Opinion ID: 2653500
Heading Depth: 2
Heading Rank: 1

Heading: Jean Brett

Text: ¶ 7. This is Jean Brett’s second appeal to this Court concerning the denial of her requests for a deduction for the cost of personal care services from her patient share obligation under the Choices program. See In re Brett , 2011 VT 28, 189 Vt. 345, 19 A.3d 154 . As we noted in the first appeal, Brett has been eligible for home-based long-term care through the Choices program since 2007. Id . ¶ 2. She is in her mid-eighties, disabled, and living with her daughter. Brett initially sought only five days a week of third-party personal care services through Choices because her daughter cared for her on weekends. From 2007 through 2009, DCF determined Brett’s patient share for five days a week of personal care services provided by Choices to be zero after deducting from her gross income, among other things, $1,451 in noncovered medical expenses for personal care services provided by her daughter the other two days. Brett’s monthly patient share increased to $45 between April and June 2009. In July 2009, DCF determined Brett’s monthly patient share to be $1,155, concluding that the cost of personal care services provided by her daughter, beyond the five days covered by Choices, could no longer be deducted as noncovered medical services as the result of DAIL’s decision that seven days of general supervision was not medically necessary. ¶ 8. Brett appealed DCF’s patient-share determination to the Human Services Board, which found that the evidence supported the medical necessity of covered personal care services seven days a week. Because Choices provided Brett with personal care services for only the five days that she had requested, the Board ordered DCF to deduct the cost of the additional two days of personal care services provided by her daughter, thereby reducing her patient share to nearly zero. The Secretary of the Agency of Human Services reversed that decision, concluding that the Board had granted relief beyond Brett’s appeal by providing personal care services for seven days when she was asking only for five days and had contravened state and federal law by deducting medical expenses that were or could be covered by Choices. The Secretary made no finding as to the medical necessity of the additional two days of care. ¶ 9. On appeal to this Court, Brett argued that the two additional days of personal care services provided by her daughter should be deducted because they were medically necessary and not covered by Choices even though Choices might have covered them if she had asked for such coverage. We rejected this argument, finding no compelling basis to overturn the Secretary’s determination that DCF correctly disallowed the deduction because Brett could have asked for and received personal care services for the additional days under the Choices program. See In re Brett , 2011 VT 28, ¶ ¶ 12-13. Concluding that the additional two days of personal care services were coverable under Vermont’s Medicaid statutes given Brett’s condition, we upheld the Secretary’s determination that costs for those services could not be deducted from her patient share. Id . ¶ 17. We noted that Brett could request seven days of personal care under the Choices program, in which case it would be up to DAIL staff to determine whether those services were medically necessary. Id . ¶ 10. We also noted Brett’s argument that her personal care services, even if listed as coverable under the Choices program, were in fact noncoverable in her case because the amount of services she required exceeded the program limits. Id . ¶ 17 n.3. We stated that until Brett requested the additional days of care, the Agency could not know how many additional hours she wanted. Id . We acknowledged that the Choices regulations established maximum hours for certain services, but noted that variances could be obtained if necessary to protect the beneficiary’s health. Id . We specifically left open “the question of whether, upon denial of a variance, those services would be considered ‘ noncovered ’ for deduction purposes.” Id . ¶ 11. That question is now before us. Following this Court’s prior ruling, DCF notified Brett that her patient share would be set at $1,353 beginning on May 1, 2011. Brett requested reconsideration and a fair hearing through DCF’s variance procedure. Meanwhile, DAIL conducted its annual assessment of Brett’s Choices service plan. Brett requested 115 hours of personal care services every two weeks, a significant increase of hours from previous requests because of her need to make up for the hours that had been provided by her daughter but for which she no longer received a deduction from her patient share. After review, DAIL denied the request for increased services, approving only 68.75 hours of personal care services for each two-week period. Brett did not appeal that decision but instead requested that DCF allow a deduction for the cost of general supervision or for the cost of 3.3 hours per day for personal care services (the difference between her request to DAIL and the services DAIL actually approved) in calculating her patient share. DCF denied the request. ¶ 12. Brett appealed to the Human Services Board, arguing in relevant part that the additional 3.3 hours of personal care services were medically necessary “ noncovered ” services because DAIL had refused to grant a variance for the additional hours. Following a hearing, the hearing officer recommended that the Board affirm DCF’s patient-share calculation. The Board adopted the proposed order, concluding that Brett did not meet the criteria for a deduction based on general supervision and that the additional requested hours could not be considered noncovered services under the Medicaid plan pursuant to our decision in Brett . The Board also noted that Brett had failed to avail herself of her right to appeal DAIL’s determination of her medical needs under the Choices program.