In re J.H.
160 A.3d 1023
| Vt. | 2016Background
- J.H., who aged out of Dr. Dynasaur (Medicaid) at 19, applied for coverage on Vermont Health Connect; household income reported ~ $36,868.
- Her husband’s employer offers an ACA-compliant employer-sponsored plan that would cover J.H. as a spouse, but the plan conditions family enrollment on the employee’s (husband’s) enrollment.
- Husband was eligible for premium-free Medicaid (as an unadopted former foster child under 26) and chose not to enroll in his employer plan.
- DCF denied J.H. advance premium tax credits (APTC) and other subsidies on the ground the employer plan was “available” to her; the Human Services Board reversed.
- The legal question: under Treas. Reg. § 1.36B-2, is J.H. ineligible for exchange subsidies because coverage was available to her through her husband’s employer even though her enrollment depended on his independent election?
Issues
| Issue | Plaintiff's Argument (State/DCF) | Defendant's Argument (J.H./HCA) | Held |
|---|---|---|---|
| Whether J.H. was ineligible for APTC because an employer-sponsored plan was available through her husband | DCF: Household eligibility controls; because both spouses "could have enrolled," J.H. is eligible for MEC under employer plan and thus not eligible for subsidies | HCA/J.H.: J.H. could not independently enroll because husband did not elect employer coverage; her inability to enroll is not imputable to him | Held for J.H.: Because J.H. could not have enrolled unless husband enrolled, she was not eligible for MEC under his employer plan and may receive subsidies |
| Whether the husband’s choice to decline employer coverage is imputable to spouse for subsidy eligibility | DCF: Husband’s decision is relevant; household decision affects availability | HCA: Spouses are treated as individuals for subsidy eligibility; one spouse’s election should not be imputed to the other | Held: Election is not imputed; eligibility is assessed individually under the regulation |
| Proper interpretation of Treas. Reg. § 1.36B-2(c)(3) (employee vs. related individual) | DCF: Regulation supports treating family availability based on what employee could do | HCA: Regulation treats employee and related individual separately; related individual must themselves be able to enroll | Held: Regulation separates employees and related individuals; related individual’s independent ability to enroll is required |
| Whether any conflict exists between HBEE rules on MEC and enrollment | DCF: No conflict; rules consistently require applying availability standards (household/employer) | HCA/Board: Conflict arises if government-sponsored MEC is treated as mandatory over employer offer; requiring duplicative employer enrollment is unreasonable | Held: No operative conflict; federal regulation governs and supports individual-based inquiry, affirming Board’s outcome though on different rationale |
Key Cases Cited
- Hogan v. Dep’t of Soc. & Rehab. Servs., 168 Vt. 615 (agency interpretation of federal law not binding on courts) (mem.)
- Dutton v. Dep’t of Soc. Welfare, 168 Vt. 281 (state rules implementing federal law require judicial construction)
- In re Jones, 187 Vt. 1 (statutory interpretation principles)
- Delta Psi Fraternity v. City of Burlington, 185 Vt. 129 (plain meaning unless inconsistent with statutory scheme)
- Nat’l Fed’n of Indep. Bus. v. Sebelius, 132 S. Ct. 2566 (principal purpose of ACA is to increase coverage and reduce cost)
- Med. Ctr. Hosp. of Vt. v. Lorrain, 165 Vt. 12 (spouses treated as separate legal persons)
- United States v. Craft, 535 U.S. 274 (historical note on marital unity doctrine)
Affirmed.