Court Opinion

ID: 9469873
Source: CourtListenerOpinion
Date Created: 2023-08-05 02:51:05.100805+00
Date Added: 2024-06-11T17:41:36.503032
License: Public Domain

POSNER, Circuit Judge.
This appeal is from an order upholding the validity of an Indiana regulation limiting the Medicaid benefits that may be received by individuals who transfer assets in order to establish eligibility for Medicaid. The regulation provides that if a transfer for inadequate consideration was made not more than five years before the application was made, and the “uncompensated value” of the assets transferred, which is to say the difference between what they were worth and what the transferor actually received, exceeded $12,000, the transfer will be presumed to have been made for the purpose of establishing eligibility. Unless this presumption is rebutted, the applicant is ineligible to receive Medicaid benefits until he has incurred medical expenses equal to the uncompensated value of the transfer. But the period of ineligibility has a cap: two years if the uncompensated value does not exceed $12,000, five years if it does.
The regulation thus has two parts: a five-year “reach-back” provision, and a formula for determining the period of ineligibility if an improper transfer is found. Both parts are challenged in this appeal as contrary to the Boren-Long amendment, which is section 5(a) and (b) of Pub.L. 96— 611, 94 Stat. 3567 (Dec. 28, 1980).
Section 5(b) adds to 42 U.S.C. § 1396a a new subsection, (j)(l), which provides that “notwithstanding any other provision of this subchapter” a state may deny Medicaid to an otherwise eligible applicant who would not have been eligible had he not transferred assets for less than their fair market value. However, if the state wants to take up this option it must “specify a procedure . . . which ... is not more restrictive than the procedure specified in” 42 U.S.C. § 1382b(c), added by section 5(a), which requires that in determining eligibility for assistance under certain other federal welfare programs assets transferred at less than fair market value within the preceding two years must be counted among the applicant’s assets. The Indiana regulation requiring that some assets transferred at less than market value be counted even if they were transferred more than two years before the application for Medicaid was made seems inconsistent with the terms of section 1382b(c); but before concluding that it is we must consider the special status of Indiana under the Medicaid program.
When Congress expanded Medicaid eligibility in 1972, it gave the states an option to limit Medicaid assistance to people who would have been eligible under the state’s plan that was in effect on January 1 of that year. See 42 U.S.C. § 1396a(f); 42 C.F.R. § 435.121. States that have taken up this option, and Indiana is one of them, are known as “section 209(b)” states. Those that do not, that offer broader coverage, are known as “SSI” states. See Schweiker v. Gray Panthers, 453 U.S. 34, 38-39, 101 S.Ct. 2633, 2637-2638, 69 L.Ed.2d 460 (1981). The parties agree that under the Indiana Medicaid plan in force on January 1, 1972, *1215applicants who had transferred assets at any time within the preceding five years either for the purpose or with the effect of establishing eligibility for Medicaid were ineligible by virtue of Ind.Code §§ 12-1-5-1(f), 12-1-7-14.9. We therefore have to decide whether the Boren-Long amendment was intended to broaden Medicaid eligibility in 209(b) states. If so, Indiana’s five-year reach-back provision presumably would be invalid on the authority of such cases as Beltran v. Myers, 677 F.2d 1317, 1320-21 (9th Cir. 1982), dealing with similar provisions in SSI states. But if Congress’s intent was only to allow states to disqualify applicants who previously had been eligible even though they had transferred assets for less than fair market value, then Indiana’s special status as a 209(b) state, coupled with the fact that its five-year reach-back provision dates back to January 1, 1972, would make the Indiana regulation valid.
We find — in agreement with the only decision we have found that deals with the question, Randall v. Lukhard, 536 F.Supp. 723, 732-33 (W.D.Va.1982) — no indication in the language or history of the amendment that Congress wanted to broaden Medicaid eligibility in section 209(b) states. It is true that 42 U.S.C. § 1396a(j)(l) is introduced by the words “notwithstanding any other provision of this subchapter,” and the subchapter includes section 1396a(f), which created the section 209(b) exemption. But the quoted words do not introduce the “not more restrictive” provision in section 1396a(j)(l), which is in the second sentence of the section; they introduce the first sentence, the remainder of which reads, “an individual who would otherwise be eligible for medical assistance under the State plan approved under this subchapter may be denied such assistance if such individual would not be eligible for such medical assistance but for the fact that he disposed of resources for less than fair market value.” In context the introductory words just mean that notwithstanding any statutory provision that might appear to entitle an applicant to Medicaid benefits, he may be denied them if he transferred assets at less than their fair market value. In other words, the premise for applying section 1396a(j)(l), with its restriction on implementing procedures, is that some other provision in the Medicaid statute would, but for that section, entitle the applicant to benefits. If he is not entitled to benefits under any other provision because he lives in a section 209(b) state in which he would not have been eligible for benefits under the state plan in force on January 1, 1972, section 1396a(j)(l) does not come into play at all, and it therefore does not invalidate Indiana’s reach-back provision.
This interpretation of section 1396a(j)(l) is consistent with the purpose of the BorenLong amendment, which was, in the words of Senator Long, “to grant the States more flexibility.” 126 Cong.Rec. S16505 (1980). He also said that “generally, State rules could not be more restrictive than the Federal SSI rule,” id. at S16506, but in context this is a reference to the fact that the amendment empowers the states to tighten up their existing eligibility standards. Senator Long did not want to give states carte blanche to disqualify, because of transfers of assets below fair market value, people previously eligible for Medicaid benefits; but this does not mean that he wanted to enlarge the Medicaid rolls in 209(b) states.
It seems improbable that a Congress concerned — in a time of growing national concern with waste, fraud, and extravagance in government spending — with the abuse of the Medicaid program by applicants’ transferring their assets to relatives, or friends without adequate consideration in order to become eligible for Medicaid should have used a bill designed to correct this abuse as the vehicle for covertly expanding Medicaid benefits to some of those very people — and to do so in derogation of the well-established distinction in the Medicaid statute between SSI and 209(b) states. The BorenLong amendment was added to P.L. 96-611 on the floor of Congress, by voice vote, and we doubt that it would have been adopted in this fashion if it had been intended to restrict what had become the historical prerogatives of the 209(b) states. It is at least relevant to note in this connection that out *1216of the three predecessor bills to the BorenLong Amendment that failed of passage only one would have placed limitations on section 209(b) states, and it would have done so explicitly. See H.R. 7765, 96th Cong., 2d Sess. at p. 32 (1980); H.Rep.No. 1167, 96th Cong., 2d Sess. 84 (1980), U.S. Code Cong. & Admin.News 1980, p. 5526. The others, like the Boren-Long Amendment itself, are silent on the question — and their legislative history reveals an unequivocal intention not to restrict those states. See S.Rep.No.503, 96th Cong., 1st Sess. 48 (1979), U.S.Code Cong. & Admin.News 1979, p. 2672 (accompanying H.R.934); S.Rep.No. 1111, 95th Cong., 2d Sess. 25 (1980) (accompanying H.R.5285).
Also in issue on this appeal is the provision in the Indiana regulation that makes an individual who has violated the transfer-of-assets rule ineligible for Medicaid benefits until the uncompensated value of the transfer is eaten up by the cost of any medical services that were provided to him after the transfer of assets. For example, if to establish eligibility you transferred $10,000 worth of assets on December 31, 1981, but were paid only $4,000 for them, and you incurred $6,000 in medical expenses in 1982 and another $6,000 in 1983, you would not be eligible for Medicaid until 1983, since your medical expenses in 1982 would be applied to the uncompensated value of the transfer.
The state does not defend this provision on the basis of Indiana’s section 209(b) status. The provision is new, and if it is valid it is so only by virtue of 42 U.S.C. § 1396a(j)(2), also added by the Boren-Long amendment, which provides that “in any case where the uncompensated value of disposed of resources exceeds $12,000, the State plan may provide for a period of ineligibility which exceeds 24 months. If a State plan provides for a period of ineligibility [to?] exceed 24 months, such plan shall provide for the period of ineligibility to bear a reasonable relationship to such uncompensated value.” Neither the statute nor the legislative history defines the key word in this provision — “reasonable”—but the choice of the word suggests that Congress meant to give the states a broad latitude to prescribe appropriate periods of ineligibility. We cannot say that the ineligibility period in the Indiana regulation lacks a “reasonable relationship” to the uncompensated value of the underlying transfer. If a particular transfer to which the regulation applies had not been made, the uncompensated value would have been an asset of the transferor which until consumed — presumably by the medical expenses that the transferor hoped, by making the transfer, to avoid having to pay himself — would have prevented him from obtaining Medicaid benefits. The regulation thus puts the transferor in roughly the same position, so far as eligibility for Medicaid is concerned, as if he had not made the transfer.
But the regulation is said to be in conflict with another provision added by the BorenLong amendment, 42 U.S.C. § 1382b(c)(l), which provides that “in determining the resources of an individual . . . there shall be included .. . any resources ... owned by such individual . .. within the preceding 24 months if such individual ... gave away or sold such resource ... at less than fair market value .... ” (It is this provision, of course, incorporated by reference in section 1396a(j)(l), on which the plaintiffs rest their argument that Indiana’s five-year reach-back provision is unlawful.) These words imply, the plaintiffs contend, that the only permissible consequence of an improper transfer is that its uncompensated value be added to the applicant’s assets. Therefore, if his other assets had meantime been depleted, he might be eligible for Medicaid immediately. Suppose in our previous example that during 1982 the applicant’s other assets, which were just below the level at which he would be ineligible for Medicaid, declined by $6,000. Then after adding the uncompensated value of the improper transfer — $6,000—to those assets he would still not have too many assets to destroy his eligibility for Medicaid, so he could get benefits in 1982.
But if this is the correct reading of section 1382b(c)(l) it reads section 1392a(j)(2) *1217right out of the statute, by preventing states from prescribing ineligibility periods of any length. Under the plaintiffs’ view, all that a state may do to remove the consequences of an improper transfer of assets is to add the uncompensated value to the applicant’s remaining assets to determine his eligibility; if after this is done the applicant still has too few assets to be ineligible, he is entitled to benefits forthwith. The period of ineligibility is zero in his case but in no case is it within the power of the state to prescribe. It is computed automatically by adding the uncompensated value of the transfer to the applicant’s other assets; the state has no discretion to “provide for a period of ineligibility which exceeds 24 months.”
We think it unlikely that one section of the Boren-Long amendment was intended to repeal another, and do not feel driven by the language of section 1382b(c)(l) to such a weird conclusion. That section requires all states to disregard certain transfers of assets in determining eligibility for a variety of federal welfare programs including Medicaid. Section 1396a(j)(2) allows states to prescribe periods of ineligibility as a specific sanction aimed at people who transfer assets for the purpose of establishing Medicaid eligibility. In effect this section allows a state to add an additional sanction limited to Medicaid applicants. The sections are not inconsistent, and we have no warrant for disregarding the second, as the plaintiffs ask us to do.
The plaintiffs’ last contention is that the Indiana regulation fails to provide adequate guidance to- applicants and to county welfare officers regarding their respective burdens of proof under the regulation. This contention misconceives the nature of the regulation. It establishes criteria for eligibility, not rules of procedure to govern adversary proceedings.
We conclude that the Indiana regulation is valid, and therefore that the judgment of the district court must be
Affirmed.