Exec. Office of Health & Human Servs. v. Trocki
| Decision Date | 05 August 2021 |
| Docket Number | No. 20-P-458,20-P-458 |
| Citation | 100 Mass.App.Ct. 117,174 N.E.3d 322 |
| Parties | EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES v. Cynthia TROCKI, personal representative. |
| Court | Appeals Court of Massachusetts |
Charles E. Vander Linden, Fitchburg, for the defendant.
Victoria Pulos, for Massachusetts Law Reform Institute & others.
Phoebe Fischer-Groban, Assistant Attorney General, for the plaintiff.
Present: Rubin, Kinder, & Desmond, JJ.
Stephen Pekala was enrolled in a senior care organization (SCO) run by Fallon Community Health Plan (Fallon) open to those eligible for both Medicare and MassHealth.2 Between his enrollment and his death, MassHealth made monthly "capitation payments" to Fallon for his membership in this SCO program. Capitation payments are similar to insurance premium payments in that they involve monthly payments of a set amount to cover a specified set of services and administrative costs without regard to the actual number of services provided. See G. L. c. 118E, § 9D (a ) (definition of capitation). Following Pekala's death, the Executive Office of Health and Human Services (EOHHS) brought this action against his estate seeking to recover almost $180,000 in monthly capitation payments that MassHealth had paid on the decedent's behalf from May 2013 to the decedent's death in March 2018.
We conclude that consistent with the revisions to the State Medicaid Manual (Manual) published by the Federal Health Care Financing Administration (HCFA)3 in 2001, in order for EOHHS to recover capitation payments from an estate, it must provide separate notice in advance of enrollment that the payments made will be recovered against the estate. See State Medicaid Manual, Health Care Financing Administration Pub. No. 45-3, Transmittal 75 § 3810.A.6 (Jan. 11, 2001).4 MassHealth failed to provide such separate notice. Therefore, we conclude that the Superior Court judge erred in awarding EOHHS summary judgment on its estate recovery claim. We reverse.5
Background. In an appeal from the allowance of a motion for summary judgment, we must view the evidence in the light most favorable to the nonmoving party, here the defendant, Trocki. See Pinti v. Emigrant Mtge. Co., 472 Mass. 226, 231, 33 N.E.3d 1213 (2015). The evidence in the summary judgment record viewed in that light shows the following: In December 2012, Stephen Pekala, at the time seventy-seven years old and Medicare eligible, enrolled in the Fallon Senior Plan HMO, a Medicare Advantage plan offered by Fallon. Shortly after enrolling, he received a letter from Fallon informing him that he could obtain additional assistance covering his Medicare copays, deductibles, and prescription drug coverage by joining Navicare, an SCO program run by Fallon. After reviewing the letter, Pekala's daughter, Cynthia Trocki, had a telephone conversation with Fallon's Medicaid coordinator, who explained that in order to join Navicare, Pekala needed to first enroll in MassHealth. Trocki explained that Pekala did not want to participate in any program that would lead to a claim against his estate, and the Medicaid coordinator assured Trocki that participating in the Navicare program would not give rise to such claims.
After this conversation, Trocki assisted Pekala in completing and submitting the MassHealth application. Pekala was protective of his estate and made it clear to Trocki that he wanted to protect his house, valued at about $136,000, so that it could pass without encumbrances or liens under the terms of his will. As a result of these concerns, Trocki made modifications to the language in the application in several places according to Pekala's instructions. On page ten of the application, Trocki crossed out the paragraph that said, Additionally, on the same page, it said, "I understand that if I am aged 55 or older, or I am any age and MassHealth helps pay for my care in a nursing home, MassHealth may be able to get back money from my estate after I die." Trocki underlined "nursing home" and wrote in the margin, "Just nursing home exp". The application further said, "I certify that I have read or have had read to me the information on this application, including any supplements and instruction pages attached to it, and the information in the MassHealth and You guide, and that I understand my rights and responsibilities." Trocki underlined "MassHealth and You guide," indicated in the margin, "I have not read," and crossed out the phrase "that I understand my rights and responsibilities."
Pekala was found eligible for MassHealth and was enrolled in Navicare. Pekala received no indication from Navicare, Fallon, or the Commonwealth that the modifications he made to the application form were not acceptable. In 2017, he received a MassHealth Eligibility Review form, which contained the same language about estate recovery and the MassHealth and You guide as the MassHealth application, and he completed, signed, and submitted the form without modification.
From May 2013 to February 2018, MassHealth made monthly capitation payments of about $3,000 per month to Fallon for Pekala's participation in Navicare regardless of whether Pekala used any services or how much they actually cost. Pekala never received any notice that MassHealth was paying a monthly capitation payment to Fallon, much less the amount of that monthly payment. He was never notified that his estate would be responsible for repaying the entire cost of his participation in Navicare. By the time Pekala passed away, MassHealth had paid $179,371.32 in capitation payments.6
Pekala died on March 23, 2018, at the age of eighty-two, and Trocki was appointed as the personal representative of his estate on August 21, 2018. EOHHS filed a notice of claim on August 28, 2018, in the Probate Court seeking reimbursement for $179,380.34 pursuant to G. L. c. 118E, § 31 (b ), which provides that for individuals dying on or after April 1, 1995, "There shall be no adjustments or recovery of medical assistance correctly paid except ... [f]rom the estate of an individual who was fifty-five years of age or older when he or she received such assistance" and where such assistance was provided on or after October 1, 1993. Due to Pekala's limited assets, satisfaction of this claim would require Trocki to sell Pekala's house. Trocki responded with a letter denying MassHealth's claim.
On October 4, 2018, EOHHS filed a complaint in Superior Court against Trocki, as personal representative of Pekala's estate, seeking an order directing Trocki to use Pekala's estate assets to satisfy MassHealth's claim. EOHHS moved for summary judgment on March 21, 2019, which Trocki opposed. On May 14, 2019, the judge allowed EOHHS's motion for summary judgment and ordered that judgment enter against the defendant. Trocki's motion for reconsideration was denied, and she filed a timely notice of appeal.
Discussion. In an appeal from the allowance of a motion for summary judgment, our review is de novo, and we must determine whether "all material facts have been established and the moving party is entitled to a judgment as a matter of law." Pinti, 472 Mass. at 231, 33 N.E.3d 1213, quoting Juliano v. Simpson, 461 Mass. 527, 529-530, 962 N.E.2d 175 (2012).
Medicaid is a joint State and Federal program that provides "medical assistance to individuals who cannot afford to pay for their own medical costs." Daley v. Secretary of the Executive Office of Health & Human Servs., 477 Mass. 188, 189, 74 N.E.3d 1269 (2017). State participation in Medicaid is voluntary, but participating States must comply with Federal law and regulations. Id. at 190, 74 N.E.3d 1269. Massachusetts's Medicaid program is known as MassHealth, and it is administered by EOHHS. See G. L. c. 118E, § 9.
Under Federal law, State Medicaid programs must have an estate recovery program that recovers costs paid to certain Medicaid recipients. 42 U.S.C. § 1396p(b). States must recover from the estates of individuals costs paid by Medicaid for "nursing facility services, home and community-based services, and related hospital and prescription drug services" if the recipients were age fifty-five or older when they received these services as Medicaid benefits. No such costs are at issue here. At the State's option, the State may recover "any items or services under the State plan" except for Medicare cost-sharing. § 1396p(b)(1)(B). Massachusetts has elected to recover for all "medical assistance" in its State plan. See G. L. c. 118E, § 31 (b ) (). EEOHS asserts that capitation payments amount to "medical assistance" within the meaning of the statute. It thus claims that, although Federal law does not require it, it is entitled to reimbursement for the capitation payments, regardless of whether any medical care or services were provided to Pekala. Trocki, on the other hand, argues that since "medical assistance" is defined in Massachusetts law as payment "of all or part of the cost of the medical care and services provided to recipients," G. L. c. 118E, § 8 (d ), and since capitations are paid "without regard to the actual number of services provided," G. L. c. 118E, § 9D (a ), MassHealth cannot recover the full capitation payment because it would be more than the actual cost of medical care and services provided.
We need not, however, resolve this question because we conclude that MassHealth failed to provide Pekala with adequate notice that there could be a claim against his estate for...
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