Mercy Healthcare Arizona, Inc. v. Arizona Health Care Cost Containment System, 1

Citation181 Ariz. 95,887 P.2d 625
Decision Date27 December 1994
Docket NumberNo. 1,CA-CV,1
PartiesMERCY HEALTHCARE ARIZONA, INC. dba St. Joseph's Hospital and Medical Center, Plaintiff-Appellant, v. ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM, an agency of the State of Arizona and Mabel Chen, M.D. in her capacity as director of the AHCCCS Administration, Defendants-Appellees. 94-0046.
CourtCourt of Appeals of Arizona
OPINION

McGREGOR, Presiding Judge.

Mercy Healthcare Arizona, Inc. (Mercy) challenges the trial court's determination that the obligation of the Arizona Health Care Cost Containment System (AHCCCS) to reimburse Mercy for emergency medical care to an undocumented alien ended when the patient no longer required acute care. The primary issue on appeal is whether the trial court correctly interpreted the term "emergency medical condition" in Ariz.Rev.Stat.Ann. ("A.R.S.") section 36-2905.05 (1993).

I.

On July 17, 1993, F.L., an undocumented alien, suffered serious injuries in a single vehicle, high-speed rollover accident. Comatose and suffering from a severe closed head injury, F.L. was transported to St. Joseph's Hospital (the Hospital). The Hospital treated F.L. until August 11, 1993, when the Hospital transferred him to St. Joseph's Care Center (the Care Center), a skilled nursing care facility. At the time of transfer, F.L. was non-verbal, could not move his lower extremities, had a gastrointestinal tube for feeding, and had a tracheostomy. On November 22, 1993, the Care Center discharged F.L. to his son's care. Mercy sought compensation from AHCCCS for F.L.'s treatment at the Hospital and at the Care Center.

Arizona administers AHCCCS, the state's Medicaid program, pursuant to Title XIX of the Social Security Act, 42 U.S.C. sections 1396 to 1396v (1988 & Supp. V 1993). See A.R.S. §§ 36-2901 to -2975 (1993 & Supp.1994). To participate in the federal Medicaid program, a state must provide medical benefits to members of certain defined groups of low income people. Those groups are "categorically eligible" to receive medical benefits. In Arizona, AHCCCS provides those benefits, and the federal government pays for a portion of their care. 42 U.S.C. § 1396; A.R.S. § 36-2901.4(b).

The federal government does not require a state to extend coverage to people other than those who are categorically eligible. If a state chooses to extend treatment to other groups, the state assumes the cost of health care for those "non-categorical" individuals. Arizona elected to extend coverage to three non-categorical groups: those deemed "medically needy/medically indigent" (MN/MI) under an income and financial resources test, eligible low income children, and eligible assisted children. A.R.S. §§ 36-2901.4(a), (c), -2905, and -2905.03.

In 1993, the Arizona legislature amended the AHCCCS statutes to limit the care available to undocumented aliens who otherwise are MN/MI eligible 1 to those "[s]ervices ... necessary to treat an emergency medical condition as defined in § 1903(v) of the social security act." A.R.S. § 36-2905.05. After that amendment took effect, AHCCCS no longer enrolled non-categorical, undocumented aliens in a "plan," as usually occurs for AHCCCS-eligible MN/MI people. See A.R.S. § 36-2909.C. AHCCCS, therefore, no longer provided non-emergency coverage to undocumented aliens.

AHCCCS determined that F.L. met its MN/MI financial and residency requirements, but AHCCCS did not enroll F.L. in a "plan" because he was an undocumented alien. Rather, AHCCCS assumed responsibility for managing his care. AHCCCS authorized F.L.'s treatment through August 9, 1993, but refused to pay expenses incurred after that date. Mercy then brought this action in superior court. After considering cross-motions for summary judgment, the trial court entered judgment in favor of AHCCCS. Mercy appeals. We have jurisdiction pursuant to A.R.S. section 12-2101.A (1994).

II.

To grant a motion for summary judgment, the trial court must find that no genuine issue of material fact exists in the record and that the moving party is entitled to judgment on the merits as a matter of law. Orme Sch. v. Reeves, 166 Ariz. 301, 305, 802 P.2d 1000, 1004 (1990). We review issues of law, such as questions involving statutory interpretation, de novo. Arizona State Bd. of Accountancy v. Keebler, 115 Ariz. 239, 241, 564 P.2d 928, 930 (App.1977). We view the facts in the light most favorable to the party opposing the judgment. Grain Dealers Mut. Ins. Co. v. James, 118 Ariz. 116, 118, 575 P.2d 315, 317 (1978). When the trial court applies the incorrect test to the facts, we may reverse even if the record would have supported a judgment if the trial court had applied the correct test. See Jaimes v. Industrial Comm'n, 163 Ariz. 307, 310, 787 P.2d 1103, 1106 (App.1990). Further, if our review reveals that reasonable inferences about material facts could be resolved in favor of either party, we must reverse and remand for a trial on the merits. United Bank v. Allyn, 167 Ariz. 191, 195, 805 P.2d 1012, 1016 (App.1990).

We conclude that the trial court erred as a matter of law in construing A.R.S. section 36-2905.05. We further conclude that material issues of fact remain under the statute as construed in this opinion. We therefore reverse and remand for further proceedings.

A.

The parties agree that under A.R.S. section 36-2905.05, undocumented aliens receive medical benefits for "emergency medical conditions." The parties, however, hold widely divergent views of what constitutes an "emergency medical condition" for purposes of the statute.

Mercy contends that if an undocumented alien initially suffers from an emergency medical condition, AHCCCS must cover the patient's treatment so long as the emergency medical condition necessitates uninterrupted care. AHCCCS argues, and the trial court apparently agreed, that an emergency medical condition exists only when (1) the patient suffers from acute symptoms and (2) the acute symptoms require immediate medical attention to avoid further jeopardizing the patient's health or body. AHCCCS asserts that the emergency medical condition and AHCCCS's responsibility end when the emergency condition stabilizes.

We reject both these extreme interpretations. When interpreting a statute, our primary goal is to ascertain and give effect to the legislative intent. Blum v. State, 171 Ariz. 201, 205, 829 P.2d 1247, 1251 (App.1992). We look primarily to the language of the statute and give effect to the terms according to their commonly accepted meanings, see A.R.S. section 1-213 (1989), unless the legislature provides a specific definition or the context of the statute indicates a specific meaning. Mid Kansas Fed. Sav. & Loan Ass'n v. Dynamic Dev. Corp., 167 Ariz. 122, 128, 804 P.2d 1310, 1316 (1991). Further, statutory language controls our interpretation when the language is clear and unequivocal. Janson v. Christensen, 167 Ariz. 470, 471, 808 P.2d 1222, 1223 (1991). In this instance, we believe the statute clearly defines the scope of coverage.

Arizona's legislature provided undocumented aliens with coverage for services necessary to treat "emergency medical conditions" but not "long-term care." See A.R.S. § 36-2905.05.D. In covering undocumented aliens, the legislature defined "emergency medical condition" by adopting the standard of section 1903(v) of the Social Security Act. Id.

Section 1903(v) of the Social Security Act states:

"emergency medical condition" means a medical condition (including emergency labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in--

(A) placing the patient's health in serious jeopardy,

(B) serious impairment to bodily functions, or

(C) serious dysfunction of any bodily organ or part.

42 U.S.C. § 1396b(V) (1988).

Contrary to AHCCCS's interpretation, the statute does not limit coverage to services for treatment while acute symptoms continue. 2 Rather, the statute requires that the medical condition manifest itself by "an acute symptom (including severe pain)." The statute then mandates that AHCCCS must cover services for treatment of that medical condition so long as absence of immediate treatment for that condition "could reasonably be expected to result in" one of the three consequences defined by statute.

Neither party disputes that F.L.'s condition manifested itself by acute symptoms or that he suffered from an emergency medical condition through August 9, 1993. The parties do dispute whether he remained in such a condition for all or a portion of the time after August 9, 1993 until his discharge from the Care Center on November 22, 1993.

Mercy submitted affidavits related to F.L.'s medical condition from Timothy R. Harrington, M.D. and Donald McHard, M.D. Dr. Harrington stated that, as of August 11, 1993, "[f]ailure to either keep him at the hospital or transfer him to a skilled nursing facility would have placed his health in serious jeopardy, caused additional serious impairment to bodily functions and caused additional serious dysfunction of organs." In his affidavit, Dr. McHard stated that discharging F.L. on or before October 26, 1993 "would place his health in serious jeopardy and cause serious impairment and dysfunction. It is highly likely that his condition would deteriorate rapidly, and that he would require readmission to the hospital within days, if not sooner." Neither party presented any evidence of F.L.'s condition after October 26, 1993. 3

Under the terms of the statute, AHCCCS retained responsibility for F.L. until that point in time that his condition no longer required...

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