Meza v. Div. Of Soc. Serv., 518A08.

• Citation: 692 S.E.2d 96,364 N.C. 61
• Decision Date: 15 April 2010
• Docket Number: No. 518A08.,518A08.
• Parties: Maria D. MEZA, Petitionerv.DIVISION OF SOCIAL SERVICES and Division of Medical Assistance of the North Carolina Department of Health and Human Services, Respondents.
• Court: United States State Supreme Court of North Carolina

364 N.C. 61

692 S.E.2d 96

Maria D. MEZA, Petitionerv.DIVISION OF SOCIAL SERVICES and Division of Medical Assistance of the North Carolina Department of Health and Human Services, Respondents.

No. 518A08.

Supreme Court of North Carolina.

April 15, 2010.

COPYRIGHT MATERIAL OMITTED

Appeal pursuant to N.C.G.S. § 7A-30(2) from the decision of a divided panel of the Court of Appeals, 193 N.C.App. 350, 668 S.E.2d 571 (2008), affirming a judgment and order entered on 26 January 2007 by Judge Yvonne Mims Evans in Superior Court, Mecklenburg County. Heard in the Supreme Court 1 April 2009.

Notes from the Official Reporter

1. Administrative Law; Public Assistance--judicial review of agency decision-- N.C.G.S. § 108A-79(k)--standard of review

The standard of review of an agency decision under N.C.G.S. § 108A-79(k) is de novo when the superior court exercises its statutory authority to take testimony and examine into the facts of the case to determine whether the final decision is in error under federal and State law. If, however, the superior court proceeds solely upon the administrative record, the hearing is governed by the provisions of the Administrative Procedure Act, in which questions of fact are reviewed under the whole record test and questions of law are reviewed de novo.

2. Administrative Law--judicial review of agency decision-- emergency medical condition--findings of fact--whole record test

The Court of Appeals erred in affirming the superior court's judgment and order finding that petitioner non-qualified alien was suffering from an “emergency medical condition” as defined in 42 U.S.C. § 1396b(v)(3) for the duration of both of her stays at CMC-Randolph Behavioral Health Center and was thus entitled to Medicaid benefits for the entire length of her stays because: (1) the superior court erred in reviewing DHHS's factual findings de novo, as it proceeded solely based upon the administrative record; (2) the medical experts had conflicting opinions whether petitioner was suffering from an “emergency medical condition” under 42 U.S.C. § 1396b(v)(3), the record contains substantial competent evidence to support either the position of the hearing officer or that of the superior court, and thus the Court of Appeals erred in holding that the superior court properly considered the same evidence and concluded that the hearing officer's findings were not factually and legally justified; and (3) the whole record test does not allow the reviewing court to replace the factfinder's judgment as between two reasonably conflicting views, even though the court could justifiably have reached a different result had the matter been before it de novo.

Ott Cone & Redpath, P.A., by Thomas E. Cone, Greensboro, for petitioner-appellee.

Roy Cooper, Attorney General, by Christopher G. Browning, Jr., Solicitor General, and Brenda Eaddy, Assistant Attorney General, for respondent-appellants.

PARKER, Chief Justice.

In this case we determine the appropriate standard of review to be applied by the superior court in an action commenced under N.C.G.S. § 108A-79(k), reviewing decisions by the North Carolina Department of Health and Human Services' Division of Social Services (DHHS) and Division of Medical Assistance (DMA) regarding claims for Medicaid benefits. For the reasons stated herein, we hold that when the superior court conducts a hearing based upon the administrative record, it must review questions of fact under the whole record test and questions of law de novo. In this case, the superior court having conducted a de novo review as to factual issues based solely on the administrative record, we reverse.

Petitioner Maria D. Meza was admitted to the CMC-Randolph Behavioral Health Center for psychiatric treatment on 15 October 2004 and was released on 29 October 2004. Petitioner applied for Medicaid benefits through the Mecklenburg County Department of Social Services (DSS) on 5 January 2005. On 26 January 2005, Mecklenburg County DSS issued a notice of benefits awarding Medicaid coverage for the date of admission (15 October 2004), but denying coverage for the remainder of the hospitalization. Petitioner was admitted to the same facility a second time, from 17 January 2005 through 11 February 2005, for inpatient mental health care. On 19 April 2005, petitioner again applied for Medicaid benefits through Mecklenburg County DSS. On 13 May 2005, Mecklenburg County DSS issued a notice of benefits for this hospitalization, again awarding Medicaid coverage only for the date of admission (17 January 2005).

Petitioner is a resident of Mecklenburg County, but is not a United States citizen. The parties do not dispute that for purposes of Medicaid coverage, petitioner is a “non-qualified alien.” See 42 U.S.C. § 1396b(v)(1) (2000). As such, petitioner could not receive Medicaid coverage for her inpatient treatment unless her medical condition met the definition of an “emergency medical condition” under federal law. Id. § 1396b(v)(2)(A). Federal law defines the term “emergency medical condition” as:

a medical condition ... 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.

Id. § 1396b(v)(3).

Petitioner appealed the decisions denying her claims for Medicaid coverage, and on 14 July 2005, a DHHS hearing officer conducted a hearing on both determinations. On 26 August 2005, the hearing officer issued a separate decision as to each period of hospitalization.

With respect to the first hospitalization, the hearing officer found that upon admission, petitioner was described as “ ‘acutely psychotic,’ ” with her husband reporting that she often wandered out of the house, forgot to change her clothes for several weeks at a time, threw food and clothing, and neglected her personal hygiene. The hearing officer further found that on 17 October 2004, petitioner's condition worsened to the extent that she was considered a danger to herself and forced medication was deemed necessary. According to the hearing officer, beginning on 22 October 2004 through discharge, petitioner was no longer considered to be a danger to herself.

Based on these findings, the hearing officer concluded that from 15 October 2004 through 21 October 2004, petitioner's condition required emergency medical services, and thus, she was entitled to Medicaid coverage for that period. With respect to the period from 22 October 2004 through 29 October 2004, the hearing officer concluded that petitioner's condition had stabilized to the extent that she was no longer a danger to herself, and therefore, “the remaining treatment was to cure the underlying illness.” As a result, the hearing officer reversed the decision in part and awarded petitioner Medicaid coverage for her treatment from 15 October 2004 through 21 October 2004, but not from 22 October 2004 through 29 October 2004.

With respect to petitioner's second hospitalization, the hearing officer found that she had been previously diagnosed with schizophrenia and that she was withdrawn, isolated, and suspicious and had feelings of persecution. The hearing officer concluded that petitioner's condition did not qualify as “emergent” under the federal definition because her condition had stabilized following the initial day of admission. Based on this determination, the hearing officer affirmed the decision awarding Medicaid coverage only for the date of admission, 17 January 2005.

The hearing officer's decisions became DHHS's final decisions inasmuch as petitioner did not seek further review by the chief hearing officer. On 5 October 2005, petitioner filed a petition for judicial review pursuant to N.C.G.S. § 108A-79(k) in Superior Court, Mecklenburg County. The superior court heard the matter based on the administrative record developed before DHHS. Concluding that the case involved statutory interpretation and application of law to facts, the superior court reviewed the final agency decision de novo and made findings of fact.

The superior court found as fact that at the time of each hospital admission:

Ms. Meza was in a severe psychotic state of sudden onset resulting from decompensation of her long-standing underlying illness. Throughout each [of her admissions], she demonstrated severe symptoms of psychosis, loss of touch with reality, paranoia and suspiciousness, internal distractions including delusions and hallucinations, gross disorganization, and inability to attend to basic needs such as eating, bathing, and grooming. Throughout most of both admissions, she was unable to talk or communicate in any meaningful manner with staff or her peers, and her judgment and insight were very limited. She refused medication during both admissions, and forced medication orders were required during each.

The court determined that petitioner's condition “placed her health in serious jeopardy and could reasonably have been expected to result in either placing [her] health in serious jeopardy or serious impairment to bodily functions or serious dysfunction of a bodily organ or part.” The court further found that the treatment at issue was “required and given to stabilize her condition” and that “her condition was not stabilized until her discharge.”

Based on its findings, the superior court concluded that (1) “[p]etitioner's medical condition at each admission was an emergency medical condition as defined in 42 U.S.C. § 1396b(v)(3),” and (2) “treatment throughout each admission constituted immediate, medically necessary, and appropriate treatment for [her] emergency medical condition.” The superior court reversed DHHS's decisions and ordered DHHS to provide petitioner with Medicaid coverage for the entirety of both hospitalizations.

DHHS and DMA appealed to the Court of Appeals,...