Title: Freiner v. Secretary of the Executive Office of Health and Human Services
Citation: N/A
Docket Number: SJC-13514
State: Massachusetts
Issuer: Massachusetts Supreme Court
Date: June 14, 2024

NOTICE:  All slip opinions and orders are subject to formal 
revision and are superseded by the advance sheets and bound 
volumes of the Official Reports.  If you find a typographical 
error or other formal error, please notify the Reporter of 
Decisions, Supreme Judicial Court, John Adams Courthouse, 1 
Pemberton Square, Suite 2500, Boston, MA, 02108-1750; (617) 557-
1030; SJCReporter@sjc.state.ma.us 
 
SJC-13514 
 
HOLLY T. FREINER, personal representative,1  vs.  SECRETARY OF 
THE EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES & another.2 
 
 
 
Suffolk.     February 7, 2024. – June 14, 2024. 
 
Present:  Budd, C.J., Gaziano, Kafker, Wendlandt, & Georges, JJ. 
 
 
Medicaid.  MassHealth.  Marriage.  Regulation.  Assignment.  
Administrative Law, Agency's interpretation of regulation.  
Due Process of Law, Administrative hearing.  Words, 
"Refuses to cooperate." 
 
 
 
Civil action commenced in the Superior Court Department on 
April 9, 2020. 
 
The case was heard by Maureen Mulligan, J., on a motion for 
judgment on the pleadings, and entry of separate and final 
judgment was ordered by David A. Deakin, J. 
 
The Supreme Judicial Court on its own initiative 
transferred the case from the Appeals Court. 
 
 
James R. Knudsen for the plaintiff. 
Cassandra Bolaños, Assistant Attorney General, for the 
defendants. 
 
1 Of the estate of Costa Tingos. 
 
2 Director of the board of hearings of the Office of 
Medicaid. 
 
2 
 
Patricia Keane Martin, Clarence D. Richardson, Jr., & C. 
Alex Hahn, for Massachusetts Chapter of the National Academy of 
Elder Law Attorneys, amicus curiae, submitted a brief. 
 
 
 
WENDLANDT, J.  This case arises at the intersection of 
Medicaid and marriage.  The Medicaid program must preserve its 
limited resources to pay benefits only for those who are unable 
to afford care on their own.  Consistent with that directive, 
the financial resources available to an applicant for Medicaid 
long-term benefits must fall below a threshold amount in order 
for the applicant to be eligible.  When an applicant for long-
term care benefits is married, determining eligibility requires 
a delicate balance.  On the one hand, the Medicaid program seeks 
to ensure that a financially secure couple cannot shift the 
burden of paying for the care of a married applicant 
(institutionalized spouse) onto Medicaid by sheltering assets 
under the name of the applicant's spouse (community spouse) in 
order to make the institutionalized spouse appear impoverished 
"enough" to meet the eligibility requirements for Medicaid 
benefits.  On the other hand, the Medicaid program aims to avoid 
effectively impoverishing the community spouse by forcing the 
community spouse to spend virtually all the couple's assets 
before the institutionalized spouse can obtain benefits. 
 
To address this challenge, Federal and State statutes and 
regulations govern how State Medicaid agencies must treat the 
3 
 
resources available to the community spouse when determining the 
institutionalized spouse's eligibility.  Before an 
institutionalized spouse may receive assistance, that spouse 
must disclose not only her own and the couple's joint resources, 
but also those resources ostensibly available only to the 
community spouse.  A State Medicaid agency may not, however, 
deny the institutionalized spouse benefits because of resources 
determined to be available to the community spouse, if the 
institutionalized spouse assigns to the agency her rights to 
spousal support.  This scheme allows the agency to attempt to 
recoup, through litigation if necessary, the benefits it paid on 
behalf of the institutionalized spouse from the resources 
available to the community spouse. 
Recognizing that in some circumstances an institutionalized 
spouse may not be able to determine the community spouse's 
resources, Massachusetts's Medicaid program, MassHealth,3 offers 
an additional protection for applicants; specifically, pursuant 
to 130 Code Mass. Regs. § 517.011 (2017) (regulation), if the 
community spouse "refuses to cooperate" or if that spouse's 
"whereabouts [are] unknown," MassHealth nonetheless will provide 
 
3 MassHealth is overseen by the Executive Office of Health 
and Human Services (EOHHS).  The parties refer to the State 
Medicaid program and EOHHS as "MassHealth."  For consistency, we 
do the same. 
 
4 
 
benefits to the institutionalized spouse even if the couple's 
combined resources cannot be calculated.4  At issue in this case 
is the scope of the phrase "refuses to cooperate" in the 
regulation. 
We conclude that MassHealth's board of hearings (board) 
reasonably construed the phrase "refuses to cooperate" to 
exclude the situation presented here, where the community 
spouse's principal act of noncooperation with the 
institutionalized spouse was the refusal to disclose her 
financial resources in connection with the institutionalized 
spouse's application for benefits from MassHealth.  We agree 
with the agency's reasonable determination that, in the context 
of a "long-term and ongoing level of cooperation" throughout the 
marriage, such a refusal to disclose the community spouse's 
financial resources does not fall within the type of "refus[al] 
to cooperate" required by the regulation.  Further concluding 
that the process resulting in the board's decision to deny the 
long-term care benefits in this case was not arbitrary or 
capricious, we affirm the decision of the Superior Court judge.5 
 
4 The institutionalized spouse still must assign spousal 
support rights to MassHealth or meet one of the other specified 
conditions. 
 
5 We acknowledge the brief of amicus curiae Massachusetts 
Chapter of the National Academy of Elder Law Attorneys. 
 
5 
 
 
1.  Background.  The following facts, as set forth in the 
administrative record, largely are undisputed.6 
Costa and Mary Tingos were married in September 1957.  The 
couple lived together for over fifty years, until May 2015, when 
Costa,7 who was then eighty-two years old, moved into a 
residential nursing home. 
As described by the couple, the marriage had its 
challenges; Costa had a long history of gambling problems and 
financial mismanagement, which eventually drove a wedge between 
the married couple.  Indeed, at some point Mary considered 
divorcing Costa, but the couple remained married for religious 
reasons and because their two children "did not want [them] to 
get divorced." 
Both spouses contributed financially to the marriage, 
albeit in unequal amounts.  For much of the marriage, Mary 
worked consistently and paid the couple's major expenses, 
including the mortgage on the family home;8 Costa also worked and 
 
6 Our review is confined to the facts in the administrative 
record.  See G. L. c. 30A, § 14 (5); BAA Mass., Inc. v. 
Alcoholic Beverages Control Comm'n, 49 Mass. App. Ct. 839, 840 
n.2 (2000) ("review is confined to [the administrative] 
record"). 
 
7 Because Costa and Mary Tingos share the same surname, we 
refer to each by his or her first name. 
 
8 After Costa stopped paying the mortgage on the family 
home, he transferred his ownership interest in the home to Mary 
by deed.  The transfer occurred in 1983. 
6 
 
contributed to the payment of utility and cable bills.  
Beginning sometime around 2003, Mary and Costa started keeping 
their income and assets "almost entirely separate."9  They 
continued to live together in the family home and also continued 
filing their State and Federal income taxes jointly on the 
advice of their accountant. 
 
When Costa moved into the nursing facility, Mary continued 
to assist her husband by helping coordinate his care.  She also 
served as his attorney-in-fact under his power of attorney so 
she could manage his bank account and pay bills on his behalf. 
 
2.  Prior proceedings.  a.  Initial application.  In 
September 2015, shortly after his admission into the residential 
nursing facility,10 Costa filed an application for MassHealth 
long-term care benefits.  In his application, Costa stated:   
"For decades my wife and I have kept our income and assets 
almost entirely separate, although I lived with her in her 
home and/or apartment and I contributed to some expenses 
such as cable[] and utilities.  Mary is refusing to support 
me financially or cooperate with my application for 
benefits or provide information.  I hereby assign to 
MassHealth my rights to obtain spousal support from her." 
 
 
 
9 Costa did not have independent access to Mary's financial 
information. 
 
10 Prior to his admission to the nursing home, Costa 
suffered paralysis to the left side of his body. 
 
7 
 
In response to a request from MassHealth, Costa disclosed 
certain financial information, including his and Mary's joint 
tax returns, but he did not provide additional requested 
information regarding Mary's income and assets. 
In December 2015, MassHealth issued a denial letter.  
Citing 130 Code Mass. Regs. § 515.008 (2014),11 MassHealth 
explained, "You did not give MassHealth the information it needs 
to decide your eligibility within the required time frame." 
b.  First hearing.  Costa requested a hearing to review the 
denial of his application.12  Costa asserted that "[he] should 
not be disqualified due to the refusal of [his] spouse to 
cooperate when [he] ha[d] assigned the division [his] right to 
support."  A hearing was held in February 2016.  In a written 
decision, the board denied Costa's administrative appeal, 
concluding: 
"[Costa] has not satisfied the provisions of 130 [Code 
Mass. Regs. §] 517.011.  Specifically, . . . [Costa] has 
not demonstrated by a preponderance of the evidence that 
his spouse will not cooperate.  [Costa] did not submit any 
 
11 Title 130 Code Mass. Regs. § 515.008 provides, in 
relevant part:  "The applicant or member must cooperate with the 
MassHealth agency in providing information necessary to 
establish and maintain eligibility." 
 
12 See G. L. c. 118E, § 47 ("Any applicant for or recipient 
of medical assistance . . . aggrieved by the failure of the 
division to grant medical assistance . . . shall have a right to 
a hearing, after due notice, upon appeal to the division in the 
manner and form prescribed by the division").  See also 130 Code 
Mass. Regs. §§ 610.000 (2023) (prescribing hearing rules). 
 
8 
 
evidence, other than his own statement in a letter, to 
demonstrate that the spouse will truly not cooperate 
. . . .  [Costa] did not produce any evidence from the 
community spouse, testimonial or otherwise, confirming her 
unwillingness to cooperate.  Further, there was no evidence 
presented at or post-hearing regarding any efforts [Costa] 
has undertaken to compel the spouse to cooperate." 
 
Costa sought judicial review of the board's decision, 
pursuant to G. L. c. 30A.  In February 2018, a Superior Court 
judge vacated the decision, concluding that the denial letter 
had not given Costa sufficient notice that the reason for the 
denial was insufficient evidence of Mary's noncooperation; thus, 
he was not on notice that he would have to present such evidence 
at his hearing before the board.  The judge remanded the matter 
to the board. 
c.  Second hearing.  The board held a second hearing in 
May 2018, at which Costa testified that he had not asked Mary to 
provide the requested financial information; instead, he 
explained that his attorney had notified him of Mary's refusal 
to cooperate.  In support of Costa's position at the hearing, 
Mary, who did not testify, submitted an affidavit.  She averred, 
"I refuse to cooperate with my husband with his application for 
MassHealth long-term care benefits and I will not provide him 
with any information regarding my income, assets and other 
financial information." 
The board again denied Costa's appeal, affirming the 
decision to deny his application for benefits.  The board 
9 
 
concluded that an applicant has a duty "to make reasonable 
efforts . . . to access his spouse's income and assets . . . 
[and Costa] has not demonstrated that he has made any [such] 
effort." 
Costa sought judicial review of the board's decision, 
pursuant to G. L. c. 30A.  In October 2019, a different Superior 
Court judge (second judge) vacated the board's decision and 
remanded the matter.  The second judge concluded that Costa had 
not received sufficient notice that he would be required to 
demonstrate that he had made specific efforts to access Mary's 
financial information. 
d.  Third hearing.  A third hearing was held before the 
board in January 2020.13  MassHealth argued that Costa failed to 
demonstrate that he engaged in reasonable efforts to provide 
Mary's financial information, failed to demonstrate an inability 
to access information on her assets, and had "not presented 
evidence of [Mary's] bona fide refusal to cooperate with 
MassHealth but has shown a selective and opportunistic refusal 
depending on whether noncooperation is financially beneficial."  
 
13 Costa was competent when he was admitted into the nursing 
facility, and at least as of June 2018.  By January 2, 2020, the 
time of the third hearing before the board, Costa was no longer 
competent to testify.  Costa was represented at the hearing by 
his attorney.  His later lack of competency is not, however, 
raised as an issue here. 
 
10 
 
Costa argued that he complied with his duty to make reasonable 
efforts to obtain Mary's financial information by providing the 
couple's joint tax returns, and that he had requested, through 
his attorney, financial information from Mary, but she had 
refused. 
In March 2020, the board affirmed the denial of Costa's 
application, concluding: 
"[The record] suggest[s] a long-term and ongoing level of 
cooperation that fails to satisfy the requirements of 130 
[Code. Mass. Regs. §] 517.011.  In a determination of 
eligibility, MassHealth must evaluate the countable assets 
of both spouses (130 [Code Mass. Regs. 
§] 520.002[B][2][b]).  [Costa] has not fully verified the 
couple's assets and has thus not fulfilled his duty to 
cooperate with the MassHealth agency to provide information 
necessary to establish eligibility." 
 
In reaching its conclusion, the board acknowledged Mary's stated 
refusal to provide information regarding her finances, but 
determined that Mary's "other actions, both past and present, 
belie the notion that she is a noncooperating spouse." 
Costa14 sought judicial review of the board's decision, 
pursuant to G. L. c. 30A.  In February 2022, in a thorough and 
well-reasoned decision, a different Superior court judge (third 
judge) affirmed the board's decision.  The third judge concluded 
that the board's construction of 130 Code Mass. Regs. 
 
14 Costa died on May 28, 2020; his estate was substituted as 
a party to the proceedings.  For purposes of consistency, we 
will continue to refer to Costa's estate as "Costa." 
11 
 
§ 517.011(B) was reasonable, that the construction was not 
inconsistent with Federal law, and that the board's decision to 
deny benefits was supported by substantial evidence.  Costa 
timely appealed, and we transferred the matter to this court on 
our own motion. 
 
3.  Discussion.  Our review of the board's decision denying 
Costa's application for benefits is limited; relevant here, we 
review such an agency decision to determine whether it is 
"[b]ased upon an error of law; . . . [u]nsupported by 
substantial evidence; or . . . [a]rbitrary or capricious, an 
abuse of discretion, or otherwise not in accordance with law."  
G. L. c. 30A, § 14 (7).  See Massachusetts Inst. of Tech. v. 
Department of Pub. Utils., 425 Mass. 856, 868 (1997).  A party 
challenging an administrative agency's decision "bears 'a heavy 
burden,' for we 'give due weight to the [agency's] expertise, as 
required by [G. L. c. 30A,] § 14 (7).'"  Welter v. Board of 
Registration in Med., 490 Mass. 718, 724 (2022), cert. denied, 
143 S. Ct. 2561 (2023), quoting Massachusetts Ass'n of Minority 
Law Enforcement Officers v. Abban, 434 Mass. 256, 263-264 
(2001). 
We review an agency's construction of its own regulation in 
the same manner that we would an agency construction of a 
statute it is tasked with administering.  See Matter of the 
Estate of Mason, 493 Mass. 148, 152 (2023).  Specifically, we 
12 
 
begin with "the text of the regulation, and will apply the clear 
meaning of unambiguous words unless doing so would lead to an 
absurd result."  Welter, 490 Mass. at 726, quoting Massachusetts 
Fine Wines & Spirits, LLC v. Alcoholic Beverages Control Comm'n, 
482 Mass. 683, 687 (2019).  See DeCosmo v. Blue Tarp Redev., 
LLC, 487 Mass. 690, 699 (2021) ("If the regulation is plain and 
unambiguous, it should be interpreted according to its terms").  
"Where the plain text of the . . . regulation[] is ambiguous, an 
agency's reasonable interpretation of [it] is generally entitled 
to deference."15  Id. at 695-696.  "'[W]e are generous in our 
deference to administrative agencies in their interpretation of 
their own regulations,' ensuring only that their interpretation 
is reasonable."  Massachusetts Fine Wines & Spirits, LLC, supra, 
quoting Craft Beer Guild, LLC v. Alcoholic Beverages Control 
Comm'n, 481 Mass. 506, 527 (2019).  See G. L. c. 30A, § 14 (7) 
("The court shall give due weight to the experience, technical 
competence, and specialized knowledge of the agency, as well as 
to the discretionary authority conferred upon it"); Carey v. 
Commissioner of Correction, 479 Mass. 367, 369 (2018) ("A 
 
15 "In deciding whether deference is due to an agency's 
interpretation, [we] consider whether (1) the regulatory 
language is plain or ambiguous; (2) the agency's interpretation 
is reasonable; (3) the interpretation is the agency's official 
or authoritative position; (4) the interpretation draws on the 
agency's technical and substantive expertise; and (5) the 
agency's interpretation is based on fair and considered 
judgment" (footnotes omitted).  DeCosmo, 487 Mass. at 699. 
13 
 
plaintiff challenging an agency interpretation has a 'formidable 
burden'" [citation omitted]).  This deference is not, however, 
"abdication"; we "will not hesitate to overrule agency 
interpretations of statutes or rules when those interpretations 
are arbitrary or unreasonable."  Matter of the Estate of Mason, 
supra, quoting Armstrong v. Secretary of Energy & Envtl. 
Affairs, 490 Mass. 243, 247 (2022). 
 
a.  Statutory framework.  The Medicaid program is "a 
cooperative State and Federal program [intended] to provide 
medical assistance to individuals who cannot afford to pay for 
their own medical costs."  Matter of the Estate of Mason, 493 
Mass. at 153, quoting Daley v. Secretary of the Executive Office 
of Health & Human Servs., 477 Mass. 188, 189 (2017).  See 42 
U.S.C. § 1396-1 (Medicaid's purpose is to assist qualifying 
individuals "whose income and resources are insufficient to meet 
the costs of necessary medical services").  Within the framework 
established by Federal statute and attendant regulations, 
participating States have flexibility to design and operate 
their individual programs.  Matter of the Estate of Mason, 
supra. 
The Massachusetts State Medicaid program, MassHealth, makes 
benefits available for qualifying individuals who require long-
term care services.  See G. L. c. 118E, § 9; 130 Code Mass. 
Regs. § 519.006 (2023).  Consistent with the Medicaid program's 
14 
 
purpose of providing benefits only to those unable to afford 
care on their own, see Dermody v. Executive Office of Health & 
Human Servs., 491 Mass. 223, 225-226 (2023), an applicant's 
countable assets cannot exceed a threshold amount, 130 Code 
Mass. Regs. § 520.016 (2013).16 
Where the applicant is not married, the calculation is 
relatively straightforward, requiring disclosure and evaluation 
of that individual's own resources in order to determine the 
individual's eligibility.  Where the applicant is married, the 
eligibility determination is more complex, involving 
consideration of the needs and assets of a noninstitutionalized 
spouse who remains in the community. 
If the State agency were to disregard entirely the 
community spouse's resources in determining a married 
applicant's eligibility, financially secure couples could shift 
the burden of paying for long-term care onto the State agency 
simply by placing their financial resources under the name of 
the community spouse.  See Houghton v. Reinertson, 382 F.3d 
1162, 1165 (10th Cir. 2004) ("a wealthy community spouse [could] 
shelter income and resources from inclusion in the calculation 
of the institutionalized spouse's eligibility").  Such 
maneuvering would permit a savvy couple to allow the 
 
16 Income limits also apply.  See 130 Code Mass. Regs. 
§ 520.009 (2023). 
15 
 
institutionalized spouse to appear to fall within the 
eligibility requirement for long-term benefits, while hiding the 
couple's available resources and hoarding them away for the 
community spouse and family members.  Permitting this loophole 
undermines the goal of Medicaid to preserve its benefits for the 
most needy.  See, e.g., H.R. Rep. No. 100–105, 100th Cong., 1st 
Sess., pt. 2, at 73 (1987) (Committee on Energy and Commerce) 
(noting problem of "affluent individuals . . . disposing of 
resources in order to qualify for Medicaid nursing home 
coverage" and that "Medicaid -- an entitlement program for the 
poor -- should not facilitate the transfer of accumulated wealth 
from nursing home patients to [family]"). 
By the same token, if MassHealth were to apply the same 
eligibility requirements to a married applicant as it applied to 
an unmarried applicant, a community spouse might need to spend 
the couple's assets before the institutionalized spouse could 
qualify for benefits, potentially resulting in the 
"'pauperization' of the community spouse."  Wisconsin Dep't of 
Health & Family Servs. v. Blumer, 534 U.S. 473, 480 (2002), 
quoting H.R. Rep. No. 100–105, supra at 65.  See Houghton, 382 
F.3d at 1165 ("As a result, some community spouses [could 
become] prematurely institutionalized themselves due to a lack 
of financial self-sufficiency"); H.R. Rep. No. 100–105, supra 
16 
 
("The purpose of the [Medicare Catastrophic Coverage Act17] is to 
end this pauperization by assuring that the community spouse has 
a sufficient -- but not excessive -- amount of income and 
resources available to her while her spouse is in a nursing home 
at Medicaid expense"). 
i.  Required disclosure of couple's combined resources.  To 
protect community spouses from such forced pauperization, and to 
eliminate loopholes that allowed well-resourced couples to 
shelter their resources under the name of the community spouse 
in order to allow the institutionalized spouse to appear 
qualified for Medicaid benefits, Congress enacted the "spousal 
impoverishment" provisions of the Medicare Catastrophic Coverage 
Act of 1988 (act or MCCA), 42 U.S.C § 1396r-5.  See Thomas v. 
Commissioner of the Div. of Med. Assistance, 425 Mass. 738, 740 
(1997) ("The MCCA addressed [the] problem" of prior law leaving 
"the community spouse financially vulnerable. . . .  At the same 
time, the MCCA was designed to eliminate loopholes which allowed 
couples to qualify for Medicaid even though they had substantial 
resources"). 
Pertinent here, the act imposes two requirements on State 
Medicaid agencies.  First, when determining whether a married 
applicant is eligible for long-term benefits, an agency "must 
 
17 Discussed infra. 
17 
 
calculate the total value of the couple's resources" regardless 
of whether those resources are jointly owned or owned by one 
spouse in that spouse's sole name.  Thomas, 425 Mass. at 740.  
See 42 U.S.C. § 1396r–5(c)(1)(A) ("There shall be computed . . . 
the total value of the resources to the extent either the 
institutionalized spouse or the community spouse has an 
ownership interest . . .").  This permits the State agency to 
consider the entirety of the couple's finances without regard to 
the named ownership of the particular asset.  Regardless of 
whether the asset belongs to one or both of the spouses, the 
asset is considered in the eligibility determination, 
eliminating the loophole that existed prior to the MCCA that 
permitted the couple to shelter assets in the name of the 
community spouse. 
Second, the agency must determine, using a defined formula, 
the community spouse resource allowance (CSRA), which is a 
portion of the couple's combined total resources calculated in 
the first step that is set aside for the community spouse's 
continued use.  Thomas, 425 Mass. at 740.  42 U.S.C. § 1396r-
5(f)(2).  Significantly, the CSRA is not considered as a 
countable asset when determining the institutionalized spouse's 
eligibility.  Thomas, supra at 740-741.  42 U.S.C. §§ 1396r-
5(c)(2), (f)(2)(A).  See Dermody, 491 Mass. at 227.  By 
eliminating the CSRA from the eligibility determination for the 
18 
 
institutionalized spouse, the MCCA preserves these resources for 
the community spouse, eliminating the preexisting situation that 
sometimes resulted in the forced impoverishment of the community 
spouse. 
Where a couple's combined total resources as calculated in 
the first step, less the CSRA amount, exceed the allowable 
amount for Medicaid eligibility, the MCCA provides that the 
institutionalized spouse "shall not be ineligible by reason of 
[those] resources" for long-term Medicaid benefits if "the 
institutionalized spouse has assigned to the State any rights to 
support from the community spouse."18  42 U.S.C. § 1396r-5(c)(3).  
See, e.g., Morenz v. Wilson-Coker, 415 F.3d 230, 234 (2d Cir. 
2005) (applicant eligible for long-term care benefits where 
State determined couple had excess resources but 
institutionalized spouse assigned support rights).  Thus, an 
institutionalized spouse who executes the requisite assignment 
 
18 In addition, an institutionalized spouse shall not be 
ineligible for benefits if 
 
"(B) the institutionalized spouse lacks the ability to 
execute an assignment due to physical or mental impairment 
but the State has the right to bring a support proceeding 
against a community spouse without such assignment; or 
 
"(C) the State determines that denial of eligibility would 
work an undue hardship." 
 
42 U.S.C. § 1396r-5(c)(3).  Neither of these provisions is at 
issue in this case. 
 
19 
 
in favor of the State Medicaid agency will not be ineligible by 
reason of those resources to receive Medicaid benefits even 
though the couple's combined countable resources, which exclude 
the CSRA, exceed the threshold amount; in addition, the 
assignment allows the State agency to seek reimbursement of its 
costs from the community spouse.19  Importantly, the provision 
applies only where the couple's total combined resources are 
disclosed to the State agency.  This disclosure, in turn, 
permits the agency to determine whether seeking to pursue its 
assigned rights is worthwhile. 
MassHealth follows each of these MCCA requirements.  First, 
to determine the eligibility of an institutionalized spouse, 
MassHealth "must determine the couple's current total countable 
assets, regardless of the form of ownership between the couple."  
130 Code Mass. Regs. § 520.016(B)(2).  Second, MassHealth 
determines the CSRA based on the requisite formula, and that 
"allowance is not considered available to the institutionalized 
spouse when determining the institutionalized spouse’s 
eligibility."  Id.  In addition, an institutionalized spouse 
"will not be ineligible due to . . . assets determined to be 
 
19 In certain circumstances, married individuals have the 
ability to obtain a court order requiring payment of support 
from a spouse without a divorce.  See G. L. c. 209, § 32; C.P. 
Kindregan, Jr., M. McBrien, & P.A. Kindregan, Family Law and 
Practice § 81 (4th ed. 2013). 
 
20 
 
available for the cost of care in accordance with 130 [Code 
Mass. Regs. §] 520.016(B) [based on the couple's total 
resources, less the CSRA] . . . [if] the institutionalized 
spouse assigns to the MassHealth agency any rights to support 
from the community spouse."  130 Code Mass. Regs. § 517.011.20 
 
20 The present matter concerns subsection (B) of 130 Code 
Mass. Regs. § 517.011; we note that subsection (A) of the 
regulation, as presently written, appears to contain what 
MassHealth has described as a "scrivener's error."  Title 130 
Code Mass. Regs. § 517.011 states in full: 
 
"An institutionalized spouse, whose community spouse 
refuses to cooperate or whose whereabouts is unknown, will 
not be ineligible due to 
 
"(A) assets determined to be available for the cost of care 
in accordance with 130 [Code Mass Regs. §] 520.016(B):  
Treatment of a Married Couple’s Assets When One Spouse Is 
Institutionalized; or 
 
"(B) his or her inability to provide information concerning 
the assets of the community spouse when one of the 
following conditions is met: 
 
"(1) the institutionalized spouse assigns to the MassHealth 
agency any rights to support from the community spouse; 
 
"(2) the institutionalized spouse lacks the ability to 
assign rights to spousal support due to physical or mental 
impairment as verified by the written statement of a 
competent medical authority; or 
 
"(3) the MassHealth agency determines that the denial of 
eligibility, due to the lack of information concerning the 
assets of the community spouse, would otherwise result in 
undue hardship." 
 
As discussed supra, the MCCA does not permit a State agency 
to deny benefits to an institutionalized spouse because of 
excess resources if the institutionalized spouse both (1) 
discloses the information necessary to determine the couple's 
21 
 
ii.  Inability to calculate total resources.  As discussed 
supra, the MCCA requires the institutionalized spouse to provide 
to the State Medicaid agency the information required to 
determine the couple's total combined resources.  Access to such 
information often may necessitate the cooperation of the 
community spouse, for example, to disclose the resources held 
only in the community spouse's name.  The Federal statute, 
however, does not address the circumstance in which the 
institutionalized spouse is unable to provide the information 
necessary to calculate the couple's total combined resources 
because, for example, the couple is estranged, making it 
infeasible for the institutionalized spouse to secure the 
information required from the community spouse. 
 
total combined assets and (2) assigns to the State agency the 
right to spousal support.  See 42 U.S.C. § 1396r-5(c)(3).  The 
regulation appears to impose an additional requirement on an 
institutionalized spouse to show that the community spouse 
refuses to cooperate or that the community spouse's whereabouts 
are unknown.  Such an additional requirement contravenes the 
Federal statute, which must control.  See Matter of the Estate 
of Mason, 493 Mass. at 153; G. L. c. 118E, § 9 (MassHealth must 
operate "pursuant to and in conformity with [F]ederal law"). 
 
MassHealth has represented to this court that, irrespective 
of the drafting error in its regulation, it "complies with [42 
U.S.C. § 1396r-5(c)(3)(A)] in all cases."  We urge MassHealth to 
amend 130 Code Mass. Regs. § 517.011 to bring the plain language 
of subsection (A) of the regulation into compliance with Federal 
law. 
 
22 
 
To address this gap in the Federal scheme, MassHealth has 
promulgated the regulation, which provides a path to eligibility 
for an institutionalized spouse even if the couple's combined 
resources cannot be determined as required by 42 U.S.C. § 1396r–
5(c)(1) and 130 Code Mass. Regs. § 520.016(B)(2).  The 
regulation states: 
"An institutionalized spouse, whose community spouse 
refuses to cooperate or whose whereabouts is unknown, will 
not be ineligible due to . . . [the institutionalized 
spouse's] inability to provide information concerning the 
assets of the community spouse when . . . the 
institutionalized spouse assigns to the MassHealth agency 
any rights to support from the community spouse . . . ."21 
 
130 Code Mass. Regs. § 517.011(B)(1).  Thus, pursuant to the 
regulation, the institutionalized spouse is not ineligible for 
benefits by virtue of an inability to provide information 
concerning the community spouse's assets where (1) the community 
spouse "refuses to cooperate" or the community spouse's 
"whereabouts is unknown," and (2) the institutionalized spouse 
 
21 Additional conditions may trigger the exception under 130 
Code Mass. Regs. § 517.011, but are not at issue here: 
 
"(2) the institutionalized spouse lacks the ability to 
assign rights to spousal support due to physical or mental 
impairment as verified by the written statement of a 
competent medical authority; or  
 
"(3) the MassHealth agency determines that the denial of 
eligibility, due to the lack of information concerning the 
assets of the community spouse, would otherwise result in 
undue hardship." 
 
23 
 
assigns to MassHealth any rights the institutionalized spouse 
may have to seek spousal support from the community spouse.22  
Id. 
 
b.  Refusal to cooperate.  Costa contends that Mary's 
refusal to provide the financial information required to 
determine the couple's total combined resources, without more, 
satisfies the regulation's first requirement even though Mary 
and Costa were married and cohabited for decades, they shared 
financial responsibilities for payment of household expenses, 
they filed joint tax returns, Mary had Costa's power of 
attorney, and Mary continued to take care of Costa after he was 
placed in the nursing facility.  In Costa's view, the 
regulation's use of the phrase "refuses to cooperate" 
encompasses the situation here where the community spouse's 
principal act of noncooperation is her refusal to cooperate in 
providing the financial information required for MassHealth to 
determine the couple's total combined resources.  MassHealth 
contends that where, as here, the couple has a long-term and 
ongoing practice of cooperating, the isolated act of the 
 
22 It is undisputed that Costa assigned the rights to 
spousal support to MassHealth in his application, satisfying the 
second requirement of 130 Code Mass. Regs. § 517.011(B).  The 
parties' dispute centers on whether the regulation's first 
requirement was satisfied. 
24 
 
community spouse refusing to provide the required financial 
information does not satisfy the regulation's requirement. 
i.  Construction of refusal to cooperate.  To resolve the 
parties' dispute, we begin with the plain meaning of the phrase 
"refuses to cooperate."  130 Code Mass. Regs. § 517.011.  See 
Matter of the Estate of Mason, 493 Mass. at 151-152, quoting 
Harvard Crimson, Inc. v. President & Fellows of Harvard College, 
445 Mass. 745, 749 (2006) ("We construe '[a] properly 
promulgated regulation . . . in the same manner as a statute'" 
and "begin with [the] plain language").  The term "refuse" means 
"to show or express a positive unwillingness to do or comply 
with (as something asked, demanded, expected)."  Webster's Third 
New International Dictionary 1910 (2002).  The term "cooperate" 
means "to act or work with another or others to a common end" or 
"to associate with another or others for mutual . . . benefit."  
Id. at 501.  Thus, the phrase "refuses to cooperate" could 
encompass an unwillingness to collaborate on a specific task, 
including, as suggested by Costa, an isolated refusal to provide 
the requisite financial disclosure; or the phrase could refer to 
a more comprehensive unwillingness to collaborate or associate 
for mutual benefit, as MassHealth contends. 
Of course, we do not read the words of the regulation in 
isolation.  See Plymouth Retirement Bd. v. Contributory 
Retirement Appeal Bd., 483 Mass. 600, 605 (2019) ("Courts must 
25 
 
look to the . . . scheme as a whole . . . so as to produce an 
internal consistency . . . .  Even clear . . . language is not 
read in isolation" [quotations and citations omitted]).  A 
phrase "gains meaning from other[] [words] with which it is 
associated."23  Commonwealth v. Gallant, 453 Mass. 535, 542 
(2009), quoting H.J. Alperin & L.D. Shubow, Summary of Basic Law 
§ 19.10, at 846 (3d ed. 1996).  See People for the Ethical 
Treatment of Animals, Inc. v. Department of Agric. Resources, 
477 Mass. 280, 287 (2017), quoting Commonwealth v. Hamilton, 459 
Mass. 422, 432 (2011) ("ordinarily the coupling of words denotes 
an intention that they should be understood in the same general 
sense").  Accordingly, "words and phrases used in a statute [or 
regulation] should be construed by reference to their associated 
terms in the statutory context."  Morrison v. Lennett, 415 Mass. 
857, 863 (1993).  See Commonwealth v. Magnus M., 461 Mass. 459, 
462 (2012), quoting Commonwealth v. Brooks, 366 Mass. 423, 428 
(1974) (we "interpret 'words in a statute . . . in light of the 
other words surrounding them'"); Black's Law Dictionary 1274 
(11th ed. 2019) ("noscitur a sociis"; "the meaning of an unclear 
word or phrase, esp[ecially] one in a list, should be determined 
by the words immediately surrounding it"). 
 
23 This principle of construction is known as "noscitur a 
sociis," which is Latin for "it is known by its associates."  
Black's Law Dictionary 1274 (11th ed. 2019). 
26 
 
Here, the phrase "refuses to cooperate" is followed 
immediately by the phrase "or whose whereabouts is unknown."  
130 Code Mass. Regs. § 517.011.  Both phrases modify the term 
"community spouse."  Id.  The second phrase, describing a 
community spouse "whose whereabouts is unknown," invokes a 
complete breakdown of the marital relationship such that the 
institutionalized spouse lacks even the basic knowledge of the 
community spouse's location.  Construing "refuses to cooperate" 
in this context supports MassHealth and the board's construction 
that the phrase does not refer to the situation where the 
community spouse's principal act of noncooperation is failing to 
cooperate in the disclosure needed to calculate the couple's 
total combined resources for purposes of determining Medicaid 
eligibility.  Including such an isolated refusal to cooperate 
alongside the sweeping inability even to locate the community 
spouse makes little sense. 
The purpose of the Medicaid program, as well as the aim of 
the MCCA, further bolsters MassHealth and the board's 
construction of the regulation.  See Dinkins v. Massachusetts 
Parole Bd., 486 Mass. 605, 608 (2021) ("the regulation here must 
be interpreted within the context of the larger statutory 
framework").  As we have previously noted, a core purpose of the 
Medicaid program is to preserve the Commonwealth's limited 
resources for those unable to afford medical care on their own.  
27 
 
See Dermody, 491 Mass. at 226 (Medicaid amendments "have been 
attempts to ensure that Medicaid benefits go to those who need 
them rather than to those who can afford to pay").  To further 
that purpose, as discussed supra, Congress enacted the MCCA to 
close the preexisting loophole that allowed wealthy, financially 
savvy married couples to shelter their resources from the 
eligibility calculus simply by placing the resources in the 
community spouse's sole name. 
Costa's construction would undermine the MCCA's goal to 
close this loophole by creating one that is virtually identical, 
further undermining the purpose of the Medicaid program to 
preserve resources for those in most need of assistance.  
Specifically, as before the MCCA, Costa's construction of the 
regulation would allow a couple to shelter assets by placing 
them in the community spouse's name, and then simply refusing to 
provide information about those assets in connection with the 
institutionalized spouse's application for benefits.  See 
Atlanticare Med. Ctr. v. Commissioner of the Div. of Med. 
Assistance, 439 Mass. 1, 7 n.9 (2003) (rejecting interpretation 
of regulatory statute that "would render largely meaningless the 
[superseding] Federal regulation").  By contrast, MassHealth and 
the board's construction of the regulation does not risk 
unraveling the protections in the MCCA.  See Malloy v. 
Department of Correction, 487 Mass. 482, 496 (2021), quoting 
28 
 
Attorney Gen. v. School Comm. of Essex, 387 Mass. 326, 336 
(1982) ("we will not construe a [provision] such that 'the 
consequences . . . are absurd or unreasonable'").  Accordingly, 
we conclude that the board reasonably construed the scope of the 
regulation by determining that "refusal to cooperate" requires 
that a married applicant, who has a lengthy and ongoing history 
of marital collaboration, must demonstrate more than only the 
community spouse's refusal to supply the requisite financial 
information to the institutionalized spouse. 
ii.  Mary's cooperation.  Applying the agency's reasonable 
construction of the regulation, the board's determination that 
Costa has not shown that Mary "refuse[d] to cooperate" as 
required by the regulation is supported by substantial 
evidence.24  See Medical Malpractice Joint Underwriting Ass'n of 
Mass. v. Commissioner of Ins., 395 Mass. 43, 55 (1985) 
("Substantial evidence is such evidence as a reasonable mind 
might accept as adequate to support a conclusion . . . upon 
consideration of the entire record, . . . including whatever in 
 
24 The Superior Court judges and hearing officers presumed, 
and Costa does not contest, that Costa bore the burden of 
demonstrating eligibility, including Mary's noncooperation, by a 
preponderance of the evidence.  See 130 Code Mass. Regs. 
§ 610.082(B) (2019) (board's "decision must be based upon a 
preponderance of evidence"); 130 Code Mass. Regs. § 519.006 
("Institutionalized individuals may establish eligibility for 
MassHealth Standard coverage subject to the following 
requirements"). 
29 
 
the record fairly detracts from its weight" [quotations and 
citations omitted]); G. L. c. 30A, § 1 (6). 
To be sure, the record reflects that Mary kept her finances 
separate from Costa, and MassHealth does not challenge Costa's 
position that the marriage suffered strife stemming from Costa's 
gambling and financial mismanagement.  Nonetheless, the record 
also shows that the couple maintained long-standing and ongoing 
cooperation.  The couple lived together for over fifty years 
until Costa's admission to the nursing facility, and they both 
contributed to household expenses.  They eased their tax burden 
by filing taxes jointly, which inevitably requires some degree 
of financial collaboration.  After Costa moved into the long-
term care facility, Mary continued to cooperate with Costa; she 
helped coordinate his care, served as his representative under 
his power of attorney, managed his bank account, and paid his 
bills. 
On this record, the board was warranted in determining that 
Mary's refusal to disclose her financial information to 
MassHealth did not meet Costa's burden under the regulation.  
The board could conclude reasonably that such selective 
noncooperation within the context of otherwise extensive 
collaboration in other aspects of the marital relationship was 
insufficient to constitute the type of refusal to cooperate 
required by the regulation. 
30 
 
c.  Procedural due process.  Costa also challenges the 
denial of his application on the ground that the board's 
decisional process was ad hoc and arbitrary.  As delineated 
above, the first and second judges determined that MassHealth 
and the board provided insufficient notice to Costa that 
resulted in his case being twice remanded for further 
proceedings.  Nonetheless, we disagree that this circuitous 
route renders the ultimate outcome invalid. 
 
"A decision is not arbitrary and capricious unless there is 
no ground which 'reasonable [persons] might deem proper' to 
support it."  McCauley v. Superintendent, Mass. Correctional 
Inst., Norfolk, 491 Mass. 571, 598 (2023), quoting Garrity v. 
Conservation Comm'n of Hingham, 462 Mass. 779, 792 (2012).  
Here, the record does not support the claim that MassHealth and 
the board acted arbitrarily.  MassHealth and the board did not 
concoct excuses for denying Costa's application, did not rely on 
changing rationales, and did not otherwise act unreasonably.  
See Fafard v. Conservation Comm'n of Reading, 41 Mass. App. Ct. 
565, 572 (1996) (agency criteria "devised for the occasion, 
rather than of uniform applicability" is arbitrary).  Rather, 
each of the rationales for denying Costa's application related 
to MassHealth and the board's consistent position that the 
regulation requires more than merely stating that the community 
spouse has refused to divulge financial information.  To the 
31 
 
extent that Costa did not understand, during the first two 
hearings, the full scope of his burden to demonstrate Mary's 
refusal to cooperate, the misapprehension was cured by the 
subsequent hearing.  See Yebba v. Contributory Retirement Appeal 
Bd., 406 Mass. 830, 837 (1990) (improper denial of opportunity 
to litigate issue before agency was remedied by subsequent 
opportunity do so).25 
 
 
 
 
 
 
 
Judgment affirmed. 
 
25 Costa's request for appellate attorney's fees and costs 
is denied.