Opinion ID: 2632913
Heading Depth: 1
Heading Rank: 5

Heading: Comparability Requirement

Text: ¶ 20 The federal Medicaid comparability requirement mandates that the medical assistance a state provides for any categorically needy individual shall not be less in amount, duration, or scope than the assistance provided to any other categorically needy individual. The relevant portion of the federal Medicaid comparability statute provides: (B) that the medical assistance made available to any individual described in subparagraph (A) (i) shall not be less in amount, duration, or scope than the medical assistance made available to any other such individual and (ii) shall not be less in amount, duration, or scope than the medical assistance made available to individuals not described in subparagraph (A); 42 U.S.C. § 1396a(a)(10). ¶ 21 The agency rule that interprets the federal Medicaid comparability statute provides: (b) The plan must provide that the services available to any individual in the following groups are equal in amount, duration, and scope for all recipients within the group: (1) The categorically needy (2) A covered medically needy group 42 C.F.R. § 440.240. ¶ 22 Courts have consistently recognized this requirement and found that states violated the comparability requirement when some recipients are treated differently from other recipients where each has the same level of need. Schott v. Olszewski, 401 F.3d 682, 688-89 (6th Cir.2005) (finding treatment was not comparable when Medicaid did not reimburse recipient for medical expenses she paid out of pocket after she was wrongfully denied coverage); White v. Beal, 555 F.2d 1146, 1151-52 (3d Cir.1977) (finding statute was illegal when it covered eyeglasses for those suffering from eye diseases but did not cover glasses for patients when refractive error caused poor eyesight). ¶ 23 Here, DSHS asks that we defer to its interpretation of the Medicaid statute's comparability provision because of its expertise in administering that law. We reject this argument because the Medicaid comparability provision is specific in demonstrating Congress' intent to provide comparable services to similarly situated recipients. 42 U.S.C. § 1396a(a)(10)(B); Martin v. Taft, 222 F.Supp.2d 940, 977 (S.D.Ohio 2002) (finding concepts of comparability and equality are neither vague nor ambiguous). Medicaid's manifest purpose is to provide for an individual recipient's needs; thus, the comparability provision requires comparable services when individuals have comparable needs. The question here is whether the three respondents were offered the same amount of medical assistance available to any other such individual. 42 U.S.C. § 1396a(a)(10)(B)(i). ¶ 24 The respondents argue that the comparability provision focuses on parity between individuals. We agree. The requirement of comparability is not merely for parity between groups as argued by DSHS. On the contrary, the plain language of the comparability statute provides that assistance made available to any other such individual . . . shall not be less [than that] made available to individuals. 42 U.S.C. § 1396a(a)(10)(B)(i), (ii). ¶ 25 Also, respondents argue that DSHS violates comparability when it allocates paid services using the presumption of the shared living rule, rather than an individualized determination of each recipient's need for paid services. In fact, DSHS has promulgated a rule where recipients like Jenkins, Gasper, and Myers will have certain needs unmet while others with comparable disabilities will receive adequate services. This is so because DSHS neither addresses nor evaluates the variation of individual situations where caregivers perform household tasks that may benefit both the recipient and the household generally. Without such an evaluation, DSHS cannot automatically reduce, in shared living situations, a recipient's need for assistance with housekeeping, shopping, meal preparation, and wood supply; rather, DSHS must assess those needs in the same way and to the same extent that services are provided to the meet the needs of other recipients who do not live in a shared living situation. Individual households may differ in both the total number of hours spent on chores and in each household member's ability to do the work, but this does not change an individual's overall need for assistance. ¶ 26 DSHS argues there is no provision of Medicaid law requiring an individualized determination of public assistance benefits and cites to Weinberger v. Salfi, 422 U.S. 749, 95 S.Ct. 2457, 45 L.Ed.2d 522 (1975) to support its contention. In Weinberger, the central issue concerned a law designed to bar social security payments to surviving spouses when the only purpose of the marriage was to obtain those benefits. The court stated that administrative difficulties of individual eligibility determinations are matters which policy makers may consider when determining whether to rely on rules which sweep broadly. Weinberger, 422 U.S. at 784-85, 95 S.Ct. 2457. ¶ 27 Weinberger is distinguishable because the present case does not deal with individuals who are attempting to qualify for federal benefits; rather, the individuals here are already eligible recipients of Medicaid. Moreover, DSHS decided on individualized determinations of public assistance benefits for this categorically needy group of Medicaid recipients; yet, DSHS's refusal to consider the individual needs of Jenkins, Gasper, and Myers for assistance with housekeeping, shopping, and meal preparation violates their right to be treated in the same manner as all other categorically needy Medicaid recipients who are individually assessed for the same needs. ¶ 28 Also, DSHS argues that the shared living rule is a valid part of their CARE assessment in determining the level of need for public assistance. We agree that DSHS may use the CARE assessment program to initially classify, rate, and determine a recipient's level of need because this process is consistent with the Medicaid program's purpose. DSHS violates the comparability requirement when it reduces a recipient's benefits based on a consideration other than the recipient's actual need. A 15 percent reduction across the board for all recipients who live with their caregivers does not address, and in fact ignores, the realities of the recipients' individual situations. ¶ 29 Neither DSHS nor the study provides any explanation of how the 15 percent amount is derived from the study's data. Furthermore, the study does not provide data to distinguish clients who are clinically complex from clients who are not. In each case before us, the evidence established that before any reduction, the hours required to provide for the needs of the individual plaintiffs greatly exceeded the hours actually reimbursed. ¶ 30 Once a person is assessed to require and receive a certain number of care hours, the assessment cannot be reduced absent a specific showing that fewer hours are required. To presume some recipients need fewer hours of care without individualized determination violates the comparability requirement. A recipient who does not live with a caregiver is assessed an amount needed for meal preparation, housekeeping, and shopping under WAC XXX-XXX-XXXX. Likewise, a recipient who does live with a caregiver should also be assessed with the same criteria for those same needs on an individualized basis. The needs of a recipient are not presumed met without an individual assessment. ¶ 31 We conclude that no reduction is justified unless an individual determination is made supporting that reclassification. Accordingly, we invalidate WAC XXX-XXX-XXXX(3)(b) to the extent that it presumes certain needs of the recipient are met without an individualized determination, and, the presumption results in an automatic 15 percent reduction in the recipient's assessed number of allotted care hours based only on the fact that the recipient lives with a caregiver.