Where, at the time the Department of Public Welfare denied the plaintiffs' application for Federal medical assistance benefits based on its determination that the plaintiffs' combined personal resources of $4,045.99 were in excess of the $3,000 allowed a family of two persons, the plaintiffs had incurred $21,000 in medical expenses, the department should have utilized a "resource spend down" to offset the plaintiffs' excess resources against their incurred medical expenses in determining their eligibility for benefits. [480-481]
CIVIL ACTIONS commenced in the Superior Court Department on April 5 and October 27, 1982, respectively.
The cases were heard by John L. Murphy, Jr., J., on a motion for summary judgment.
The Supreme Judicial Court on its own initiative transferred the case from the Appeals Court.
Lauren P. Curry for the plaintiffs.
Kim E. Murdock, Assistant Attorney General, for the defendant.
NOLAN, J. The plaintiffs, Catherine and Patrick Mathews, request that we vacate the Superior Court's judgments and order the Department of Public Welfare (department) to award
appropriate medical assistance (MA) benefits. [Note 2] On November 30, 1981, Cambridge Hospital (hospital) filed an application with the department for MA benefits on behalf of Mrs. Mathews. See G. L. c. 118E, Section 8. The hospital requested coverage retroactive to November 9, 1981, the date of Mrs. Mathews's admission. The department denied this application based on its determination that the plaintiffs owned excess resources. A family of two may retain $3,000 in resources. See G. L. c. 118E, Section 10 (3); 106 Code Mass. Regs. Section 505.110 (1983). The plaintiffs had combined personal resources of $4,045.99 ($2,131 in a joint account and the remaining as cash surrender value on two life insurance policies). [Note 3] At the time of the department's determination, the plaintiffs had incurred $21,000 in medical expenses. The department did not utilize a "resource spend down" in determining eligibility. See Haley v. Commissioner of Public Welfare, ante 466 (1985). A department appeals referee affirmed the denial of MA benefits. The plaintiff sought judicial review pursuant to G. L. c. 30A and G. L. c. 18, Section 16. The Superior Court dismissed the plaintiffs' complaint on a motion for summary judgment.
A resource spend down would require the department to offset the plaintiffs' excess resources against incurred medical expenses. In Haley v. Commissioner of Pub. Welfare, supra at 467-468, we examined the propriety of the department's determination of MA benefits eligibility absent a resource spend down. We held that, where Title XIX, 42 U.S.C. Sections 1396-1396p (1982), does not preclude utilization of a resource spend down and G. L. c. 118E, Section 10 (3), requires the department, in determining eligibility, to exempt a certain amount of an applicant's resources and neither take into consideration nor apply such resources to the payment or part payment available under G. L. c. 118E, the department is required to use a resource
spend down. This appeal is governed entirely by our decision in Haley, supra.
The judgments are reversed and the cases remanded to the Superior Court for action consistent with this opinion.
[Note 1] Patrick Mathews & another vs. Commissioner of Public Welfare. This companion case concerns the plaintiffs' appeal from the department's decision on a reapplication for medical assistance (MA) benefits. Both cases concern the denial of retroactive MA benefits for the same time frame. We resolve these cases on the applicability of a resource spend down. We, therefore, need not decide the merits of the various other issues raised in this appeal.
[Note 2] See Haley v. Commissioner of Pub. Welfare, ante 466, 467-468 (1985), for a description of the MA benefits program.
[Note 3] We note that the department violated its regulations when it failed to advise the plaintiffs of the possibility of adjusting the face value of the life insurance so as to become eligible. See 106 Code Mass. Regs. Section 505.160(E)(1) (1983).