Opinion ID: 660676
Heading Depth: 2
Heading Rank: 2

Heading: Connecticut's Waiver Program

Text: 12 Connecticut obtained the Secretary's approval for its waiver program, CHCPE, in 1986. CHCPE is designed to provide home care for individuals who are at least 65 years of age, and who would require nursing facility care if not provided with services under the waiver. In addition to the age and medical need requirements, Connecticut's program imposes a financial eligibility standard which limits coverage to individuals who have monthly income below 300% of SSI. At the time this action was commenced, 300% of SSI was $1,266 per month. 13 In October 1990, the Secretary approved Connecticut's request for a five-year renewal of its waiver program, subject to Connecticut's agreement to limit its program to a specified number of beneficiaries: 2,938 in the first year, rising incrementally to 7,664 in the fifth year. The Secretary's approval letter recited that the waiver request, and the additional clarifying information the State provided us, conforms fully to the requirements of the statute and Medicaid regulations.C. Named Plaintiffs 14 The facts concerning the personal and family circumstances are drawn from the pleadings and are not in dispute. 15 Marion Skandalis and Raymond Rondina are Connecticut citizens over 65 years of age. Mrs. Skandalis, a widow living in her daughter's home, has a $1307 monthly income--$41 over the waiver program's income limit in effect at the time plaintiffs filed their complaint. She has had several strokes and requires laborious care and constant attention. Her family members perform the burdens of caring for her in their home, because the alternative is to place her in a nursing home. If Mrs. Skandalis actually were institutionalized, however, her income would not meet her nursing home costs and, upon spending down to the current monthly medically needy income level of $473.48, she would qualify for assistance under Connecticut's state Medicaid plan. 16 Raymond Rondina is 69 years old and lives with his wife and mother-in-law. His monthly income is $1352--$86 over the income limit in effect at the time plaintiffs filed their complaint. He has suffered a stroke, and his wife provides all necessary care for him, as well as for her mother. These demands are impairing Mrs. Rondina's own health; yet she is undertaking to do all she can to avoid placing her husband in a nursing home. If Mr. Rondina were institutionalized, his income would be insufficient to meet the costs of care, and, like Mrs. Skandalis, he would become eligible for Medicaid assistance. 17 Both Mrs. Skandalis and Mr. Rondina applied for CHCPE services. Both were rejected solely because their incomes exceeded 300% of SSI. D. Procedural History 18 Mrs. Skandalis and Mr. Rondina filed a Complaint on December 26, 1991, individually and on behalf of a putative class. Plaintiffs moved for preliminary injunctive relief, which the district court granted. The Complaint as amended alleges that the Act does not permit Connecticut to exclude persons with incomes in excess of 300% of SSI from the waiver program, because Sec. 1396a(a)(10)(A)(ii)(VI) requires CHCPE to cover all persons over 65 years of age who would be eligible for Medicaid if institutionalized, so long as CHCPE services would be less expensive than institutional nursing care. 19 The parties filed cross-motions for summary judgment. Connecticut admitted that plaintiffs were excluded from CHCPE solely because they failed to meet the program's financial eligibility test. Connecticut denied, however, that the Act requires its waiver program to include all individuals over 65 who would be eligible for Medicaid if institutionalized. The district court invited the Secretary to file a brief amicus curiae presenting her interpretation of the Act. The Secretary's amicus brief stated that nothing in the Act requires Connecticut to cover the medically needy under its waiver program, and that both the structure of the Act and its legislative history support the view that Congress intended to permit the states substantial flexibility in designing their waiver programs. E. The District Court's Opinion 20 On January 13, 1993, the district court granted plaintiffs' motion for summary judgment, 811 F.Supp. 782. As a matter of statutory interpretation, the district court concluded that the Act provides no basis for denial of participation in [CHCPE] to a group based on the manner in which they qualify for Medicaid. Although Connecticut could elect to cover or exclude from its waiver program any group listed in Sec. 1396d(a)--in particular, individuals over 65--the district court held that the state could not exclude sub-categories of persons in those groups (such as the plaintiff class of people older than 65 whose income exceeds 300% of SSI), unless specifically authorized to do so by the statute. 21 The court rejected as unreasonable Connecticut's proffered justification for its financial eligibility test. Connecticut argued that people with incomes above 300% of SSI, as compared with poorer people requiring similar levels of care, are marginally more likely to arrange for home care without financial assistance by the state. The district court found that argument untenable, given the relevant population of people potentially eligible for waivered home care. The court concluded it was unreasonable to force the class members to choose between entering a nursing home or shouldering (with their families) the unsubsidized costs and unassisted burdens of home care. Since the state agency's view (shared by the Secretary and set out in her amicus brief) was, in the district court's opinion, incompatible with the statutory language and economically counterproductive, the district court determined that the agency's view was not sufficiently reasonable, and therefore not entitled to deference. 22 Shortly after the ruling on summary judgment, the district court granted plaintiffs' motion for class certification. 23 Judgment was entered in favor of plaintiffs and the class on March 17, 1993. The judgment ordered Connecticut to begin processing applications for waiver services from class members (determining eligibility by subtracting from income the average Medicaid reimbursement rate for nursing facilities if the applicant had not been accepted at a specific facility) and to provide notice of the available services to potential applicants (including posters in nursing facilities and senior centers). The judgment also required Connecticut to file a new application with the Secretary, seeking a modification of the federal waiver that would bring the waiver into compliance with the district court's construction of the Act. 24 In compliance with the court's order, Connecticut requested an amendment to CHCPE to allow services to be provided to the members of the plaintiff class. By letter dated September 13, 1993, the Secretary informed Connecticut that its request could not be approved as submitted, but suggested three alternatives by which Connecticut might make the plaintiff class eligible to receive CHCPE services. F. The Appeal 25 On appeal, Connecticut contends that the district court erred (a) in ruling that the Act forbids Connecticut from excluding the class from its waiver program, and (b) in failing to give appropriate deference to the Secretary's interpretation of the Act. Since we reverse on those grounds, we do not address Connecticut's attack on the nature and scope of the relief afforded by the judgment, or other grounds of appeal.