Opinion ID: 1810146
Heading Depth: 2
Heading Rank: 2

Heading: Medicare's Exception for Insulin Services

Text: TLC argues it is also entitled to coverage under the Medicare exception to the intermittent requirement allowing coverage for insulin injections. Medicare provides an exception to the intermittent requirement for skilled nursing services that permits daily home health care services for insulin injections. Medicare Guide to Billing for H[ome] H[ealth] A[gencie]s, at 38 (Jan. 1, 1997). Medicare contains a blanket requirement that a patient be considered homebound to be eligible for coverage under Medicare. See 42 U.S.C. § 1395f(a)(2)(C). The Medicare insulin injection exception to intermittent care accordingly requires that a patient be declared homebound to be eligible for coverage under this exception. Iowa's Medicaid law does not provide an exception for insulin injections. TLC contends because Medicaid does not contain such an exception that it is silent on the issue; therefore, the Department must follow Medicare law and read the insulin injection exception into the Iowa Medicaid statute. We disagree and conclude Medicaid is not silent on the issue. We must determine, from the words of the statute, if the Iowa Medicaid statute precisely addresses which skilled nursing services shall be covered in the state plan. Here, we must interpret what the legislature included, as well as excluded, in the Iowa Medicaid statute. We must give meaning to all of the terms included in the statute. Federal Medicare defines Medicare coverage of services which includes an exception allowing coverage for insulin injections. This allowance for insulin injections is an exception to coverage under the Medicare intermittent services requirement. If an individual does not qualify for coverage under the intermittent requirement, he or she may apply for coverage under the insulin injection exception to this provision. The Iowa Medicaid statute also defines which services shall be covered in Iowa Administrative Code rule 441-78.9(3). This section clearly defines what constitutes covered skilled nursing services. It also provides an exception for additional daily visits beyond the allowed three-week time period for services based on the medical necessity of the service. Finally, this section concludes by clearly stating there are no other exceptions to the intermittent definition under which skilled nursing services will be provided. The language of the Iowa Medicaid statute does not speak of vague generalities but in precise terms. See Thomas Jefferson Univ., 512 U.S. at 517, 114 S.Ct. at 2389, 129 L.Ed.2d at 418. The Department was well within its discretion in interpreting this statute as to impose substantive restrictions on which services are considered covered skilled nursing services. See id. If we interpret the statute otherwise, it would allow the Department to create de facto a new exception to the intermittent requirement. Given the words of the statute, it cannot be said the Iowa Medicaid statute is silent on the issue of coverage of Medicaid services. If the legislature intended an exception for insulin injections, it would have included the exception in Iowa Administrative Code rule 441-78.9(3). However, noticeably absent from the list of covered skilled nursing services is any mention of an exception for insulin injections. [6] Generally, there is an inference that omissions are intentional. 2A Norman J. Singer, Sutherland Statutory Construction § 47.25, at 234 (5th ed. rev.vol.1992). Under the doctrine of inclusio unius est exclusio alterius, we will exclude from operation items not included in a list of elements that are given effect expressly by statutory language. Id. If the legislature intends such an exception, it is its duty, not the court's, to provide the exception in the statute. Even if the legislature intended Medicaid to contain such an exception, as TLC contends, that is not clear from the words of the statute. We cannot and will not infer such a meaning and we decline to read the Medicare insulin injection exception into the Iowa Medicaid statutes. Even assuming arguendo the Iowa Medicaid statute is silent on whether to allow an exception for insulin injections, our conclusion is still the same. TLC asserts if the state Medicaid statute is silent on whether to allow an exception for insulin injections, we must defer to the Medicare policies. As a result, TLC contends we must read the insulin injection exception into the state Medicaid statute. In support for this contention, TLC primarily relies on Iowa Administrative Code rule 441-79.9 which provides Medicare definitions and policies shall apply to services provided unless specifically defined differently.... (Emphasis added.) TLC interprets this rule based on testimony from Connie Banks, a program manager in the Division of Medical Services at the Department of Human Services. Banks stated, [I]f the administrative rules that govern the policies of the Department of Human Services addressed an issue, then that would take precedence over the Medicare,... guidelines. If the administrative rules are silent, then the Medicare guidelines would be followed. TLC misconstrued Banks' testimony and consequently incorrectly interpreted Iowa Administrative Code rule 441-79.9 to mean Medicaid must cover all of the services Medicare explicitly covers, but which are not explicitly included in the Medicaid statutes. Instead, this section means Medicare policies and definitions apply to services already explicitly provided for and covered by Medicaid. For example, if Medicare and Medicaid contain a similar policy provision, but Medicaid does not define a crucial word in the provision while Medicare provides such a definition, the Medicare definition should be applied. It does not mean all services and benefits provided by Medicare, but absent in Medicaid, must be included in Medicaid statutes. In conclusion, nothing in the statute suggests each state is required to include the insulin injection exception in its particular state Medicaid plan. This issue depends on a particular state's Medicaid coverage policy. At the time in question, Iowa had elected not to include this exception and we will not read it into the statute. The court ruled on the insulin injection exception issue, considering all of the evidence including Banks' statements, and ruled against TLC. We find there was substantial evidence for the court to make factual findings and conclusions contrary to TLC's contentions. We affirm.