Hale v. State

• Decision Date: 06 August 1981
• Citation: 433 A.2d 374
• Parties: Ronda L. HALE v. STATE of Maine and Michael Petit.
• Court: Maine Supreme Court

Page 374

433 A.2d 374

Ronda L. HALE v. STATE of Maine and Michael Petit.

Supreme Judicial Court of Maine.

Argued May 6, 1981.

Decided Aug. 6, 1981.

Pine Tree Legal Assistance, Inc., Deborah Shaw Rice (orally), Lucinda E. White, Portland, Kim M. Vandermeulen, Augusta, for plaintiff.

William C. Nugent, Dept. of Human Services, Asst. Atty. Gen. (orally), Augusta, for defendants.

Before WERNICK, GODFREY, ROBERTS and CARTER, JJ.

WERNICK, Justice.

Plaintiff Ronda L. Hale has appealed from a judgment entered in the Superior Court (Cumberland County) following a hearing on a motion for summary judgment made by plaintiff. The judgment granted plaintiff certain medicaid benefits but denied her requests for declaratory and injunctive relief, class certification and attorney fees.

We sustain the appeal and remand the case for further proceedings.

Plaintiff is married to Charles Hale, and they live with Robert Hale, Charles' 13 year old son by a prior marriage. By reason of physical disability Charles receives Social Security (OASDI) and Supplemental Security Income (SSI). Both plaintiff and Robert Hale receive Social Security benefits as dependents of Charles Hale.

On September 11, 1979, plaintiff applied to the Maine Department of Human Services for medical assistance under the "medically needy" portion of this State's medicaid program. Her application was denied. Plaintiff then requested, and was given, a fair hearing at which she was represented by counsel. After this hearing the initial department decision was affirmed, on the grounds that plaintiff was neither individually eligible for medical assistance nor eligible by reference to her husband or step-son.

Plaintiff thereafter sought Superior Court review of the department's action, pursuant to the procedures established by 5 M.R.S.A. § 11001 et seq. and Rule 80B M.R.Civ.P. In her complaint she alleged that the State of Maine was depriving her, and all step-parents similarly situated, of a right to medicaid assistance guaranteed them by federal statutory law, 42 U.S.C. § 1396 et seq; 42 U.S.C. § 601 et seq; and 42 U.S.C. § 1983. She requested: (1) certification of the class of step-parents seeking to qualify for medicaid assistance through their step-children, (2) a declaratory judgment that she and all persons within her class were eligible for medicaid assistance, and (3) attorney fees in accordance with the provisions of 42 U.S.C. § 1988.

In ruling on plaintiff's motion for summary judgment, the Superior Court interpreted the relevant provisions of Maine's medicaid program to provide medicaid assistance to plaintiff individually as a "medically needy" person. The court further concluded, however, that such coverage being provided by state law was not required by the federal law. In addition, the court denied plaintiff's requests for class certification and attorney fees.

On appeal, plaintiff challenges the correctness of the rationale by which the Superior Court awarded her the medicaid assistance, contending that she is entitled to such assistance by reason of the mandate of federal law. Plaintiff also claims that the Superior Court erred by denying class certification and her request for attorney fees.

1.

To assist understanding of the issues plaintiff raises we deem it appropriate to discuss, initially, the standards for medicaid eligibility established by federal statute, and the relationship of these federal standards to the medicaid program administered by this State.

Subchapter XIX of the federal Social Security Act, entitled "Grants to States for Medical Assistance Programs", establishes the framework for the medicaid program. 42 U.S.C. § 1396 et seq. Subchapter XIX makes federal funds available for distribution by individual States according to State plans created within federal statutory requirements and approved by the U.S. Department of Health and Human Services. The federal statutory requirements for State medicaid programs establish several classes of potential medicaid recipients. The first of these is generally referred to as the "categorically needy" classification. Section 1396(a)(10)(A) of 42 U.S.C. requires State medicaid programs to provide medical assistance to those people receiving assistance under either the Supplemental Security Income program (SSI) established by Subchapter XVI of the Social Security Act, 42 U.S.C. § 1381 et seq., or the Aid to Families with Dependent Children (AFDC) program established by Part A of Subchapter IV of the Social Security Act, 42 U.S.C. § 601 et seq. ¹

Section 1396a(a)(10)(C) further provides that a State may choose to extend medical assistance to persons who do not qualify for the "categorically needy" level of assistance. The federal statute also provides, however, that if the State opts to provide medical assistance to persons or groups of people whose income levels exceed that of the "categorically needy", the State must provide medical assistance, albeit at a reduced level, to those persons meeting the definitional requirements for AFDC or SSI assistance but who are not receiving such assistance because their income exceeds the financial limits of the AFDC or SSI programs, if such persons have "insufficient ... income and resources to meet the costs of necessary medical and remedial care." 42 U.S.C. § 1396a(a)(10)(C)(i). ²

Such persons described in 42 U.S.C. § 1396a(a)(10)(C)(i), who meet the definitional requirements for AFDC or SSI assistance but do not meet the financial requirements for such assistance, are classified as persons who are "medically needy." The State of Maine has chosen to provide medical assistance to the "medically needy." 22 M.R.S.A. § 3174, Maine Public Assistance Payments Manual, Chapter IV, Section B. Plaintiff's claim is that she is entitled to the benefits of the "medically needy" part of the medicaid program.

As the preceding description of the various subprograms of medicaid assistance reveals, an individual's eligibility for medicaid is directly linked to that person's eligibility for either SSI benefits or AFDC assistance. Plaintiff's claim for medicaid benefits under the "medically needy" program is premised on her eligibility for AFDC assistance. If plaintiff is found to satisfy the definitional requirements for AFDC eligibility established by 42 U.S.C. § 606(a) and (b), she is eligible for medicaid benefits by reason of 42 U.S.C. § 1396a(a)(10)(C) and this State's opting to provide assistance to the "medically needy."

The AFDC program was established "(f)or the purpose of encouraging the care of dependent children in their own homes or in the homes of relatives." 42 U.S.C. § 601. This purpose is accomplished by providing federal financial assistance through State created and administered programs ³ to any needy, dependent child and "the relative with whom ... (such) child is living." 42 U.S.C. § 606(a) and (b). Only one adult will be included in the AFDC grant as "the relative with whom any dependent child is living", 42 U.S.C. § 606(b)(1) and § 606(c) except that a second adult can be included who is the

"spouse of such relative if living with him and if such relative is the child's parent and the child is a dependent child by reason of the physical or mental incapacity of a parent or is a dependent child under section 607 of this title." 42 U.S.C. § 606(b)(1) and § 606(c). ⁴

The concept of a child as being "dependent", on which the AFDC eligibility of a child and his adult relative turns, is defined by 42 U.S.C. § 606(a) to mean that the child is one

"who has been deprived of parental support or care by reason of the death, continued absence from the home, or physical or mental incapacity of a parent, and who is living with his father, mother, grandfather, grandmother, brother, sister, stepfather, stepmother, stepbrother, stepsister, uncle, aunt, first cousin, nephew, or niece, in a place of residence maintained by one or more of such relatives as his or their own home, and (2) who is (A) under the age of eighteen, or (B) under the age of twenty-one and (as determined by the State in accordance with standards prescribed by the Secretary) a student regularly attending a school, college, or university, or regularly attending a course of vocational or technical training designed to fit him for gainful employment;"

A child who meets the statutory definition of dependency is "categorically eligible" for AFDC assistance. Whether a particular child is thus categorically eligible for AFDC as a dependent child is a question of federal law, to be determined by reference to the federal statutory definition. Bryant v. Swoap, 121 Cal.Rptr. 867, 48 Cal.App.3d 431 (1975); Slochowsky v. Lavine, 342 N.Y.S.2d 525, 73 Misc.2d 563 (1973).

In order to receive AFDC assistance a child and his adult relative must be not only categorically eligible but also financially needy. The federal statutory structure allows the states great flexibility to determine whether a particular individual or family is needy. Lopez v. Vowell, 471 F.2d 690 (5th Cir. 1973), cert. denied, 411 U.S. 939, 93 S.Ct. 1903, 36 L.Ed.2d 401. Whether an AFDC applicant meets the financial criteria for need is a question of state law. A State, however, may not utilize financial eligibility requirements as an indirect technique of restricting, or avoiding, federally mandated criteria of categorical eligibility.

In this case, plaintiff applied for medicaid benefits under the "medically needy" program. Her eligibility for such medical assistance does not depend on whether, in consequence of her satisfying both the definitional and financial criteria for AFDC assistance, she is actually receiving AFDC aid. Under the medically needy portion of the medicaid program the State must make

"medical assistance available to all individuals who would, except for income and resources, be eligible for aid or assistance under any such State plan (any plan of the State approved under subchapter I, X, XIV, or XVI...