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| [1] | SUPREME COURT OF THE UNITED STATES |
| [2] | No. 00-952 |
| [3] | 2002.SCT.0000033 <http://www.versuslaw.com> |
| [4] | February 20, 2002 |
| [5] | WISCONSIN DEPARTMENT OF HEALTH AND FAMILY SERVICES, PETITIONER v. IRENE BLUMER |
| [6] | SYLLABUS BY THE COURT |
| [7] | OCTOBER TERM, 2001 |
| [8] | Argued December 3, 2001 |
| [9] | In developing standards for determining Medicaid eligibility, participating
States must "tak[e] into account only such income and resources as
are, as determined in accordance with standards prescribed by the Secretary
[of Health and Human Services (Secretary)], available to the applicant."
42 U. S. C. §1396a(a)(17)(B) (emphasis added). Because spouses typically
possess assets and income jointly and bear financial responsibility for
each other, Medicaid eligibility determinations for married applicants have
resisted simple solutions. Until the Medicare Catastrophic Coverage Act
of 1988 (MCCA or Act), state standards often left a spouse living at home
(called the "community spouse") destitute, the couple's assets
drained to qualify his or her mate (the "institutionalized spouse")
for Medicaid, and the couple's posteligibility income diminished to reduce
the amount payable by Medicaid for institutional care. The MCCA's "spousal
impoverishment" provisions responded to this problem by including in
the Medicaid statute requirements with which States must comply in allocating
a couple's income and resources. The Act's income allocation rules direct
that, in any month in which one spouse is institutionalized, "no income
of the community spouse shall be deemed available to the institutionalized
spouse," §1396r-5(b)(1); require States to set for the community spouse
a "minimum monthly maintenance needs allowance" (MMMNA), §1396r-5(d)(3);
and prescribe that, if the community spouse's posteligibility income is
insufficient to yield income equal to or above the MMMNA, the shortfall
-- called the "community spouse monthly income allowance" (CSMIA)
-- may be deducted from the institutionalized spouse's income and paid to
the community spouse, §1396r-5(d)(1)(B). The MCCA's resource allocation
rules provide, inter alia, that, in determining the institutionalized spouse's
Medicaid eligibility, a portion of the couple's resources -- called the
"community spouse resource allowance" (CSRA) -- shall be reserved
for the benefit of the community spouse, §1396r-5(c)(2). To calculate the
CSRA, the couple's jointly and separately owned resources are added together
as of the time the institutionalized spouse's institutionalization commenced;
half of that total, subject to certain limits, is then allocated to the
community spouse, §§1396r-5(c)(1)(A), (2)(B), (f)(2)(A), (g). The CSRA is
deemed unavailable to the institutionalized spouse in the eligibility determination,
but all resources above the CSRA (excluding a $2,000 personal allowance
reserved for the institutionalized spouse under federal regulations) must
be spent before eligibility can be achieved, §1396r-5(c)(2). Section 1396r-5(e)(2)(C)
provides a "fair hearing" mechanism through which a couple may
obtain a higher CSRA by establishing that the standard CSRA (in relation
to the amount of income it generates) is inadequate to raise "the community
spouse's income" to the MMMNA. The States have employed two methods
for making this determination; the two methods differ in their construction
of the subsection (e)(2)(C) term "community spouse's income."
Under the "income-first" method used by most States, "community
spouse's income" includes not only the community spouse's actual income
at the time of the eligibility hearing, but also an anticipated posteligibility
CSMIA authorized by §1396r-5(d)(1)(B). The income-first method, because
it takes account of the potential CSMIA, makes it less likely that the CSRA
will be increased; it therefore tends to require couples to expend additional
resources before the institutionalized spouse becomes Medicaid eligible.
In contrast, the "resources-first" method employed in the remaining
States excludes the CSMIA from consideration. The Secretary has circulated
for comment a proposed rule allowing States the threshold choice of using
either the income-first or resources-first method. |
| [10] | After entering a Wisconsin nursing home, respondent Irene Blumer applied
for Medicaid through her husband Burnett. The Green County Department of
Human Services (County) determined that the Blumers could retain $74,822
in assets -- $72,822 as Burnett's standard CSRA and $2,000 as Irene's personal
allowance. The County next found that, as of the date of Irene's application,
the couple possessed resources exceeding their $74,822 limit by $14,513.
The County accordingly concluded that Irene would not be eligible for Medicaid
until the couple's spending reduced their resources by the $14,531 amount.
Irene sought a hearing to obtain a higher CSRA, arguing that, because Burnett's
monthly income ($1,639) fell below the applicable MMMNA ($1,727), the hearing
examiner was obliged to increase Burnett's CSRA. Because a Wisconsin statute
adopts the income-first rule, the examiner concluded that he lacked authority
to increase Burnett's CSRA: The difference between Burnett's posteligibility
income and the MMMNA could be erased if, after achieving eligibility, Irene
transferred to Burnett, as a CSMIA, a portion of her monthly income. Because
Irene's posteligibility income would be sufficient to allow the transfer,
the examiner found no reason to reserve additional assets for Burnett and,
consequently, no cause for advancing Irene's Medicaid eligibility. The Circuit
Court affirmed, but the Wisconsin Court of Appeals reversed, concluding
that the State's income-first statute conflicts with the MCCA, which, the
appeals court held, unambiguously mandates the resources-first method. |
| [11] | Held: The income-first method qualifies as a permissible interpretation
of the MCCA. Pp. 13-21. |
| [12] | (a) Neither §1396r-5(e)(2)(C)'s text nor the MCCA's structure forbids
Wisconsin's approach. This case turns on whether the words "community
spouse's income" in §1396r-5(e)(2)(C) may be interpreted to include
potential, posteligibility transfers of income from the institutionalized
spouse permitted by §1396r-5(d)(1)(B). According to Blumer, the plain meaning
of "community spouse's income" precludes such inclusion; by choosing
the possessive modifier "community spouse's," Blumer maintains,
Congress clearly expressed its intent that only income actually possessed
by the community spouse at the time of the hearing may count in the calculation.
The Court rejects this argument. Use of the possessive case does not demand
construction of the quoted phrase to mean only income actually possessed
by, rather than available or attributable to, the community spouse; to the
contrary, use of the possessive is often indeterminate. Cf., e.g., Smiley
v. Citibank (South Dakota), N. A., 517 U. S. 735, 739. The Court finds similarly
unpersuasive Blumer's argument that the Act's design as a whole precludes
use of the income-first method. In this regard, Blumer contends that, because
the (e)(2)(C) hearing to obtain an enhanced CSRA occurs at the time an eligibility
assessment is conducted, while no CSMIA income may be transferred until
after eligibility has been achieved, the Wisconsin statute reverses the
priority ordered by the MCCA. The Court disagrees with Blumer's conclusion:
The (e)(2)(C) hearing is properly comprehended as a preeligibility projection
of the couple's posteligibility financial situation; it is not unreasonable
for a State to include in its estimation of the "community spouse's
income" in that posteligibility period an income transfer the law permits
at that time. The same misunderstanding of the (e)(2)(C) hearing also underlies
the contention that the income-first method renders meaningless §1396r-5(b)(1)'s
key prohibition against deeming income of the community spouse available
to the institutionalized spouse. This argument confuses the inclusion of
an anticipated CSMIA in the preeligibility calculation of the community
spouse's posteligibility income with the actual transfer of income permitted
by the CSMIA provision. Far from precluding Wisconsin's approach, the MCCA's
design offers affirmative support for the income-first method. Subsection
(b)(1) has no counterpart prohibiting attribution of the institutionalized
spouse's income to the community spouse. Indeed, §1396r-5(d)(1)(B) specifically
permits a transfer of income from the institutionalized spouse to the community
spouse through the CSMIA. Mindful that spouses may be expected to support
each other, see, e.g., Schweiker v. Gray Panthers, 453 U. S. 34, 45, the
Court is satisfied that a State reasonably interprets the MCCA by anticipating
the CSMIA in the (e)(2)(C) hearing. This conclusion is bolstered by a further
consideration: A fair hearing is not limited to a CSRA redetermination,
but may also be used to adjust the CSMIA itself, §1396r-5(e)(2)(A)(i); therefore,
it cannot be concluded that the States are barred from taking account of
the potential CSMIA in the hearing to increase the CSRA. Pp. 13-18. |
| [13] | (b) Because the parties have not also disputed the permissibility of the
resources-first approach, this Court does not definitively resolve that
matter. The Court notes, however, that the leeway for state choices urged
by Wisconsin and the United States is characteristic of the Medicaid statute,
which is designed to advance cooperative federalism. See Harris v. McRae,
448 U. S. 297, 308. When interpreting other statutes so structured, the
Court has left a range of permissible choices to the States, at least where
the superintending federal agency has concluded that such latitude is consistent
with the statute's aims. See, e.g., Batterton v. Francis, 432 U. S. 416,
429-431. The Secretary, who possesses authority to prescribe standards relevant
here, §1396a(a)(17), has proposed a rule explicitly recognizing that the
MCCA permits both the income-first and resources-first methods. That position
statement warrants respectful consideration. Cf., e.g., Gray Panthers, 453
U. S., at 43-44. The MCCA affords the States large discretion regarding
two related variables: the level of the MMMNA, §1396r-5(d)(3), and the amount
of assets the couple is permitted to retain, §1396r-5(f)(2)(A). Nothing
in the Act indicates that similar latitude is inappropriate with respect
to the application of §1396r-5(e)(2)(C). Eliminating a State's discretion
to choose income-first would hinder the State's efforts to strike its own
balance in implementing the Act. Lukhard v. Reed, 481 U. S. 368, 383. States
that currently allocate limited funds through income-first would have little
choice but to offset the greater expense of the resources-first method by
reducing the MMMNA or the standard CSRA. That would benefit the relatively
few applicant couples who possess significant resources, while offering
nothing to, and perhaps disadvantaging, couples who lack substantial assets.
Nothing in the Act contradicts the Secretary's conclusion that such a result
is unnecessary and unwarranted. Pp. 18-21. |
| [14] | 2000 WI App. 150, 237 Wis. 2d 810, 615 N. W. 2d 647, reversed and remanded. |
| [15] | Ginsburg, J., delivered the opinion of the Court, in which Rehnquist,
C. J., and Kennedy, Souter, Thomas, and Breyer, JJ., joined. Stevens, J.,
filed a dissenting opinion, in which O'Connor and Scalia, JJ., joined. |
| [16] | Court Below: 2000 WI App. 150, 237 Wis. 2d 810, 615 N. W. 2d 647 |
| [17] | The opinion of the court was delivered by: Justice Ginsburg |
| [18] | 534 U. S. ____ (2002) |
| [19] | On Writ Of Certiorari To The Court Of Appeals Of Wisconsin, District Iv |
| [20] | This case requires interpretation of the "spousal impoverishment"
provisions of the Medicare Catastrophic Coverage Act of 1988 (MCCA or Act),
102 Stat. 754, 42 U. S. C. §1396r-5 (1994 ed. and Supp. V), a complex set
of instructions made part of the federal Medicaid statute. The spousal impoverishment
provisions permit a spouse living at home (called the "community spouse")
to reserve certain income and assets to meet the minimum monthly maintenance
needs he or she will have when the other spouse (the "institutionalized
spouse") is institutionalized, usually in a nursing home, and becomes
eligible for Medicaid. |
| [21] | The Act shelters from diminution a standard amount of assets (called the
"community spouse resource allowance," "CSRA," or "resource
allowance"). The MCCA allows an increase in the standard allowance
if either spouse shows, at a state-administered hearing, that the community
spouse will not be able to maintain the statutorily defined minimum level
of income on which to live after the institutionalized spouse gains Medicaid
eligibility. |
| [22] | In determining whether the community spouse is entitled to a higher CSRA,
i.e., to shelter assets in excess of the standard resource allowance, Wisconsin,
like a majority of other States, uses an "income-first" method.
Under that method, the State considers first whether potential income transfers
from the institutionalized spouse, which the MCCA expressly permits, will
suffice to enable the community spouse to meet monthly needs once the institutionalized
spouse qualifies for Medicaid. |
| [23] | Respondent Irene Blumer, whose Medicaid eligibility was delayed by the
application of petitioner Wisconsin Department of Health and Family Services'
income-first method, challenges that method as inconsistent with the MCCA
provision governing upward revision of the community spouse resource allowance,
§1396r-5(e)(2)(C) (1994 ed.). The Wisconsin Court of Appeals upheld her
challenge. We reverse that court's judgment. Neither the text of §1396r-5(e)(2)(C)
nor the structure of the MCCA, we conclude, forbids Wisconsin's chosen approach.
Consistent with the position adopted by the Secretary of Health and Human
Services, we hold that the income-first method represents a permissible
interpretation of the Act. |
| [24] | I. |
| [25] | A. |
| [26] | The federal Medicaid program provides funding to States that reimburse
needy persons for the cost of medical care. See Social Security Act, tit.
XIX, as added, 79 Stat. 343, and as amended, 42 U. S. C. §1396 et seq. "Each
participating State develops a plan containing reasonable standards ...
for determining eligibility for and the extent of medical assistance"
within boundaries set by the Medicaid statute and the Secretary of Health
and Human Services. Schweiker v. Gray Panthers, 453 U. S. 34, 36-37 (1981)
(internal quotation marks omitted); §1396a(a)(17).*fn1
In formulating those standards, States must "provide for taking into
account only such income and resources as are, as determined in accordance
with standards prescribed by the Secretary, available to the applicant."
§1396a(a)(17)(B) (emphasis added). |
| [27] | Because spouses typically possess assets and income jointly and bear financial
responsibility for each other, Medicaid eligibility determinations for married
applicants have resisted simple solutions. See, e.g., id., at 44-48. Until
1989, the year the MCCA took effect, States generally considered the income
of either spouse to be "available" to the other. We upheld this
approach in Gray Panthers, observing that "from the beginning of the
Medicaid program, Congress authorized States to presume spousal support."
Id., at 44; see id., at 45 (quoting passage from S. Rep. No. 404, 89th Cong.,
1st Sess., pt. 1, p. 78 (1965), including statement that "it is proper
to expect spouses to support each other"). Similarly, assets held jointly
by the couple were commonly deemed "available" in full to the
institutionalized spouse. |
| [28] | At the same time, States generally did not treat resources held individually
by the community spouse as available to the institutionalized spouse. Accordingly,
assets titled solely in the name of the community spouse often escaped consideration
in determining the institutionalized spouse's Medicaid eligibility. See
H. R. Rep. No. 100-105, pt. 2, pp. 66-67 (1987). |
| [29] | As Congress later found when it enacted the MCCA in 1988, these existing
practices for determining a married applicant's income and resources produced
unintended consequences. Many community spouses were left destitute by the
drain on the couple's assets necessary to qualify the institutionalized
spouse for Medicaid and by the diminution of the couple's income posteligibility
to reduce the amount payable by Medicaid for institutional care. See id.,
at 66-68. Conversely, couples with ample means could qualify for assistance
when their assets were held solely in the community spouse's name. |
| [30] | In the MCCA, Congress sought to protect community spouses from "pauperization"
while preventing financially secure couples from obtaining Medicaid assistance.
See id., at 65 (bill seeks to "end th[e] pauperization" of the
community spouse "by assuring that the community spouse has a sufficient
-- but not excessive -- amount of income and resources available").
To achieve this aim, Congress installed a set of intricate and interlocking
requirements with which States must comply in allocating a couple's income
and resources. |
| [31] | Income allocation is governed by §§1396r-5(b) and (d). Covering any month
in which "an institutionalized spouse is in the institution,"
§1396r-5(b)(1) provides that "no income of the community spouse shall
be deemed available to the institutionalized spouse." The community
spouse's income is thus preserved for that spouse and does not affect the
determination whether the institutionalized spouse qualifies for Medicaid.
In general, such income is also disregarded in calculating the amount Medicaid
will pay for the institutionalized spouse's care after eligibility is established. |
| [32] | Other provisions specifically address income allocation in the period
after the institutionalized spouse becomes Medicaid eligible. Section 1396r-5(b)(2)(A)
prescribes, as a main rule, that if payment of income is made solely in
the name of one spouse, that income is treated as available only to the
named spouse (the "name-on-the-check" rule). Section 1396r-5(d)
provides a number of exceptions to that main rule designed to ensure that
the community spouse and other dependents have income sufficient to meet
basic needs. Among the exceptions, §§1396r-5(d)(3) establishes for the community
spouse a "minimum monthly maintenance needs allowance," or MMMNA.
The MMMNA is calculated by multiplying the federal poverty level for a couple
by a percentage set by the State. Since 1992, that percentage must be at
least 150%, §§1396r-5(d)(3)(A)-(B), but the resulting MMMNA may not exceed
$1,500 per month in 1988 dollars ($2,175 in 2001 dollars), §§1396r-5(d)(3)(C),
(g).*fn2 |
| [33] | If the income of the community spouse determined under §1396r-5(b)(2),
which states the "name-on-the-check" rule, is insufficient to
yield income equal to or above the MMMNA, §1396r-5(d)(1)(B) comes into play.
Under that provision, the amount of the shortfall is "deducted"
from the income of the institutionalized spouse -- reducing the amount of
income that would otherwise be considered available for the institutionalized
spouse's care -- so long as that income is actually made available to the
community spouse. The amount thus reallocated from the institutionalized
spouse to the community spouse is called the "community spouse monthly
income allowance," or CSMIA, §1396r-5(d)(1)(B). The provision for this
allowance ensures that income transferred from the institutionalized spouse
to the community spouse to meet the latter's basic needs is not also considered
available for the former's care. As a result, Medicaid will pay a greater
portion of the institutionalized spouse's medical expenses than it would
absent the CSMIA provision. |
| [34] | Resource allocation is controlled by §§1396r-5(c) and (f).*fn3
For purposes of establishing the institutionalized spouse's Medicaid eligibility,*fn4
a portion of the couple's assets is reserved for the benefit of the community
spouse. §1396r-5(c)(2). To determine that reserved amount (the CSRA), the
total of all of the couple's resources (whether owned jointly or separately)
is calculated as of the time the institutionalized spouse's institutionalization
commenced; half of that total is then allocated to each spouse (the "spousal
share"). §1396r-5(c)(1)(A). The spousal share allocated to the community
spouse qualifies as the CSRA, subject to a ceiling of $60,000 indexed for
inflation (in 2001, the ceiling was $87,000) and a floor, set by the State,
between $12,000 and $60,000 (also indexed for inflation; in 2001, the amounts
were $17,400 and $87,000). §§1396r-5(c)(2)(B), (f)(2)(A), (g).*fn5
The CSRA is considered unavailable to the institutionalized spouse in the
eligibility determination, but all resources above the CSRA (excluding a
small sum set aside as a personal allowance for the institutionalized spouse,
currently $2,000, see 20 CFR §416.1205 (2001)) must be spent before eligibility
can be achieved. §1396r-5(c)(2). |
| [35] | The MCCA provides for a "fair hearing" mechanism through which
a couple may challenge the State's determination of a number of elements
that affect eligibility for, or the extent of assistance provided under
Medicaid. §§1396r-5(e). The dispute in this case centers on §1396r-5(e)(2)(C),
which allows a couple to request a higher CSRA. That section provides in
relevant part: |
| [36] | "If either ... spouse establishes that the [CSRA] (in relation to
the amount of income generated by such an allowance) is inadequate to raise
the community spouse's income to the [MMMNA], there shall be substituted,
for the [CSRA] under subsection (f)(2) of this section, an amount adequate
to provide [the MMMNA]." §1396r-5(e)(2)(C). |
| [37] | If the couple succeeds in obtaining a higher CSRA, the institutionalized
spouse may reserve additional resources for posteligibility transfer to
the community spouse. The enhanced CSRA will reduce the resources the statute
deems available for the payment of medical expenses; accordingly, the institutionalized
spouse will become eligible for Medicaid sooner. |
| [38] | In allocating income and resources between spouses for purposes of §1396r-5(e)(2)(C),
the States have employed two divergent methods: an "income-first"
method, used by most States; and a "resources-first" method, preferred
by the others. The two methods differ in their construction of the term
"community spouse's income" in subsection (e)(2)(C). Under the
income-first method, "community spouse's income" is defined to
include not only the community spouse's actual income at the time of the
§1396r-5(e) fair hearing, but also a potential posteligibility income transfer
from the institutionalized spouse -- the CSMIA authorized by §1396(d)(1)(B),
see supra, at 5-6. Thus, only if the community spouse's preeligibility income
plus the CSMIA will fall below the MMMNA may the couple reserve a greater
portion of assets through an enhanced CSRA. |
| [39] | The resources-first method, by contrast, excludes the CSMIA from consideration.
"Community spouse's income" under that approach includes only
income actually received by the community spouse at the time of the §1396r-5(e)
hearing, not any anticipated posteligibility income transfer from the institutionalized
spouse pursuant to §1396r-5(d)(1)(B). If the community spouse's income so
defined will fall below the MMMNA, the CSRA will be raised to reserve additional
assets sufficient to generate income meeting the shortfall, whether or not
the CSMIA could also accomplish that task. |
| [40] | In sum, the income-first method, because it takes account of the potential
CSMIA, makes it less likely that the CSRA will be increased; it therefore
tends to require couples to expend additional resources before the institutionalized
spouse becomes Medicaid eligible. |
| [41] | The Secretary of Health and Human Services has issued several statements
supporting the income-first method. Initially, the Secretary interpreted
the MCCA as requiring state hearing officers to use that method. See HCFA,
Chicago Regional State Letter No. 51-93 (Dec. 1993), App. to Pet. for Cert.
78a-83a. More recently, the Secretary has concluded that the Act permits
both income-first and "some other reasonable interpretation of the
law." HCFA, Chicago Regional State Letter No. 22-94, p. 2 (July 1994),
App. to Pet. for Cert. 89a. |
| [42] | The Secretary has circulated for comment a proposed rule "allow[ing]
States the threshold choice of using either the income-first or resources-first
method when determining whether the community spouse has sufficient income
to meet minimum monthly maintenance needs." 66 Fed. Reg. 46763, 46765
(2001). The proposed rule details the Secretary's reasons for concluding
that the Act does not "clearly requir[e] the use of either [method]
to the exclusion of the other." Id., at 46767. Accordingly, "in
view of the cooperative federalism considerations embodied in the Medicaid
program," id., at 46765, the Secretary found it appropriate to "leave
to States the decision as to which alternative to use," id., at 46767.*fn6 |
| [43] | B. |
| [44] | The facts of this case illustrate the operation of the Act and the different
consequences of the income-first and resources-first approaches. Irene Blumer
was admitted to a Wisconsin nursing home in 1994 and applied for Medicaid
assistance in 1996 through her husband Burnett. In accord with §1396r-5(c),
the Green County Department of Human Services (County) determined that as
of Irene's institutionalization in 1994, the couple's resources amounted
to $145,644. Dividing this amount evenly between the Blumers, the County
attributed $72,822 to each spouse. Burnett was allocated this $72,822 share
as his CSRA,*fn7 and Irene was entitled
to reserve a personal allowance of $2,000, 20 CFR §416.1205 (2001). Combining
these sums, the County determined that the Blumers could retain $74,822
in assets. |
| [45] | The County next found that, as of the date of Irene's application, the
Blumers' resources had been reduced from $145,644 to $89,335. That amount
exceeded by $14,513 the couple's resource eligibility threshold. The County
accordingly concluded that Irene would not be eligible for Medicaid until
the couple's assets were spent down to the $74,822 limit. |
| [46] | Seeking to obtain a higher CSRA, Irene requested a hearing. For purposes
of the hearing, Burnett's monthly income amounted to $1,639, consisting
of $1,015 in Social Security benefits, $309 from an annuity, and $315 generated
by the assets protected in his CSRA.*fn8
Irene argued that because Burnett's monthly income fell below the applicable
MMMNA of $1,727, the examiner was obliged to increase his CSRA, thereby
protecting additional assets capable of covering the income shortfall. |
| [47] | Excluding Irene's $2,000 personal allowance, the Blumers' total remaining
assets exceeded Burnett's $72,822 standard CSRA, as just noted, by $14,513,
an amount generating roughly $63 in monthly income. Attributing that income
to Burnett would have raised his monthly income to $1,702, still $25 short
of the MMMNA. Thus, had the hearing officer applied the resources-first
method -- addressing Burnett's income shortfall by first reserving additional
assets for his benefit -- the examiner would have increased Burnett's CSRA
to encompass all of the Blumers' remaining available resources, and Irene
would have become immediately eligible for Medicaid. The remaining $25 deficit
in Burnett's income could then have been covered posteligibility by a monthly
transfer of income (or CSMIA) from Irene, who at the time of the hearing
received $927 per month in Social Security and $336 from a pension. |
| [48] | Wisconsin, however, has adopted the income-first rule by statute: |
| [49] | "If either spouse establishes at a fair hearing that the community
spouse resource allowance determined under sub. (6)(b) without a fair hearing
does not generate enough income to raise the community spouse's income to
the [MMMNA] ... , the department shall establish an amount to be used under
sub. (6)(b)3. that results in a community spouse resource allowance that
generates enough income to raise the community spouse's income to the [MMMNA]
... . Except in exceptional cases which would result in financial duress
for the community spouse, the department may not establish an amount to
be used under sub. (6)(b)3. unless the institutionalized spouse makes available
to the community spouse the maximum monthly income allowance permitted under
sub. (4)(b)." Wis. Stat. Ann. §49.455(8)(d) (West 1997) (emphasis added). |
| [50] | Applying this rule, the hearing examiner concluded that he was without
authority to increase Burnett's CSRA: The difference between Burnett's monthly
income and the MMMNA could be erased if, after achieving eligibility, Irene
made available to Burnett $88 per month from her own income. This, the examiner
concluded, Irene would be able to do; accordingly, there was no need to
reserve additional assets for Burnett, and no acceleration in Irene's Medicaid
eligibility. |
| [51] | The following table illustrates the differences between the income-first
and resources-first methods as applied to the Blumers: |
| [52] |
Analysis of the Blumers' Financial Situation |
| [108] | The hearing examiner's determination was affirmed by the Circuit Court
of Green County. The Wisconsin Court of Appeals, however, reversed. Concluding
that the MCCA unambiguously mandates the resources-first method, the Wisconsin
appellate court declared that the State's income-first statute impermissibly
conflicts with federal law. 2000 WI App. 150, 237 Wis. 2d 810, 615 N. W.
2d 647. The Wisconsin Supreme Court denied discretionary review. |
| [109] | The decision of the Wisconsin Court of Appeals, holding the income-first
method impermissible and the resources-first method required, accords with
the position adopted by Ohio intermediate appellate courts. See, e.g., Kimnach
v. Ohio Dept. of Human Servs., 96 Ohio App. 3d 640, 647, 645 N. E. 2d 825,
829-830 (1994), appeal not allowed, 71 Ohio St. 3d 1447, 644 N. E. 2d 409
(1995). Most courts to consider the issue, however, including the highest
courts of New York and Massachusetts, as well as two Federal Courts of Appeals,
have upheld the Secretary's view that the Act permits the income-first method.
See Cleary ex rel. Cleary v. Waldman, 167 F. 3d 801, 805 (CA3), cert. denied,
528 U. S. 870 (1999); Chambers v. Ohio Dept. of Human Servs., 145 F. 3d
793, 801 (CA6), cert. denied, 525 U. S. 964 (1998); Golf v. New York State
Div. of Soc. Servs., 91 N. Y. 2d 656, 662, 697 N. E. 2d 555, 558 (1998);
Thomas v. Commissioner of Div. of Medical Assistance, 425 Mass. 738, 746,
682 N. E. 2d 874, 879 (1997). We granted certiorari to resolve this conflict,
533 U. S. 927 (2001), and now reverse the judgment of the Wisconsin Court
of Appeals. |
| [110] | II. |
| [111] | The question presented is whether the income-first prescription of the
Wisconsin statute, requiring that potential income transfers from the institutionalized
spouse be considered part of the "community spouse's income" for
purposes of determining whether a higher CSRA is necessary, conflicts with
the MCCA. The answer to that question, the parties agree, turns on whether
the words "community spouse's income" in §1396r-5(e)(2)(C) may
be interpreted to include potential, posteligibility transfers of income
from the institutionalized spouse permitted by §1396r-5(d)(1)(B). |
| [112] | In line with the decision of the Wisconsin Court of Appeals, 2000 WI App.
150, ¶ ;20, but in conflict with the weight of lower court authority, see,
e.g., Cleary, 167 F. 3d, at 807; Chambers, 145 F. 3d, at 802, Blumer first
argues that the plain meaning of the term "community spouse's income"
unambiguously precludes the income-first method. She does not dispute that
a monthly allowance regularly transferred from one spouse to the other could
qualify as "income" under any relevant definition, but instead
focuses on the modifier "community spouse's," contending that
"[b]y choosing the possessive ... Congress clearly expressed its intent
that the income possessed by the community spouse" is the relevant
measure. Brief for Respondent 16. We disagree. Congress' use of the possessive
case does not demand construction of "community spouse's income"
to mean only income actually possessed by, rather than available or attributable
to, the community spouse; to the contrary, the use of the possessive is
often indeterminate. See J. Taylor, Possessives in English: An Exploration
in Cognitive Grammar 2 (1996) ("[T]he entity denoted by a possessor
nominal does not necessarily possess (in the everyday, legalistic sense
of the term) the entity denoted by the possessee."); see also Smiley
v. Citibank (South Dakota), N. A., 517 U. S. 735, 739 (1996) (questioning
characterization of a statutory term as unambiguous when its meaning has
generated a division of opinion in the lower courts). |
| [113] | Blumer maintains as well that the "design of the Act as a whole"
precludes use of the income-first method. K mart Corp. v. Cartier, Inc.,
486 U. S. 281, 291 (1988). She relies heavily, as did the Wisconsin Court
of Appeals, 2000 WI App. 150, ¶ ;¶ ;21-23, on the Act's distinction between
rules governing the initial Medicaid eligibility determination and those
that apply posteligibility to the extent-of-assistance calculation. See
Brief for Respondent 17-18. Blumer notes that the (e)(2)(C) hearing to obtain
an enhanced CSRA occurs only at the time an eligibility assessment is conducted,
while no CSMIA income is transferred until after eligibility has been achieved,
see supra, at 5-6. This sequence, she contends, shows that Congress intended
the CSRA enhancement and the CSMIA to operate at discrete stages: The former
remedies a shortfall in the income possessed by the community spouse prior
to eligibility, while the latter provides further relief posteligibility
if the previous CSRA enhancement proves inadequate. See Brief for Respondent
18. Because the Wisconsin statute requires imputation of the CSMIA to the
community spouse before additional assets may be reserved, Blumer concludes,
the statute reverses the priority established by the MCCA. |
| [114] | In accord with the Secretary, we do not agree that Congress circumscribed
the (e)(2)(C) hearing in the manner Blumer urges. Although that hearing
is conducted preeligibility,*fn9 its purpose
is to anticipate the posteligibility financial situation of the couple.
The procedure seeks to project what the community spouse's income will be
when the institutionalized spouse becomes eligible. See Tr. of Oral Arg.
14 (officer conducting (e)(2)(C) hearing makes a calculation that "concerns
the post eligibility period"; question is will "the at-home spouse
... have sufficient income in the post eligibility period, or does the resource
allowance need to be jacked up in order to provide that additional income").
The hearing officer must measure that projected income against the MMMNA,
a standard that, like the CSMIA, is operative only posteligibility. §§1396r-5(b)(2),
(d)(3). |
| [115] | In short, if the (e)(2)(C) hearing is properly comprehended as a preeligibility
projection of the couple's posteligibility situation, as we think it is,
we do not count it unreasonable for a State to include in its estimation
of the "community spouse's income" in that posteligibility period
an income transfer that may then occur.*fn10 |
| [116] | Blumer's skewed view of the (e)(2)(C) hearing also underlies the contention,
advanced at oral argument, see Tr. of Oral Arg. 6-10, that the income-first
method renders meaningless the Act's key prohibition against deeming income
of the community spouse available to the institutionalized one. §1396r-5(b)(1).
According to this argument, including the CSMIA as part of the "community
spouse's income" under subsection (e)(2)(C) effectively converts some
income of the institutionalized spouse into income of the community spouse.
And prior to eligibility, the argument continues, all of the institutionalized
spouse's income is considered available for medical expenses. §1396a(a)(10)(A);
42 CFR §435.120 (2000). Thus, the theory concludes, under income-first the
CSMIA would, as a logical matter, be considered both "community spouse's
income" and "available" for the institutionalized spouse's
medical expenses in clear contravention of subsection (b)(1). |
| [117] | This argument confuses the inclusion of a projected CSMIA in the preeligibility
calculation of the community spouse's posteligibility income with the actual
transfer of income contemplated by the CSMIA provision. The (e)(2)(C) hearing
is, again, simply a projection of the state of affairs that will exist posteligibility.
The theoretical incorporation of a CSMIA into the community spouse's future
income at that hearing has no effect on the preeligibility allocation of
income between the spouses. A CSMIA becomes part of the community spouse's
income only when it is in fact transferred to that spouse, §1396r-5(d)(1)(B),
which may not occur until "[a]fter [the] institutionalized spouse is
determined ... to be eligible." §1396r-5(d)(1). At that point, the
actual CSMIA is deducted from the institutionalized spouse's income, ibid.,
and is no longer available for medical expenses. Thus, at all times the
rule of subsection (b)(1) is honored, for at no time is any income of the
community spouse simultaneously deemed available to the institutionalized
spouse.*fn11 |
| [118] | Far from precluding Wisconsin's chosen approach, the MCCA's design offers
affirmative support for the permissibility of the income-first method. Subsection
(b)(1), prohibiting attribution of the community spouse's income to the
institutionalized spouse, has no counterpart running in the opposite direction.
Indeed, the Act specifically provides for a transfer of income from the
institutionalized spouse to the community spouse through the CSMIA. §1396r-5(d)(1)(B).
Mindful of the Medicaid program's background principle that "it is
proper to expect spouses to support each other," Gray Panthers, 453
U. S., at 45 (quoting S. Rep. No. 404, pt. 1, at 78) (internal quotation
marks omitted), we are satisfied that a State reasonably interprets the
MCCA by anticipating the CSMIA in the (e)(2)(C) hearing.*fn12 |
| [119] | We further note that subsection (e), governing fair hearings in general,
is not limited to a redetermination of the CSRA. It also permits a hearing
if the couple is dissatisfied with: |
| [120] | "(i) the [CSMIA]; |
| [121] | "(ii) the amount of monthly income otherwise available to the community
spouse ... ; |
| [122] | "(iii) the computation of the spousal share of resources under subsection
(c)(1) of this section; [and] |
| [123] | "(iv) the attribution of resources under subsection (c)(2) of this
section." §1396r-5(e)(2)(A). |
| [124] | Given that the CSMIA itself may be adjusted in a fair hearing under subsection
(e)(2)(A)(i), we cannot conclude that the States are forbidden to consider
the projected CSMIA in the related hearing, authorized by subsection (e)(2)(A)(v),
to increase the CSRA. Accord, Cleary, 167 F. 3d, at 810. |
| [125] | III. |
| [126] | We thus hold that the income-first method is a permissible means of implementing
the Act. The parties here have not also disputed the permissibility of the
resources-first approach. We therefore do not definitively resolve that
matter, although we note that the leeway for state choices urged by both
Wisconsin and the United States is characteristic of Medicaid. |
| [127] | The Medicaid statute, in which the MCCA is implanted, is designed to advance
cooperative federalism. See Harris v. McRae, 448 U. S. 297, 308 (1980).
When interpreting other statutes so structured, we have not been reluctant
to leave a range of permissible choices to the States, at least where the
superintending federal agency has concluded that such latitude is consistent
with the statute's aims. In Batterton v. Francis, 432 U. S. 416, 429 (1977),
for example, we upheld a regulation promulgated by the Secretary of Health,
Education, and Welfare affording the States discretion in the implementation
of the Aid to Families with Dependent Children (AFDC) unemployed parent
program. The challenged regulation allowed States to cover or exclude from
coverage persons whose unemployment resulted from participation in a labor
dispute or whose conduct would disqualify them for benefits under the State's
compensation law. Noting that the AFDC program involved the "concept
of cooperative federalism," id., at 431, we concluded that the Secretary
had the authority to "recognize some local options in determining ...
eligibility," id., at 430. Similarly, in Lukhard v. Reed, 481 U. S.
368 (1987), a plurality of this Court concluded that Virginia's policy of
treating personal injury awards as income rather than resources under the
AFDC program was reasonable and consistent with federal law, see id., at
377-381. The superintending federal agency, the plurality pointed out, had
for many years permitted Virginia's choice while allowing other States to
treat such awards as resources. Id., at 378. |
| [128] | The Secretary of Health and Human Services, who possesses the authority
to prescribe standards relevant to the issue here, §1396a(a)(17),*fn13
has preliminarily determined that the MCCA permits both the income-first
and resources-first methods. See 66 Fed. Reg. 46763, 46767 (2001); HCFA,
Chicago Regional State Letter No. 22-94, at 2, App. to Pet. for Cert. 89a.*fn14
In a recently proposed rule, the Secretary declared that "in the spirit
of Federalism," the Federal Government "should leave to States
the decision as to which alternative [income-first or resources-first] to
use." 66 Fed. Reg. 46763, 46767 (2001). |
| [129] | The Secretary's position warrants respectful consideration. Cf. United
States v. Mead Corp., 533 U. S. 218 (2001); Thomas Jefferson Univ. v. Shalala,
512 U. S. 504, 512 (1994) (reliance on Secretary's "significant expertise"
particularly appropriate in the context of "a complex and highly technical
regulatory program" (internal quotation marks omitted)); Gray Panthers,
453 U. S., at 43-44 (Secretary granted "exceptionally broad authority"
under the Medicaid statute). As Blumer acknowledges, Brief for Respondent
31-32, the MCCA affords large discretion to the States on two related variables:
the level of the MMMNA accorded the community spouse, §1396r-5(d)(3), see
supra, at 5, and the amount of assets the couple is permitted to retain,
§1396r-5(f)(2)(A), see supra, at 6-7. Nothing in the Act indicates to us
that similar latitude is inappropriate with respect to the application of
subsection (e)(2)(C). |
| [130] | Eliminating the discretion to choose income-first would hinder a State's
efforts to "strik[e] its own balance" in the implementation of
the Act. Lukhard, 481 U. S., at 383. States that currently allocate limited
funds through the income-first approach would have little choice but to
offset the greater expense of the resources-first method by reducing the
MMMNA or the standard CSRA. Such an alteration would benefit couples seeking
Medicaid who possess significant resources -- "not ... a lot of people"
by Blumer's own account, Tr. of Oral Arg. 38 -- while offering nothing to,
and perhaps disadvantaging, those who do not, couples for whom the other
variables provide the primary protection against spousal impoverishment.
Blumer would thus have us conclude that Congress pushed States toward altering
standards that affect every person covered by the MCCA in order to install,
without any increased spending, a resources-first rule that affects only
those whose assets exceed the formula resources allowance. We perceive nothing
in the Act contradicting the Secretary's conclusion that such a result is
unnecessary and unwarranted. |
| [131] | For the reasons stated, the judgment of the Wisconsin Court of Appeals
is reversed, and the case is remanded for further proceedings not inconsistent
with this opinion. |
| [132] | It is so ordered. |
| [133] | Justice Stevens, with whom Justice O'Connor and Justice Scalia join, dissenting. |
| [134] | The Medicare Catastrophic Coverage Act of 1988 (MCCA), 42 U. S. C. §1396r-5
et seq. (1994 ed. and Supp. V), provides important protections for married
couples who need financial assistance when one spouse is institutionalized
in a nursing home. Eligibility for financial assistance in paying nursing
home costs is limited by a ceiling on the couple's resources and a ceiling
on their income. The MCCA responded to pre-1988 eligibility rules that often
required both spouses to deplete their combined resources before an institutionalized
spouse became eligible for benefits. In order to prevent the "pauperization"
of the spouse who remains at home (the "community spouse"), the
1988 Act gives couples two important rights that are implicated by this
case. H. R. Rep. No. 100-105, pt. 2, pp. 66-67 (1987). The first is a preeligibility
right of the spouse who remains at home (the "community spouse")
to retain a defined share of their joint resources, called the "community
spouse resource allowance" (CSRA).*fn15
The second is a posteligibility right of the institutionalized spouse to
use a defined share of her income for purposes other than paying for the
cost of her care. |
| [135] | The two statutory rights involved in this case are designed, in part,
to assure that the community spouse's income may be maintained at a minimum
level -- the "minimum monthly maintenance needs allowance" (MMMNA).*fn16
To safeguard these rights and this minimum level of subsistence for the
community spouse, the statute provides for a "fair hearing," at
which a couple seeking medical assistance for an institutionalized spouse
may challenge several calculations that are used to determine eligibility
for Medicaid. 42 U. S. C. §1396r-5(e)(2) (1994 ed.). The determination of
the CSRA is one such calculation that may be challenged. §1396r-5(e)(2)(A)(v). |
| [136] | During this pre-eligibility hearing, if the institutionalized spouse has
income-producing resources and the community spouse's income is below the
MMMNA, the provision in issue in this case, §1396r-5(e)(2)(C), is applicable.
By its terms, it allows the institutionalized spouse to transfer sufficient
resources to the community spouse to provide him with an income equal to
the MMMNA. Since only those resources that remain with the institutionalized
spouse are counted for eligibility purposes, §1396r-5(e)(2)(C) enables some
institutionalized spouses who would otherwise be ineligible to qualify for
financial assistance. |
| [137] | The text of §1396r-5(e)(2)(C) is straightforward. As its caption indicates,
it deals only with the "[r]evision of community spouse resource allowance"
and it is applicable when an eligibility determination is made. It provides: |
| [138] | "If either such spouse establishes that the community spouse resource
allowance (in relation to the amount of income generated by such an allowance)
is inadequate to raise the community spouse's income to the minimum monthly
maintenance needs allowance, there shall be substituted, for the community
spouse resource allowance under subsection (f)(2) of this section, an amount
adequate to provide such a minimum monthly maintenance needs allowance." |
| [139] | Thus, under the plain language of the statute, if the CSRA that has been
calculated in accordance with §1396r-5(c)(1)(A) is insufficient to raise
the community spouse's income to the MMMNA level, there "shall be substituted"
a new CSRA that will produce sufficient income. §1396r-5(e)(2)(C). |
| [140] | With respect to income, the sole provision in the federal statute that
authorizes a transfer of income from the institutionalized spouse to the
community spouse applies only after the eligibility determination has been
made. §1396r-5(d)(1). It authorizes the institutionalized spouse to use
some of her income to take care of her own needs, to provide support for
the community spouse when his income is below the MMMNA, and to help other
family members before paying for her care. But as the text of the provision
expressly states, it only applies "[a]fter an institutionalized spouse
is determined or redetermined to be eligible for medical assistance."*fn17 |
| [141] | Wisconsin has passed a statute that prohibits the resource transfer authorized
by §1396r-5(e)(2)(C) unless the institutionalized spouse first transfers
any available income to the community spouse.*fn18
Unless this prohibition is authorized by federal law, it is plainly invalid
because it qualifies the federal right created by §1396r-5(e)(2)(C). |
| [142] | There are two possible bases for arguing that the Wisconsin statute is
consistent with §1396r-(e)(2)(C): first, that despite the express limitation
in §1396r-5(d) to deductions authorized "[a]fter an institutionalized
spouse is determined or redetermined to be eligible," Congress really
meant "before or after"; and second, that when Congress used the
term "community spouse's income" in §1396r-5(e)(2)(C), it really
meant "community spouse's income plus any deduction from the institutionalized
spouse's income that may in the future be made available to him." As
is clear, both of these arguments require altering the plain text of the
statute. |
| [143] | Rather than admitting that its reading strains the text of the MCCA, the
Court engages in an analytical sleight of hand: It conceives of the transfer
of income that is commanded by the Wisconsin statute as a condition of eligibility,
not as a required transfer, but only as a prediction of things to come.
Ante, at 16 ("In short, if the §1396r-5(e)(2)(C) hearing is properly
comprehended as a pre-eligibility projection of the couple's posteligibility
situation, as we think it is, we do not count it unreasonable for a state
to include in its estimation of the `community spouse's income' in that
posteligibility period an income transfer that will then occur"). The
Court's temporal manipulation of the §1396r-5(e)(2)(C) hearing is innovative;
but it is wrong for at least three reasons. |
| [144] | First, in speculating that Wisconsin does not actually require a preeligibility
transfer, but only predicts a future income transfer, the Court neglects
to consider the text of the State statute in issue. In holding that Wisconsin's
"income-first" approach is permissible, the Court states: "The
theoretical incorporation of the CSMIA [Community Spouse Monthly Income
Allowance] into the community spouse's future income at that hearing has
no effect on the pre-eligibility allocation of income between the spouses.
The CSMIA becomes part of the community spouse's income only when it is
in fact transferred to that spouse, §1396r-5(d)(1), which may not occur
until `[a]fter [the] institutionalized spouse is determined ... to be eligible.'
§1396r-5(d)(1)." Ante, at 16-17 (emphasis added). The Court's own statement,
which replaces the statutory phrase "made available to" from §1396r-5(d)(1)(B)
with the phrase "transferred to," exposes precisely why the Wisconsin
statute is in conflict with the MCCA. As the text of the Wisconsin statute
makes clear, there is nothing "theoretical" about the income transfer
that it requires: "[T]he department may not [substitute an increased
CSRA] unless the institutionalized spouse makes available to the community
spouse the maximum monthly income allowance permitted." Wisc. Stat.
§49.455(8)(d) (1993-1994) (emphasis added). The state statute requires that
an institutionalized spouse "make available" income to the community
spouse. In other words, Wisconsin requires a pre-eligibility transfer of
income from the institutionalized spouse to the community spouse. Because
42 U. S. C. §1396r-5(d)(1) permits the income transfer to take place only
after eligibility has been established, the Wisconsin statue is in conflict
with the plain language of the MCCA.*fn19 |
| [145] | Second, although the MCCA permits an institutionalized spouse to transfer
income to the community spouse after eligibility has been established, it
by no means requires that she do so.*fn20
Thus, by requiring the CSMIA transfer, and therefore not increasing the
CSRA to meet the community spouse's income needs, the Wisconsin statute
mandates an income transfer that Congress left optional. Furthermore, if
the Wisconsin statute could be interpreted to require only a prediction,
rather than a mandatory preeligibility transfer, there are several plausible
reasons why such a "prediction" may not ultimately come to fruition.
For example, the institutionalized spouse might choose not to contribute
to the support of the community spouse. Alternatively, the institutionalized
spouse's income could fluctuate over time and may not in a given month be
sufficient to augment the community spouse's monthly income. Finally, a
hearing examiner's finding of ineligibility -- based on a fictional prediction
that a posteligibility transfer of income would occur -- might (as it did
in this case) actually prevent the posteligibility transfer from occurring.*fn21
If any of these events occurs, a primary purpose of the statute -- ensuring
the financial security of the community spouse -- will have been undermined.
Thus, either the Wisconsin statute mandates the income transfer, in which
case it contradicts the MCCA, or it diminishes the §1396r-5(e)(2)(C) hearing
into a thought experiment that is inconsistent with the purpose of the statute. |
| [146] | Third, an important posteligibility provision of the statute, which expresses
the "name-on-the-check" policy of the MCCA, also exposes why the
Wisconsin statute is in conflict with the federal one. Section 1396r-5(b)(2)(A)(i)
states: "[Posteligibility,] if payment of income is made solely in
the name of the institutionalized spouse or the community spouse, the income
shall be considered available only to that respective spouse." By mandating
an income transfer from the institutionalized spouse to the community spouse,
the Wisconsin statute effectively treats the institutionalized spouse's
income as that of the community spouse, and, therefore, violates the prohibition
of §1396r-5(b)(2)(A)(i). |
| [147] | As a final matter, the Court pays "respectful consideration"
to an opinion letter and policy memoranda in which the Secretary of Health
and Human Services " `in the spirit of Federalism' " has allowed
the States to use either an income-first or a resources first approach.
Ante, at 20. The weight that should be accorded to such a document depends
" `upon the thoroughness evident in its consideration, the validity
of its reasoning, its consistency with earlier and later pronouncements,
and all those factors which give it power to persuade.' " United States
v. Mead Corp., 533 U. S. 218, 228 (2001). The Secretary has taken inconsistent
positions on this issue over time, see App. to Pet. for Cert. 78a-90a, and
the current opinion letter offers no analysis of the potentially conflicting
provisions in the federal and state statutes. It is devoid of any "
`power to persuade.' " |
| [148] | The Court concludes its opinion with an explanation of why the income-first
rule may represent a better policy choice than the resource-first rule.
It is not, however, a policy choice that Congress made. Indeed, the fact
that the text of the federal statute expressly authorizes the resource-first
approach without mentioning the income-first rule commanded by the Wisconsin
statute, at the very least, identifies a congressional preference for the
former. |
| [149] | This statute is not ambiguous. The resource adjustment authorized by §1396r-5(e)(2)(C)
is not conditioned on any prior or predicted transfer of income. The state
statute imposing that condition is therefore invalid. Because I agree with
the analysis of the statute in the opinion of the Wisconsin Court of Appeals,
I would affirm its judgment. I therefore respectfully dissent. |
|
|
|
| Opinion Footnotes | |
|
|
|
| [150] | *fn1 The Secretary has delegated his
rulemaking power to the Health Care Financing Administration (HCFA), see
Statement of Organization, Functions, and Delegations of Authority for the
Dept. of Health and Human Services, Pt. F, 46 Fed. Reg. 13262-13263 (1981),
now called the Centers for Medicare and Medicaid Services, see 66 Fed. Reg.
35437 (2001). We nevertheless refer throughout this opinion to the Secretary
as the entity charged with interpretive authority. |
| [151] | *fn2 The State must also provide for
an "excess shelter allowance" if necessary to cover, inter alia,
unusually high rent or mortgage payments. §§1396r-5(d)(3)(A)(ii), (d)(4).
Either spouse may request a hearing to seek a higher MMMNA for the community
spouse; such an increase will be allowed if the couple establishes "exceptional
circumstances resulting in significant financial duress." §1396r-5(e)(2)(B). |
| [152] | *fn3 The Act excludes from the definition
of "resources" the couple's home, one automobile, personal belongings,
and certain other forms of property. §§1382b(a), 1396r-5(c)(5). |
| [153] | *fn4 Once the institutionalized spouse
is determined to be eligible, "no resources [gained by] the community
spouse shall be deemed available to the institutionalized spouse."
§1396r-5(c)(4). |
| [154] | *fn5 As the United States points out,
Brief for United States as Amicus Curiae 8, n. 4, the MCCA technically defines
the CSRA as only a portion of the assets protected for the benefit of the
community spouse. Under §1396r-5(f)(2), the CSRA denotes the amount by which
the community spouse's "spousal share" of the couple's resources
falls below the resource allowance set by the State pursuant to §1396r-5(f)(2)(A).
Assets covering this shortfall are automatically excluded from consideration
in the eligibility determination and transferred to the community spouse
after eligibility is achieved. §§1396r-5(f)(1), (2). We observe, however,
that the parties here, like the court below, refer to the CSRA as the total
resources the community spouse is permitted to retain, an amount generally
equal to the spousal share. See Brief for Petitioner 7, n. 6; Brief for
Respondent 5; 2000 WI App. 150, ¶ ;10, 237 Wis. 2d 810, 816, ¶ ;10, 615
N. W. 2d 647, 650, ¶ ;10. The Secretary of Health and Human Services employs
the same broad definition: According to the Secretary, the CSRA means "the
amount of a couple's combined jointly and separately-owned resources ...
allocated to the community spouse and considered unavailable to the institutionalized
spouse when determining his or her eligibility for Medicaid." 66 Fed.
Reg. 46763, 46768 (2001). We adhere to this common understanding of the
CSRA throughout this opinion. |
| [155] | *fn6 Comments on the proposed rule were
to be submitted by November 6, 2001. As the Government related at oral argument,
however, the Secretary fears that comments have not reached the agency due
to the disruption of the Nation's postal system in October and November
2001. See Tr. of Oral Arg. 16-17. It remains unclear when the Secretary
will take further action on the proposed rule. See 66 Fed. Reg. 61625 (2001). |
| [156] | *fn7 Wisconsin sets the CSRA floor at
$50,000. Wis. Stat. §49.455(6)(b)1m. (2001). Because Burnett's $72,822 spousal
share exceeded that amount but fell below the federally imposed ceiling,
which was then $79,020 ($60,000 indexed for inflation to 1996), the spousal
share became his CSRA. App. to Pet. for Cert. 28a. |
| [157] | *fn8 The hearing examiner incorrectly
calculated Burnett's relevant monthly income to be $1,702, mistakenly attributing
to him all of the $378 in income generated by the full $87,355 in the couple's
remaining available resources, rather than the $315 yielded by the $72,822
in assets reserved in his CSRA. See App. to Pet. for Cert. 25a; Tr. 8 (Apr.
29, 1997). Although the error does not affect our decision, we use the correct
figures (rounded to the nearest dollar) for illustrative purposes. |
| [158] | *fn9 That the hearing must occur preeligibility
is dictated by the mechanics of the process; in order to preserve the assets,
if any, that will be necessary for the community spouse's support in the
posteligibility period, a couple must know in advance what resources it
need not and should not expend before the institutionalized spouse becomes
Medicaid eligible. |
| [159] | *fn10 Taking issue with this characterization
of the (e)(2)(C) hearing, the dissent emphasizes the Wisconsin statute's
prescription that no CSRA enhancement will be allowed "unless the institutionalized
spouse makes available to the community spouse the maximum monthly income
allowance permitted," post, at 5-6 (quoting Wis. Stat. §49.455(8)(d))
(emphasis supplied by dissent). Only by omitting essential language from
the Wisconsin provision can the dissent construe the statute as "requir[ing]
a preeligibility transfer of income from the institutionalized to the community
spouse," post, at 6 (emphasis added). The State statute in fact provides
that the CSRA may not be enhanced "unless the institutionalized spouse
makes available to the community spouse the maximum monthly income allowance
permitted under sub. (4)(b)." Wis. Stat. §49.455(8)(d) (emphasis added).
Subsection (4)(b) is substantially identical to §1396r-5(d)(1), the very
provision of the MCCA that the dissent finds in conflict with §49.455(8)(d).
Like §1396r-5(d)(1), subsection (4)(b) directs that any income transfer
from the institutionalized spouse to the community spouse may occur only
"after [the] institutionalized spouse is determined . . . to be eligible."
Wis. Stat. §49.455(4)(b). Because subsection (4)(b) of the Wisconsin statute
therefore would not "permit" a pre-eligibility income transfer
from the institutionalized spouse, §49.455(8)(d) by its terms does not do
so either. In drawing a contrary inference based on an incomplete reading,
the dissent, not the Court, "neglects to consider the text of the State
statute in issue," post, at 5. |
| [160] | *fn11 Blumer also contends that subsection
(a)(3) of the MCCA forbids the income-first method because that provision
expressly leaves in place the existing Supplemental Security Income (SSI)
program rules for determining what constitutes income and resources, including
the standards and methods used in such determinations. See Brief for Respondent
19-22. In particular, Blumer emphasizes that subsection (a)(3) imposes the
SSI requirement, codified at §1396a(r)(2)(B), that States may not adopt
income-assessment standards that reduce the number of people eligible for
SSI. See id., at 21. As Wisconsin points out, however, the issue carved
out by §1396r-5(a)(3) -- what qualifies as income or resources -- is not
implicated by this case. Reply Brief 5; see supra, at 14. At issue here
is the different question, governed entirely by the MCCA, of whether money
that is indisputably "income" may be attributed to the community
spouse. |
| [161] | *fn12 According to the dissent, anticipating
the CSMIA in this manner effectively "mandates an income transfer that
Congress left optional," post, at 6. The dissent presumably means that
the CSMIA, once projected as part of the "community spouse's income"
in the (e)(2)(C) hearing, must in fact be transferred post-eligibility lest
the community spouse receive income below the statutorily guaranteed MMMNA.
As this case illustrates, however, application of the resources-first method
may yield the same situation. If the hearing examiner had granted Irene's
request to increase Burnett's CSRA without regard to a potential CSMIA,
Burnett's income would still have fallen $25 short of the MMMNA, see supra,
at 12. A post-eligibility income transfer in that amount would therefore
have been "mandatory" as the dissent understands that term, post,
at 6. Thus, the dissent's issue is not with the income-first method, but
rather with the friction between Congress' decision to guarantee a minimum
level of income for the community spouse and its failure to mandate the
transfer of income necessary in many cases to realize that guarantee. Similarly,
in faulting the income-first method for the possibility that its projections
may prove inaccurate, see post, at 7, the dissent attacks a problem inherent
in the design of the Act itself. As long as the (e)(2)(C) hearing is conducted
pre-eligibility, see supra, at 15, n. 9, the hearing examiner must inevitably
make predictions, and those predictions "may not ultimately come to
fruition," post, at 6. Under the resources-first method, just as under
income-first, the examiner must decide whether to enhance the CSRA based
on speculation about the community spouse's income in the post-eligibility
period. If that income diminishes unexpectedly, the community spouse may
be left without the level of income that the examiner "predicted"
at the (e)(2)(C) hearing, and on the basis of which the examiner denied
a CSRA enhancement. |
| [162] | *fn13 Blumer argues that §1396r-5(a)(1)
of the Act divests the Secretary of the authority granted under §1396a(a)(17)
to prescribe standards governing the allocation of income and resources
for Medicaid purposes. See Brief for Respondent 39. Subsection (a)(1) states
that the eligibility provisions of the MCCA "supersede any other provision
of this subchapter (including sections 1396a(a)(17) and 1396a(f) of this
title) which is inconsistent with them," but says nothing about the
regulatory authority of the Secretary under §1396a(a)(17). We have long
noted Congress' delegation of extremely broad regulatory authority to the
Secretary in the Medicaid area, see Schweiker v. Gray Panthers, 453 U. S.
34, 43 (1981); Batterton v. Francis, 432 U. S. 416, 425 (1977), and we will
not conclude that Congress implicitly withdrew that authority here. |
| [163] | *fn14 Contrary to the dissent's suggestion,
post, at 8, the Secretary has never wavered from his position that the income-first
method represents at least a permissible interpretation of the Act. See
HCFA, Chicago Regional State Letter No. 51-93 (Dec. 1993), App. to Pet.
for Cert. 78a-83a; HCFA, Chicago Regional State Letter No. 22-94, p. 2 (July
1994), App. to Pet. for Cert. 89a; 66 Fed. Reg. 46763, 46765 (2001). |
| [164] | *fn15 A portion of the couple's assets
is allocated to the community spouse pursuant to a formula found in 42 U.
S. C. §1396r-5(C)(1)(A) (1994 ed). This allocated amount, the CSRA, is reserved
for the benefit of the community spouse and is not considered in establishing
assistance eligibility for the institutionalized spouse. §1396r-5(c)(2). |
| [165] | *fn16 Section 1396r-5(d)(3) sets the
boundaries of the MMMNA. Although this provision grants States some flexibility
in setting the MMMNA, it must be set no lower than 150% of the poverty level
for a family of two. In 2001, States could set the MMMNA between $1,406.25
and $2,175 per month. Wisconsin established its MMMNA at $1,935. |
| [166] | *fn17 Allowances to be offset from
income of institutionalized spouse "After an institutionalized spouse
is determined or redetermined to be eligible for medical assistance, in
determining the amount of the spouse's income that is to be applied monthly
to payment for the costs of care in the institution, there shall be deducted
from the spouse's monthly income the following amounts in the following
order: "(A) A personal needs allowance (described in section 1396a(q)(1)
of this title), in an amount not less than the amount specified in section
1396a(q)(2) of this title. "(B) A community spouse monthly income allowance
(as defined in paragraph (2)), but only to the extent income of the institutionalized
spouse is made available to (or for the benefit of) the community spouse.
"(C) A family allowance, for each family member... ." §1396r-5(d)(1). |
| [167] | *fn18 Wis Stat. §49.455(8)(d) (1993-1994)
provides in part: "Except in exceptional cases which would result in
financial duress for the community spouse, the department may not establish
an amount to be used under sub. (6)(b)3. unless the institutionalized spouse
makes available to the community spouse the maximum monthly income allowance
permitted under sub. (4)(b) or, if the institutionalized spouse does not
have sufficient income to make available to the community spouse the maximum
monthly income allowance permitted under sub. (4)(b), unless the institutionalized
spouse makes all of his or her income ... available to the community spouse
... ." |
| [168] | *fn19 The Court asserts in response
that the dissent fails to consider that the Wisconsin statute only requires
the institutionalized spouse to make available that which she is "permit[ed]"
to make available pursuant to subsection (4)(b). Ante, at 16, n. 10. But
subsection (4)(b), which is substantially identical to §1396r-5(d)(1), describes
the amount of income that can be made available posteligibility, whereas
subsection (8)(d) of the Wisconsin statute requires that it be made available
as a condition of eligibility. In overlooking the difference between the
permissive character of the federal provision and the mandatory character
of the Wisconsin statute, the Court's response continues to ignore the text
of the Wisconsin statute. |
| [169] | *fn20 Counsel for the Wisconsin Department
of Health and Family Services conceded at oral argument that the income
transfer is not required. Tr. of Oral Arg. 14 ("It doesn't explicitly
require the transfer"). The Court itself waffles between describing
the income transfer as something that has the "potential" to occur,
ante, at 13, and something that "will ... occur," ante, at 16.
Nevertheless, the Court's analysis of the 42 U. S. C. §1396r-5(e)(2)(C)
hearing clearly contemplates a mandatory posteligibility transfer. |
| [170] | *fn21 Under the hearing examiner's
ruling in this case, the predicted posteligibility transfer of income could
not occur because he found her ineligible for assistance. It is ironic,
to say the least, that the predicate for the so-called "income first"
approach is a hypothetical transfer of income that is actually precluded
by the application of that approach. The effect of the Wisconsin statute
in this case is to preclude the reallocation of resources that (a) is expressly
authorized by §1396r-5(e)(2)(C) of the statute, (b) would establish her
eligibility, and (c) make it possible for the posteligibility transfer to
take place. |
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