Court Opinion

ID: 2687710
Source: CourtListenerOpinion
Date Created: 2014-07-31 21:43:06.493855+00
Date Added: 2024-06-11T09:48:54.413149
License: Public Domain

IN THE SUPREME COURT OF IOWA
                              No. 12–1593

                         Filed January 10, 2014

IN THE MATTER OF THE ESTATE OF ARNOLD MELBY, Deceased

IOWA DEPARTMENT OF HUMAN SERVICES,

      Appellant,

vs.

JAMES D. LOHMAN,

      Appellee.

      Appeal from the Iowa District Court for Monona County, Steven J.

Andreasen, Judge.

      The Iowa Department of Human Services appeals a district court

ruling on the department’s claim in probate for recovery of Medicaid

payments made for services provided to an elderly married couple.

REVERSED AND REMANDED.

      Thomas J. Miller, Attorney General, and Barbara E.B. Galloway

and Timothy L. Vavricek, Assistant Attorneys General, for appellant.

      Bradley J. Nelson of Norelius Nelson PC, Denison, for appellee.
                                          2

HECHT, Justice.

       The Iowa Department of Human Services appeals from a district

court ruling on the department’s claim in probate for recovery of

Medicaid payments made for services provided to an elderly married

couple.     The recipients of the services were trustors of separate

irrevocable trusts.     The district court’s ruling concluded the trustors’

interests in the trusts were limited to their right to receive the net income

from the trusts’ assets, and the department’s statutory right to recover

the Medicaid payments could be enforced against such income, but not
against the corpus of the trusts. We conclude the department’s right to

recover Medicaid payments under the facts of this case extends beyond

the trustors’ net income interests. We further conclude the district court

erred in its determination of the scope of medical assistance for which

recovery has been authorized by the general assembly. Accordingly, we

reverse and remand for further proceedings.

       I. Background Facts and Proceedings.

       Arnold and Vesta Melby (the Melbys) owned a farm in Monona

County.     In 1991, Arnold and Vesta created substantially identical

irrevocable trusts and funded the trusts with their respective one-half

interests in the farm.        The trusts named the Melbys’ son Duane as

trustee.

       The trusts contained several terms addressing administration. The

trusts were to pay net income to their respective trustors while the

trustors were living.1      Upon the death of a trustor, in the event the

trustor had no other resources available, each trust was to pay “all

        1The record reveals the trusts never reported any substantial annual income and

rarely reported any income at all.
                                              3

expenses of” its respective trustor’s “last illness and funeral,” “any

indebtedness owed by the Trustor,” and “any estate tax, gift tax,

inheritance tax or income tax owed by the Trustor.”2                 Each trust also

provided the surviving spouse net income from the decedent spouse’s

trust upon the decedent’s death.                  Then, following the deaths of both

trustors, each trust directed any remaining assets be distributed in equal

shares to the Melbys’ three children.

      In November 2000, Vesta was deemed eligible for and began

receiving Medicaid benefits. She passed away in December 2002. The
Iowa Department of Human Services (the department) later advanced

evidence it had made Medicaid payments totaling $53,118.62 on Vesta’s

behalf. Vesta’s assets at the time of her death, excluding any interest in

the corpus of her trust, totaled $661.97, and her estate was probated

without present administration.

      After Vesta’s death, Duane submitted a Medicaid Debt Response

Claim Form and information about Vesta’s trust for the department’s

review. The director of the department concluded there were no assets in

Vesta’s estate from which the department could recover the Medicaid

payments it had made on her behalf. The department advised Duane to

dispose of the trust assets as he deemed appropriate. Because Arnold

      2This   provision stated in its entirety:
      The Trustee, if there are no other resources owned by the Trustor
      available, shall pay from the trust all expenses of the last illness and
      funeral of the Trustor, any indebtedness owed by the Trustor, and any
      estate tax, gift tax, inheritance tax or income tax owed by the Trustor. If
      there are other funds available in Trustor’s estate for the payment of the
      above-noted expenses, then the Trustee shall pay these expenses from
      the trust only after the other resources in the estate of the Trustor have
      been exhausted.
                                        4

was still living, Vesta’s trust was administered to provide him with net

income in accordance with the surviving spouse provision.

      In January 2002, Arnold was deemed eligible for and began

receiving Medicaid benefits.        Arnold continued to receive Medicaid

benefits for several years, until he passed away in November 2009. The

department later advanced evidence it had made Medicaid payments

totaling $251,254.14 on Arnold’s behalf. Arnold’s assets at the time of

his death, excluding any interest in the corpus of his trust or Vesta’s

trust, totaled $2529.25.3
      Following Arnold’s death, Duane and the Melbys’ daughter Sharon

were appointed coexecutors of Arnold’s estate (the estate).                 Duane

submitted    a    new    Medicaid   Debt    Response    Claim    Form     to    the

department’s Estate Recovery Program, detailing Arnold’s assets and

expenses    and    his   trust   information.      Reviewing     Arnold’s      trust

documentation, the department concluded Arnold had an interest in his

trust beyond the net income interest from which the department could

recover the Medicaid payments it had made on his behalf.

      The department’s review of Arnold’s file also prompted a new

review of Vesta’s file. After this second review, the department concluded

it had mistakenly determined Vesta held no interest in her trust beyond

her net income interest from which the department could recover the

Medicaid payments made on her behalf.              The department therefore

notified the estate it would seek reimbursement for all Medicaid expenses

it had paid on behalf of Arnold and Vesta, in the total amount of

$321,263.96.

       3As noted above, the farm had produced very little income while held in the

Melby trusts.
                                      5

      Duane and Sharon filed a petition for probate of Arnold’s estate as

a small estate. The department filed its Medicaid recovery claim, but the

claim was denied. In December 2010, the farm was sold for $904,024

and proceeds were set aside in an amount sufficient for repayment of the

Medicaid claim if required by an order of the court. In January 2011,

Duane passed away, and Sharon was appointed as successor trustee of

both trusts. Sharon transferred the sale proceeds from Iowa to Oregon,

where she resides.4

      The department filed an application in the estate seeking a
judgment declaring the Melbys had interests in the corpus of their

trusts—in addition to the income interests—that should be counted as

assets available for repayment of the department’s Medicaid claim. The

estate filed its resistance again denying the department’s claim.          The

trustee of the Melby trusts filed a general appearance and answer joining

in the defenses asserted by the estate.

      After a bench trial on the department’s contested claim and

application in September 2011, the district court concluded the Melbys’

interests in the trusts at the time of their deaths were limited to net

income from the trusts, and thus the department’s right to recover was

limited to $3191.22. Both the department and the estate then moved to

enlarge and amend the district court’s ruling.       After considering these

motions, the district court amended its order, ruling: (1) the Medicaid

payments made on behalf of the Melbys did not constitute debts of the

Melbys under Iowa’s Medicaid recovery statute—instead, the payments

constituted debts of the Melbys’ estates; (2) the department was entitled

     4Although she continued to serve as trustee, Sharon was succeeded by James

Lohman as executor of Arnold’s estate.
                                     6

to recover from the income interests available to the Melbys at the time of

their deaths but was not entitled to recovery from the corpus of the

trusts; (3) any right of recovery for Medicaid expenses established under

the recovery statute was limited to “medical assistance” as defined in

section 249A.2(7) of the statute;         (4) the department had provided

sufficient evidence to establish the amounts it paid on behalf of the

Melbys; (5) the department had failed to demonstrate its Medicaid

payments constituted “expenses of last illness” as contemplated by the

language of the trusts given the structure of the probate debt
classification provision in Iowa Code section 633.425; (6) the court had

jurisdiction to decide the department’s claims notwithstanding the

location of the trust assets in Oregon.

      On appeal, the department asserts the district court erred in

limiting the department to recovery from the Melbys’ income interests in

the trusts.   The department contends caselaw and the language and

structure of the Medicaid recovery statute instead establish the

department’s right to recover from both the Melbys’ income interests and

the corpus of the trusts. The department also contends the district court

erred in concluding the department was limited to recovery of expenses

incurred for provision of the narrowly drawn categories of services listed

within the definition of “medical assistance” in section 249A.2(7) of the

recovery statute. The plain language of the recovery provision at issue,

the department argues, allows for a broader recovery. The estate cross-

appeals, contending      the district court erred in        determining the

department    produced    substantial     evidence   it   had   paid   medical

assistance under Iowa Code section 249A.5(2), and therefore, the district
court should have denied any recovery.
                                           7

       II. Scope of Review.

       The department’s claims in this case were tried in a probate

proceeding. Contested claims in probate are tried and reviewed at law.

Iowa Code § 633.33 (2011); see also In re Barkema Trust, 690 N.W.2d 50,

53 (Iowa 2004) (citing Iowa Code § 633.33). We review the district court’s

interpretation of statutory provisions for errors at law.              In re Estate of

Whalen, 827 N.W.2d 184, 187 (Iowa 2013).

       III. Discussion.

       A. Recovery of Medicaid Payments Under Section 249A.5. We
have previously undertaken a three-part analysis in determining whether

certain trust assets may be subject to Medicaid recovery under our

Medicaid recovery statute’s provisions. See Barkema, 690 N.W.2d at 53,

55–56; see also In re Estate of Gist, 763 N.W.2d 561, 565 (Iowa 2009).

That analysis has typically required a classification of the trust at issue,

a determination of whether the beneficiary’s interest in the trust is a type

included in the recovery statute’s definition of the recipient’s estate, and

a determination of whether that interest existed at the time of the

medical assistance recipient’s death. See Gist, 763 N.W.2d at 565.5

       1. Trust classification.      The Medicaid recovery statute defines a

Medicaid assistance recipient’s estate, for purposes of Medicaid recovery,

as including any asset “in which the recipient . . . had any legal title or

interest . . . including . . . interests in trusts.” Iowa Code § 249A.5(2)(c).

In both Barkema and Gist, we were tasked with determining the nature

        5While we have previously characterized these inquiries as constituting an

analytical framework proceeding in discrete steps and in a specific order, see In re
Estate of Gist, 763 N.W.2d 561, 565 (Iowa 2009), we think it prudent to note that,
depending on the circumstances, whether trust assets are available under the statute
for satisfaction of the department’s claim may be resolved by any of the three inquiries,
and thus the analysis need not follow the same sequence in every case.
                                           8

of a decedent Medicaid recipient’s interest in a trust.                See Gist, 763
N.W.2d at 564–65; Barkema, 690 N.W.2d at 53–55. In each case, the

decedent’s estate disputed the extent of the recipient’s interest, aiming to

prevent Medicaid recovery from the corpus of the trust. Gist, 763 N.W.2d

at 563; Barkema, 690 N.W.2d at 53. In each case, precise classification

of the trust at issue was instructive, because classification allowed us to

determine the extent to which the assets from the trusts would have

been available for the support of the beneficiaries.6 Gist, 763 N.W.2d at

565–66; Barkema, 690 N.W.2d at 55–56.                  Those determinations then
allowed us to decide whether, given the specific trust at issue, the

Medicaid recipient’s interest extended to the trust corpus for purposes of

the definition of “estate” in section 249A.5(2)(c). Id.

       The parties’ respective characterizations of the Melbys’ trusts are

not identical.     The department describes the devices as “self-settled,

irrevocable inter vivos trusts” with “spendthrift clause[s]” and “mandatory

obligation[s] to use the net income for the benefit of the respective

trustors during their lifetimes, to pay the expenses of the trustors’ last

illnesses, their funeral expenses, their debts, and certain taxes.”                 The

estate characterizes the trusts as discretionary support trusts with

standards.7         We    conclude,      however,      neither    party’s     proposed

       6We   concluded the trust instrument at issue in Barkema established a
discretionary support trust with standards. In re Barkema Trust, 690 N.W.2d 50, 55–56
(Iowa 2004). We concluded the same for the trust in Gist. Gist, 763 N.W.2d at 566.
       7The  Melbys were entitled without limitation to the net income of their trusts
during their lifetime. The trusts further provided if a beneficiary had not attained the
age of twenty-five when both of the trustors had died, the trusts would continue for
such beneficiary until he or she attained the age of twenty-five. In the interim, the
trustee was granted sole discretion to determine the distribution of income or principal,
and principal could be disbursed “only to provide for the education, health, support and
maintenance of the beneficiary.”
                                    9

classification has much bearing on our determination of whether the

recovery statute allows the department’s recovery in this case.

      In deciding whether a Medicaid recipient has an interest in a trust

extending to the trust corpus for purposes of recovery, we must

determine the extent to which the “assets of a trust are actually available

to a trust beneficiary.” Barkema, 690 N.W.2d at 55. Because the parties

agree here that regardless how the trust is classified, the Melbys had an

interest in payment of any debts they owed from the assets of the trusts,

our determination of whether the department can recover from the
corpus of the trusts will turn on whether the provision of Medicaid

assistance creates a debt owed by the recipient of the assistance under

the recovery statute. We turn to that question now.

      2. The Melbys’ interests in the trusts and section 249A.5(2)(c). As

previously noted, after reviewing the language of the recovery statute and

the language of the Melby trusts, the district court concluded the

department could recover only from the Melbys’ income interests in their

trusts. The district court acknowledged the Melbys had an interest in

the trusts for payment from both the trust income and corpus of any

“indebtedness owed,” but determined the language of section 249A.5(2)

forecloses the possibility Medicaid payments may constitute debts of

individual recipients.   In particular, the district court concluded the

statute creates a debt due the department not from the recipient of the

services, but “from the individual’s estate.” See Iowa Code § 249A.5(2)

(emphasis added).

      The parties agree the Melbys had an interest in payment of their

debts from the trusts; they dispute instead the district court’s conclusion
that the language of the recovery provision does not allow for

characterization of the medical assistance paid on behalf of the Melbys
                                    10

as debts of the Melbys as individuals. The estate contends the district

court correctly concluded the general assembly’s directive that the

provision of medical assistance “creates a debt due from the individual’s

estate” forecloses a determination that the assistance may create a

personal debt of the recipient.     The estate emphasizes the general

assembly used different language in section 249A.5(1) in making

incorrectly paid Medicaid assistance “recoverable from the provider, or

from the recipient, while living, as a debt due the state.”       See id.

§ 249A.5(1).    That language, the estate suggests, clearly makes
incorrectly paid assistance a personal debt due from an individual. The

contrasting language in section 249A.5(2), the estate argues, indicates a

clear distinction between the statutory treatment of improperly paid

assistance and properly paid assistance and indicates only the former

may constitute the debt of a recipient.

      The department dismisses the estate’s argument as unavailing

because we previously rejected a related argument in In re Estate of

Nagel, 580 N.W.2d 810 (Iowa 1998). In Nagel, we considered whether an

automobile accident victim’s estate could reach the corpus of a

decedent’s trust for payment of a wrongful death claim. Id. at 811. The

language of the trust created an interest for the decedent trustor similar

to the interest created here—namely, it required that “any indebtedness

owed by the Trustor” be paid from the assets of the trust.       Id.   The

decedent’s trustee argued the trust’s corpus could not be reached for

payment of the wrongful death claim, because the claim was not a debt

owed by the trustor—the claim arose only after the trustor’s death. Id. at

812. We rejected that argument, reasoning that even if the tort claim
had not been reduced to judgment until after the trustor’s death, the
                                           11

facts precipitating the claim had arisen during the trustor’s lifetime, and

thus the claim could constitute a debt owed by the trustor. Id.

       The department suggests our reasoning in Nagel should apply here

because the department’s payments of the Melbys’ Medicaid expenses

occurred during their lifetimes. Such payments, the department argues,

created a debt owed by the Melbys payable from the trust assets, just as

the accident in Nagel created a debt owed by the trustor.                      In Nagel,

however, we were not required to consider the effect of our Medicaid

recovery statute, because there we confronted solely the interaction of a
wrongful death claim and a decedent’s interest in a living revocable trust.

Here, by contrast, the general assembly’s enactment of the recovery

statute requires we look to the statute in determining the nature and

genesis of the debt created by the department’s payment of the Melbys’

Medicaid expenses.

       Iowa’s Medicaid recovery statute establishes that

       [t]he provision of medical assistance to an individual who is
       fifty-five years of age or older . . . creates a debt due the
       department from the individual’s estate for all medical
       assistance provided on the individual’s behalf, upon the
       individual’s death.

Iowa Code § 249A.5(2).8 The statute adds “[t]he department shall waive
the collection of the debt created under this subsection from the estate of

       8We   note at common law, a recipient of public assistance was not obligated to
reimburse the state for payments made on the recipient’s behalf. See State ex rel. Dep’t
of Human Servs. v. Brooks, 412 N.W.2d 613, 614 (Iowa 1987). The common law rule
was modified with respect to Medicaid benefits in 1994 when Iowa adopted its recovery
statute. See 1994 Iowa Acts ch. 1120, § 10 (codified at Iowa Code § 249A.5(2) (1995)).
The estate contends the statute nevertheless maintains a presumption against recovery,
relying on the first paragraph of section 249A.5, which provides “[m]edical assistance
paid to, or on behalf of, a recipient or paid to a provider of services is not recoverable,
except as provided in subsection 2, unless the assistance was incorrectly paid.” Iowa
Code § 249A.5(1) (2011). But as that language itself suggests, the language informs,
but cannot answer directly, the question of what recovery section 249A.5(2) authorizes,
which is the inquiry we must address here.
                                     12

a recipient of medical assistance” to the extent collection “would result in

. . . [r]eduction in the amount received from the recipient’s estate by a

surviving spouse . . . .” Id. § 249A.5(2)(a)(1). In the event collection of a

debt is waived under that subsection, the statute provides “the amount

waived shall be a debt due from . . . [t]he estate of the medical assistance

recipient’s surviving spouse . . . upon the death of such spouse,” to the

extent “the medical assistance recipient’s estate was received by” the

surviving spouse. Id. § 249A.5(2)(b)(1).

      At first glance, section 249A.5(2) may be read to suggest the
department’s medical assistance payments are strictly debts of the

recipient’s estate and foreclose the possibility payments create debts

owed by the recipients themselves, consistent with the interpretation of

the estate and the district court.        We note, however, the statutory

language says nothing about the timing of the creation of the debt—

instead, the language merely makes clear that medical assistance

payments will create a debt and that the debt will be due the department

from the recipient’s estate upon the recipient’s death.       See id. (“The

provision of medical assistance . . . creates a debt due the department

from the individual’s estate for all medical assistance provided on the

individual’s behalf, upon the individual’s death.”). In other words, the

statute leaves room for the possibility that either: (1) the department’s

provision of medical assistance creates a debt upon the recipient’s death,

at which point the debt is payable from the recipient’s estate; or (2) the

department’s provision of medical assistance creates a debt immediately,

and that debt will be due from the recipient’s estate upon the recipient’s

death.
      Given this ambiguity, the legislature’s use of specific language to

distinguish debt recoverable from a living recipient in section 249A.5(1)
                                    13

from debt recoverable from an estate upon a recipient’s death in section

249A.5(2) does not dispose of our inquiry here. Section 249A.5(1) merely

provides incorrectly paid assistance may be recovered from a recipient

while living or, upon the recipient’s death, recovered “as a claim

classified with taxes having preference under the laws of this state.” Id.

§ 249A.5(1). That language suggests the general assembly distinguished

the timing of recovery of incorrectly paid assistance from the timing of

recovery of correctly paid assistance, but like the language of section

249A.5(2), the language of section of 249A.5(1) makes no reference to
when, precisely, the debt for incorrectly paid medical assistance is

created.

      In previously examining section 249A.5 language having multiple

possible meanings, we have considered the language itself in the context

of the subject matter of the statute, the statute’s purpose and underlying

policies, and any consequences of adopting the dueling interpretations.

See Barkema, 690 N.W.2d at 55. The Medicaid program was designed to

serve individuals and families lacking adequate funds for basic health

services, and it was designed to be a payer of last resort. Id. In Medicaid

eligibility-determination cases, we have said the program contemplates

that families will spend available resources first, and when those

resources are completely depleted, Medicaid may provide payment. See

Strand v. Rasmussen, 648 N.W.2d 95, 106 (Iowa 2002).           In Medicaid

recovery cases, we have permitted the department’s recapture of the

value of a medical assistance recipient’s life estate after the death of the

recipient, concluding the Iowa legislature has chosen to define “estate”

for purposes of the Medicaid recovery statute more broadly than required
by federal law. See In re Estate of Laughead, 696 N.W.2d 312, 316–17

(Iowa 2005); see also In re Estate of Serovy, 711 N.W.2d 290, 294 (Iowa
                                          14

2006) (“The purpose of this legislation was to capture and make available

for payment of Medicaid-reimbursement claims certain interests in

property that are not ordinarily subject to the payment of a decedent’s

debts.”).    We have also allowed recovery from a Medicaid recipient’s

interest in a discretionary support trust following the death of the

recipient, despite the fact that any interest in the trust was to pass to a

named beneficiary upon the recipient’s death. Barkema, 690 N.W.2d at

54–56.      Recovery in these scenarios, we have explained, is consistent

with the Medicaid program’s broad purpose of providing for care for those
in need, and allowing for recovery by the state in these instances frees

more funds for provision of future services. See id. at 55 (citing Estate of

DeMartino v. Div. of Med. Assistance & Health Servs., 861 A.2d 138, 144

(N.J. Super. Ct. App. Div. 2004)); cf. Iowa Code § 249A.4(1) (requiring

director to “[d]etermine the greatest amount, duration, and scope of

assistance which may be provided . . . under this chapter within the

limitations of available funds”).

       With this broad purpose in mind, we think it prudent to resolve the

ambiguity regarding the timing of creation of medical assistance debt in

section 249A.5(2) in favor of the department’s recovery here.                       Our

interpretation creating the debt immediately upon provision of assistance

rather than at the death of the recipient, and allowing recovery from the

corpus of the trust, is consistent with the Medicaid program’s goal of

recovering from those with an ability to pay so as to make future funds

available for those having the most need.9 Cf. Laughead, 696 N.W.2d at

       9We  note several other jurisdictions dealing with estate recovery have taken a
similar approach and characterized Medicaid debt as created during the lifetime of the
recipient. See, e.g., Estate of Wood v. Ark. Dep’t of Human Servs., 894 S.W.2d 573, 576
(Ark. 1995) (explaining relationship created after enactment of Arkansas’s estate
recovery statute “was as if [the recipient] had a loan from [the department] to be repaid
                                            15

315 (“[I]t is the receipt of benefits that gives rise to the repayment

obligation.”).    This reading, providing for creation of a debt when the

medical     assistance     is   provided,     dovetails     appropriately      with    our

legislature’s very clear deviation from federal law in defining “estate”

under the recovery statute to broadly include interests available to the

recipient only during the recipient’s lifetime.             See id. at 317; see also

Iowa Code § 249A.5(2)(c) (defining “estate” for purposes of the recovery

statute as “including but not limited to interests in jointly held property,

retained life estates, and interests in trusts”).
       Moreover, immediate debt creation is consistent with the operation

of section 249A.6, which establishes that when the department makes

payment “for medical care . . . on behalf of a recipient, the department

shall have a lien, to the extent of those payments, upon all monetary

claims which the recipient may have against third parties.” Iowa Code

§ 249A.6(2). Setting forth the mechanics for the operation of this section,

section 249A.6(3) requires recipients to “notify the department of any

possible [monetary] claims when those claims arise,” suggesting the

department may have an interest in immediate pursuit of those claims.

Id. § 249A.6(3). Section 249A.6(1) requires the recipient to both “[a]ssign

to the department any rights to payments of medical care from any third

party,” and “[c]ooperate with the department in identifying and providing

________________________
from the assets of her estate”); In re Estate of Reimers, 746 N.W.2d 724, 728 (Neb. Ct.
App. 2008) (“While the debt arising under [the estate recovery] statute accrues during
the recipient’s lifetime, it is held in abeyance for payment until the recipient’s death.”);
In re Estate of Hooey, 521 N.W.2d 85, 87 (N.D. 1994) (“Although the [d]epartment’s
ability to enforce the claim was tolled until [the recipient]’s death, the obligation [to
repay] was incurred by [the recipient] during her lifetime.”); In re Estate of Burns, 928
P.2d 1094, 1099 (Wash. 1997) (“The precipitating event is, therefore, the receipt of the
benefits giving rise to the contingent indebtedness, and not the creation of the
decedent’s estate.”).
                                     16

information to assist the department in pursuing any third party who

may be liable to pay for medical care . . . ,” again suggesting immediate

debt creation. See id. § 249A.6(1)(a). And in scenarios where a recipient

incurs court costs or attorney fees for the purpose of enforcing a

monetary claim upon which the department has a section 249A.6 lien,

section 249A.6(5) provides upon receipt of the settlement or judgment,

the court costs and reasonable attorney fees shall first be deducted from

the total judgment, the recipient shall receive one-third of the remaining

total, and the department’s lien is then to be repaid from the remaining
balance.    Id. § 249A.6(5).   Although these provisions make no specific

reference to the timing of the creation of medical assistance debts, a

plain reading of each suggests the debt for provision of medical services

is created during a recipient’s lifetime, and thus section 249A.6 guides

our conclusion here.

      Two additional features of the statutory language and structure

inform our conclusion here. Section 249A.5(2) includes a comma late in

its directive, separating the clause “creates a debt due the department

from the individual’s estate for all medical assistance provided on the

individual’s behalf,” from the clause “upon the individual’s death.” Id.

§ 249A.5(2).    In the absence of the comma, we might conclude the

provision envisioned only those services provided on behalf of a recipient

in close temporal proximity to the recipient’s death would create a debt,

because the statute would then direct that provision of medical

assistance “creates a debt due the department . . . for all medical

assistance provided on the individual’s behalf upon the individual’s

death.”    That result would clearly be at odds with the purpose of the
statute—broad recovery so as to make funds available for future

provision of services—and at odds with our interpretation of the
                                     17

provision in prior caselaw. See, e.g., Laughead, 696 N.W.2d at 314, 315

(concluding decedent’s estate was liable for all Medicaid benefits paid on

decedent’s behalf over seven years, including nursing home care). The

inclusion of the comma suggests a distinction between the timing of the

provision of services and the timing of the recipient’s death, thereby

making all medical assistance provided on a recipient’s behalf—including

but not limited to those services provided at death—recoverable.         We

think it reasonable to conclude, based on the use of the comma to

distinguish the timing of the provision of services from the timing of the
recipient’s death and the inclusion of the debt creation principle in the

clause making reference to the provision of services, the statutory

language indicates the timing of the debt creation matches the timing of

the provision of services, as opposed to the timing of the recipient’s

death.

      Our interpretation of the section 249A.5(2) recovery language is

also supported, indirectly, by the mechanics of the waiver and

substitute-recovery provisions of sections 249A.5(2)(a) and 249A.5(2)(b),

mentioned above.     Section 249A.5(2)(a) provides for the department’s

temporary waiver of collection of debt from a recipient’s estate in the

event collection would result in reduction in the amount received from

the estate by a surviving spouse or a surviving child under age twenty-

one with a disability, or in the event collection would otherwise work an

undue hardship as determined on the basis of federally established

criteria. See Iowa Code § 249A.5(2)(a)(1) (allowing for waiver of collection

if collection would result in reduction of amount received by surviving

spouse or child); id. § 249A.5(2)(a)(2) (allowing for waiver of collection if
collection would work undue hardship). In the event collection is waived

under section 249A.5(2)(a), however, section 249A.5(2)(b) provides for
                                     18

reciprocal recovery from the estate of the surviving spouse upon the

spouse’s death, or from the surviving child when the child reaches age

twenty-one, or from the recipient of a hardship waiver when the hardship

no longer exists. See id. § 249A.5(2)(b)(1)–(3). Although these provisions

cannot tell us much explicitly about the genesis of the medical assistance

debt, they lend support to the conclusion the statute requires the

department regard medical assistance debts as immediately established

but also directs the department defer collection of these debts, out of

respect for the recipient and the recipient’s vulnerable kin, until a time at
which collection would work less hardship. See, e.g., id. § 249A.5(2)(b)(3)

(allowing for recovery from a hardship waiver recipient when the

hardship no longer exists); cf. Gist, 763 N.W.2d at 568 (noting our

legislature took “a more humanitarian approach” in “allowing recipients

to keep certain assets to pay for items not covered by Medicaid” and

explaining “[t]o the extent such assets are not exhausted at the time of

the recipient’s death, however, the legislature allows the State to recoup

its payments from those assets”).

      Based on the language of the recovery provision, the structure and

purpose of the statute, and our prior caselaw, we conclude section

249A.5(2) establishes a debt owed by the recipient of medical services

when the services are provided, while mandating the department will

refrain from collecting that debt until the death of the recipient.

Therefore, we conclude section 249A.5(2)(c)’s broad definition of the

estate assets from which the department may recover Medicaid payments

encompasses the Melbys’ interests in payment of their debts from the

corpus of their trusts.
      3. The Melbys’ interests at the time of their deaths. In Barkema, we

explained the department may recover its debt under the recovery statute
                                    19

from any interest in trust the recipient had at the time of the recipient’s

death.      See Barkema, 690 N.W.2d at 56; see also Iowa Code

§ 249A.5(2)(c). We concluded the statutory requirement the interest be

available “at the time of the recipient’s . . . death” meant the interest

must be available at the time immediately preceding the recipient’s

death, reasoning that any definition contemplating some later time would

render portions of the recovery statute meaningless. See Barkema, 690
N.W.2d at 56.

      Here, although the district court concluded the Melbys’ interest in
the trusts at the time of their deaths was limited to the net income of the

trust, we note the parties agree the plain language of the trust dictates

that at the time immediately preceding the deaths, the Melbys had an

interest in payment from the trusts of “any indebtedness owed by the

Trustor.”   Because we have determined the recovery statute creates a

debt immediately upon provision of services to a Medicaid recipient, we

conclude the Melbys had interests in the corpus of their trusts at the

time of their deaths from which the department may recover. Cf. Iowa

Code § 633A.2304 (“If a settlor is a beneficiary of a trust created by the

settlor, a transferee or creditor of the settlor may reach the maximum

amount that the trustee could pay to or for the settlor’s benefit.”); Gist,
763 N.W.2d at 566–67 (concluding department could recover from trust

to the extent creditors could have reached decedent’s interest in the

trust).

      B. The Meaning of “Medical Assistance” in Section 249A.5(2)

and the Sufficiency of the State’s Evidence.

      1. The meaning of “medical assistance” in section 249A.5(2). As
noted, the district court concluded the department’s right to recover

under section 249A.5(2) was limited to recovery of expenses paid in
                                    20

providing services constituting medical assistance as defined in section

249A.2(7).     Recognizing   the   general   assembly   defined   “medical

assistance,” “additional medical assistance,” and “discretionary medical

assistance” separately in section 249A.2, and observing section 249A.5(2)

refers only to recovery of “medical assistance” and “all medical

assistance,” the district court reasoned the general assembly would have

included references to additional and discretionary medical assistance in

section 249A.5(2) had the statute been designed to allow for recovery of

payment for those categories of services.
      The estate contends the district court’s reasoning was sound and

adds that “medical assistance” and “additional medical assistance” are

used elsewhere in the statute to signify that provision of certain services

would be mandatory while provision of others would be within the

discretion of the department as costs and available funds might allow.

Any reading failing to maintain the general assembly’s classification

scheme for provision of these services, the estate insists, would bankrupt

our Medicaid system.

      The department counters that the general assembly’s use of the

phrase “all medical assistance” in section 249A.5(2) signifies a departure

from the narrower meaning of “medical assistance” in section 249A.2(7)

and allows for broader recovery, including assistance provided as

“additional medical assistance” and “discretionary medical assistance.”

Further, the department argues, an evaluation of the entirety of chapter

249A reveals the general assembly rarely used the phrases “additional

medical assistance” and “discretionary medical assistance,” and instead

freely used the phrases “medical assistance” and “medical assistance
program” in contexts where their meanings might encompass provision

of “additional medical assistance” and “discretionary medical assistance.”
                                       21

The department contends the use of the phrase “all medical assistance”

in   section     249A.5(2)   constitutes   an   instance   where   the   statute

incorporates this broader meaning.

           When construing statutes, we assess not just isolated words and

phrases, but statutes in their entirety, and we avoid constructions

rendering parts of a statute redundant, irrelevant, or absurd. See Iowa

Beta Chapter of Phi Delta Theta Fraternity v. State, 763 N.W.2d 250, 260

(Iowa 2009).       Absent a statutory definition or meaning established by

law, “we give words their ordinary and common meaning by considering
the context in which they are used.”             Id.   We construe statutory

provisions in ways that best achieve a statute’s purpose. Id.

           We have previously explained Congress gave states wide latitude in

seeking Medicaid recovery and allowing recovery from the estates of

those who have received assistance furthers Medicaid’s broad purpose of

providing for medical care of the needy. See Barkema, 690 N.W.2d at 55.

We have also noted the general assembly used broad language in chapter

249A, enabling broad recovery and promoting as much care as possible

for those in need.       Id. at 55–56; cf. Gist, 763 N.W.2d at 565 (noting

section 249A.5 includes an “expansive” definition of “estate” for recovery

purposes); Serovy, 711 N.W.2d at 293 (observing the legislature’s 1994

amendment of section 249A.5 “expanded the category of assets”

reachable by the department for recovery of assistance provided to

Medicaid recipients).

           Here, the general assembly has not defined the phrase “all medical

assistance,” but it previously defined the phrase “medical assistance” to

mean “payment of all or part of the costs of the care and services
required to be provided by Tit. XIX of the federal Social Security Act

. . . .”     Iowa Code § 249A.2(7) (2011).       An isolated reading of that
                                          22

definition in conjunction with the more discretionary definition of

“additional medical assistance” might suggest, as the estate contends,

our statute duplicates without deviation the mandatory–additional–

discretionary classification scheme of the federal act in each instance a

concept involving the provision of medical services appears in our own

statute. A closer reading of section 249A.5(2) in the context of chapter

249A, however, reveals the phrase “all medical assistance” in section

249A.5(2) cannot be read as narrowly as the definition of “medical

assistance” in section 249A.2(7).10
       In examining this question, we observe chapter 249A, entitled the

“Medical Assistance Act,” id. § 249A.1, establishes the framework for the

department’s administration of Iowa’s Medicaid program—a program that

by the terms of the statute encompasses the provision of mandatory,

additional, and discretionary services and care as defined by both our

statute and the federal statute.           We think it instructive the general

assembly used the phrase “medical assistance” and not some different

phrase in titling the statute for this broad-reaching program.                    More

importantly, we note for purposes of the recovery portion of the statute, a

       10The  general assembly has recently amended the definition of “medical
assistance” in subsection 249A.2(7), largely eliminating this confusion for cases
involving provision of services going forward. The definition now provides that medical
assistance “means payment of all or part of the costs of the care and services made in
accordance with Tit. XIX of the federal Social Security Act and authorized pursuant to
this chapter.” 2013 Iowa Acts ch. 138, § 63 (to be codified at Iowa Code § 249A.2(7)
(Supp. 2013)). The definition no longer makes reference to services required under the
federal act—instead, the definition more clearly contemplates medical assistance might
encompass any services provided in accordance with the federal act, whether
mandatory or discretionary. While this new definition provides support for a broad
meaning for medical assistance in various instances in the statute including the
recovery provision, we focus our inquiry here on the previous version of the statute, as
the parties have founded their arguments on the previous version, and the previous
version was in effect both when the Medicaid services were provided and the debt was
created, and when the department attempted to recover upon Arnold’s death.
                                           23

reading of “all medical assistance” allowing for recovery of costs

expended for the provision of both mandatory and additional services is

consistent with the statutory purpose we have identified here and in our

previous cases—namely, broad recovery so as to promote the future

provision of services.       See, e.g., Barkema, 690 N.W.2d at 55; cf. Iowa

Code § 249A.4(1) (instructing director to “[d]etermine the greatest

amount, duration, and scope of assistance which may be provided, and

the broadest range of eligible individuals to whom assistance may

effectively be provided . . . within the limitations of available funds”). A
narrower reading of section 249A.5(2), allowing for recovery of only

expenses incurred in providing mandatory services, particularly in cases

where substantial additional services have also been provided, could

quickly drain the funds of the program and thereby thwart its purpose.

Absent some other indication, we do not believe the statute allows the

recovery provision to operate in that way.

       In determining the phrase “all medical assistance” encompasses

additional and discretionary assistance for recovery purposes, we are

also guided by the legislature’s use of the concepts of “assistance” and

“medical assistance” broadly, synonymously, and interchangeably in

certain contexts in chapter 249A.11              We need not catalog all those

examples here, but a few are instructive. For example, section 249A.4,

       11We  note the general assembly very clearly contrasts “medical assistance” with
“additional assistance” and “discretionary assistance” in section 249A.3, in directing the
department’s provision and allocation of services in accordance with the Federal Social
Security Act. Compare Iowa Code § 249A.3(1) (directing that “[m]edical assistance shall
be provided to” certain enumerated groups in need), with id. § 249A.3(3) (allowing the
provision of additional medical assistance “within the limits of available funds and in
accordance” with section 249A.4(1)). Despite the clear distinction in that context,
however, we must also consider the less clearly contoured use of the phrase “medical
assistance” in numerous other instances in chapter 249A.
                                    24

in establishing the duties of the department director, requires the

director consider “[t]he level of state and federal appropriations for

medical   assistance,”   to   determine    “the   method    and   level   of

reimbursement for all medical and health services referred to in section

249A.2, subsection 1 or 7.” Iowa Code § 249A.4(9). Because we believe

the statute instructs the director to consider appropriations for both

“medical assistance” and “additional medical assistance” in determining

reimbursement rates for “medical assistance” (in section 249A.2,

subsection 7) and “additional medical assistance” (in section 249A.2,
subsection 1), we conclude the statute adopts a broader meaning for

“medical assistance” in this particular provision. Accordingly, the linking

of the phrase “all medical and health services”—and the subsequent

specification that it includes both “medical assistance” and “additional

medical assistance” as defined in section 249A.2, subsections 1 and 7—

with the reference to “medical assistance” in section 249A.4(9)(c) provides

further evidence the statute in certain contexts incorporates a broader

meaning for “medical assistance” than the meaning set forth in the

narrow definition in section 249A.2(7).

      We have also observed the apparent interchangeability and broad

usage of “assistance” and “medical assistance” in section 249A.3, which

establishes Medicaid eligibility standards.       Compare id. § 249A.3(5)

(instructing that “[a]ssistance shall not be granted under this chapter to”

certain groups whose income exceeds federally prescribed limitations),

with id. § 249A.3(6) (instructing that in “determining the eligibility of an

individual for medical assistance under this chapter,” the department

should consider certain resources an individual sold or transferred for
the purpose of establishing “eligibility for medical assistance under this
                                          25

chapter”).12    The general assembly’s somewhat indiscriminate use of

“assistance” and “medical assistance” is even apparent in the language of

the recovery provision itself, as section 249A.5(1)—allowing for recovery

of incorrectly paid assistance—uses “medical assistance,” and then

simply “assistance,” in making reference to services provided to a

recipient, and in reference to those services for which recovery might be

available. See id. § 249A.5(1).

       Given the purpose of the statute, as identified in our caselaw and

in the statute itself, the structure of the statute and its often broad use
of the language at issue, and the specific context of the use of this

language in the recovery provision, we cannot conclude the phrase “all

medical assistance” should be read narrowly in section 249A.5(2) to

preclude recovery of expenses incurred for the provision of additional and

discretionary medical assistance.           We therefore conclude the district

court erred in concluding the department’s right of recovery established

in section 249A.5 was limited to recovery of medical assistance as

defined in section 249A.2(7). Instead, we conclude the use of the phrase

“all medical assistance” in this context establishes the department’s right

to recover costs incurred for all medical assistance, including additional

medical assistance, and discretionary medical assistance provided to the

Melbys during their lifetimes.

       2.   The sufficiency of the department’s evidence.             In its original

ruling declaring the department’s right to recover, the district court

        12The broad language of “under this chapter” in section 249A.3(6) by itself

suggests “medical assistance” might encompass additional assistance in this context.
See Iowa Code § 249A.3(6). That broader reading is bolstered by the unlikelihood the
statute requires the department consider certain prior resource transfers in determining
an individual’s eligibility for mandatory services but refrain from considering those
transfers in determining eligibility for additional services.
                                           26

found the department had incurred expenses for medical assistance for

the Melbys “in the amounts claimed” and had “proven the full value of its

claims under” the recovery provision.                 The estate then moved for

amendment of that ruling under rule 1.904(2), raising hearsay and

foundation objections to certain exhibits admitted at trial, and arguing

that if the exhibits were deemed inadmissible, the department had failed

to produce sufficient evidence establishing the amounts paid on behalf of

the Melbys for medical assistance. The district court enlarged its ruling

in response, noting it was overruling the evidentiary objections as it had
done at trial and concluding again the exhibits taken together

established sufficient evidence of the expenses incurred by the

department for provision of medical services to the Melbys. As noted, the

estate now argues the district court erred in finding substantial evidence

in support of any part of the department’s claims.                    The department

maintains it presented the same quantum and quality of evidence it has

presented in other Medicaid estate recovery cases.                        Further, the

department argues, the estate apparently does not dispute the amounts

expended by the department, as the estate instead focuses on whether

the department’s evidence adequately identified provision of “medical

assistance” as defined in section 249A.2(7).13

       As we have concluded the district court erred in limiting the

department’s recovery to the trustors’ net income interests and in

       13We   note the estate’s brief does not precisely state whether its challenge is
based on a contention that (1) the department’s evidence failed to distinguish between
medical assistance it paid as defined in Iowa Code section 249A.2(7) and other medical
assistance it paid not fitting within that definition, or (2) the department’s evidence
failed to establish the department’s claimed costs for provision of medical services to the
Melbys. Because we have concluded the recovery provision mandates the department’s
recovery of all medical assistance, including additional and discretionary assistance, we
conclude only the second contention is germane to the dispute here.
                                  27

concluding the department’s recovery is limited to the cost of medical

assistance as defined in Iowa Code section 249A.2(7), we must reverse

and remand this case.    Our scope of review of this appeal is at law,

dictating that findings of fact regarding the appropriate amount of the

recovery here should be made by the district court consistent with this

opinion.

      IV. Conclusion.

      For the foregoing reasons, we conclude the Melbys had interests in

the corpus of their trusts from which the department may recover
payments made for the provision of medical assistance on their behalf.

Accordingly, we reverse and remand for further proceedings consistent

with this opinion.

      REVERSED AND REMANDED.