Opinion ID: 1899690
Heading Depth: 1
Heading Rank: 2

Heading: medicaid program

Text: Medical Assistance (Medicaid) is the principal national assistance program covering medical care. It was established in 1965 by Title XIX of the Social Security Act, 42 U.S.C.A., §§ 1396-1396d, and created a program under which participating states may provide federally-funded medical aid to needy persons. [6] Minnesota's medical assistance program is authorized by Minn.St. c. 256B and administered by the Minnesota Department of Public Welfare. The Medicaid program, as a project in cooperative federalism, is administered jointly by the Federal and individual state governments. To encourage states to provide medical coverage, Title XIX established a program whereby the Federal government would supply 50 percent to 83 percent of the funds (see, 42 U.S.C.A. § 1396d(b)) depending on state income, to participating states if they would establish plans for medical assistance which complied with the general program requirements with respect to types of persons covered, types of services offered, and the minimum conditions which health care providers must meet. The Federal medicaid statute prescribes certain categories of service which states have to cover, and permits states, at their option, to include additional services. Within these general guidelines states may define the scope, duration, and amount of services available so long as the state plan has reasonable standards    for determining    the extent of medical assistance under the plan which    are consistent with the objectives of [Title XIX]. 42 U.S.C.A., § 1396a(a)(17). Within the statutory stricture of reasonableness, however, a state has considerable discretion in forming the content of its medicaid program. With respect to persons covered, the Federal statute requires a state, if it participates, to provide recipients of Federal programs for dependent children, as well as the aged, blind, and disabled (the categorically needy) with at least the following general services (commonly known as mandatory or required services): inpatient hospital services outpatient hospital services other laboratory and X-ray services skilled nursing facility services, periodic screening and diagnosis of children, and family planning services physician's services. 42 U.S.C.A., §§ 1396a(a)(13)(B), 1396d(a)(1) to (5). In addition, the statute allowed a state, if it so desired, to include the following so-called optional services in 42 U.S.C.A., § 1396d: (6) medical care, or any other type of remedial care recognized under State law, furnished by licensed practitioners within the scope of their practice as defined by State law; (7) home health care services; (8) private duty nursing services; (9) clinic services; (10) dental services; (11) physical therapy and related services; (12) prescribed drugs, dentures, and prosthetic devices; and eyeglasses   ; (13) other diagnostic, screening, preventive and rehabilitative services; (14) inpatient hospital services, skilled nursing facility services, and intermediate care facility services for individuals 65 years of age or over in an institution for tuberculosis or mental diseases; (15) intermediate care facility services; (16)    inpatient psychiatric hospital services for individuals under age 21   ; (17) any other medical care, and any other type of remedial care recognized under State law, specified by the Secretary;    In addition, a state, if it so desired, could also provide coverage for persons who are medically needy, i. e., generally those persons whose resources are sufficient to cover ordinary living expenses, but not medical care. These are persons who would be eligible for Federally-aided financial assistance if they had less income and resources. Any service offered to the categorically needy also must be offered to the medically needy. See, 42 U.S.C.A. § 1396a(a)(10)(B). Although the Federal statute prescribes the categories of services which participating states must cover and gives states the option of adding other specified services, it does not define the extent of each service, leaving this task largely up to the states. See, 42 U.S.C.A., §§ 1396a(10), (14), (17), and 1396d(a). Thus, a state may define the scope, duration, and amount of provided services. The regulations under the Federal statute only specify the following guidelines for the state plan requirements: [Such plans must] [s]pecify the amount and/or duration of each item of medical and remedial care and services that will be provided to the categorically needy and to the medically needy, if the plan includes this latter group. Such items must be sufficient in amount, duration and scope to reasonably achieve their purpose.    Appropriate limits may be placed on services based on such criteria as medical necessity or those contained in utilization or medical review procedures. 45 C.F.R. § 249.10(a)(5)(i). Minnesota began to participate in the medicaid program in 1967 when the legislature passed the state medicaid statute, now codified as Minn.St. c. 256B. The policy of the act is stated in § 256B.01 as follows: Medical assistance for needy persons whose resources are not adequate to meet the cost of such care is hereby declared to be a matter of state concern. To provide such care, a statewide program of medical assistance, with free choice of vendor, is hereby established. The statute covers both the categorically and the medically needy (see, Minn.St. 256B.06) and medical assistance is defined in Minn.St. 256B.02, subd. 8 to include: (1) Inpatient hospital services. (2) Skilled nursing home services. (3) Physicians' services. (4) Outpatient hospital or clinic services. (5) Home health care services. (6) Private duty nursing services. (7) Physical therapy and related services. (8) Dental services. (9) Laboratory and x-ray services. (10) The following if prescribed by a licensed practitioner: drugs, eyeglasses, dentures, and prosthetic devices. (11) Diagnostic, screening, and preventive services. (12) Health care pre-payment plan premiums and insurance premiums if paid directly to a vendor and supplementary medical insurance benefits under Title XVIII of the Social Security Act. (13) Transportation costs incurred solely for obtaining medical care when paid directly to an ambulance company, common carrier, or other recognized providers of transportation services. (14) Any other medical or remedial care licensed and recognized under state law. This listing covers all general types of services, both required and elective, allowed by the Federal statute. The Minnesota medicaid statute also required the Department of Public Welfare to promulgate regulations to carry out and enforce the statute. See, Minn.St. 256B.04, subd. 2. Accordingly, the department duly enacted DPW 47 which defines more extensively the services covered under each of the general areas enumerated in the state statute and sets forth other regulations for the administration of the medical assistance program and the review of services. Of importance here are the following regulations defining the scope of various services: (m) Types of services for which medical assistance payments may be made (1) Inpatient hospital care. `Inpatient Hospital Services' are those items and service ordinarily furnished by a hospital for the care and treatment of inpatients that are provided under the direction of a physician or dentist in an institution that is maintained primarily for treatment and care of patients with disorders other than tuberculosis or mental diseases and that is licensed and formally approved as a hospital by the Minnesota Department of Health;   . Care in a licensed hospital shall be provided and paid for only when ordered by a physician and after the county has received notification of such hospitalization on the prescribed Department of Public Welfare form from the receiving facility. Such notification shall be made within three working days after admission of the patient. The county welfare agency shall appropriately respond within three working days after receipt of such notice.       (2) Outpatient hospital services. Medical Assistance payments may be made for emergency, preventive, diagnostic, therapeutic, rehabilitative, and palliative services if furnished at the outpatient department of an approved hospital.       (5) Physician servicesdental services. Medical Assistance payments may be made for all services provided by a licensed physician or licensed dentist.    Elective surgery shall always require prior authorization.          (11) Other diagnostic, screening, preventive, and rehabilitative service. Medical Assistance payments may be made for these services to eligible recipients unless unusual services are involved. When there exists a question about the propriety of the service or its costs, consultation with the appropriate medical advisory committee must be sought. Unresolved questions shall be referred to the State Agency for decision. DPW 47(m). In addition, DPW 47 established certain standards for the individual counties: (a) County Medical Assistance plan. Counties shall, with the advice and cooperation of the local or administrative area medical advisory or other provider committee, administer the Medical Assistance Program in accordance with the rules, regulations, and policies of the Minnesota Department of Public Welfare. In its administration of the Medical Assistance Program, each local agency shall provide such methods and procedures relating to the utilization review by provider of, and the payment for, medical services available under the plan as may be necessary to safeguard against abuse and/or unnecessary utilization of such care and services   . DPW 47(a). All of the portions of the Federal and state statutes and regulations quoted above were passed before the decisions of the United States Supreme Court in Roe v. Wade, 410 U.S. 113, 93 S.Ct. 705, 35 L.Ed.2d 147 (1973), and Doe v. Bolton, 410 U.S. 179, 93 S.Ct. 739, 35 L.Ed.2d 201 (1973). In Roe v. Wade the court held that a state criminal abortion law which excepted from criminality only a life-saving procedure on the mother's behalf without regard to the stage of her pregnancy violated the due process clause of the Fourteenth Amendment. The decision, by way of summary, concluded with the following directive: 1. A state criminal abortion statute of the current Texas type, that excepts from criminality only a life saving procedure on behalf of the mother, without regard to pregnancy stage and without recognition of the other interests involved, is violative of the Due Process Clause of the Fourteenth Amendment. (a) For the stage prior to approximately the end of the first trimester, the abortion decision and its effectuation must be left to the medical judgment of the pregnant woman's attending physician. (b) For the stage subsequent to approximately the end of the first trimester, the State, in promoting its interest in the health of the mother, may, if it chooses, regulate the abortion procedure in ways that are reasonably related to maternal health. (c) For the stage subsequent to viability the State, in promoting its interest in the potentiality of human life, may, if it chooses, regulate, and even proscribe, abortion except where it is necessary, in appropriate medical judgment, for the preservation of the life or health of the mother. 410 U.S. 164, 93 S.Ct. 732, 35 L.Ed.2d 183. In the companion case of Doe v. Bolton , the court held unconstitutional a Georgia statute which permitted an abortion only if one of the following conditions existed: (1) A continuation of the pregnancy would endanger the life of the pregnant woman or would seriously and permanently injure her health; or (2) The fetus would very likely be born with a grave, permanent and irremediable mental or physical defect; or (3) The pregnancy resulted from forcible or statutory rape. Ga.Code, § 26-1202 (1971). Eleven days lateron February 2, 1973this court in the companion cases of State v. Hodgson, 295 Minn. 294, 204 N.W.2d 199 (1973), and State v. Hultgren, 295 Minn. 299, 204 N.W.2d 197 (1973), followed Roe v. Wade and Doe v. Bolton and held that Minn.St. 617.18, the Minnesota criminal abortion statute, was unconstitutional. [7] In response, on February 28, 197337 days after the Federal decisions and 26 days after the state decisionsthe commissioner of Public Welfare issued the following policy bulletin: STATE OF MINNESOTA Department of Public Welfare Centennial Office Building St. Paul, Minnesota 55155 February 28, 1973 1973 Policy Bulletin # 12 To: Chairman, County Welfare Board ATTENTION: Welfare Director SUBJECT: Termination of Pregnancy Recent decisions of the United States and Minnesota Supreme Courts have projected policy on the procedures for termination of pregnancy. Such terminations, when performed by licensed providers shall be reimbursed pursuant to the Medical Assistance Program as provided for by Title XIX of the Social Security Act and Minnesota Statutes, Chapter 256B (1971). All present regulations remain in effect for those procedures related to the above insofar as eligibility, qualifications of the procedure, and payment methods are concerned. Very truly yours, /s/ VERA J. LIKINS Commissioner The plaintiff McKee argues that this policy bulletin was ineffective because it violated the notice provisions of the Minnesota APA. On the other hand, the commissioner contended initially that the funding of abortions was mandated by the United States Constitution and, alternatively, that the policy bulletin was not a rule within the meaning of the Minnesota APA. At oral argument both parties argued the constitutionality of barring the use of government funds for abortions. A ruling favorable to the state on that issue by the United States Supreme Court would have been controlling and precluded consideration of the APA issue. Subsequent to those arguments, however, the United States Supreme Court in the cases of Beal v. Doe, 432 U.S. 438, 97 S.Ct. 2366, 53 L.Ed.2d 464 (1977), and Maher v. Roe, 432 U.S. 464, 97 S.Ct. 2376, 53 L.Ed.2d 484 (1977), held (1) that the provisions of Title XIX of the Social Security Act did not require a state, as a condition of participation, to include the funding of elective abortions in its medicaid program; and (2) that the equal protection clause did not require a state that elects to fund expenses incident to childbirth also to provide funding for elective abortions. In the Beal decision, the court upheld a Pennsylvania regulation which limited financial assistance to those abortions that were certified by physicians as medically necessary. [8] In reaching its decision that Title XIX did not require a state to fund under its medicaid program the cost of all abortions that were permissible under state law, the court relied on the fact that Title XIX lacked a specific provision with respect to abortion, that the prevailing state law at the time of the passage of Title XIX in 1965 precluded the use of elective abortions, and that the agency charged with the administration of Title XIXthe Department of Health, Education, and Welfarehad taken the position that the statute allowed but did not require states to fund nontherapeutic abortions. The court emphasized, however, that Title XIX left a state free to provide coverage for nontherapeutic abortions if it so desired. Thus, the issue which this court must now consider is whether the Minnesota medicaid statute or any duly-adopted regulation of the Minnesota Department of Welfare enacted pursuant to that statute requires the funding of nontherapeutic abortions. It should be noted, however, that this case does not present any question whether the Minnesota Constitution requires the funding of nontherapeutic abortions, since the issue was not raised by the parties at trial or at oral argument before this court, or whether as a matter of statutory construction such abortions must be allowed under state welfare statutes other than the medicaid statute, such as Minn.St. c. 261 which covers the Poor Relief program. The only question raised in this case and therefore the only question before this court to be decided by it is whether the present state medicaid statute mandates the coverage of elective, nontherapeutic abortions. The language of the Minnesota medicaid statute does not make clear the status of elective, nontherapeutic abortions. The principal source of concern is subpart (m)(5) of DPW Rule 47, which provides in pertinent part that: Elective surgery shall always require prior authorization. The term elective surgery would appear to cover nontherapeutic abortions. [9] The thrust of the policy bulletin issued by the commissioner, however, as it has in effect been interpreted by the Department of Public Welfare was either to declare that abortions, whether therapeutic or nontherapeutic were not elective surgery, or to declare that such procedures automatically had prior authorization. Thus, if a source is to be found for the coverage of nontherapeutic abortions it must be in the policy bulletin issued by the commissioner. Therefore, the validity of the issuance of the bulletin itself must be considered in light of the application of the rulemaking requirements under the Minnesota APA.