514 A.2d 204 | Pa. Commw. Ct. | 1986
Opinion by
William Martin (petitioner) appeals from a final order of the Department of Public Welfare (DPW) dismissing an appeal from a denial of Medical Assistance (MA)
Petitioner and his family were named insureds under a policy of insurance issued by the New World Maintenance Association, Inc. (NWMA), an organization then purporting to operate as a licensed health and disability insurer under the laws of the State of California.
On March 1, 1983, petitioners wife, Louise Martin, went to the Westmoreland County Assistance Office (CAO) and requested Medical Assistance (MA) benefits for herself and her family. At the time, petitioners family was laced with more than $6,500.00 in bills from the September, 1982, surgery on Louise Martin and nearly $6,000.00 in bills from the December, 1982, surgery on Theodora Martin. The amount due for the April, 1983, surgery would prove to be nearly $8,000.00, making for a total of approximately $20,500.00 in medical bills in
Mrs. Martin was told by a CAO worker that her application could not be considered or processed, and her eligibility established, unless she first submitted the following items to the CAO:
(1) a 1982 profit-loss statement or a 1982 Federal tax return;
(2) verification of money spent on prescriptions;
(3) verification of payment of monthly hospital premiums.
On March 18, 1983, the CAO sent the Martins a notice of its decision to deny the application based upon the Martins’ failure to provide “essential” information. The information was not specified on the denial form. The notice of denial contained no reference to any of the above-requested information or to a time limit for furnishing the information. The notice of denial was not preceded by either an oral or a written request for the furnishing of this information.
The testimony of Mrs. Martin before the hearing officer was that no definite time was assigned by which she had to submit the requested information, and that she had told the CAO worker it would take her family some time to gather the information together, as they had not yet filed a federal tax form for 1982. The CAO worker at the hearing testified that Mrs. Martin had been told to return the forms within fifteen (15) days. The hearing officer made no finding of fact regarding this issue. The denial form makes no mention of a fifteen (15) day deadline.
Subsequently, on April 7, 1983, the Martins reapplied for MA, this time providing sufficient information.
The instant issue arose when the Martins discovered that DPW would not furnish MA reimbursement to cover the costs of daughter Theodora Martins December, 1982, surgery or of wife Louise Martins, September, 1982, surgery. On November 14, 1983, DPW received a letter from the Martins dated October 25, 1983, purporting to be an appeal of the March 18, 1983, denial of eligibility.
The hearing officer, after holding a hearing by telephone, proceeded to dismiss this appeal for want of timeliness pursuant to 55 Pa. Code §275.3(b). The Office of Hearings and Appeals affirmed and the petitioners request for reconsideration was denied by the Executive Deputy Secretary of DPW.
I. Timely Appeal
Before we can address the merits of the March 18, 1983, denial,
The Martins argue that the CAO never gave them a time limit for submitting the information as of March 1, 1983; that they reapplied on April 17, 1983, in a belief fostered by CAO workers, that their April 17, 1983, reapplication and subsequent eligibility approval constituted an appeal of the March 18, 1983, denial; that when the second application was approved, and their eligibility for MA established, the Martins were under the impression that any defects arising from the March 18, 1983, denial had been cured; that when they inquired about retroactive benefits, a CAO worker told them that the matter was being worked on; and that the necessity of filing a timely appeal was never discussed by the CAO. The record contains no findings as to these allegations. We suggest that in remanding, a record of testimony and findings of fact can be produced regarding these issues so that we can consider if the Martins’ appeal should be heard.
Normally speaking, a time period for appeal may be extended nunc pro tunc upon a showing of fraud or breakdown in the administrative process. See Department of Transportation, Bureau of Traffic Safety v. Royster, 31 Pa. Commonwealth Ct. 647, 377 A.2d 1038
In the recent case of St. Christophers Hospital for Children, A Division of United Hospitals, Inc. v. Department of Public Welfare, 78 Pa. Commonwealth Ct. 113, 466 A.2d 1134 (1983), we held that it was incumbent upon the hearing officer to hold a hearing and take evidence on the issue of when an appeal was timely. Moreover, we held in St. Christophers Hospital that the due process concerns of Goldberg v. Kelly, 397 U.S. 254 (1970), are of special importance in evaluating the process due an applicant for public welfare benefits. An applicant for MA clearly fits within the Goldberg sphere of due process concerns. No applicant may be determined ineligible for benefits without adequate notice of the reason for rejection and the opportunity to be heard and to defend in an orderly proceeding adapted to the nature of the case. Where the timeliness of an appeal turns on factual considerations, an applicant must be afforded a hearing in which those considerations are explored and an opportunity must be given to the applicant to offer proof in support of a claim that an appeal was timely filed. St. Christophers Hospital, 78 Pa. Commonwealth Ct. at 116-117, 466 A.2d at 1136-37. Compare Mathews v. Eldridge, 424 U.S. 319 (1976) (tripartite test in evaluating what process is due); Wolff v. McDonnell, 418 U.S. 539 (1974); Gagnon v. Scarpelli, 411 U.S. 778 (1973). See also Cleveland Board of Education v. Loudermill, 470 U.S. 532, 105 S. Ct. 1487 (1985); Adamovich v. Department of Public Welfare, 95 Pa. Commonwealth Ct. 22, 504 A.2d 952 (1986).
(1) Did the CAO tell Mrs. Martin to file a reapplication form instead of telling her to appeal the March 18, 1983 denial?
(2) Were the Martins prejudiced or misled by the CAO’s actions?
(3) Were the Martins misled subsequently such that they failed to file a timely appeal?
These types of findings are essential to determining whether the CAO violated DPW regulations to the extent that an appeal nunc pro tunc should be permitted on equitable grounds. Because we find below that the March 18, 1983, denial form foiled to furnish the Martins with adequate notice of the grounds of denial, the remand will be for the purposes of determining what factual grounds, if any, exist for extending the time for the Martins’ appeal nunc pro tunc beyond the six months normally provided for in 55 Pa. Code §275.3(b)(3).
II. Basis for Denial
The March 18, 1983, denial by the CAO of the Martins’ benefits was defective on due process grounds because it foiled to accord the Martins notice of the grounds and reasons for denying their application for benefits. Consequently, the thirty-day limit for appeals set forth in 55 Pa. Code §275.3(b)(1) is inapplicable.
No mention of a time, limit allegedly set by the CAO for the return of information or of the three items of information allegedly requested by the CAO was made on the March 18, 1983, denial form provided to the Martins. Indeed, all the denial form actually states is
As a preliminary observation, we note that a person who is medically needy is statutorily eligible for MA.
An application [for MA] will be disposed of only if one of the following occurs:
(a) The applicant is found to be eligible and an identification card is issued.
(b) The applicant is found to be eligible but an identification card has not been issued because of excess assets.
(c) The applicant is found to be ineligible.
(d) The applicant withdraws or fails to complete the application.
Only 55 Pa. Code §131.84(a)(2)(i)(D) appears to be at all relevant, and it is not cited anywhere on the March 18, 1983, denial form provided to the Martins. Assuming arguendo it had been cited, 55 Pa. Code §131.84(a)(2)(i) (D) could not furnish authority for a denial of eligibility because no time limit is specified anywhere in this regulation mandating a two-week maximum for provision of information.
The denial form fails to meet the minimum due process requirements of state and federal law that an applicant be informed sufficiently of the reason for a denial of eligibility. While it is true that the burden is normally on a welfare claimant to demonstrate eligibility for benefits, Dempsey v. Department of Public Welfare, 45 Pa. Commonwealth Ct. 121, 404 A.2d 1373 (1979), we have also held that a failure to specify reasons, evidence and regulations in an administrative adjudication may be violative of Section 507 of the Administrative Agency Law, 2 Pa. C. S. §507 and may also be violative of federal regulations governing the assistance program. Heinsohn v. Department of Public Welfare, 66 Pa. Commonwealth Ct. 517, 521-22, 445 A.2d 271, 273 (1982).
The notice in this case was deficient. It did not specify that the CAO still required specific items of information, such as a 1982 tax return, verification of prescriptions and hospital premiums paid, before eligibility could be determined. Nor did the denial form specify that there had been a fifteen-day limit for provision of these items of information. The regulations cited to in the denial form are mere omnibus provisions, full of sound and fury but signifying nothing in terms of notice and due process. In the absence of written notice of the actual basis for denial, DPW did not follow its own regulations, failed to afford the Martins due process, and acted in violation of 2 Pa. C. S. §507.
There is no relief we can possibly afford the Martins in terms of the costs of the September, 1982, surgery on Mrs. Martin. The ninety-day retroactivity regulation, 55 Pa. Code §141.81(g)(1), has been upheld in a prior decision of this Court, Berry v. Department of Public Welfare, 42 Pa. Commonwealth Ct. 640, 401 A.2d 602 (1979).
We have reviewed the legislative history of 42 U.S.C. §1396(a)(34), which was not originally part of Title XIX of the Social Security Act (Medicaid) when it was first enacted in 1965.
Apparently, when only thirty-one (31) states decided to provide this coverage, the Congress in enacting 1972 amendments to Title XIX (and other portions of the Social Security Act) made three-month retroactive eligibility coverage mandatory for the states, by means of what is now present day 42 U.S.C. §1396(a)(34).
persons who are eligible for medicaid but do not apply for assistance until after they have received care, either because they did not know about the medicaid eligibility requirements, or because the sudden nature of their illness prevented their applying.15
The provision in question was again amended without extensive comment in 1973 to provide retroactive coverage for persons who died before eligibility could be claimed.
Based on this legislative history, we cannot grant eligibility to the Martins for assistance beyond the ninety-day period. While we sympathize with the Martins’ plight, we hesitate to revise the scope of state medical assistance regulations on equitable grounds where the supervening federal authority is so clearly to the con
For the above reasons, the decision below is vacated in part and remanded. The referee is directed to hold a hearing and make findings as to why the petitioner failed to take an appeal within six (6) months of March 18, 1983, and proceed to a determination consistent with this opinion.
Order
And Now, this 30th day of July, 1986, the order of June 6, 1984, by the Executive Deputy Secretary of the Department of Public Welfare is hereby vacated in part and remanded for an evidentiary hearing and further proceedings consistent with this opinion.
Jurisdiction relinquished.
Medical Assistance (MA) is defined in 55 Pa. Code §101.2. The Pennsylvania Medical Assistance (MA) Program is authorized by Sections 441.1-453 of the Public Welfare Code, Act of June 13, 1967, P.L. 31, added by Act of July 31, 1968, P.L. 904, as amended, 62 P.S. §§441.1-^153. Those who are categorically needy or medically needy under the standards of financial eligibility established by DPW are eligible for MA. See 62 P.S. §§441.1, 442.1 and 55 Pa. Code §§141.81, 171.81. The MA program is funded jointly by the state and the federal government. Federal funding is contingent upon adherence to the requirements of the federal Medicaid statute, Title XIX of the Social Security Act, 42 U.S.C. §§1396-1396(p) and its accompanying regulations. Adherence is normally evaluated by submission of a plan to the Secretary of the Health and Human Services Department (HHS), who then approves or disapproves the plan.
See Cal. Ins. Code, §§1-15062 (West 1972 & Supp. 1986).
See Cal. Ins. Code, §700(a) (West 1972 & Supp. 1986).
See 11 U.S.C. §§701-766.
The crux of this appeal centers on 55 Pa. Code §141.81(g)(1), which states:
(g) Initial Application. Eligibility for any of the MA services will begin with the service provided during the 90-day period preceding the date of application for Medical Assistance, if the applicant was eligible for the service during that period.
This regulation is not authorized specifically by state law but instead is based on 42 U.S.C. §1396(a)(34), which requires state medicaid plans to:
provide that in the case of any individual who has been determined to be eligible for medical assistance under the plan, such assistance will be made available to him for care and services included under the plan and furnished in or after the third month before the month in which he made*350 application (or application was made on his behalf in the case of a deceased individual) for such assistance if such individual was (or upon application would have been) eligible for such assistance at the time such care and services were furnished.
If the Martins’ initial application date is considered to have been March 1, 1983, then the surgery of December 12, 1982, on their daughter, Theodora, would foil within the provisions for retroactive reimbursement eligibility. However, the September, 1982, surgery would only be reimbursable if the three-month limitation were to be equitably waived or extended by judicial flat.
See Sections 441.1 and 442.1 of the Public Welfare Code, 62 P.S. §§441.1, 442.1.
The U. S. Supreme Court has usually relied upon the due process clause or the constitutional right to travel rather than upon equal protection in affording rights to the poor. Compare Santosky v. Kramer, 455 U.S. 745 (1982); Memorial Hospital v. Maricopa County, 415 U.S. 250 (1974); Fuentes v. Shevin, 407 U.S. 67 (1972); Goldberg v. Kelly, 397 U.S. 254 (1970); and Shapiro v. Thompson, 394 U.S. 618 (1969) with Harris v. McRae, 448 U.S. 297 (1980); Maher v. Roe, 432 U.S. 464 (1977); San Antonio Independent School District v. Rodriguez, 414 U.S. 1 (1973); Jefferson v. Hackney, 406 U.S. 535 (1972); and James v. Valtierra, 402 U.S. 137 (1971).
Another portion of the regulation, located at 55 Pa. Code §131.84(a)(2)(iii)(E) specifies statistical codes to be marked on the standard disposition of application form. Only Code 59, “refuses to provide essential information,” or Code 68, “voluntary withdrawal,” could be relevant to a premature denial, based on a lack of needed information, but the hearing examiner made no findings as to whether the Martins voluntarily withdrew from applying or willfully refused to supply information. The denial form simply says that “the client failed to supply essential information requested;” it says nothing about refusal to supply, which would imply a willful act or omission, or about withdrawal from the application process. There exists a Code 99, which in omnibus fashion stands for “other (to be used only if none of the specified Codes apply).” Of course, none of these Codes were marked or indicated on the March 18, 1983, denial form received by the Martins.
We note in passing that there is no basis whatsoever in the applicable DPW regulations for treating the requested information
We have, moreover, reviewed the relevant income eligibility provisions of the DPW regulations, see 55 Pa. Code §§141.81(a)(4), 183.71-74, 183.81-84, and can find no underlying authority for the CAOs requesting that the Martins furnish a 1982 tax return as of March 15, 1983. Indeed, there is no requirement anywhere in DPW regulations specifying that a claimant must furnish a tax return or a profit-loss statement before MA eligibility can be determined.
Nor do we find any authorization for requesting prescription expenditure verification, see 55 Pa. Code §175.84, or for requesting verification of monthly hospital premiums, see 55 Pa. Code §§177.71-84, 179.71-73, 179.81-84, 181.81-84. Indeed, the hearing officer at the hearing asked the testifying CAO workers what the basis was for requesting all these various items of information, and the workers did not offer satisfactory answers, based on our review of the transcript.
There were no findings of feet on the issue of whether the CAO frustrated the Martins’ taking of an appeal by telling them to reapply rather than appeal. If the CAO had told the Martins to reapply rather than appeal, the CAO would have acted in further dereliction of its duty to aid claimants in taking appeals from eligibility denials. We take particular note of 55 Pa. Code §275.4(a)(1), which places an affirmative duty on the CAO to aid claimants in understanding decisions and in making appeals:
(a) Requesting a hearing. The following procedures will be employed in requesting a hearing:
(1) Aid to clients making appeals. The County of Assistance Office or administering or provider agency will provide whatever help the applicant/recipient needs in requesting a hearing. This may include the following:
(i) Clearly explaining the basis for questioned decisions or actions.
(ii) Explaining the rights and fair hearing proceedings of the applicant/recipient.
(iii) Providing the necessary forms and explaining to the applicant/recipient how to file his appeal and, if necessary, how to fill out the forms.
(iv) Advising the applicant/recipient that they may be represented by an attorney, relative, friend, or other spokesman and explaining that he may contact his local bar association to locate the legal services available in the county.
(v) For food stamps, upon request, making available without charge case record materials relevant to the decision or action of the agency which are necessary for a household or its representative to determine whether a hearing should be requested or to prepare for a hearing. If the individual making the request speaks a language other than English and requires an interpreter pursuant to 7 C.F.R.*359 §272.4(c)(3), the agency shall provide bilingual staff or interpreters to explain the hearing procedures in that language.
This regulation should normally be followed by DPW personnel. The Martins point out that instead of receiving appeal forms and assistance in filling out such forms, the CAO merely provided them with reapplication forms. Indeed, when the Martins did finally appeal, they did so using their own typewriter and paper instead of a form furnished them by the CAO in accordance with 55 Pa. Code §275.4(a)(l)(iii). We cannot approve of DPW and CAO inadherence to explicit regulations requiring caseworkers to explain adverse adjudications and facilitate the taking of appeals.
However, in the absence of findings of feet in the record regarding these allegations, we cannot proceed to a resolution of the issues involved based solely on a recitation of the law. A remand is required for further factfinding on this issue. Naturally, the burden of proof will be on the Martins to demonstrate that they were misled in violation of 55 Pa. Code §275.4(a)(1) and other applicable regulations.
Social Security Amendments of 1965 (Medicaid), Pub.L. 89-97, §§1901-1905, reprinted in 1965 U.S. Code Cong. & Ad. News (79 Stat. 344) 370-380 (codified as amended at 42 U.S.C. §1396(a)).
See H. Rep. No. 213, 89th Cong., 1st Sess., reprinted in 1965 U.S. Code Cong. & Ad. News 1943, 2020.
Social Security Amendments of 1972, Pub.L. 92-603, §255(a), reprinted in 1972 U.S. Code & Cong. Ad. News (86 Stat. 1381) 1692 (codified as amended at 42 U.S.C. §1396(a)(34)).
H. Rep. No. 231, 92d Cong. 2d Sess., reprinted in 1972 U.S. Code & Cong. Ad. News 4989, 5008, 5099.
Id. at 5099.
Social Security Amendments of 1973, Pub.L. 93-233, §18(o), reprinted in 1973 U.S. Code & Cong. Ad. News (87 Stat. 960) 1085 (codified as amended at 42 U.S.C. §1396(a)(34)).