No. 2-09- 0581 File d: 6-16-10

_____________________________________________________ _____ ______________________ _ IN THE APP ELL ATE C OURT

OF IL LINO IS SECOND DI STRICT

_____________________________________________________________ _____ ______________

_ ELVIRA A

RELLA NO, ) Ap peal f rom th e Ci rcui t Court ) o f Win ne ba go Co un t y. Pl ai n ti f f -A pp el l an t, )

) v. ) No. 08-- MR--223 ) TH E D EP ARTM EN T O F HUM AN ) SERVIC ES, CA

ROL L. A DA MS, Se cretary ) of t he De par t ment o f Human S er vices, and ) THE DE PARTMENT OF HEALTHCARE ) AN D FA MIL Y SERV ICES, ) Ho no r ab le ) J. Edward Pro chaska, Defendan ts-Appellees. ) Judge, Presi din g.

_______________________________________________________ _____ ____________________

_ JU STI CEO' MA

LL EY de l i v er ed th e op i ni on of th e c our t: Pl ai n ti f f , El v i ra A re l l an o, a pp ea l s f rom th e r ul i n g of th e c i rc ui t cou rt of W i n n eb ag o Co un

ty affirming the deci si on of def

endan t, t he Il li nois Depa rtmen t o f Hum an Serv i ces (the D epartm

en t), deny in g her Medi

cai d ben efi ts in connecti on with h

er hospi tali zation an d treat me nt for pneum

onia
. (P laintiff'sco mpla int als o na med as de fen da nt s t he I llino is D ep ar t men t o f He alt hc ar e a nd Fa mily Services and Car

ol A dam s, the Secre tary of the Dep artm

en t.) T he lo ne iss ue pr es en t ed in t his appeal is whether th

e m edi cal servi ce s p l ai

nti f f rec ei ve d w ere i n r eacti on to the "s udd en ons et" of an acute me dic al cond i tion , so asto quali f

y her, an al ie n not lawf ull y a dmi tt ed for perm

anen t United States resi dence, f

or M edi cai d b en

ef i ts. H owe ve

r, f orthe reasons that fol

low, we concl

ude that the "sudden
on se t" requirem

ent im permi ssi bl y m odif ie s the Medi

cai d statut e and thus ca

nnot be en

forced
.No. 2-- 09--0581

-2-

Ac co r di ng ly, we

v ac ate th e D ep ar

tmen t' s d ec i si on , w h i ch wa s pre m

i se d on th e " sudd en

on set" requiremen

t, and reman

d with directions. The re cord f

rom th e proc ee di

ng s b ef ore th e D ep artm

en t i nc l ude s m edi cal rec ords f rom plaint iff 's hospi tali zation as well as a t ra nscr ipt of p laintiff's te st imony at a De par t ment a dministr at ive heari ng. That evidence contains v arious, and c onflict ing, d esc ript ions of the ti m i ng an d c ha racter of t he sympt oms t hat led t o p laintiff's hosp italizat ion. In her test im

ony, plai ntif f i ndi cated t hat she vi sited a doct or a "f ew day s" pr ior to her ad miss io n int o t he ho sp it al. A hosp i tal record of pl ai ntif f 's history and ph y sical , f ro m May 7, 2 006, the fi

rst day of h

er hos pit alizat ion, i

n di ca tes th at sh e w en

t to the hospi

talco mplaining of sho rt ness o f brea t h. Ac co rd ing to the m edi

cal record, p l ai

ntif f "state[ d] tha

t she wasi n [h er] us ual state of he al th un til [the pri or] evening around 11 o'clock wh en sh e went to bed. She h

ad sh ortn es s of br ea th a nd the sh ortn es s of b re ath pr og re ssed and w as no bet t er , a nd she had t ro uble slee ping t hro ugho ut t he night so she ca me to t he [ hos pit al] * ** in t he morni ng." The report continued: "[Pl ai ntif f] state[d] that she [had] been having a no npr od uct ive co ugh s t ar t ing abo ut t hre e we eks [p rio r] and ove ra ll the co ugh fr equ ency and i ntensi ty [was] l ess en i ng." A s econ d Ma y 7 hi story and ph y sical reportind ica t es t ha t pla int iff ( an d t he family mem bers who accompan

ie d her to t he h

ospital and transl

ated for her) "report [ed] that appro xi ma tely two to three weeks ago [pl aintif f] b ega n fe eling [ ill] w it h sh o r t ne ss o f br ea t h a s t he pr inc ip[ al] symp t o m. Over th e en su []i

n g tw o we ek s, [i

t] has graduall

y progressed and she fi

rst sough t medi cal atte nti on ap pr o ximat ely

three day s ago at which

tim e i nha le rs *** were prescri

bed. Ov er the

week end, thereNo. 2-- 09--0581

-3-

was n o i m pr ov em en t an d th usth e pa t ient sought medi cal attention to day

[at t he h ospital ] as her sym pto ms persi sted and wo rsened." A May 7 em ergency -roo m report in

dic ated that plai

ntif f "s tate[ d] that sin

ce Friday [May 5] she ha s b een

f eel i ng s hortof breath an

d saw her doctor t hat day . She state[d] she [h ad] got ten muc

h
worse s i nc e the n." The record of

a Ma y 10 pul monary co nsult at ion indicat ed t hat t he reason f or t he consul

t was that pl ai ntif f wassuf f eri ng f rom " di f f use l ower l obe c onsol

i dation wi th h y poxem i c res pi ratory f ail ure and l ow gra def

ev er, wh i ch rep orted l y be ga n a br uptl y one da y pri or to h er h

osp i tal ad m i ss i on on 5/7/2006, but wa s p rec ed ed by a th ree we ek hi story of nonproductive cough tha t apparently

[had] i m prove d." The re co rd o f a

May 13 i n f ec ti ous -di se as e c on su

l tati on i n di ca ted as f oll ows , i n perti n en t pa rt: "[ Pla int iff] presented one week ago wi th respi rato ry distress. She i s pr im ar ily Spa ni sh -s pe ak i ng . There

wa s a tran sl ator i n the room

and, even

wi th the trans l ator, I had a har d t ime get t ing t he pat ient d ow n. At one po int, she sa ys tha t she becam e acutely il l a day
orso pri ort o a dmission, wit h co ugh a nd sho rt ness o f brea t h. H ow ever , a t ano t her t ime, she will say that she no t iced t hat she w as g et t ing winded a we ek o r t wo befo re she c ame t o t he ho sp it al, an d it is real

l y ha rd to pin her down as to which i s the best descripti on. As be st I can t ell, it soun

ds l i ke a week or two b ef

ore admissio n, she knew t her e wa s so mething different wi th ma yb e a little dy

spnea [ i.e. , di ffic ul t y br ea t hin g] wit h e xe r t io n p r o gr es siv ely, al though
no ort hopnea

[ i.e. , in abi li ty to breathe unless i

n an uprigh t po si tion], and then

it go t ac ut ely worse just pri

or to admi ssi

on." The recor d of a May 10 rheum ato logy consul

tat ion stated as follows:No. 2-- 09--0581

-4- "[ Pla int iff] wa s in he r u su al st at e o f hea lth u nt il about t hre e we eks ago when s he started [t o] have dy

spnea on exertion an

d dry cough. Sh

e deni ed fev er, but compl ai

ned of upper back pai n wh ic h ha d been going on f

or t hreeyears. Her sy

mptoms got worse three day s pri or to admi ssi

on to the poi

nt tha t she could not sl

eep th e day be f ore adm i ssi on." The sa me M ay 1 3 c o nsu lt at io n re co rd ind icat ed t hat plaint iff re po rt ed ha ving been in "e xcellent healt h" pr ior t o t he onset of her i ll ness . The m

edi cal impr es sio n in t he r ec o rd indic at ed t hat pla int iff "pre se n ts with wh

at sound[ed] li

ke a two- t o t hree-week l

ower respiratory course without fev er but wi th a n onproducti

ve cough , progres si

ve dyspn ea wi th ex erti on, an d now dyspn eic at rest." Her dis chargesum

ma ry, produced on May

25, in dic ated t ha t pla int iff "c ame t o [ t he ho sp it al]
co mplaining

of sh ort ness of breath that

[had] not been gettin

g better. She [had] b een

h av i n g di f f i cul ty sleep ingat nig ht an d s he [ ha d] als o be en c omplai ni ng of a n onproduct iv

e cough whi

ch started ap pr o ximat ely

three weeks [pri or t o her hospi tali zation]. Her breathi

ng [had] b ee nget t ing progres si ve l y worse." The records in

to tal i ndicate that plai

ntif f was treat ed for pneum

onia
. In her testi mony, pl ai

ntif f sai d (throug h a n i nterpreter) that he

r cond i tion worsen ed j ust b ef ore she went to the hos

pi tal on Ma y 7 (an d i n the day s af ter sh e vi si ted a doctor) and t hat she w ent t o t he hospi talemerg ency ro om bec aus e she "had a high fever ." She d enied ha vi ng h ad an y dif f i cul ty sleep ing t he ni

ght b ef ore sh e wen t to t he hosp i tal
. W h en aske d w h eth er sh e ex perien ce d di f f i cul ty bre at hingbefo re she w ent t o t he ho spit al, p laintiff sta t ed t hat "whe n she go t up she felt li ke she was go ing t o fa ll." When as ked t o c larify when her sympto ms bega n, in light of medical re co rd s saying that she ha d exp er ienced sho rt ness o f brea t h t wo t o t hre e we eks befo re she w ent to thehospit al, pla int iff an sw er ed t ha t "it 's b ee n t hr ee mo nt hs, " a nd , in response to a foll

ow-up question, sh

e agreedNo. 2-- 09--0581

1 Wh en the clie nt-assessm

ent uni t critici zed pla in tif f f or not hav in g vi si ted a docto r prior to her hos pit alizat ion, it apparentl y ove rlooked the port ions

of her m edi cal records indi

catin g that she had in fact visited a do ct or in the d ays befo re her hos pit alizat ion. -5- that sh e w as re f er ri n g to th re e m on th s b ef oresh e w en t to t he hos pit al. When a ske d if she had so ught
me dic al at t ent ion befo re she wen

t to th e h osp i tal, s h e s ai d th at sh e w en

t to the docto r "li

ke two, three weeks bef ore" she wen

t t o t he h ospital . (Earli er in

her testim

ony, sh e had in dic ated that she had s een t he do ct o ra fe w d ays , no t we ek s, be fo r e h er ho sp it al a dmis si on.) Pl ai ntif f ex pla in ed that she had init ially attr ib uted her cough to a min

or co ld, an

d she agreed that sh

e even tuall y went to t he h

ospital when t he sympt oms w or sene d t o t he po int t hat she c ou ld no t t oler at e t hem and reali zed she w as suf feri ng f rom some thin g more than a c old. T he Dep ar t ment's client- asse ssment unit initially denied plaint iff

benefit s bec aus e plaint iff 's cough had

begun t hr ee we ek s p r io rt o he rho sp it aliz at io n a nd pr o gr es se d t he r ea ft er an d, t hu s, "d id not oc cur sud denly and u nexpe ct edly." I n a sec ond dec ision, the clie

nt-assessm

ent uni t stat ed that pla in tif f' s "sy mptoms had b een pr es en t x 3 we ek s p r io rt o he rad miss io n [ an d] she co uld ha ve like ly been s ee n by he rdo ct o r** * b efo r e t his [ ho sp it aliz at io n] [ a] dmis sio n [ an d] a s ud de n a cu t e li f e t hre at ening con

di ti on wasnot d

em ons trate d on adm i ssi on. Theref

ore em ergen t nee d [was ] not m

et." 1 In a t hird d ecisio n, the clie

nt-assessm

ent uni t not ed t ha t t he r ec o r ds ind ica t ed t ha t pla int iff's symp t o ms ha d p r o gr es se d o ve rt hr ee we ek s be fo r e w o r se ning an d c au sing he r t o visit t he ho sp it al. Thu s, t he client- asse ssment uni

t again concl uded t hat plaint if

f' s condi tion was "[n

]ot em ergent ***, sudden
occurrence o f co nd it io n is no t no t ed ." Pla int iff continue d to pursue ben

efi ts and even

tuall y obtai ned t he Dep ar t ment d ecisio n she no w ap pea ls. ( Her t est imony was t ake n aft er t he client- asse ssment un itNo. 2-- 09--0581

-6-

dec isions bu

t be f ore th e D ep artm

en t de ci si on. ) Th at D ep artm

en t de ci si on held as follow s, in p er t inent pa rt: "In order to rece i

ve Emergen cy Med i cal As si stan ce, anin eligi ble non ci tizen mus t have a
me dic al condi tion that occurs suddenl

y a nd une xpectedl y. The record shows that [p laint iff] had been expe riencing a pr og re ssio n of sympt oms fo r a t least t hre e we eks befo re she so ught t re at ment at the h

ospi tal . Ac cordi

ngl y , the re cord

sho ws [ pla int iff's ] med ica l co nd it io n d id not occur suddenl

y a nd un ex pe cte dly *** in order t o be eligi

ble for Eme

rgency Medical Assi stance. Acco rd ingly, the dec ision o f [t he cl i en t-as se ssmen

t un i t] th at [p l ai

nti f f ] wa s n ot el i gi bl e f or Em ergen

cy Med i cal As si stan ce wi l l be upheld." On ad m i ni stra ti ve rev i ew , th e c i

rcu i t cou rt not ed the dis crepanci

es i n pl ai ntif f' s m edi cal
re co rd s re gar ding t he t imi ng and nat ur e o f her sympt oms bu t uphe ld t he De par t ment's dec ision, on t he grou nd tha t the rec ord " asa w

hol e" su ppor ted the De pa rtm en t's rul i ng tha t he r con di ti on h ad not occurred sud denly and t hu s t he De pa r t men t 's r ulin g w as no t cle ar ly er r o ne o us . Pla int iff t imely appe al s. As t he pa rt ies o bser ve, t he Departmen t is an adm in is trat iv e agency , and, therefore, judi

ci al reviewof it s de cisions is

governed by the Adm in is trat iv e Revi ew Law (735 ILCS 5/3--101 et seq. (West 20 08 ) )
. T he su bje ct o f o ur r ev iew is t he ag ency's final det er minatio n, no t t hat of t he cir cu it
cou rt ( Vin cent v. Departmen

t o f Hum an Servi ces , 392 Il

l . Ap p. 3d 88 , 93 (20 09)), and our revi ew extends to al l que stions of

la wand fact presented in the admi ni strat iv e recor d (735 I LCS 5/3--110 (Wes t 200 8)) . F or an

y gi ve n i ss ue , our sta nd ard of rev i ew , wh i ch em bod i esthe l evel of deferen ce we affor d t he ag ency o n t hat issue, dep ends on w hether the issu e i s one of f act, one of l aw, or a mi xed question of

la w and f act withi n the agen

cy's area of

expertis e. AFM

Messen ger Servi ce, Inc.No. 2-- 09--0581

-7-

v . D ep ar tmen t of Em pl oy men t Se cu ri ty , 198 Ill . 2d380, 39 0 (200 1). A re v i ewi n g c our t af f ord s to
an agen cy no de f eren ce on questions of

l aw, an d i t wi l l there f ore cons i der de no vo any

le gal is sues rais ed in an administr at iveappe al
. Ci ty of Bel vi dere v . Il l i noi s State L ab or Rel

ati ons B oard , 18 1 I ll. 2d 1 91, 205 (1 998 ). An administr at ive age ncy's findings o f fact , o n t he oth er h an d, a rede em ed to be pr ima fa cie true and c or re ct and w ill not be up set unless t hey are aga inst t he man i f es t we i gh t of t he evi den

ce. Ci ty of Bel vi dere , 18 1 I l l . 2d

at 2 04, citing 735 ILC S 5 /3
-- 110 (Wes t 199 4) . An age ncy's re so lut ions o f mi

xed q ues t ions o f law and fact--t hose i ssues f or whi ch the h i stori cal f acts a re establ is hed and the r ule o f la w u nd isp ut ed , so t ha t t he o nly q ue st io n is wh et he rt he fa ct s s at isfy a statutory st anda rd or whet her as a pplied t o t he fact s t he rule of la w is vi olated--wil

l n ot be overturned
on revi ew un

l ess clearl y errone ous. AFMMessen ger , 198 Ill . 2d at 391. T he suprem e court ado pted t his "c lea r ly er r o ne o us " s t an da r d o f r ev iew , an d t his " mixed qu es t io n o f law an d fa ct " c at eg o ry, in order to al low def

erence to agencies o n ma t t er s w it hin t he ir ex pe r t ise wh en r ev iew o t he rwis e w o uld have be en de novo . See Ci ty of Bel vi dere , 181 Il

l . 2d at 20 5 ("w e f

i nd th at the a ppl i cab l e stan

dard
o f r ev iew sho uld be bet wee n a manifest weight of t he evi dence stan

dard and a de no vo standard so as to provi de s ome

def eren ce to the B oard' s ex

peri ence a nd e xpe rtis e"). The curr en

t c ase ra ises a q ues t ion o f law re gar ding wha t legal st anda rd go ver ns plaint iff 's ent itlement t o be ne fit s, fac t ua l qu es t io ns r eg ar din g t he t imi n g a n d n atu re of her sy

mptoms , and a mi xed que st ion o f whet her , g iven the re so lut ion o f the legal and fact ual qu est ions, she met t he le gal standard. We be gi n wi th the l egal i ssue. I n 1 965, t itle XIX of the Social Securi ty Act (42 U. S.C. §§1396 through 1396v (1994)) establ is hed Medi cai d, "a fede

ral program that prov i deshe al th ca re f un di ng f orn ee dy pers on s th

rough cost-s h ari

n g w i th stateselecti

ng to pa rtic i pate i n the progra

m ."No. 2-- 09--0581

-8-

Greenery Reha bi l i tation G roup , In c. v . Ha m mon , 150 F.3d 226, 227 (2 d C i r. 1 99 8) . To p ar

ti ci pa te in the fede ral M edi cai d program, states must "abi de b y f ederal st at ut o ry law go ve rning Me dic aid
re i m b ur se men t" or "risk l

osin g Med ic ai d reim

bursem ent from the fede ral govern

me nt for that paym ent." Dia z v. Di vi si on of Social

Services , 360 N .C. 384 , 386, 62 8 S.E.2d 1 ,3 (200 6). Wh en it was passed i

n 1965, the Medi

cai d statut e was si

le nt as to whether it provided b en ef i ts to und ocum en ted al i en s. Le wi s v . Th om ps on , 252 F.3d 567, 571 (2d Ci r. 2001 ). However, in

1986, in response to a federal

cou rt rul i ng tha t de ni al of Med icaid co ver age t o a n ill ega l alien violate d t he Me dic aid statut e (see Lewis v . Gro ss , 663 F. Supp. 1164 (E. D.N.Y. 1986)), Congress i ncorporat ed
re st rict ions on

b en ef i ts to alie ns, vi a the Om ni bus Budget Reconci

li ation Act of 1986 (OBRA 1986) (P ub. L. No. 99--509, 100 St at. 1874 (1986) ). See Le wis , 252 F.3d at 573-74. Pursuant t o OBRA 1986, th e M ed

i ca i d s tatu te now prov i de s, w i th two exce

ptions , th at " no p ay

men t may be mad e to a Sta te [ un de rMe dic aid ] fo rmed ica l as sis t an ce fur nish ed t o an alie n w ho is no t law fully adm itted f or per manent resi dence

or oth erw

i se pe rm an en tl y res i di ng i n th e U ni ted State s u nd er c ol orof law." 42 U.S. C. §1396

b(v )(1) (20 06). The poli

cy underl yi ng thi s provis ion of

OBRA 1986 h

as been expl ai ned
as attempting to serve b ot h " ' a compel li ng governm

ent in terest t o rem ov e the i

ncen tive f or ille gal im mi gration provi ded

by the avail abili ty of publ ic b enefi ts' " ( Dia z , 360 N.C. at 390, 628 S.E.2d at 5, quo ting 8 U.S.C. §16 01( 6) (2 000 )) and " t he cl ea r p ur pos e * ** to m

ake g ov er n men t m orecosteff ective" ( Le wis , 252F. 3d a t 576 ). Th

e p arti esagree tha t plai nti f f wa s a n a l i en not la wful ly adm itted f orperm an en t re si den ce i n th e U n i ted Sta tes , s o th at th

e a b ov e p rov i si on pr oh i b i ts he r f rom re ceiving bene f i ts un l ess one of i ts excepti ons a ppl i es. The f i rs t ex ce pti on to th e a b ov e p rov

i si on , that i t do es no t ap ply t o c hildren a nd pr egna nt wom en l aw f ul l y res i di ng i n th e U ni ted State s ( Pub . L. No. 111--3 , 2009 U .S.C.C.A .N. (123 Stat.)No. 2-- 09--0581

-9-

56 (to be codi

f i ed at 42U.S.C. § 1396b (v)(4 ))), is not relevan

t here. The second ex

ception provides as foll ows: "(2) Pay

men t sh al l be mad e u nd er th i s s ec ti on for care and s ervices that are furn is hed to an al i en *** on l y i f
-- (A) such care a

nd serv ic es are nec essary

for the treatmen

t of an em

ergency medi cal cond i tion of the al i en , (B) such al

ie n otherwis e m

eets the eli

gibil ity requirem

ents f or medical assi stance unde

r the Stat e pl an approved un der this subch apter ***, and (C) such care an

d servi ces are not related to an organ transpla nt procedure. (3) Fo rpu r

po se s o f t his subs ect ion, the ter m ' emergency medi cal condi tion' m eans a me dic al condi tion (i ncl udin g em ergency la bor an d del iver y

) m an i f esti n g i tse l f b y acute symp t o ms of su ffi

cient seve rit y (including se ver e pa in) suc h t hat t he abs ence of i m med i ate
medi cal attenti on coul d reas onab l

y be ex pected to resul t in
-- ( A) pl ac ing t he pa t ien t 's he alt h inse r io us jeo pa r dy, (B)seriousi

m pai rm en t to bod i l y f un cti ons , or (C) seri ous dy sf unc tion of a ny bodi l y organ or part." 42 U.S.C. §§ 1396b (v)(2 ), (v)( 3) (200 6). The corol l ary

f ederal an d I l l i n oi s reg ul ati on s c on tai n si m i l ar prov i si on s, al b ei t b oth wi th th e addi ti on of the phrase "sudden onset. " The federal regulation provides as fol lows: "(c) *** [A]lie

ns wh o are not lawful

ly adm itted for perma

nen t residen ce i n the Un ited State s or pe rm an en tl y res i di ng i n th e U ni ted State s u nd er th e c ol orof law must re ceive t he
serv i ces ne ces sary

to treat the con

di tion def i ne d i n pa ragra ph ( 1) of thi s se cti on if

--No. 2-- 09--0581

-10- (1) T he ali en has , a fte r su dde n ons et , a medical co ndit ion ( including
em ergency la bor and del

iv ery) m anifes ting i tself by acute sym

pto ms of suf fi cient
se v eri ty (i nc l udi ng s ev erepai

n) such that t he ab sence of

im me dia te medi cal atte nti on co uld r eas ona bly be expec t ed t o r esu lt in:

( I ) P lac ing t he pa t ien t 's he alt h inse r io us jeo pa r dy; (ii ) Seriousi

m pai rm en t to bod i l y f un cti ons ; or (ii i) Seri ous dysf unction of

any bodil y organ or part, and (2) The al i en otherwi se m eets the requ

i re ment s [c ont ained e lsewhe re in the f edera l regul ati ons] ." 42 C .F.R . §440.2 55(c) ( 2006)
. The Ill in ois regulation provides as f ollows: "No t wit hst anding [t he r egu latio n's ge ner al ban o n assist ance t o no n-c itizens ], any nonci tizen is eligi ble for m edi cal assist ance if the no n-c itizen o t her wise meet s t he in come, asse

t and categorical

requirem ents of the m

edi cal as sista nc e p rogram

an d i s i n n ee d of em ergency servi ces required af

ter t he sudden

onset of a m

edi cal co nd it io n ( inc lu di ng lab o ran d d eliv er y) manifesting i

t se lf b y acut e sympt oms o f sufficient se ver ity (includ ing seve re pain) t hat t he abse nce o f im

mediat e medica l att ent ion co uld r eas ona bly be expec t ed t o r esu lt in: A) pl ac ing t he no n- cit ize n's he alt h inse r io us jeo pa r dy; B) s eri ousi m pai rm en ts of bod i l y f un cti ons ; or C) seri ous dysf uncti on of a ny organ or part (42 USC [§]139 6[b](v)." 89 I ll. Ad m. Code §1 20.310 (b)(3 ), ame nde d a t 29 Ill. Re g. 93 9, 14 93 9, 14 95 6, eff. Septembe r 20, 2005.No. 2-- 09--0581

-11-

The pa r t ies ag r ee t ha t t he o nly ex pl i ci t b as i s f or th e D ep ar tmen t' s dec i si on wa s i ts fi ndi ng that plaint iff 's con di ti on did no t sat isfy the "su dde n ons et " re quir ement co nt ain ed in t he fed er al a nd I llino is regulations. Th ere f

ore, i n or de r to ga uge the propri ety of the Departmen

t's deci si on, we wil

l c onsi der
o nly t he "su dde n ons et " re quir ement fro m the a bove re gulat ions, and n ot th e r em ai n i n g r eq ui re men ts fo relig ibilit y. In or der t o s et t le the par t ies' disp ut e r ega rd ing t he "s udden on set" req

ui re men t, we must fi

rst in terpret t he meaning o f the phr ase . T he pa rt ies ag re e t hat t he li mi ted case law in

terp reting OBRA 1986 does not address the "sudden ons et" requirem ent but in steadaddre ss esthe

dur ati on of t re at ment covered fo rad mit t ed ly eme r ge nc y co nd it io ns or ad dre ss esothe r com ponen ts of the de f i ni ti on of "em ergency medi cal cond i tion ." See Gre en

ery Reha bi l i tati on G roup , In c. v . Ha m mon , 893 F. Supp. 1195 (N.D.N.Y . 1995) , re v'd , 15 0 F .3d 226 (7th Ci r. 1 998 ) (on

goi ng ca re of chronic condi

tions does not qua l i f y f or cov era ge) ; Sco t t sda le Hea lthca re , I nc. v. Ar izona Hea lth Ca re Co st Co nt ainment System A dm i ni stra ti on , 206 Ariz. 1, 7 5 P. 3d 9 1 (2 003 ) ( same); Merc y Heal thca re Arizo na, Inc . v. Arizo na He al th Care Cost Contain

me nt System , 181 Ariz. 95, 887 P.2d 625 (App. 1994) (co verage continue s after stabi

li zation, until pa

tient no l onger requires

i m med i ate care to avoid seri ous harm

); S ze wc zyk v. Departmen

t o f Soci al

Services , 77 Conn. App. 38, 822 A.2d 957 (2003 ), re v'd , 275 Co nn. 464, 88 1 A .2d 259(2005 ) (sam e); Dia z v. Di vi si on of Social

Services , 166 N.C. App. 209, 600 S.E.2d 877 (2 004), re v'd , 360 N .C. 384 , 628 S.E.2 d 1 (20 06) ( me dic al em er gency

ends wh en patien t 's co nd ition is st abili

zed) ; Medi

na v . Div is ion of Social Services , 165 N.C. App. 502, 598 S.E.2d 707 (2004) (continued care is covered so long as pa ti en t' s c on di ti on man i f ests i tse l f b y acute symp t o ms an d imme dia t e me dic al t r ea t men t is req uired t o p revent serio us har m); Lu na v. Di vi si on of Social Services , 162 N.C. App. 1, 589 S.E. 2d 917 (2004) (same) ; se e al so Quice no v. Dep ar t mentNo. 2-- 09--0581

2 Because there is no appreciabl e di ff erence b etween the f

ederal and Ill in ois regulations'use of the phrase "s ud de n o nse t , " a nd be ca us e t he I llino is r eg ula t io n mu st in any even t foll ow the federal la win o r de rfo rI llino is t o qu alify fo rMe dic aid reim bursem ent, we dr aw no dist inctio n bet wee n t he feder al and s t at e r egu latio ns for pur po ses o f ou r int er pr et at ion. -12- of Social Services , 45 Conn. Supp. 580, 728 A.2d 55 3 (Super . Ct . 19 99)(ongoi ng trea tmen t of ch r o nic co ndit ions not co vered ); No rwo o d H o sp it al v
. Co mmiss io ne ro f Pu blic We l f are , 417 Mass. 54, 627 N.E.2d 914 (1994) ( no coverage f or chronic condi

tion whe re there was no i

mm edi ate danger of se r io us ha r m). Ac co r din gly, wh ile weha ve con sul ted thos e c as esf

or us ef ul ba ck grou nd on OBRA 1986 and related laws, we m ust ind ep en de nt ly

undertake the task of i

nterpreting the ph

rase "sudden
on set" i n th e cur ren t con tex t. As we n ot e above, the fede

ral an d Ill in ois regul ations i ncl ude the phrase " sudden

on set" to define t he ty

pe of "emerg en

cy medi cal con di ti ons " f or wh i ch Me dicai d c ove

rs trea tmen t f or undocum ented ali ens, but OBRA 1986does not . We must therefore interpret the regulations. 2 A court wil l i nterpret an adm

in is trat iv e regula tion i n the sam e m ann er as i t would in

terpret a statut e. Fi rst Nat ional Ba nk o f Chicago v. Stand ard Bank & Trust , 17 2 F.3 d 47 2, 4 76 ( 7t h Cir. 1 999 ); Un i on E lec t r ic Co. v. Department of Rev enue , 136 Ill . 2d 385, 39 1 ( 19 90 )
. T hu s, o ur pr imar y aim is t o g ive eff ect t o t he dr aft er s' inte nt , a nd t he bes t indicat or of t hat intent is the regulations' l

anguage, giv

en it s pl ai n a nd or di na ry mean i ng. Nol an

v. H i l l ard , 309 Ill . App. 3d 129, 143 (1999); see Ioffe v . Sk o kie Moto r Sales , Inc. , 414 F .3d 708 , 710-1 1 (7th C i r. 2005 ) (i nqu i ry into meaning o f sta t ut e and regul ati on m ust b egi n b y revi ewi ng th ei r plai n l anguag e). The impor t of t he phrase "sudden onset" i s n ot i m medi ate l y cl ea r f rom the pl ai n l an gua geof t he regulations. The word "sudden" c an ref er, among other thin

gs, to "an un

expected occurrence"No. 2-- 09--0581

-13-

orem ergen cy, or a ha

ppen i ng " wi thout prev

i ous n otice ." Web ster' s Th ird New In ternational Dicti onary

2284 (1986 ). Unde r t his definitio n, t he phr ase "su dde n ons et " ad ds a re st rict ion t o t he typeof "emergency

medi cal condi tions" f or whi ch Med i cai d cov ers treat me

nt. See A ri zon a H ea l th Care Cost Containm

ent Sys tem Admi ni stration v. Carondelet Health Sy stem , 188 Ari

z. 266, 270, 935 P.2d 844, 8 48 (A

pp . 19 97 ) (ex

pl ai n i n g th at a sta te reg ul ati on th at a dd ed a " sudd en

on set"
re quir ement to a state stat ute pro vi din g ben efi ts for "em ergency me dic al care" restricted

t he meaning of " em ergen cy medi cal care "). Such an int er pr et at io n w o uld vio lat e t he rule t ha t a c o ur t av o id readin g regulations i

n a way that bri ngs them in to confl ict wi th s tatutor y orconstituti

onal l aw. Robbi

ns v . Bentsen , 41 F.3d 1195, 1198- 99 (7th

Ci r. 199 4); North

ern Ill i noi s A utom oti ve W recke rs & R

eb ui l de rs A ss 'n

v. Di xon, 75 I ll. 2d 53, 59-60 (1979). An adm in is trat iv e agency de l eg ate d r

ul em ak i n g a uth ori ty h as n o pow er to
ma ke la w, but instead is

li mi ted to creating rul

es to effe ctuate t he wi

ll of the legi sl ature as expressed in the r elevant statute. Ernst & Ernst v. Hochf el der , 425 U.S. 185, 213-14, 47 L. Ed. 2d 668, 688, 96 S. Ct . 13 75, 139 1 (1 976 ); Di xon , 75 Il l . 2d at 6 0 (" a s tatute

may not b e al tere d or add ed t o by t he
exerc ise of a po wer to make ru les ther eunde r") ; Pe er les s Wh o les ale Liquors, Inc. v . Il l i noi s L i quor Con trol Co mm'n, 296 Ill . App. 3d 230, 235 (1998) ("A dm i ni stra ti ve rul esca nn ot be rea d to l i m i t or ex ten d the s cope of

a statute" ). Here , the O BRA 1986 s tatute, whi ch

the re gul

ati ons were promulgated to imple men t , r eq uir es t ha t "[ p] ayme nt sha ll be made * ** f

or care a nd s ervi ces

that are furn is hed t o an a lien * ** if *** suc h care an d servi ces are ne cessary

for the treatment of an
em ergency med i ca l con di ti on of th e a lie n." 42 U.S.C. §1396b(v)(2)(A) (2006). OBRA 1986
co nt ains no li

mi tation that t he em

ergency me dic al condi tion m ust also ha

ve h ad a "su dden

onse t." OBRA 1986 a l so p rov ide s a speci fi c defi ni tion of the ph

rase "em ergency me dic al condi tion" (42No. 2-- 09--0581

-14-

U.S. C. §1396

b(v )(3) (20 06)), and that defi

ni tion does not i

nc l ude an y req ui rem en t tha t the con di ti on have had a "sudden

onset." Bot h the f

ederal and the Il

li nois regulations repeatand inco rp or at e t he OBRA 198 6 de f i ni ti on of "em ergency me dic al condi tion," but both also add jus t be f

ore th at d ef i ni ti on that the "m

edi cal condi tion" covered m

ust also ha

ve h ad a "sudden

onset." See 42 C.F .R. §440.255(c) (2 006 ) ( beginning t he exc ept ion by stating, "[t]he al

ie n has, af ter sudden onset, a medi

cal cond i tion ," be f ore repea tin g the Med i cai d statute' s de f

i ni tion of a n emergen

cy medi cal cond i tion ); 89 I ll. Adm . Code §120.310(b), amended at 29 Ill. Reg. 14 93 9, 14 95 6, eff. Septem ber 20, 20 05 (s am

e). The ma xi m that, where possi

ble, a court mus

t interpret a regulati on to be valid a nd not to confl

ict wi th statut ory law di ctates t hat we not in terpret th e r eg

ul ati on s' us e of th e p h ra se "s udden on set" as addi ng a l im itation on M edi cai d ben

efi ts not co ntain

ed i n OBRA 1986. On the other han

d, we could avoid thi s proble m b y i nterpreting the ph

rase "sudden

onset" as
re dund ant with M edi cai d's requi remen t t hat t he t re at ment fo r w hich reimbur sement i s s ough t be f or an "em ergency me di cal condi tion" wh

ose sy mptoms are "acute." See Greenery , 150 F.3d at 232 (r eas oning that t he term " em ergency" denotes a " 'su dde n' " eve nt and that the term "acute" desc rib es a sy m ptom wi th " ' a sudden

onse t' "), quoti ng W eb ster' s Th

i rd New Intern ati onal Dicti onary

23, 741 (1981 ); Szewczy

k v. Departmen

t o f Soci al Services , 275 Conn. 464, 511, 881 A.2d 259, 288 (2005) (S ulliva n, C.J., joined

by Za rel l a, J ., di ss en ti ng) (" [t]h e i njury i s acu te i n th e s en se tha t i t wa s of sudd enon se t a nd i s severe"); see al so Webs ter's Thi rd New International

Dic tionary 23 (1986) (d efining "ac ute" a s a m

edi cal term used to de scri

be a c ond i ti on w i th " sh arpne ss or s everi ty " or having "a sudden

onset, sharp ris e, and sh ort course"). This s olution, h owever, carries i

ts own pr o ble m: it requi

re s that wevi

ol atethe max i m tha t a c ourt shou

l d a voi d i nte rpreti ng sta tutory orNo. 2-- 09--0581

-15-

regul atory langua ge in a wa y

that ren ders i t super f l uous. Gil

lespie v . Tr ans Union, LLC , 43 3 F. Sup p. 2 d 90 8, 9 13 ( N.D . I ll . 20 06) ; Gaston v. CHAC, In c. , 375 Il l . Ap p. 3d 16 , 45 (20 07). Based on th e a b ov e d i sc us si on , w e c on cl

ud e th at t he regulations' pla

in la nguage is am

bi guous on the proper interpretation to be accorded the phrase "sud den o ns et," and we contin ue our in terpret ation by

consul ting the rel

evan t legi sl ative

and regul ator y h is to ry. That

hi story provides

a very clear pict ur e o f the intent unde rlying the inclusion o f the "su dde n ons et" phrase i n t he regulations. The feder al Dep ar t ment o f Healt h and H uman S er vices ad ded t he "su dde n ons et " re quir ement to t he federal

regulations i

n 1990, i n order to im

ple me nt chan ges m ade by OBRA 1986. See 55 Fed. Reg. 36813 (September 7, 1990) (to be codif ie d at 42 C. F.R. pt. 435, 436, 440). When the rules
were pu blish ed , in

response t o co mment s t ha t "t he de finit io n o f eme r ge nc y med ica l co nd it io n sh o uld be ex panded an

d more preci sel

y de fi ned," the Departm

ent of Heal

th and Hum

an Servi ces stated as foll ows: "[W]e have r evised t he de f i ni ti on of em ergency me dic al servi ces to say that 'af

ter t he sudden onseto f a me dic al c o nd it io n * **
. ' T his chan ge wil l m ake the def

in ition of em

ergency servi ces co nsist ent wi

th th e def i n i ti on al re ad y i n us e i n th e M ed

i ca i d p rogra m at 42 C.F.R. 447.53(b)(4) an

d w i th the de f i ni ti on c onta i ne d i n s ec ti on 1 867 (e) (1) of

th e [ Soc i al

Se cu ri ty Act], relati

ng to hospital

em ergency departments['] i

nappropr iat e fa ilur e t o t r ea t ce r t ain pa ti en ts (the anti-dum

pin g provisi on)." 55 F ed. Re g. 368 16 ( Sep t ember 7 , 1 990 ) ( t o be codi f i ed at 42C.F .R. pt. 435 , 436, 44 0).No. 2-- 09--0581

-16-

T his passage i

ndicates that t he ph

rase "sudden

onset" was added

t o t he fed er al r eg ula t io ns in order t o mirr or t wo laws se par at e fro m, but re late d t o, t he OBR A 198 6 pr ovisio ns f or tre atm en t of undocumented aliens. We therefore exami ne both of tho se laws. We first examine sec t ion 1 867 of t he So cial Sec ur ity Act , c od ifi ed a t 42 U .S .C . § 139 5dd and better kno wn as t he E merg ency Med ical Tr eat ment and A ctive Labor Act

(EMT ALA). EMT ALA pr oh i b i ts hospi tals f rom rej ectin

g patien ts suff erin g from em ergency me dic al co ndit ions without first st abilizing or t ra nsferr ing t he patients. See 42 U.S.C. §1395dd(b) (2006). S ave f or incons equenti al
var iatio ns i

n pu n ctuati on an d th e n om en cl atu reus ed to i de nti f y the pa ti en t, EM TA LA 's de f i ni ti on of t he phr as e " eme r ge nc y med ica l co nd it io n" is p r ec ise ly t he sa me a s t ha t co nt ain ed in t he Me dic aid st at ut e's undocum

en te d- alien pr ovisio ns. S ee 4 2 U. S. C. §13 95d d( e) (1 ) ( 200 6) . E MTAL A's defi ni tion of "em

ergency me dic al co ndit ion" c ont ains no qualif ie r that t he condi

tion m ust have h

ad
a "su dde n ons et ." Thu s, d esp ite t he st at ement fro m the D epa rt ment of H ealt h and Human Servi ces, EMTALA canno t have insp ired its inclus ion o f the ph r as e " su dd en o nse t " inthe f ed era l reg ul ati on at issue here. The sec ond law ci

ted by the Depart men

t o f Heal th and Human Servi

ces, 42 C.F.R. §447.5 3(b )(4), is a r eg

ul ati on pr om ul ga ted to imple men t 42 U. S. C. §1 39 6o , a s ec t io n o f t he Me dic aid sta tute governi ng cost-shari

ng ch arges f or cert ai n patie nts. See Pharm

aceutical So ciet y of t he Sta

te of New York v. New York St ate Department of Socia l Serv ic es , 50 F.3d 1168, 1170 (2d Ci r. 1995) (c iting both). 42 C.F.R. §447.53(b)(4) (herein after, the Cost Sharin

g Regulation) does in

deed use t he phr ase "su dde n ons et ." In fac t , t he Co st Shar ing Re gu lat io n u se s p r ec ise ly the sam e l anguage as the fede ral regul ation now at i ssue:No. 2-- 09--0581

3 Afte r w e dir ect ed t he pa rt ies t o be pr epa re d t o d iscuss at or al arg ument t he legislat iveand adm in is trat iv e hi story in

form in g this case, the De pa rtm en t f i l ed a m oti on for l eave to cite Chevr on, U. S. A. Inc. v. Natural R

esources Def

ense C ounsel , Inc. , 467 U.S. 837, 843, 81 L. Ed. 2d 694, 703, 104 S. Ct. 2778 , 2782 ( 1984) , as addi tional authority, f

or t he proposition tha

t, "if [a] st at ut e is silent -17- " Emergen cy servi ces . Servic es provi ded i

n a h ospital , cli

nic, off ic e, or o ther

f ac i l i ty that is equi pped to furni sh the requi

red care, af

ter th e sudd en ons et of a m edi cal con di ti on manifesting it se lf by ac ut e s ympt o ms o f su fficie nt se ve r it y (in clu din g sever e pa in) t hat t he ab sen ce of i m medi ate m edi cal attenti on coul d reas onab l

y be ex pected to resul t in
-- ( I ) P lac ing t he pa t ien t 's he alt h inse r io us jeo pa r dy; (ii ) Seriousi

m pai rm en ts to b odi l y f un cti ons ; or ( iii) Ser i ousdy sf un cti on of an y bod i l y orga n or pa rt. " (Em phases adde d.) 42 C.F .R. §44 7.53(b)(4) (20 06). Thus, i t ap pe ar s th at th e C os t Shari

ng Re gul ati on s erv ed asthe mode l f or th e re gul

ati on we n ow i nterpret, 42 C .F.R . §440.2 55(c). Th i s rev elati on rai ses two im portant poi

nts. Fi rs t, as w e have said, t he Co st Shar ing Regulation was prom

ulga ted to im ple me nt 42 U.S. C. §13 96o. Tha t st at ut e pr ovid es no definitio n of t he ph r as e " eme r ge nc y se r vic es "; inst ea d, it ex pr es sly states that the phras e "emergency services" is to be "defi

ned by the Secret ary" ( i.e. , defi

ned b y a n agen cy and not the

l egi slature). 42 U .S .C . § 139 6o (a )( 2) (D ) ( 200 6) . H er e, on t he o t her hand, t he relevant statut e ful

ly defi nes the ph

rase "em ergency me dic al condi tion" an d expl ic itl y s tates t ha t coverage sha ll

ex tend f or the ca re of such c ondi

tions. Th us, a "sudden ons et" requirem ent that may have be en ap pr op riat e ( and con siste n t wi th t he ena bling sta t ut e) in the c ont ext of t he Co st Shar ing Regu l ati on i s n ot nece ssa

ri l y so i n the con text of section 440.25 5(c). 3No. 2-- 09--0581

oram bi guous w i th res pect to [a] s

peci f i c i ssue," a

court sh oul d de f er to a n a ge nc y's i nte rpreta ti on of t he statut e, so l

on g a s th at i n ter pr eta ti on i s rea son ab l e. W e h

er eb y al l ow th e m oti on to ci te additiona

l
au t ho r it y, but we declin

e to apply so-call ed Ch ev ron defer ence t o t he st at ut e and regulations atis sue here because

Congress di

d not leave vag

ue or ambi

gu ous its def

in ition of "em

ergency me dic al cond i tion ." It spe ci

f i ca l l y pr ov i de d a

de f i n i ti on of th e te rm wi thou t t he qu alifi

er t he r egu latio ns added. -18- Second, the Cost Sharin

g Regulation was prom

ulga ted in 1985 (see 50 Fed. Reg. 23009 (May 30, 1985) ( to be codif

ied at 42 C.F.R. pt . 431 , 447 )), before Co ngress pas sed EMT ALA in 1986 (see Pu b. L. 99--272 §9121(b), 100 S tat. 164, 165 (1986)). "[E MTALA 's] def in ition of em

ergency me di cal condi t ion co nt ained lang uag e su bst ant ially simi lar t o t he langu age of [ t he Co st Shar ing Regu l ati on], with the e

xcepti on that t he statute did not list the faci li ties at whi ch em ergency me dic al servi ces m ust b e provi ded or i

nc l ude a sudd en onse t requi rem en t." S ze wc zyk , 275 Conn. at 495-96, 881 A.2 d at 279 (S ullivan, C.J., j oin ed b y Zare l l a, J., d

i sse nti ng)
. We can

not att rib ute to in advertence Co ngr ess's dec ision t o e xclude spe cifically fro m EMT ALA t he "s

udden on set" r eq uir eme nt wh en it ot herwise adopted virtua ll

y w h olesal e the rema

in der of the Cost Sharin

g Regulation. Rather, we must co nc lud e t ha t wh en Co ng r es s s pe cific ally e xc ise d " su dd en o nse t " fr o m re gu lat o ry lang ua ge it ot herwise ado pt ed u nchang ed, it int ende d tha t "sud den onse t" not b e m

ade a requi rem en t for a
con di ti on t o qu alify as an " em

ergency medical co ndit ion" u nder EMT ALA. T he amend ment t o t he Me dic aid statut e excl

udin g undocum

ented alie ns was passed aft er E MTALAand, as we h ave stated,
uses EMT ALA's de finit io n o f "e mer ge nc y med ica l co nd it io n. " Wh en it cop i ed EMTA LA

's de f i ni ti on of "em ergency me dic al condi tion," Congress n

ecessari ly repeated its i

mpl ic it rej ection of the " sudden onset" lan guage.No. 2-- 09--0581

-19-

Thus, t he legislat ive histo ry and the hi story beh in d section 440.255(c), the fe deral reg ul ati on now at issue, indicat e ( 1) t hat Co ngr ess int ende d t o e xclude fro m the M edica id st at ut e's de f i ni ti on of "emer genc y medical co ndit ions" t he Co st Shar ingReg ulat ion's "sudden ons et" li mi tation, and (2) that the "su dde n ons et " re quir ement was add ed t o s ect ion 4 40. 255 (c ) t o includ e t he Co st Shar ing Reg ulat ion's "sudden ons et" li mi tation. Accordin

gly , although we h

ave a duty

to construe a reg ul ati on as consistent with the law wherever possible, we m ust concl ude that such

a c ons tructi on is not po ssi

ble here. Based on the h is to ry un derly in g section 440.255(c) , we con cl ud e th at i ts "sudden onset" r equirem

ent im pro perly restr icts a

nd c ontravenes the M edi cai d statut e, and we th er ef oreca n n ot en f orc e i t. In so holdi ng, we observe that the Dep ar tmen t ob j ec ts to an

y re l i an ce on EM TA LA to in terpret OBRA 1986, b ecaus e, acc or ding to the De part ment, t he purp ose u nderlyi ng EMTALA (p re vent ingpatien

t "dumpi ng" by hospitals) dif

f er s f rom th ose un derl y i n g O BR A 19 86 (to s av

e c ost s and di sc ourag e i

l l eg al i m m i gr ati on). W e f ur th er n ote tha t the l evel of care mandat ed under EMTALA mi ght dif fer f rom that man

dated under OBRA 1986: EMTA LA requi res onl y tha t a pa ti en

t' s em ergency me dic al cond i tion be "stabi l ize[d] " (42 U.S.C. §1395dd(b)(1) ( 2006)), whil e OBRA 1986 requires t hat an u ndo cu ment ed alien re ce ive c o ver ag e fo r " t re at ment " o f an em erge ncy me dic al
con di ti on (42 U.S.C . §1396

b(v )(2)(A ) (2006 )). See Sc o t t sd ale Heal thcare, Inc. , 206 Ariz. at 7 n.6, 75 P.3d at 97 n .6 (con

trasti ng th e di ctates of EMTA LA wi th OB RA 1986)
. However, while these dif feren ces between

EMTALA

and OBRA

1986 mi ght be i nstructive in ot her contexts (such as

t he que sti on of the extent an

d duration of treatmen

t covered under ei

ther law), i

t do es not alte r t he fact that t he leg isla t ive his t o ry un de r ly in g OBRA 1986 incl

udes EMTALA and excl udes the phrase "su dden onse t."No. 2-- 09--0581

-20-

At oral argu men t, the Departmen

t added the argumen

t t hat we sho uld r ely o n t he pr inc iple of le gis la tive a cqui escenc e to uphold the regul ations' "sudden ons et" req

ui rem en t. The p ri nc i ple of acqui escenc e, de scri

be d by our s upr em e c ourt a s a

" 'we ak ree d on wh i ch to base a d eterm i na ti on of
*** drafters' intent' " ( Pe o ple v. Marker , 233 Il l . 2d 158 , 175 (2 009), quot in g People v . Marker , 382 Ill . App. 3d 464, 490 (2008) (O'Mal le y, J., di ssen

ting)), holds tha

t, wh ere j udi ci al i nte rpreta ti on of
a statut e has n

ot evoked an

amendment t o t he st at ut e, t he drafters are presum ed to have acquiesced, and thus ratif

ie d, court s' i

nterpretat ion of

the statut e ( Marker , 233 Ill . 2dat 1 78, citi ng Peo ple v. Do wns , 371 Ill . App. 3d 1187, 1191 (2007)). According to t he Dep artm en t, t he fact t hat t he regulations' "su dde n ons e t" req uirem ent has long persi sted without any corr ection from Congress in dic ates that Co ngress has a cqui esced t o t he r equ irement . T he difficulty wit h t he De par t ment's the ory i s th at, b y the De pa rtm en t's own ad m i ss i on, the re i s n o ca se l aw addre ss i ng the propri ety of t he "sudden ons et" requirem ent, much le s s any case l

aw endorsi

ng i t. Thus, Congress has b een pres en ted wi th no ju di cial rul i ngs i n w hi ch to acqui esc e. Even though it ackn

owledges t hat Co ngr ess ha s see n no c ase law dir ect ly on po int, t he Dep ar t ment ar gue s t hat t he Se co nd Cir cuit 's de cision in Greenery , a lt ho ug h dir ec t ed at a d iff ere nt poi n t, reli ed on the assum

pt io n t ha t a " su dd en o nse t " r eq uir eme nt wa s inc lud ed in t he Me dic aid st atute. We a gr ee wit h t he D ep ar t ment 's r ea ding o f Greenery as as su m i n g a "s udden on set"
re qui re men t to b e a pa rt of th e M ed i ca i d s tatu te, b ut w e d

i sa gr ee wi th the De pa rtm en t's con cl us i on that th at a ss

um pti on , c oup l ed

wi th Congress' failu r e t o r es po nd , is s uffic ien t t o t r igg er t he pr inc iple of l egi slati ve acqu i esc ence. As we say above, Greenery

is am ong the several

deci si ons that struggled to det ermi ne wh ether
se cti on 1396b(v)(3) covers t reatment for chro nic or o ngoing condi tions; t he pa rt ies ass umed t hat t heNo. 2-- 09--0581

4 Furth er, based on the l

egi sl ative and regul ator y h is to ry we di

scuss ab ove, we di sa

gr ee wi th t he Greenery

co ur t 's co nclusio n t hat Co ngr ess mea nt t he terms "em ergency me dic al co ndit ion" a nd "acute" to require that the onset of a condition covered by Medi caid be " sudden." If Congress in deed in tended to require that a condi

tion be s udden in order for its treat me

nt to be covered un

der se cti on 1396b (v)(3 ), i

t woul d n ot ha ve exci se d the " sudde

n on set" l an gua gef rom t he lan gu ag e it ot herwise adopted i n s ection 139 6b(

v)(3 ). -21- pati en ts' tre atmen

t was c overe d upon

thei r i ni tia l hosp i tal ization. Greenery , 150 F.3 d at 231 ("T he que sti on is si mpl y w hether ch ronic debil

itatin g condi tions that r es ult from

sudden an

d seri ous in

juri es *** are 'em

ergen cy me dic al c o nd it io ns' as pr o vid ed un de r§1 39 6b ( v) ( 3) ")
. T he Se co nd Cir cu it reasoned th at t r ea t me nt for chroni

c condi tions was n

ot covered, because the

phrases " em

ergency me dic al con di ti on " a n d " acute " " un

am b i gu ous l y con v ey [e d] th e m

ea n i n g th at eme rge ncy

me dic al
co ndit ions ar e s ud de n, se ve r e a nd sho r t - lived ph ysic al inju r ies o rillnes se s t ha t r eq uir e imme dia t e t re at ment t o pr eve nt furt her harm." Greenery , 15 0 F
. 3d at 23 2. Alt ho ug h t he Se co nd Cir cu it in cl uded suddenn

ess am ong the componen

ts of its def

in ition of "em

ergency medi cal cond i tions," it did n ot f ocu s, or re l

y , on an y sudd en n es s req ui re men t; i t i n ste ad re l i ed on th e " sh ort- li ved" and "i mm edi at e med ic al tr eat ment" co mpo nent s o f its d efinition t o r eac h its ho lding t hat ong oing t re at ment f

or chron i c con di tions i s n ot covere d. W e d o not c on strue t hi s men tion of suddenness, whi ch t he Se co nd Cir cu it n ei

th er ex tra pol ate d n or re l i ed on , to be the ty

pe of j udic ia

l s tatement that
wo uld precipi

tate a reaction f

rom Congress regardi

ng the "sudde

n onset" requi

remen t contained

in t he Medicai d regulation. We theref ore rejec t t he De

pa rtm en t's con ten ti on th at the p ri nc i pl e of acqui escenc e dict at es t hat we u pho ld t he "s udden on set" re quir ement co nt ained in t he r egu latio n. 4No. 2-- 09--0581

-22-

Because we c onc lude t hat we ca nn ot en f orc e a n y "s udden on set" req

ui re men t re l ate d to OBRA 19 86 , we als o co nc lud e t ha t t he De pa r t men t emp lo yed an inc o rr ec t leg al s tand ardwh en it rejected plai

ntif f' s clai m due to her fail

ure t o meet a "s ud de non se t" req ui rem en t. The q ue sti on re mainswhether pl

ai ntif f' s condi tion otherwise

qualif ie das an " em

ergency me dic al co ndit ion. " The Dep ar t ment's f

i ndi ngs of f act, wh i ch were di rected en ti rel y at the " sudde

n on set" re qui rem en t, do n ot address this

is sue. Li

kewi se, the De part men

t's a pplicat ion o f law t o t he fact s wa s base d o n t he im proper "s ud de n o nse t " r eq uir eme nt and did no t ad dr es s w het her pla int iff 's c ondition otherwise qualif ie d as an "e merg ency medica l cond itio n." We t her efo re have no basis o n which t o a ffi rm t he Dep ar t ment's dec ision. Ind eed , in its brief, t he Departmen t do es not urge any b asi s to affi rm other than the " sudd

en onse t" requ i rem en t we hav e h eld to be i

m proper. In sum , the "sudden

ons et " re quir ement was t he exc lusive basis fo r t he De par t ment's dec ision. It en tere d n o f i nd i ng s on an y of the othe r pos si bl e b as esf orde nying pla int iff's cla im, a nd it of course hashad n o oppo rtunity

to appl y the correct le gal

st anda rd (w ith no "s

udden on set" req

ui re men t) to t he fac t s o f t his c as e. We t he r efo r e v ac at e t he De pa r t men t 's d ec is i on a nd rem an d the c as e f

or co nsider at ion u nder t he lega l sta ndar d ar t iculat ed he re in. Vacated and r eman

ded with directions. JORGENSEN and HUDSON, JJ., concur
.