237 Conn. 550 | Conn. | 1996
The dispositive issue in this administrative appeal is whether the department of social services is required to grant retroactive medicaid benefits to the plaintiff for medical expenses incurred while her resources exceeded the statutory limit if, during the months for which retroactive benefits are sought, her incurred medical expenses exceeded her excess resources. The defendant, Patricia A. Giardi, acting commissioner of the department of social services (department), appeals from the judgment of the trial
The following facts are undisputed. In September, 1993, the plaintiff applied to the department for medicaid benefits. She sought financial assistance for medical expenses incurred while she was a nursing home resident. At the time of the plaintiffs application, she possessed resources in excess of the state’s limit of $1600. See General Statutes §§ 17b-80 and 17b-264. By the end of September, the plaintiff had applied the excess resources to her incurred medical expenses. The defendant granted benefits to the plaintiff commencing September, 1993. The defendant denied retroactive eligibility for the three months prior to September, 1993,
The fair hearing officer upheld the denial of retroactive benefits. The plaintiff appealed to the Superior Court pursuant to the Uniform Administrative Procedure Act, General Statutes § 4-166 et seq. The trial court reversed the decision of the hearing officer, holding that this court’s decision in Matarazzo required the defendant to award retroactive benefits if application of resource spend down would render the plaintiff eligible. The trial court remanded the case to the hearing officer for fact-finding concerning the amount of the medical expenses incurred in the three months prior to the application for benefits. The defendant appealed from the judgment of the trial court to the Appellate Court, and we transferred the appeal to this court pursuant to Practice Book § 4023 and General Statutes § 51-199 (c).
I
The plaintiff claims that the defendant improperly refused to apply resource spend down to her application
The defendant argues that we erroneously concluded in Matarazzo that federal law requires the defendant to continue to apply resource spend down if it was required by the 1972 plan. The defendant concedes that the 1972 plan did provide for some form of resource spend down, but argues that federal law does not require the defendant to continue to apply this methodology. The defendant asks this court to reconsider our contrary determination in Matarazzo.
To resolve the plaintiffs claim and the defendant’s challenge to our prior decision, we are required to wade once again into the virtually impenetrable “Serbonian bog” of federal and state laws governing the medicaid system.
A
“Stare decisis gives stability and continuity to our case law. This court, however, has recognized many times that there are exceptions to the rule of stare decisis. ... A court, when once convinced that it is in error, is not compelled to follow precedent. ... If,
In Matarazzo, we provided the following review of the history of the medicaid program. “The medicaid program, established in 1965 as Title XIX of the Social Security Act, and codified at 42 U.S.C. § 1396 et seq., provides] federal financial assistance to States that choose to reimburse certain costs of medical treatment for needy persons. Harris v. McRae, 448 U.S. 297, 301, 100 S. Ct. 2671, 65 L. Ed. 2d 784, reh. denied, 448 U.S. 917, 101 S. Ct. 39, 65 L. Ed. 2d 1180 (1980); 42 U.S.C. § 1396 et seq. Although states participate voluntarily, a state electing to participate must develop a plan, approved by the secretary of health and human services, containing reasonable standards . . . for determining eligibility for and the extent of medical assistance .... 42 U.S.C. § 1396a (a) (17). Clark v. Commissioner of Income Maintenance, 209 Conn. 390, 394, 551 A.2d 729 (1988). Connecticut has elected to participate in the medicaid program and has assigned to the depart
“As originally enacted, [the] Medicaid [Act] required participating States to provide medical assistance to categorically needy individuals who received cash payments under one of four welfare programs established elsewhere in the Act. . . . The categorically needy were persons whom Congress considered especially deserving of public assistance because of family circumstances, age, or disability. States, if they wished, were permitted to offer assistance also to the medically needy — persons lacking the ability to pay for medical expenses, but with incomes [or resources] too large to qualify for categorical assistance. Schweiker v. Gray Panthers, 453 U.S. 34, 37, 101 S. Ct. 2633, 69 L. Ed. 2d 460 (1981).
“Since its enactment, the Social Security Act has undergone substantial revisions. In 1972, Congress replaced three of the four categorical assistance programs with a new program called Supplemental Security Income for the Aged, Blind and Disabled (SSI), 42 U.S.C. § 1381 et seq. . . . Under SSI, the Federal Government displaced the States by assuming responsibility for both funding payments and setting standards of need. In some States the number of individuals eligible for SSI assistance was significantly larger than the number eligible under the earlier, state-run categorical need programs.
“The expansion of general welfare accomplished by SSI portended increased Medicaid obligations for some States because Congress retained the requirement that all recipients of categorical welfare assistance — now SSI — were entitled to Medicaid. Congress feared that these States would withdraw from the cooperative Medicaid program rather than expand their Medicaid coverage in a manner commensurate with the expansion of
Connecticut has elected the § 209 (b) option. Id., 322; Clark v. Commissioner of Income Maintenance, supra, 209 Conn. 394-95 n.4; Gnutti v. Heintz, 206 Conn. 628, 633, 539 A.2d 118 (1988). As a § 209 (b) state, Connecticut may choose to apply more restrictive eligibility criteria
After careful reconsideration of this issue, including a review of the relevant statutory and regulatory provisions and recent precedent, we conclude that, under its categorically needy program,
As we stated in Matarazzo v. Rowe, supra, 225 Conn. 325, “we agree with the defendant that § 209 (b) does not authorize the state to create an alternative basis for eligibility for medicaid inconsistent with federal law, but merely permits the state to restrict the eligibility of persons who would otherwise qualify for such benefits under SSI standards. Roloff v. Sullivan, 975 F.2d 333, 340 (7th Cir. 1992); Savage v. Toan, 795 F.2d 643, 645-46 (8th Cir. 1986); Morris v. Morrow, 783 F.2d 454, 459-60 (4th Cir. 1986); Foley v. Suter, [1989-1 Transfer Binder] Medicare and Medicaid Guide (CCH), ¶37,695, pp. 19,700,19,704 (N.D. Ill. 1988). This principle is incorporated into the federal medicaid regulations at 42 C.F.R. § 435.121 (1991). Consequently, § 209 (b) does not confer authority upon states to create less restrictive eligibility standards than exist nationally for SSI. Morris v. Morrow, supra, 459.”
The plaintiff argues, and Matarazzo effectively held, that although the § 209 (b) option reduced the states’ obligation to provide medical assistance to the categorically needy, it also imposed on a § 209 (b) state an obligation that an SSI state does not have — to provide benefits to those who do not qualify for SSI but who had been eligible under the 1972 plan. We now conclude that § 209 (b) was not intended to have this effect. To conclude otherwise would require us to accept the proposition that the purpose of § 209 (b) was not merely to protect the state from the expanded burden of provid
We do not agree, however, that the federal government intended to freeze in time the class of individuals to whom the state must provide medicaid benefits. Moreover, we do not agree that § 209 (b) was intended to have the effect of placing an additional burden on the state not otherwise imposed on it by the other provisions of the medicaid statutes. Rather, we conclude that the statutory language, legislative history, federal regulations and recent precedent all indicate that the sole purpose of § 209 (b) is to relieve the states of the burden placed upon them by the federal government’s expansion of cash assistance eligibility, by allowing states to eliminate individuals from the pool of applicants to whom they are otherwise required to provide benefits by applying more restrictive eligibility criteria than applied by the SSI program.
First, we examine the statutory language. Section 209 (b), as codified at 42 U.S.C. § 1396a (f), provides that “[notwithstanding any other provision of this subchapter .. . no State . . . shall be required to provide medical assistance to any aged, blind, or disabled individual . . . for any month unless such State would be (or would have been) required to provide medical assistance to such individual for such month had its plan for medical assistance approved under this subchapter and in effect on January 1, 1972, been in effect in such month . . . .’’By its plain language, the statute establishes an exception to obligations placed upon the state by other statutory provisions. Roloff v. Sullivan, supra, 975 F.2d 336, 340; Morris v. Morrow, supra, 783 F.2d
The legislative history of the statute also supports this conclusion. The report issued by the House of Representatives Ways and Means Committee provides: “Under [the] present law, States are required to cover under medicaid all people eligible for cash assistance payments. If this provision were carried over into the new assistance programs, many thousands of additional people, the great majority of whom would be people made newly eligible for assistance to the aged, blind, and disabled, would be required to be covered under medicaid. In view of the serious financial and other problems of many State medicaid programs, your committee decided not to require the States to cover the newly eligible but rather leave the decision up to each individual State. Your committee’s bill would, therefore, provide that despite any other requirements of Title XIX, no State shall be required to provide medicaid coverage to any individual or family member in any month where such person would not have been eligible for such assistance under the State plan in effect on Januaiy 1, 197[2].” H.R. Rep. No. 231, 92d Cong., 2d Sess. (1972), reprinted in 1972 U.S.C.C.A.N. 4989, 5183. Similarly, the report issued by the Senate Finance Committee stated that “[u]nder present law, the States are required to cover all cash assistance recipients under the medicaid program. The committee bill, like the House-passed bill, would exempt from this requirement persons who are eligible for Supplemental Security Income but would not have been eligible for assistance under the State welfare programs for the aged, blind,
“These explanations demonstrate that under the § 209 (b) option states were required to cover only SSI recipients who also were eligible under the criteria used under the state’s January 1, 1972 state plan. The sole purpose of § 209 (b) was to protect states from the fiscal burden of the broader SSI standards enacted in 1972.” Morris v. Morrow, supra, 783 F.2d 460; accord Savage v. Toan, supra, 795 F.2d 645-46.
The federal regulations governing the administration of the medicaid statutes further lead us to the conclusion that § 209 (b) merely reheves the states of the obligation to provide medical assistance to the categorically needy. At the time of the plaintiffs application, the federal regulation governing the § 209 (b) option, 42 C.F.R. § 435.121 (1992), provided that “[t]he agency may use Medicaid eligibility requirements for the aged, blind, or disabled that are more restrictive than the eligibility requirements for SSI. . . . If an agency uses more restrictive requirements under this section . . . [e]ach requirement may be no more restrictive than that in effect under the State’s Medicaid plan on January 1, 1972, and no more liberal than that applied under SSI . . . .”
The language of this regulation emphasizes the state’s ability to apply more restrictive eligibility criteria than the SSI program. The regulation does not indicate that the state applying the more restrictive criteria is obligated to apply criteria in the 1972 plan that is not more restrictive, i.e., that would result in medicaid eligibility for individuals not eligible for SSL In fact, the section of the regulation that describes the state’s duty to apply requirements that are no more restrictive than the 1972 plan also states that the requirements applied may be
The same regulation, as amended effective August 18, 1994, strongly supports the conclusion that states are not required to apply criteria in their 1972 plans that would render eligible for medicaid those ineligible for SSL The regulation now provides that “the agency may elect to apply more restrictive eligibility requirements to the aged, blind, and disabled that are more restrictive than those of the SSI program. The more restrictive requirements may be no more restrictive than those requirements contained in the State’s Medicaid plan in effect on January 1,1972. If any of the State’s 1972 Medicaid plan requirements were more liberal than [those] of the SSI program, the State must use the SSI requirement instead of the more liberal requirements, except to the extent the State elects to use more liberal criteria under §435.601.” 42 C.F.R. §435.121 (a) (2) (1995).
This amended regulation, which was not effective when we decided Matarazzo, clarifies that states are not required by § 209 (b) to apply requirements that are more liberal than the SSI program merely because those requirements are contained in the state’s 1972 plan. States may elect to apply more liberal criteria pursuant to separate statutory and regulatory provisions; 42 U.S.C. § 1396a (r) (2); 42 C.F.R. § 435.601; but they are not required to do so if they have elected the § 209 (b) option.
Moreover, the federal agency responsible for the administration of the social security program, the Health Care Financing Administration, also has adopted this interpretation of § 209 (b). The agency has stated that the § 209 (b) option “acts as a shield against other provisions of the Medicaid statute which would otherwise compel States to cover any aged, blind, or disabled
The agency’s interpretation of the statute is entitled to substantial deference. Sullivan v. Everhart, 494 U.S. 83, 89, 110 S. Ct. 960, 108 L. Ed. 2d 72 (1990); Connecticut Dept. of Income Maintenance v. Heckler, 471 U.S. 524, 532, 105 S. Ct. 2210, 85 L. Ed. 2d 577 (1985); Chevron U.S.A., Inc. v. Natural Resources Defense Council, Inc., 467 U.S. 837, 843-45, 104 S. Ct. 2778, 81 L. Ed. 2d 694 (1984). Our deference is particularly warranted in this case, in which we are required to interpret a statutory scheme that “is among the most intricate ever drafted by Congress.” Schweiker v. Gray Panthers, supra, 453 U.S. 43. “In a statutory area as complicated as this one, the administrative authorities are far more able than this Court to determine congressional intent in the light of experience in the field.” Lukhard v. Reed, 481 U.S. 368, 383, 107 S. Ct. 1807, 95 L. Ed. 2d 328 (1987) (Blackmun, J., concurring); Mowbray v. Kozlowski, 914 F.2d 593, 598-99 (4th Cir. 1990).
For these reasons, we conclude that § 209 (b) serves to relieve states of an existing obligation to provide medicaid benefits to the categorically needy. See Roloff v. Sullivan, supra, 975 F.2d 340-41; Savage v. Toan, supra, 795 F.2d 645; Morris v. Morrow, supra, 783 F.2d 459-61. If the individual does not meet the SSI eligibility criteria, then the state is not required to provide benefits and therefore has no obligation from which to be
We do not hold, however, that the state is never required to apply resource spend down in its medicaid eligibility determinations. Such an absolute rule would create the anomalous situation in which the state would be permitted to deny medicaid benefits to an individual who is receiving SSI benefits and who would have been eligible for medicaid benefits under the state’s 1972 plan. For example, an unmarried SSI recipient who has resources worth $1700 satisfies the current SSI standard, which allows the applicant to have resources worth no more than $2000. 42 U.S.C. § 1382 (a) (3) (B); 20 C.F.R. § 416.1205 (c). That individual would not, however, satisfy the current state medicaid standard allowing the applicant to have resources worth no more than $1600. General Statutes §§ 17b-80 and 17b-264. If we were to hold that the state is never required to apply resource spend down, then the state could deny benefits
To allow the state to deny benefits to this hypothetical applicant, we conclude, would violate § 209 (b), which allows the state to avoid its obligation to provide medicaid benefits to SSI recipients “unless such State would be (or would have been) required to provide medical assistance to such individual for such month had its plan for medical assistance approved under this subchapter and in effect on January 1, 1972, been in effect in such month . . . .” 42 U.S.C. § 1396a (f). We hold, therefore, that the state may not deny medicaid benefits to one who is receiving SSI benefits, and who would also have been eligible for benefits under the state’s 1972 plan. To comply with this rule, a state may be required to apply resource spend down, as required by the 1972 plan, in order to render eligible for benefits such an SSI recipient who does not satisfy the state’s current resource eligibility limits but who would satisfy the resource criteria of the 1972 plan.
The Indiana Supreme Court relied upon the decision of the Seventh Circuit Court of Appeals in Roloff v. Sullivan, supra, 975 F.2d 340, in which the federal court rejected the plaintiffs’ claim that Indiana, a § 209 (b) state, should have applied resource spend down to their applications under the state’s categorically needy program. The Court of Appeals held, as we do today, that § 209 (b) serves solely as an exception to the state’s obligation to provide benefits to the categorically needy. Id. “Section 209 (b), an exemption, cannot reasonably be read to be a means for expanding, rather than restricting, the class of applicants eligible for Medicaid.” Id.
Thus, the court in Roloff concluded, the state is bound by the duty created by § 209 (b) to provide benefits to an applicant who would have been eligible under the
“(1) Does the ‘otherwise applicable law’ apply, i.e., is the applicant categorically needy at the time of application? If no, then the applicant is not entitled to Medicaid coverage (unless she is medically needy and lives in a medically needy state). If yes, continue to the next step.
“(2) Does the exception apply, i.e., even if the applicant is categorically needy, would the applicant have been entitled to benefits under the January 1, 1972 mies? If no, then the applicant is not entitled to Medicaid coverage. If yes, the applicant is entitled to Medicaid coverage.” Id., 340-41.
In Roloff, the plaintiffs could not demonstrate that they were entitled to receive SSI benefits for the months in which they were denied medicaid benefits. The court therefore rejected their claim for benefits. Id., 341. Noting that “the status of Indiana’s law in 1972 is unclear,” the court declined to resolve “the claims of persons (if any) who would be eligible both for SSI benefits under current federal standards and for Medicaid benefits under the mies in force in Indiana at the beginning of 1972, but to whom Indiana has denied Medicaid eligibility.” Id., 341-42.
The Indiana Supreme Court, in Payne, relied upon the foundation laid by the Roloff decision to reach the question that the Court of Appeals declined to resolve. The Indiana Supreme Court concluded, as we do, that the state may not refuse to apply resource spend down to the application of an SSI recipient who would have been eligible for resource spend down under the state’s 1972 plan. Indiana Dept. of Public Welfare v. Payne, supra, 622 N.E.2d 468. “In Section 209 (b) states such
We recognize that our conclusion constitutes a partial rejection of our analysis in Matarazzo. We acknowledge, as we must, that our adherence to the doctrine of stare decisis serves the fundamental interest of our judicial system in stability and consistency. “It must also, however, be acknowledged that ‘[i]t is more important that the court should be right upon later and more elaborate consideration of the cases than consistent with previous declarations. . . .’ Barden v. Northern Pacific R. Co., 154 U.S. 288, 322, 14 S. Ct. 1030, 38 L. Ed. 992 (1894). The United States Supreme Court has said that when it has become ‘convinced of former error,’ it has ‘never felt constrained to follow precedent.’ Smith v. Allwright, 321 U.S. 649, 665, 64 S. Ct. 757, 88 L. Ed. 987 (1943), reh. denied, 322 U.S. 769, 64 S. Ct. 1052, 88 L. Ed. 1594 (1944).” White v. Burns, supra, 213 Conn. 336. This principle is particularly appropriate when we interpret federal law, as we do in this case, because in such a case our state legislature
B
In this case, the plaintiff does not dispute that she is not eligible for SSI benefits. Thus, we must conclude that the state is not required to provide medicaid benefits to her under its categorically needy program, regardless of whether her incurred medical expenses exceed her excess resources.
The defendant argues that, having reached this conclusion, our inquiry should now end. The plaintiff does not claim, however, that she is eligible for medical assistance under the state’s categorically needy program. Rather, the plaintiff maintains that she qualifies for benefits under the state’s medically needy program if the state is required to apply resource spend down in its determination of eligibility for that program. We have undertaken an analysis of § 209 (b) and the state’s obligations under its categorically needy program, however, because the intricately interdependent nature of the medicaid statutory scheme prevents resolution of the plaintiffs claim without an accurate understanding of these fundamental provisions. We now proceed to an examination of whether application of resource spend down is required under the state’s medically needy program.
II
The defendant argues that the federal statutes do not require the state to provide medicaid benefits to the
The defendant’s argument, however, oversimplifies this question, which is governed by federal statutes and regulations that strongly resist simplification. Although the state conducts its medically needy program on a voluntary basis, once the state elects to conduct such a program it is required to do so in conformity with federal statutory and regulatory guidelines. See 42 U.S.C. § 1396a (a) (10) (C); 42 C.F.R. § 435.300 et seq. These statutes and regulations limit the ability of a state that chooses to conduct a medically needy program to establish whatever requirements it prefers.
Specifically, the statutes and regulations limit the state’s freedom to establish eligibility criteria under its medically needy program by reference to the eligibility criteria of the SSI program and the state’s categorically needy program. For example, 42 U.S.C. § 1396a (a) (10) (C) (i) (III) and (r) (2) (B) provide that, for its medically needy program, the state must use a methodology for resource eligibility determinations that is no more restrictive than the methodology employed under the SSI program. Section 1396a (r) (2) (B) provides that a “methodology is considered to be ‘no more restrictive’ if, using the methodology, additional individuals may be eligible for medical assistance and no individuals who are otherwise eligible are made ineligible for such assistance.” That section further provides that the methodology may be less restrictive than that used by the SSI program.
Thus, the regulation required the state to deduct from the applicant’s resources the amounts that would be deducted under the § 209 (b) state’s more restrictive requirements for its categorically needy program.
Our review of these statutes and regulations leads us to the conclusion that the state is not granted unfettered control over the eligibility requirements for its medically needy program. Specifically, the resource eligibility methodology applied in the medically needy program must not be more restrictive than that of the SSI program, and the state may not consider resources under its medically needy program that it would not consider under its categorically needy program.
In this case, the defendant does not seek to consider resources of the plaintiff that would not be considered under the SSI program or that would not be considered under the state’s categorically needy program. The plaintiff is not ehgible for resource spend down under the SSI program because that methodology is not apphed by that program. Nor is she ehgible under the state’s categorically needy program for the resource spend down available through the 1972 plan because her resources exceed the standard set by the SSI program. Thus, the defendant is not required to apply resource spend down to the determination of the plaintiffs application for benefits under the medically needy program. The defendant is not applying a methodology to the plaintiffs application that is “more restrictive” than the methodologies apphed by the SSI program or the state’s categorically needy program. In other words, the defendant’s treatment of the plaintiffs apphcation does not result in a denial of benefits to an individual who would be ehgible for benefits if the resource methodologies of those other programs were apphed to her. Because we conclude that the defendant’s determination that the plaintiff possessed excess resources under the state’s medically needy program was not more
Ill
We again conclude, as we did in Matarazzo, that resource spend down represents a permissible and reasonable method of evaluating resources whose use would further the statutory goal of providing benefits to individuals whose income and resources are insufficient to meet necessary medical expenses. Matarazzo v. Rowe, supra, 225 Conn. 334-35. Moreover, we recognize that the state’s policy of prohibiting the use of resource spend down may work to the detriment of relatively unsophisticated individuals or individuals who, because of their medical condition, are not able to expend their excess resources as soon as they incur medical expenses. Id., 335. Nevertheless, we conclude that the federal medicaid statutes leave this policy decision to the state. It is apparent, in light of precedent, federal statutes and regulations, that § 209 (b) does not require the defendant to provide medicaid benefits to an applicant unless that applicant qualifies for SSI benefits. Thus, the defendant was not required to apply resource
The judgment is reversed and the case is remanded to the trial court with direction to render judgment dismissing the plaintiffs appeal.
In this opinion the other justices concurred.
In the interests of clarity and convenience, we refer to the decedent, Mary Guttman, as the plaintiff. This action has been brought on behalf of her estate by the named plaintiff, Mina Ross, acting in her capacity as administratrix of the estate.
Section 17-3Í-1 of the Regulations of Connecticut State Agencies, as permitted by federal regulations codified at 42 C.F.R. § 435.914, allows benefits to be granted retroactively to the third month prior to the month of application if the applicant satisfies all conditions of eligibility during each of those months. See Dept, of Income Maintenance, Uniform Policy Manual (1989) § 1560.10.
The plaintiff claims that in June, 1993, she owned resources worth $14,930.79 and had incurred medical expenses of $21,230. In July, 1993,
“The relevant statutory scheme has also been described, by Judge Henry J. Friendly, as ‘almost unintelligible to the uninitiated.’ Friedman v. Berger, 547 F.2d 724, 727 n.7 (2d Cir. 1976), cert. denied, 430 U.S. 984, 97 S. Ct. 1681, 52 L. Ed. 2d 378 (1977); see also Friedman v. Berger, 409 F. Sup. 1225, 1225-26 (S.D.N.Y. 1976) (describing statutory scheme as ‘aggravated assault on the English language, resistant to attempts to understand it’).” Matarazzo v. Rowe, supra, 225 Conn. 318 n.4.
Section 209 (b) of the Social Security Act, as codified at 42 U.S.C. § 1396a (f), provides in relevant part: “Notwithstanding any other provision of this subchapter ... no State not eligible to participate in the State plan program established under subchapter XVI of this chapter shall be required to provide medical assistance to any aged, blind, or disabled individual (within the meaning of subchapter XVI of this chapter) for any month unless such State would be (or would have been) required to provide medical assistance to such individual for such month had its plan for medical assistance approved under this subchapter and in effect on January 1, 1972, been in effect in such month, except that for this purpose any such individual shall be deemed eligible for medical assistance under such State plan if (in addition to meeting such other requirements as are or may be imposed under the State plan) the income of any such individual as determined in accordance with section 1396b (f) of this title (after deducting any supplemental security income payment and State supplementary payment made with respect to such individual, and incurred expenses for medical care as recognized under State law regardless of whether such expenses are reimbursed under another public program of the State or political subdivision thereof) is not in excess of the standard for medical assistance established under the State plan as in effect on January 1, 1972. . . .”
We treat the terms “requirements” and “criteria” as synonymous. We recognize a distinction between the terms “standard” and “methodology.” These terms are not defined by statute or regulation but they are employed
We recognize that states are statutorily required to provide medicaid benefits only to those individuals who are receiving SSI benefits and those who are deemed to be SSI recipients, and not to individuals who merely would be eligible for SSI benefits if they sought to receive them. See 42 U.S.C. § 1396a (a) (10) (A); 42 C.F.R. § 435.120. Although we frequently refer to SSI eligibility as a touchstone for the state’s medicaid obligations, we do not intend to imply that the state’s burden to provide medicaid benefits is broader than that imposed by federal law.
We limit our analysis in part I of this opinion to the state’s obligations under its mandatory categorically needy program. We discuss the state’s obligations under its voluntary medically needy program in part II.
In Matarazzo, we relied upon three federal cases for the proposition that a § 209 (b) state must not apply eligibility requirements that are more restrictive than those applied by the 1972 plan unless federal law prohibits application of the 1972 requirement. Matarazzo v. Rowe, supra, 225 Conn. 326 n.11, 330-31 n.16. One of those cases, Indiana, Dept. of Public Welfare v. Payne, 592 N.E.2d 714 (Ind. App. 1992), was vacated by the Indiana Supreme Court subsequent to our decision in Matarazzo, based on the same reasoning we apply today. See Indiana Dept. of Public Welfare v. Payne, 622 N.E.2d 461 (Ind. 1993). The other two cases, Foley v. Suter, [1989-1 Transfer Binder] Medicare and Medicaid Guide (CCH), ¶37,695, pp. 19,700, 19,704 (N.D. Ill. 1988), and Brogan v. Miller, 537 F. Sup. 139, 144 n.12 (N.D. Ill. 1982), are both United States District Court cases from Illinois, and are governed by the subsequent decision of the Seventh Circuit Court of Appeals in Roloff v. Sullivan, supra, 975 F.2d 340-41, in which the Court of Appeals concluded, based on its interpretation of the medicaid statutes, that a state’s obligation to provide benefits to an applicant who would have been eligible under the 1972 plan does not arise unless (hat applicant is eligible for SSI benefits.
In Matarazzo, we distinguished Roloff by noting that the plaintiff in Rolojf sought benefits under Indiana’s categorically needy program, unlike the plaintiff in Matarazzo (and the plaintiff in the present case), who sought benefits under the state’s medically needy program. Matarazzo v. Rowe, supra, 225 Conn. 326 n.11. We concluded that this difference was significant in part because of the amendments made to the medicaid statutes by the Medicaid Catastrophic Coverage Act of 1988 (MCCA), Pub. L. No. 100-360, § 303 (e) (5), 102 Stat. 683, 763 (1988), as amended by Pub. L. No. 100-485, § 608 (d), 102 Stat. 2343, 2418 (1988), codified at 42 U.S.C. § 1396a (r) (2), which allowed stales to adopt resource methodologies in their medically needy programs that are more liberal than the methodologies used in the SSI program. Matarazzo v. Rowe, supra, 326 n.11. The significance of this fact rested solely, however, upon our conclusion in that case, which we now reject, (hat “[i]f not otherwise prohibited by federal law, a § 209 (b) state may not adopt eligibility requirements that are more restrictive than those that the state applied on January 1, 1972, under the state plan.”
The plaintiff argues that an examination of whether resource spend down is employed in the SSI program is not productive because resource spend down is not a methodology that would be applied logically for a cash assistance program. Whether this is true, we conclude that it is irrelevant. Section 209 (b) allows states to avoid an obligation. If the obligation does not exist, i.e., if the medicaid applicant is not an SSI recipient, then § 209 (b)’s mechanism for relieving the obligation does not operate and the state is not bound by § 209 (b)’s prohibition on criteria more restrictive than the state’s 1972 plan. Unless the applicant qualifies for SSI, there is no § 209 (b) analysis required. Compare, however, our discussion in part II of this opinion of the state’s obligations under its medically needy program.
We decline to undertake an analysis of the resource spend down provision of the 1972 plan because such an analysis is not necessary to our resolution of the issue presented.
We also decline to resolve the defendant’s claim that the plaintiff should not be awarded benefits even if the state were required to apply resource spend down because the plaintiff does not satisfy other eligibility criteria contained in the 1972 plan. We note that the state is not required to apply the criteria of the 1972 plan; it simply must apply criteria that are no more restrictive than the criteria of the 1972 plan. The state may choose to adopt criteria that are less restrictive than the 1972 plan, to the extent that federal law permits. The defendant argues that, if an applicant challenges the denial of medicaid eligibility on the basis that the agency’s action is more restrictive than permitted by the 1972 plan, that applicant should be required to demonstrate that he or she would have been eligible under every category of
Although this language of the court in Payne might suggest that the rule also applies to one who is not receiving SSI benefits but would be eligible therefor, we note that the relevant statutory language makes clear that the state’s obligation to the categorically needy extends only to those who are receiving SSI benefits. See footnote 7.
Indiana has not elected to provide benefits to the medically needy.
The same regulation now provides in relevant part: 'To determine eligibility on the basis of resources for medically needy individuals, the agency must . . . [d]educt the amounts that would be deducted in determining resource eligibility for the medically needy group as provided for in § 435.601 or under the criteria of States using more restrictive criteria than SSI as provided for in § 435.121. . . .” 42 C.F.R. § 435.845 (b) (1995). Thus, the regulation continues to require a § 209 (b) state to use the same methodology it used under its categorically needy program, unless the state chooses to apply amethodology that is less restrictive than the SSI program as permitted by 42 U.S.C. § 1396a (r) (2) and 42 C.F.R. § 435.601.
The state’s freedom to set its medically needy resource standard is also limited by reference to the criteria it uses in its categorically needy program. The regulation governing resource standards that was in effect at the time of the plaintiffs application in September, 1993, permitted a § 209 (b) state to establish a medically needy resource standard that was lower than the SSI program only if the resource standard was not lower than the medically needy resource standard under the 1972 plan. 42 C.F.R. § 435.841 (1992). The applicable regulation now permits a § 209 (b) state to set a medically needy resource standard that is lower than the SSI program, but it must be no more restrictive than either the state’s most restrictive categorically needy resource standard or the medically needy resource standard contained in the 1972 plan, whichever is least restrictive. See 42 C.F.R. § 435.840 (1995).
We recognize the apparent incongruity of allowing the state to apply resources eligibility criteria in its medically needy program that are no more liberal than its categorically needy program. The medically needy program is designed to extend medical assistance to those who do not qualify for assistance under the categorically needy program and, if none of the medically needy criteria are more liberal, then the program will not serve this purpose. The state’s operation of the medically needy program is voluntary, however, and the statutes allow the state to decide whether it will provide medical assistance to the class of medically needy applicants who possess greater resources than the categorically needy. A state may choose to evaluate the resources of its medically needy applicants in a manner that is no more liberal than the categorically needy program without rendering its entire medically needy program nugatory.
