State of Illinois v. Heckler

609 F. Supp. 1421, 1985 U.S. Dist. LEXIS 19564
District Court, N.D. Illinois·Decided May 23, 1985·No. No. 84 C 6343·Published·Cited by 1 cases

Opinion

MEMORANDUM OPINION AND ORDER

ASPEN, District Judge:

Medicaid is a welfare program which in theory is run cooperatively by state and [1423]*1423federal agencies. This case reveals a breakdown of state-federal cooperation, or at least a communication breakdown. The State of Illinois (“Illinois”) has sued Margaret Heckler, Secretary of U.S. Department of Health and Human Services (“the Secretary”), claiming that she is trying, to put it bluntly, to cheat it out of about $4,000,000 in federal reimbursement for medical services provided by Illinois. The Court is asked to review a decision of the Secretary’s “Departmental Grant Appeals Board” (“the Board”) which upheld an earlier administrative decision to disallow Illinois’ claims for the $4,000,000. The parties have submitted cross-motions for summary judgment based upon a certified administrative record. For the reasons stated below, we grant the Secretary’s motion and deny that of Illinois’.

The background of this case is somewhat complex and needs some elaboration. We will first sketch the relevant statutory and regulatory background. Then we shall describe the facts as revealed by the record, which show how Illinois came to believe it was entitled to the $4,000,000 in reimbursement. Finally, we will summarize the decision of the Board and explain why that decision must be upheld.

1. Statutory and Regulatory Background

Congress passed Title XIX of the Social Security Act (“Medicaid” or “Title XIX”), 42 U.S.C. § 1396 et seq., in 1965 to help provide certain medical services to the poor. The lifeblood of the program is federal money, which is given to the states, which in turn afford the services to the beneficiaries. 42 U.S.C. § 1396.

Under Title XIX, a state must designate one state agency to administer the State’s Medicaid “plan.”1 42 U.S.C. § 1396a(a)(5). In Illinois that agency is plaintiff Illinois Department of Public Aid (“IDPA”). IDPA must create and then implement a “plan for medical assistance” which is consistent with Title XIX and the Secretary’s regulations. The plan describes the services covered, the method by which providérs are reimbursed and the manner in which the program is administered. The plan is submitted to the Secretary for approval. After the plan is approved, the State becomes entitled each quarter to be reimbursed for a percentage of its expenditures made in providing specific types of “medical assistance” under the plan. 42 U.S.C. § 1396b(a)(l). This federal reimbursement is' called “federal financial participation,” or in bureaucratic jargon, “FFP.” IDPA had such an approved plan during the time period of this suit.

The term “medical assistance” encompasses a broad range of services, but in general excludes services of a type central to the dispute here — inpatient services to people of ages 22-64 in an “institution for mental diseases” (“IMD”):

(a) The term “medical assistance” means payment of part or all of the cost of the following care and services ...
(1) inpatient hospital services (other than services in an institution for ... mental diseases);
>{< % # $ >1» #
(4)(A) skilled nursing facility services (other than services in an institution for ... mental diseases) ...
* * # # # *
(14) inpatient hospital services, skilled nursing facility services, and intermediate care facility services for individuals 65 years of age or over in an institution for ... mental diseases;
(15) intermediate care facility services (other than such services in an institution for ... mental diseases) ...
[1424]*1424(16) effective January 1, 1973, inpatient psychiatric hospital services for individuals under age 21 ...
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except as otherwise provided in paragraph (16), such term does not include—
******
(B) any such payments with respect to care of services for any individual who has not attained 65 years of age and who is a patient in an institution for ... mental diseases.

42 U.S.C. § 1396d(a). Despite the statute’s seemingly clear exclusion of IMD services for patients between ages 22-64 (“the general IMD exclusion”), the dispute here centers about whether IDPA is entitled to FFP for exactly that type of service. The source of the dispute is conflicting interpretations of the Secretary’s regulations promulgated under Title XIX.

The regulations in general echo the statute’s general exclusion of IMD services to people between 21-65 years old. See 42 C.F.R. 435.1008(a)(2) (1984).2 However, another part of this regulation can generally be read to create an exception to this general exclusion:

(a) Except as provided in paragraph (b) of this section, FFP is not available in expenditures for services provided to—
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(2) Individuals under age 65 who are patients in an institution for tuberculosis or mental diseases unless they are under age 22 and are receiving inpatient psychiatric services under § 440.160 of this subchapter.
(b) FFP is available in expenditures for services furnished to eligible individuals during the month in which they become ... patients in an institution for tuberculosis or mental diseases.

42 C.F.R. § 435.1008(a), (b). IDPA argues that this provision allows FFP for the first month of all “services,” even otherwise excluded IMD services to those between 21 and 65. It reasons that this is consistent with the usual Medicaid rule of administrative convenience that the “month” is the interval of eligibility. See 42 C.F.R. § 435.-914(b) (1984) (if individual is eligible for Medicaid at any time during a month, individual is eligible for entire month); S.Rep. 404, Part I, 89th Cong., 1st Sess. 82 (1965), reprinted in 1965 U.S.Code Cong. & Ad. News 1943, 2022 (for administrative convenience medical assistance may include payment for care provided any time during month individual becomes eligible). We will expand on Illinois’ theory below, as its whole case turns on these provisions. But we turn first to what happened in this case between IDPA and HHS.

2. Factual Background

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State of Illinois v. Heckler, 609 F. Supp. 1421, 1985 U.S. Dist. LEXIS 19564 (N.D. Ill. 1985).

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