Leon v. v. Nebraska Dept. of Health & Human Servs.
302 Neb. 81
| Neb. | 2019Background
- Leon and Cristy V. applied for Medicaid and requested AABD waiver services for their 12‑year‑old daughter Paige based on serious gastrointestinal impairments beginning in 2016.
- DHHS denied AABD eligibility, finding Paige’s impairments would not last 12 months (the Medicaid durational requirement).
- Leon and Cristy administratively appealed; DHHS affirmed its denial. They then sought judicial review under the Administrative Procedure Act in Lancaster County district court.
- The district court found by a preponderance of the evidence that Paige met the 12‑month durational requirement and thus was medically eligible for Medicaid; it reversed DHHS and remanded with directions to award AABD waiver services and reimburse medical expenses retroactively to October 1, 2016.
- DHHS appealed, not contesting the disability finding but arguing the district court exceeded its authority by directing award of waiver services and retroactive payments without there having been a waiver eligibility assessment and completion of regulatory prerequisites.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether Paige met the Medicaid disability durational requirement | Paige’s parents: evidence shows impairments expected to last ≥12 months, so Medicaid eligible | DHHS: originally determined impairments would not meet 12‑month durational requirement | Court: affirmed district court — Paige meets durational requirement and is medically eligible for Medicaid |
| Whether a judicial finding of Medicaid eligibility requires DHHS to award AABD waiver services immediately | Leon & Cristy: remand should direct award and retroactive waiver benefits and reimbursements | DHHS: eligibility for Medicaid ≠ automatic entitlement to waiver services; additional regulatory steps (assessment, consent, NF level, slot availability, cost cap) required | Court: reversed district court’s directive awarding waiver services; holding that waiver services require separate regulatory procedures and cannot be ordered solely from a Medicaid eligibility finding |
| Whether waiver benefits can be made retroactive based solely on Medicaid eligibility determination | Leon & Cristy: asserted entitlement to retroactive waiver period/payment | DHHS: retroactivity requires compliance with waiver rules (e.g., signed consent, eligibility period rules, slot availability) | Court: remand to DHHS for further proceedings; parties may complete waiver steps; district court exceeded scope by ordering retroactive waiver payments without required administrative steps |
| Proper scope of judicial review under the APA | Leon & Cristy: court may grant complete relief including benefits award after finding eligibility | DHHS: court’s review limited to whether DHHS’s disability determination was correct; cannot supplant agency’s role in administering waiver program | Court: affirmed that judicial review asks whether agency action conforms to law and evidence, but courts cannot impose requirements or awards that bypass agency‑administered regulatory processes |
Key Cases Cited
- J.S. v. Grand Island Pub. Schs., 297 Neb. 347 (standard of review for APA judicial review)
- Lingenfelter v. Lower Elkhorn NRD, 294 Neb. 46 (appellate deference to district court factual findings supported by competent evidence)
- Melanie M. v. Winterer, 290 Neb. 764 (appellate courts independently decide questions of statutory/regulatory interpretation)
- Merie B. on behalf of Brayden O. v. State, 290 Neb. 919 (waiver services are for those meeting nursing‑facility level choosing home/community services; agency regulations have force of law)