Opinion ID: 1810146
Heading Depth: 2
Heading Rank: 1

Heading: Part-time Versus Intermittent Home Health Care Services

Text: TLC argues the Department's interpretation of Iowa's Medicaid regulations directly conflicts with federal Medicare and Medicaid statutes. Additionally, TLC contends the services provided by TLC comply with both Iowa and federal law and should be covered by the Department. Finally, TLC contends if we uphold the Department's interpretation of 42 Code of Federal Regulations section 440.70, we must invalidate Iowa Administrative Code rule 441-78.9 because it directly conflicts with federal Medicaid statutes. Because it conflicts with federal law, TLC asserts we should apply Medicare regulations and overturn the agency finding denying TLC payment under Medicaid. Before we turn to the merits of this issue, we first briefly examine the Medicaid program. The roots of Medicaid are found in federal legislation that became effective in 1967, which made grants available to the states for state-administered medical assistance programs. 42 U.S.C. §§ 1396 et seq. Medicaid is a cooperative federal-state program through which the federal government provides financial assistance to states so that they may furnish medical care to needy individuals. Madrid Home for the Aging v. Iowa Dep't of Human Servs., 557 N.W.2d 507, 511 (Iowa 1996) (citing 42 U.S.C. § 1396 (1994)); Wilder v. Virginia Hosp. Ass'n, 496 U.S. 498, 502, 110 S.Ct. 2510, 2513, 110 L.Ed.2d 455, 462 (1990). The Medicaid program was established by Congress as part of Title XIX of the Social Security Act. 42 U.S.C. §§ 1396-1696q. Medicaid is designed to provid[e] federal financial assistance to States that choose to reimburse certain costs of medical treatment for needy persons. Harris v. McRae, 448 U.S. 297, 301, 100 S.Ct. 2671, 2680, 65 L.Ed.2d 784, 794 (1980). States electing to participate in Medicaid must develop state Medicaid plans consistent with the federal Medicaid statute, regulations, and administrative rules. Id. As a condition of receipt of federal Medicaid funds, a state plan must comply with federal laws and regulations. See Madrid Home for the Aging, 557 N.W.2d at 511 (citing Wilder, 496 U.S. at 502, 110 S.Ct. at 2513, 110 L.Ed.2d at 462). To qualify for federal assistance, a state must establish a plan and submit it to the Health Care Financing Administration (HCFA) for approval. Id. Upon approval of the state plan, the federal government will reimburse the state for a percentage of the program's expenses, including administrative costs and other program-related expenses. Madrid Home for the Aging, 557 N.W.2d at 511 (citing Connecticut Hosp. Assn, v. Weicker, 46 F.3d 211, 213 (2d Cir.1995)). We now turn to the issue before us. At the heart of this issue is 42 Code of Federal Regulations section 440.70 which defines covered home health services, in part, as follows: Home Health Services. (a) Home health services means the services in paragraph (b) of this section that are provided to a recipient  (b) Home health services include the following services and items. Those listed in paragraphs (b)(1), (2), and (3) of this section are required services; those in paragraph (b)(4) of this section are optional. (1) Nursing service, as defined in the State Nurse Practice Act, that is provided on a part-time or intermittent basis by a home health agency as defined in paragraph (d) of this section, .... 42 C.F.R. § 440.70. TLC contends this section requires states to provide home health care services on both a part-time and intermittent basis. The Department maintains the phrase part-time or intermittent permits states to provide services either on a part-time or intermittent basis. Because the Department has adopted such a construction of 42 Code of Federal Regulations section 440.70, it chose to provide nursing services through home health agencies only on an intermittent basis. Iowa Administrative Code rule 441-78.9(3) provides, in part: Skilled nursing services. ... Skilled nursing services shall be available only on an intermittent basis. Intermittent services for skilled nursing services shall be defined as a medically predictable recurring need requiring a skilled nursing service at least once every 60 days, not to exceed five days per week (except as provided below), with an attempt to have a predictable end. Daily visits (six or seven days per week) that are reasonable and necessary and show an attempt to have a predictable end shall be covered for up to three weeks. Coverage for additional daily visits beyond the initial anticipated time frame may be appropriate for a short period of time, based on the medical necessity of service .... Daily skilled nursing visits which are ordered for an indefinite period of time and designated as daily skilled nursing care do not meet the intermittent definition and shall be denied. Iowa Administrative Code rule 441-78.9(3) (emphasis added). To determine whether 42 Code of Federal Regulations section 440.70 permits the states to choose the basis upon which they will provide services, we must refer to our rules of statutory construction. It is a basic rule of statutory construction that we must give effect, if possible, to every clause and word of a statute. See United States v. Menasche, 348 U.S. 528, 538-39, 75 S.Ct. 513, 520, 99 L.Ed. 615, 624 (1955) (citing Inhabitants of the Township of Montclair v. Ramsdell, 107 U.S. 147, 153, 2 S.Ct. 391, 395, 27 L.Ed. 431, 433 (1883)). Upon examination of the words of the statute, we find four elements of the statute determinative of this issue. First, section 440.70(a) begins by stating the information in the section shall define what home health services means. Then, section 440.70(b) explicitly states home health services include the following services and items. (Emphasis added.) Finally, this subsection also clearly states the services and items in paragraph (b)(1) are  required services. (Emphasis added.) Paragraph (b)(1) addresses nursing services provided on a part-time or intermittent basis. The focus of statutory construction is to give effect to the intent of Congress. We first look to the plain language of the statute to establish this intent. In doing so, we give a plain, ordinary meaning to words, phrases, and punctuation. 3 Norman J. Singer, Sutherland Statutory Construction § 72.04, at 303 (5th ed. rev. vol.1992). In general, we attribute ordinary meaning to the words of a statute, unless there is contrary congressional intent. There is a presumption that no part of an act is intended to be superfluous and all parts of a Medicare statute are read as a whole. Id. § 72.04, at 304. In general, we construe Medicaid statutes in favor of coverage for the recipient. See, e.g., Cowan v. Myers, 187 Cal.App.3d 968, 995, 232 Cal.Rptr. 299, 316 (1986), cert. denied, 484 U.S. 846, 108 S.Ct. 140, 98 L.Ed.2d 97 (1987). We now turn to the textual cues we have been given by Congress. First, Congress used the phrase home health services means. The intent behind this phrase was to restrict the definition of home health services to those things specifically stated in the statute. Second, Congress chose to use the phrase home health services include the following. The word include can enlarge the meaning of a word or it can function as a restriction. State Pub. Defender v. Iowa Dist. Ct., 633 N.W.2d 280, 283 (Iowa 2001). Where a general term is followed by the word `including,' which is itself followed by specific terms, the intent may be one of limitation. Id. Here, Congress used the word synonymously with means or comprise. There is little doubt the legislative intent was to use the word include in the sense of limiting or restricting the class of covered home health services. The statute continues on to state the services and items listed in paragraph (b)(1) are required. This obligation read together with paragraph (b)(1) provides nursing services provided on a part-time or intermittent basis are required. The final step in this analysis requires us to determine the meaning of the word or within this context. In interpreting a statute, we will not rely too heavily upon characterizations such as disjunctive or conjunctive forms to resolve difficult issues, but we will look to all parts of the statute. 2A Norman J. Singer, Sutherland Statutory Construction § 46.05, at 203 (5th ed. rev.vol. 1992). Given the words and phrases preceding or in this particular statute, we conclude or means both and is used as a word of inclusion, rather than exclusion. In this context, we will not give or disjunctive character. There is nothing in the text that makes part-time nursing services inapplicable to this statute section. Also important to our interpretation of this statute is the fact that remedial legislation, such as Medicaid, is ordinarily construed in favor of coverage for the recipient. See, e.g., Dingle v. Lam, 434 F.Supp. 1173, 1176 (D.C.Haw.1977); Cowan, 232 Cal.Rptr. at 316; Baez v. Bane, 220 A.D.2d 166, 173, 633 N.Y.S.2d 765, 769 (1995). The principal goal of Medicaid is to further the best interests of eligible recipients. Given this perspective, we may not construe this statute as providing Iowa discretion to limit the type of covered skilled nursing services. In requiring states to cover both part-time and intermittent services, the statute promotes the best interests of the recipient by covering the most appropriate care for each individual's circumstances. Thus, the statute requires the states to provide skilled nursing services to recipients. Skilled nursing services are those services provided on either a part-time or intermittent basis, as is necessary. Congress could have used a number of different words and phrases and intended the result urged by the Department. However, the four provisions discussed above are included in the statutory language and must be given meaning. Given these textual cues, it is not possible to interpret this statute in such a way as to permit the states to choose which nursing services it will provide. The statute clearly directs the states to provide both intermittent and part-time nursing services. In covering only intermittent services, the Iowa statute conflicts with the federal statute. We therefore reject the Department's implementation of 42 Code of Federal Regulations section 440.70. Since the Iowa Medicaid statute must be consistent with the Federal Medicaid statute, we invalidate only that portion of the Iowa Medicaid statute that is inconsistent with 42 Code of Federal Regulations section 440.70. We further remand with instructions that coverage be determined in accordance with the lawful interpretation of the Federal Medicaid statute requiring coverage for both part-time and intermittent services. [4] We also note that a determination of whether TLC's claims qualify for coverage under part-time skilled nursing services requires the district court on remand to determine what constitutes eight hours of skilled nursing services. [5]