Tiggs v. Ohio Dep't of Job & Family Servs.

• Court: Ohio Court of Appeals
• Writing for the Court: FRANK D. CELEBREZZE, JR., J.
• Citation: Tiggs v. Ohio Dep't of Job & Family Servs., 118 N.E.3d 985, 2018 Ohio 3164 (Ohio App. 2018)
• Decision Date: 09 August 2018
• Docket Number: No. 106022,106022
• Parties: Persey TIGGS c/o Indianhills Healthcare Group, Inc., Plaintiff-appellee v. OHIO DEPARTMENT OF JOB AND FAMILY SERVICES, Defendant-appellant

118 N.E.3d 985

2018 Ohio 3164

Persey TIGGS c/o Indianhills Healthcare Group, Inc., Plaintiff-appellee

v.OHIO DEPARTMENT OF JOB AND FAMILY SERVICES, Defendant-appellant

No. 106022

Court of Appeals of Ohio, Eighth District, Cuyahoga County.

RELEASED AND JOURNALIZED: August 9, 2018

JOURNAL ENTRY AND OPINION

FRANK D. CELEBREZZE, JR., J.:

{¶ 1} Defendant-appellant, the Ohio Department of Job and Family Services (hereinafter "appellant"), brings this appeal challenging the trial court's order modifying appellant's decision. After a thorough review of the record and law, this court affirms in part and dismisses in part.

I. Factual and Procedural History

{¶ 2} Persey Tiggs (hereinafter "Tiggs") was a Medicaid recipient residing in a long-term care nursing facility, The Willows. In May 2013, Tiggs was adjudicated mentally incompetent and a guardianship was appointed by the probate court. See Cuyahoga P.C. No. 2013GRD188248. In September 2015, Tiggs's Medicaid benefits were terminated because appellant became aware that Tiggs, as a beneficiary, had come into possession of a life insurance policy. This policy made Tiggs financially ineligible for Medicaid because Tiggs could liquidate the policy and receive a cash value.

{¶ 3} On September 12, 2015, appellant sent Tiggs a notice stating that his Medicaid benefits were proposed to be terminated because of the life insurance policy. However, through an error, Tiggs continued to receive Medicaid benefits through August 2016.

{¶ 4} On August 4, 2016, Tiggs's guardian, a relative of Tiggs, executed a "designation of authorized representative" form pursuant to Ohio Adm.Code 5160:1-2-08(C)(1), naming The Willows as Tiggs's authorized representative. On August 12, 2016, The Willows reapplied for Tiggs's Medicaid benefits and Tiggs's reapplication was subsequently denied on October 20, 2016, because of the life insurance policy.

{¶ 5} Tiggs requested a state hearing to appeal the denial of his August 2016 reapplication. At issue was whether or not Tiggs had the ability to access the proceeds of the life insurance policy. Under the Medicaid rules, if Tiggs had access to the policy, the policy would be deemed a resource and because the cash surrender value of the policy ($5,289.40) exceeded Medicaid eligibility requirements, Tiggs would be ineligible for Medicaid.

{¶ 6} The Willows represented Tiggs at the state hearing. The Willows, as Tiggs's authorized representative, argued that Tiggs was the insured under the policy but not the policy owner. The Willows further stated that the policy owner was deceased. The Willows also stated that at the probate level proceedings, Tiggs's guardian inquired of the probate court magistrate whether the magistrate would allow Tiggs access to the policy. The Willows stated that the probate court magistrate "preferred not" to allow Tiggs to access the policy. However, the state hearing officer noted that no proof was submitted at the hearing to support the probate court magistrate's statement.

{¶ 7} On November 14, 2016, the hearing officer overruled Tiggs's appeal and found that the weight of the evidence supported denial of Tiggs's Medicaid benefits, noting the lack of evidence demonstrating that the life insurance policy could not be accessed by Tiggs through reasonable efforts. The state hearing decision did not address the merits of the September 2015 termination of Medicaid benefits but ruled that because Tiggs was presently not eligible for Medicaid, his appeal of the September 2015 termination of Medicaid was moot.

{¶ 8} Tiggs requested an administrative appeal challenging the state hearing decision. On appeal, Tiggs argued that the state hearing decision erred by not addressing the September 2015 termination of Tiggs's Medicaid benefits. The administrative appeal overruled this argument stating that because Tiggs was presently not eligible for Medicaid, his appeal of the September 2015 termination of Medicaid was moot. The administrative appeal also overruled Tiggs's appeal of the state hearing decision's findings that the insurance policy was not unavailable. The administrative appeal noted that:

[w]hile [The Willows] testified that the probate court magistrate would not allow [Tiggs] access to the policy, there are no court documents or letters from the magistrate in [the] state hearing record. Without some evidence to support his claim that the policy is unavailable, we agree with the state hearing decision that the weight of the evidence supports the denial.

{¶ 9} The Willows filed a notice of appeal of the administrative appeal decision to the trial court. After holding oral arguments, the trial court issued an order modifying the December 15, 2016 administrative appeal decision. Specifically, the trial court ordered appellant to determine if either The Willows or Tiggs's guardian could assist in accessing the life insurance policy. Further, the trial court ordered that if neither The Willows nor Tiggs's guardian can assist with accessing the life insurance policy, then appellant is ordered to refer the matter to appellant's legal counsel for further review.

{¶ 10} Appellant filed this instant appeal requesting that this court reverse the trial court's order and affirm the administrative appeal decision. Here, appellant raises the following assignments of error for review:

(1) The lower court wrongly concluded that Mr. Tiggs's nursing facility could bring an appeal in court to challenge the termination of his Medicaid benefits.

(2) The lower court wrongly entertained the nursing home's argument that Mr. Tiggs's life insurance policy was inaccessible due to his incompetence and that this triggered a duty to assist on the part of the agency.

(3) The lower court wrongly concluded that the agency had an obligation under Ohio Adm.Code 5160:1-2-01(F)(5) to determine whether someone was available to assist Mr. Tiggs in accessing his life insurance policy.

II. Law and Analysis

{¶ 11} The Medicaid program provides "federal financial assistance to States that choose to reimburse certain costs of medical treatment for needy persons." Harris v. McRae , 448 U.S. 297, 301, 100 S.Ct. 2671, 65 L.Ed.2d 784 (1980) ; see also Wisconsin Dept. of Health & Family Servs. v. Blumer , 534 U.S. 473, 479, 122 S.Ct. 962, 151 L.Ed.2d 935 (2002). Specific to the instant case, Ohio's Medicaid eligibility requirements are defined within R.C. Chapter 5163, which authorizes appellant to act as the sole state agency to supervise the administration of the Medicaid program, and to promulgate rules relating to Medicaid eligibility.

{¶ 12} " R.C. 5101.35 authorizes an administrative appeal from the Ohio Department of Job and Family Services' decision [on Medicaid eligibility issues]." Clark v. Ohio Dept. of Job & Family Servs. , 8th Dist. Cuyahoga, 2017-Ohio-9173, 101 N.E.3d 1238, ¶ 7-8. As we recently noted in Clark :

"An appellant is first entitled to a state hearing by the ODJFS. R.C. 5101.35(B). That decision may be appealed to the director of the ODJFS. R.C. 5101.35(C). An appellant who disagrees with the administrative appeal decision of the director (or the director's designee) may appeal the decision to the court of common pleas, pursuant to R.C. 119.12. R.C. 5101.35(C)."

Clark at ¶ 3, fn. 1, quoting Rodefer v. McCarthy , 2015-Ohio-3052, 36 N.E.3d 221, ¶ 35 (2d Dist.). See also George v. Ohio Dept. of Job & Family Servs. , 10th Dist. Franklin No. 04AP-351, 2005-Ohio-2292, 2005 WL 1109658, ¶ 32. The trial court must then conduct a hearing, consider the entire record, and must affirm an agency's decision where it is supported by "reliable, probative, and substantial evidence and is in accordance with law." R.C. 119.12. See also Univ. of Cincinnati v. Conrad , 63 Ohio St.2d 108, 109-110, 407 N.E.2d 1265 (1980). " ‘[C]ourts * * * must give due deference to an administrative interpretation formulated by an agency that has accumulated substantial expertise, and to which the General Assembly has delegated the responsibility of implementing the legislative command.’ " Bernard v. Unemp. Comp. Rev. Comm. , 136 Ohio St.3d 264, 2013-Ohio-3121, 994 N.E.2d 437, ¶ 12, quoting Swallow v. Indus. Comm. of Ohio , 36 Ohio St.3d 55, 57, 521 N.E.2d 778 (1988). See Jones Metal Prods. Co. v. Walker , 29 Ohio St.2d 173, 181, 281 N.E.2d 1 (1972) (finding that deference is afforded to an administrative agency's interpretation of its own rules and regulations if such an interpretation is consistent with statutory law and the plain language of the rule itself).

{¶ 13} A court of appeals' review is more limited, determining only whether the court of common pleas abused its discretion in finding that the decision of the administrative agency was supported by reliable, probative, and substantial evidence. Kinasz-Reagan v. Ohio Dept. of Job & Family Servs. , 164 Ohio App.3d 458, 2005-Ohio-5848, 842 N.E.2d 1067, fn. 2 (8th Dist.), citing Pons v. Ohio State Med. Bd. , 66 Ohio St.3d 619, 621, 614 N.E.2d 748 (1993). As the Ohio Supreme Court stated:

In reviewing an order of an administrative agency, an appellate court's role is more limited than that of a trial court reviewing the same order. It is incumbent on the trial court to examine the evidence. Such is not the charge of the appellate court. The appellate court is to determine only if the trial court has abused its discretion.

Lorain City School Dist. Bd. of Edn. v. State Emp. Relations Bd., 40 Ohio St.3d 257, 260-261, 533 N.E.2d 264 (1988). Thus, when a court of appeals reviews a common pleas court's decision in an administrative appeal, its standard of review is far more circumscribed than that employed by the court of common pleas. See Farran v. Cleveland Civ. Serv. Comm. , 8th Dist. Cuyahoga No. 99851, 2014-Ohio-823, 2014 WL 888427, ¶ 2.

{¶ 14} An administrative agency may also appeal a trial court's decision; however, such an appeal is permissible in a limited capacity. R.C. 119.12 specifically grants an administrative agency a limited right of appeal to a...