people of 65 years of age or older. 42 U.S.C. §§ 426(a), 1395c. Medicare has two parts, Part A and Part B: Medicare Part A, 42 U.S.C. §§ 1395c to 1395i-4, provides reimbursement for inpatient hospital care, and related post hospital, home health and hospice care; and, Medicare Part B, 42 U.S.C. §§ 1395j to 1395w-4, which is a supplemental voluntary insurance program.

Also enacted in 1965, Medicaid, Title XIX of the Social Security Act, 42 U.S.C. §§ 1396-1396v, established a federal-state cooperative cost-sharing program to provide medical assistance to families and individuals with insufficient income and resources. While a state's participation in Medicaid is not mandatory, once a state chooses to participate it receives federal funds for its Medicaid program. Louisiana, through the LDHH, provides guidance and implementation to give effect to the federal statutes.

Medicaid and Medicare statutes intersect for coverage when the population is poor and (1) disabled or (2) people 65 years of age or older. These people are considered Dual QMB. However, the other group, Pure QMB, are Medicare eligible and also meet certain criteria of poverty but not the state's eligibility requirement for Medicaid. See Rehabilitation Association of Virginia, Inc. v. Kozlowski, 42 F.3d 1444 (4th Cir.1994).

Relevant Louisiana Statute

The crux of Law's argument is with respect to the Louisiana statute R.S. 46:157 entitled "Prosthetic dentures; eligibility; rules and regulations," which states:

The office of family security of the Department of Health and Hospitals shall make available to persons of this state who are eligible for Medicaid benefits under Title XIX of the Social Security Act, [FN1] prosthetic dentures, upon certification by a dentist licensed under Louisiana law that the person is in need of prosthetic dentures, and upon certification of such need by the Department of Health and Hospitals.
The secretary of the Department of Health and Hospitals shall promulgate the necessary rules and regulations to implement the provisions of this Section.

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989 So. 2d 871, 2008 WL 3401950, Counsel Stack Legal Research, https://law.counselstack.com/opinion/law-v-department-of-health-hospitals-lactapp-2008.