921 N.W.2d 584
Neb.2019Background
- Leon and Cristy V. applied for Medicaid/AABD waiver services on behalf of their 12-year-old daughter Paige after serious gastrointestinal illness and hospitalizations in 2016.
- DHHS denied AABD eligibility, finding Paige’s impairment would not last 12 months (durational requirement), and affirmed that denial after an administrative hearing.
- Leon and Cristy sought judicial review under the Administrative Procedure Act; the district court found Paige disabled for Medicaid purposes and reversed DHHS.
- The district court remanded with directions to award AABD Medicaid waiver services and to reimburse medical expenses retroactively to October 1, 2016.
- DHHS appealed only the scope of the remand, agreeing Paige met Medicaid disability eligibility but arguing additional regulatory steps are required before waiver services or retroactive payments can be ordered.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether Paige is disabled for Medicaid eligibility (12-month durational requirement) | Paige meets the durational and impairment criteria and is disabled for Medicaid eligibility | DHHS did not successfully rebut evidence that Paige’s impairment met the durational requirement | Court affirmed district court: Paige is disabled for Medicaid eligibility |
| Whether district court could order DHHS to award AABD Medicaid waiver services on remand | District court ordered waiver services and retroactive reimbursement based on finding of Medicaid eligibility | DHHS: Medicaid eligibility alone does not satisfy separate regulatory criteria for waiver services; additional procedural and substantive steps required | Court reversed the remand order insofar as it directed immediate award of waiver services and payments; district court exceeded scope of review |
| Whether waiver eligibility may be made retroactive | Plaintiffs argued an ultimate award of waiver services may be retroactive | DHHS’s briefing appears to concede retroactivity may be possible but triggers regulatory processes | Court did not foreclose retroactivity but held procedures and eligibility steps under regulations must be completed before awards/payments |
| Proper scope of judicial review under APA for agency disability determinations | Plaintiffs sought full relief (waiver and reimbursement) after winning disability finding | DHHS argued judicial review was limited to disability determination and agency must follow waiver regulations | Court held judicial review properly confirmed disability but remand must allow agency to follow waiver regulations and procedures |
Key Cases Cited
- J.S. v. Grand Island Public Schools, 297 Neb. 347, 899 N.W.2d 893 (standards for APA judicial review)
- Lingenfelter v. Lower Elkhorn NRD, 294 Neb. 46, 881 N.W.2d 892 (appellate deference to district court factual findings supported by competent evidence)
- Melanie M. v. Winterer, 290 Neb. 764, 862 N.W.2d 76 (statutory/regulatory interpretation reviewed de novo)
- Merie B. on behalf of Brayden O. v. State, 290 Neb. 919, 863 N.W.2d 171 (describing Medicaid waiver services and effect of properly adopted regulations)