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Haley v. Commissioner of Public Welfare, 394 Mass. 466, 476 N.E.2d 572, Med & Med GD (CCH) P 34,585

Facts

The plaintiffs, including James E. Haley and Leon Moreau, applied for retroactive medical assistance benefits after being denied by the Department of Public Welfare due to excess resources. Haley had a bank account balance exceeding the limit, while Moreau's ward, Mary Verona, had assets that were deemed excessive until a transfer reduced them below the threshold. The Department's denials were based on their interpretation of eligibility criteria without considering a resource spend down, which the plaintiffs argued was necessary.

We briefly summarize the relevant facts concerning each plaintiff as found in the record.

Issue

Whether the Department of Public Welfare's method of determining eligibility for medical assistance benefits without utilizing a resource spend down was proper.

The major issue which controls resolution of this dispute is whether a 'resource spend down' should be used to calculate available resources.

Rule

Eligibility for medical assistance benefits must consider a resource spend down, allowing individuals to offset incurred medical expenses against excess resources, as per the applicable statutes and regulations.

Eligibility is based on an individual's available income and resources. G.L. c. 118E, §§ 5 and 10. 106 Code Mass.Regs. §§ 505.000–505.470 (1983). An individual may have available resources of $2,000 and remain eligible for MA benefits.

Analysis

The court determined that the Department's refusal to apply a resource spend down was inconsistent with the legislative intent and the goals of the medical assistance program. It noted that the lack of a spend down would lead to unreasonable outcomes, where individuals with excess resources could be denied benefits despite having significant medical expenses. The court emphasized that the statutes allowed for a reasonable evaluation of resources, which should include the application of a spend down.

We conclude that a resource spend down is the proper method of calculating available resources in determining an individual's eligibility for MA benefits.

Conclusion

The Supreme Judicial Court vacated the judgments of the lower courts and remanded the cases, concluding that the Department's method of determining eligibility without a resource spend down was not in accordance with the law.

For the foregoing reasons, we conclude that the department's method of determining eligibility without a resource spend down is 'not in accordance with law.' G.L. c. 30A, § 14(7)(g).

Who won?

The plaintiffs prevailed in the case because the court found that the Department's method of determining eligibility was improper and did not comply with the statutory requirements.

The department argues that the plaintiffs did not raise below the issue whether the interpretation of G.L. c. 118E would require a resource spend down. We disagree. A fair reading of the record indicates that this issue was properly raised.

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