2018 Ohio 3164
Ohio Ct. App.2018Background
- Persey Tiggs, a Medicaid recipient and probate-adjudicated incompetent, lived at The Willows nursing facility; a life insurance policy made him financially ineligible for Medicaid because it had cash surrender value.
- ODJFS (appellant) sent notice in Sept. 2015 proposing termination of benefits; due to error Tiggs continued receiving benefits until Aug. 2016.
- Tiggs’s guardian executed a written designation naming The Willows as his authorized representative; The Willows reapplied for Medicaid on Tiggs’s behalf in Aug. 2016 and the application was denied because of the life insurance policy.
- At the state hearing The Willows argued the policy was inaccessible to Tiggs; the hearing officer and ODJFS administrative appeal found no documentary proof the policy was inaccessible and denied relief.
- The Willows appealed to the common pleas court; the court modified ODJFS’s decision and ordered ODJFS to determine whether The Willows or the guardian could assist in accessing the policy or to refer the matter to counsel.
- ODJFS appealed to the court of appeals, raising three assignments of error: (1) The Willows lacked standing to pursue the judicial appeal, (2) ODJFS had no duty to assist because Tiggs was incompetent, (3) ODJFS had no obligation under Ohio Adm.Code 5160:1-2-01(F)(5) to seek someone to assist Tiggs.
Issues
| Issue | Plaintiff's Argument (The Willows/Tiggs) | Defendant's Argument (ODJFS) | Held |
|---|---|---|---|
| 1. Whether an authorized representative can appeal administratively to the common pleas court | Designation authorized The Willows to act in “all Medicaid-related matters,” including judicial appeal | Authorized representatives may act only at the agency level, not as litigants in court | Court of appeals: The trial court did not err; The Willows had standing to appeal under 42 C.F.R. 435.923(b) and Ohio Adm.Code 5160 provisions |
| 2. Whether ODJFS had a duty to assist an incompetent recipient in accessing an allegedly inaccessible asset | ODJFS should help identify or secure assistance to access the life insurance policy when beneficiary is incompetent and guardian unable | ODJFS argued no such duty arose and challenged the trial court’s conclusion | Not reached on merits by this court: ODJFS’s appeal on this point was dismissed for lack of jurisdiction under R.C. 119.12(N) |
| 3. Whether Ohio Adm.Code 5160:1-2-01(F)(5) required ODJFS to determine whether someone was available to assist Tiggs | The regulation imposes an obligation to determine availability of assistance when recipient cannot obtain verifications | ODJFS contends the rule was misapplied and the trial court’s factual application was erroneous | Not reached on merits by this court: appellate jurisdiction lacking; assignments disregarded |
| 4. Scope of appellate review available to ODJFS under R.C. 119.12(N) | (Implicit) Agency may appeal legal questions about agency rules | ODJFS appealed; court analyzed limits of agency appeal rights under R.C. 119.12(N) | Court: Jurisdiction exists to review statutory/rule interpretation claims (so it entertained standing issue) but rejects ODJFS’s appeal on duties that required factual application rather than pure statutory/rule interpretation |
Key Cases Cited
- Harris v. McRae, 448 U.S. 297 (federal funding limits for Medicaid programs)
- Wisconsin Dept. of Health & Family Servs. v. Blumer, 534 U.S. 473 (state administration and federal Medicaid standards)
- Bernard v. Unemp. Comp. Rev. Comm., 136 Ohio St.3d 264 (deference to agency interpretation of rules)
- Univ. of Cincinnati v. Conrad, 63 Ohio St.2d 108 (standard for common pleas review of agency decisions)
- Pons v. Ohio State Med. Bd., 66 Ohio St.3d 619 (appellate role in reviewing administrative decisions)
- Lorain City School Dist. Bd. of Edn. v. State Emp. Relations Bd., 40 Ohio St.3d 257 (appellate limits when reviewing trial court administrative appeals)
- Jones Metal Prods. Co. v. Walker, 29 Ohio St.2d 173 (deference to agency interpretation of its own regulations)
- Miller v. Dept. of Indus. Relations, 17 Ohio St.3d 226 (agency appeal rights under R.C. 119.12 are limited to questions of law)
- Santa v. Ohio Dept. of Human Servs., 136 Ohio App.3d 190 (standing and real-party-in-interest issues in Medicaid appeals)