Karim v. R.I. Exec. Office of Health & Human Servs., C. A. PC-2021-03640

CourtSuperior Court of Rhode Island
Writing for the CourtCRUISE, J.
Docket NumberC. A. PC-2021-03640
Decision Date05 August 2022



C. A. No. PC-2021-03640

Superior Court of Rhode Island, Providence

August 5, 2022

For Appellant: Nora Salomon, Esq.

For Appellee: Amy Vignali Coleman, Esq.



In this administrative appeal, Appellant Husain Abdullah Karim (Karim) seeks judicial review of a final decision of the Rhode Island Executive Office of Health and Human Services (OHHS). The decision found Karim ineligible to receive benefits under the state's Medicare Premium Payment Program (MPPP). This Court exercises jurisdiction pursuant to the Administrative Procedures Act (APA), G.L. 1956 chapter 35 of title 42.


Facts and Travel

The relevant factual background of Karim's appeal is undisputed. As of December 2, 2019, Karim received Social Security disability benefits of $1478 per month. (Certified Record of Karim Hearing (Record) Ex. 10 (Letter from Social Security Administration), at 1.) Karim lives with his minor daughter, who receives a monthly child's Social Security benefit of $739 due to Karim's disability. Id. at 3. Karim is enrolled in Medicare. (Compl. ¶ 4.) On December 30, 2019, Karim submitted his application for MPPP benefits to OHHS, which, if approved, would provide financial assistance for Karim and his daughter's payment of Medicare Part A and B premiums, Medicare deductibles, and coinsurance. (Record Ex. 9 (MPPP Application), at 5); 210 RICR 40-05-1.1. On January 9, 2020, Karim's application for MPPP benefits was denied by OHHS. (Record Ex. 7


(OHHS Benefits Decision Notice), at 1.) The OHHS decision stated "[Karim] do[es] not qualify for the Medicare Premium Payment Program category QI-1 because [Karim] [is] eligible for Medicaid." Id. at 3. On February 12, 2020, Karim timely appealed this OHHS decision to deny MPPP eligibility. (Record Ex. 6 (Appeal Form), at 1-4.)

On February 25, 2021, OHHS conducted an appeal hearing with Karim's counsel present. (Admin. Hr'g Tr. 1-11, Feb. 25, 2021.) During the administrative appeal, OHHS representative Sherry Silva (Silva), Senior Eligibility Technician for the Pawtucket Department of Human Services, testified that Karim qualified for MPP as a QI-1, meaning "[h]e's only eligible for either Medicaid or MPP[P], [but] not both." Id. at 3. Specifically, Silva testified that because Karim was eligible for Modified Adjusted Gross Income (MAGI) Medicaid with his child, he was ineligible for MPPP. Id. Silva went on to testify that Beneficiary Status of QI-1 is determined by the number of adults in the household, so in Karim's case, he is a household of one, and only his income is countable, and therefore he is ineligible for MPPP based on only his income. Id. at 4.

Karim agreed that for MPPP purposes, if Karim is a family of one counting only his income, then he has QI-1 status and he cannot have both MPPP and Medicaid, but Karim argued that OHHS's interpretation of family size, namely that he was a family of one for MPPP purposes, was incorrect. Id. at 4-5. Karim argued that the term "family" should be defined by the dictionary definition because it is not defined in the State's Medicaid regulations. Id. at 5-6. Accordingly, Karim argued that because he lives with his minor daughter, the dictionary definition of "family" should apply, and OHHS should consider Karim a family of two when determining MPPP eligibility. Id. at 7. Karim's contention was that "as a family of two with only [Karim's] income counted which is what the SSI methodology would point to, he would be eligible for SLMB and would be eligible for Medicaid [and MPPP]. Id. at 9.


On April 30, 2021, OHHS filed an Administrative Hearing Decision denying Karim's appeal of OHHS's initial denial of Karim's MPPP eligibility. (Record Ex. 15 (OHHS Decision), at 1.) Specifically, OHHS found that "[i]n review of the case [law] cited . . . the family size pertains to a husband and wife not father and child." Id. at 7. The OHHS Decision found that "[Karim's] minor child in this case is not eligible for Medicare, therefore her income should not be counted, and she should not be counted in the family size." Id. Further, the OHHS decision stated, "[t]he Appellant is eligible for MAGI-Medicaid with his minor child therefore, ineligible for MPPP as category QI-l, counting a family size of one and only counting his income as required." Id. In closing, the OHHS stated:

"After careful and considerate review of the Agency's Rules and Regulations, as well as the evidence and testimony presented, this Appeals Officer concludes that the Agency properly applied the federal and state regulations to deny the Appellant MPPP. The Appellant is eligible for either MPPP or Medicaid, not both as a MPPP, category QI-l." Id. at 7-8

On May 27, 2021, Karim filed the instant Complaint for judicial review of the OHHS Decision and requests that this Court reverse the agency's decision and provide Karim MPPP benefits. (Compl. 2.) On June 24, 2021, OHHS answered Karim's Complaint, requesting that this Court dismiss Karim's Complaint with prejudice. (Answer 2.) On August 12, 2021, Karim submitted a Brief in Support of Reversal of the final decision of OHHS. (Pl.'s Brief in Supp. of Reversal (Pl.'s Brief.) On October 22, 2021, OHHS submitted its brief in opposition to reversal of the OHHS Decision. (Def.'s Brief in Opp'n to Reversal of Decision (Def.'s Opp'n Brief).) On October 28, 2021, Karim submitted his Reply Brief. (Pl.'s Reply Brief.)



Standard of Review

When reviewing the decision of an administrative agency, the Superior Court "sits as an appellate court with a limited scope of review." Mine Safety Appliances Co. v. Berry, 620 A.2d 1255, 1259 (R.I. 1993). The Court's review is governed by the Rhode Island Administrative Procedures Act (APA), G.L. 1956 chapter 35 of title 42. See Iselin v. Retirement Board of Employees' Retirement System of R.I., 943 A.2d 1045, 1048 (R.I. 2008) (citing Rossi v. Employees' Retirement System of R.I., 895 A.2d 106, 109 (R.I. 2006)). Section 42-35-15(g) provides, in pertinent part:

"The court shall not substitute its judgment for that of the agency as to the weight of the evidence on questions of fact. The court may affirm the decision of the agency or remand the case for further proceedings, or it may reverse or modify the decision if substantial rights of the appellant have been prejudiced because the administrative findings, inferences, conclusions, or decisions are:
"(1) In violation of constitutional or statutory provisions;
"(2) In excess of the statutory authority of the agency;
"(3) Made upon unlawful procedure;
"(4) Affected by other error of law;
"(5) Clearly erroneous in view of the reliable, probative, and substantial evidence on the whole record; or
"(6) Arbitrary or capricious or characterized by abuse of discretion or clearly unwarranted exercise of discretion." Sec. 42-35-15(g).

"In essence, if 'competent evidence exists in the record, the Superior Court is required to uphold the agency's conclusions.'" Auto Body Association of Rhode Island v. State of Rhode Island Department of Business Regulation, 996 A.2d 91, 95 (R.I. 2010) (quoting Rhode Island Public Telecommunications Authority v. Rhode Island State Labor Relations Board, 650 A.2d 479, 484 (R.I. 1994)). When reviewing a decision under the APA, the Court may not substitute its judgment for that of the agency on questions of fact. See Johnston Ambulatory Surgical Associates, Ltd. v. Nolan, 755 A.2d 799, 805 (R.I. 2000). The Court defers to the administrative agency's factual


determinations, provided that they are supported by legally competent evidence. Arnold v. Rhode Island Department of Labor and Training Board of Review, 822 A.2d 164, 167 (R.I. 2003). The Court cannot "weigh the evidence [or] pass upon the credibility of witnesses [or] substitute its findings of fact for those made at the administrative level." E. Grossman &Sons, Inc. v. Rocha, 118 R.I. 276, 285, 373 A.2d 496, 501 (1977).

Accordingly, the Court will '"reverse factual conclusions of administrative agencies only when they are totally devoid of competent evidentiary support in the record."' Baker v. Department of Employment and Training Board of Review, 637 A.2d 360, 363 (R.I. 1994) (quoting Milardo v. Coastal Resources Management Council, 434 A.2d 266, 272 (R.I. 1981)).

The Court is free to conduct a de novo review of determinations of law made by an agency. See Arnold, 822 A.2d at 167 (citing Johnston Ambulatory Surgical Associates, 755 A.2d at 805). Great "weight and deference" should be given to an administrative agency's interpretations of the statute it is empowered to enforce, as long as "that construction is not clearly erroneous or unauthorized." Labor Ready Northeast, Inc. v. McConaghy, 849 A.2d 340, 344 (R.I. 2004). This is true "even when other reasonable constructions of the statute are possible." Id. at 345. The Court is limited to the certified record in its determination as to whether legally competent evidence exists to support the agency's decision. Barrington School Committee v. Rhode Island State Labor Relations Board, 608 A.2d 1126, 1138 (R.I. 1992). Legally competent or substantial evidence is "relevant evidence that a reasonable mind might accept as adequate to support a conclusion, and means [an] amount more than a scintilla but less than a preponderance." Caswell v. George Sherman Sand &Gravel Co., Inc., 424 A.2d 646, 647 (R.I. 1981).




A Applicable Law

States are not required to participate in the federal-state program known as Medicaid, but those states that participate are required to comply with federal Medicaid law. Wilder v. Virginia Hospital Association, 496 U.S. 498, 501 (1990). General Laws 1956 § 42-7.2-6.1 and 210 RICR 10-05-2.2 authorizes and designates OHHS as the entity responsible for appeals and hearings related to...

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