In the Matter of the Application of Robert Lynch, individually and as the spouse of June Lynch,, Petitioner, For a Judgment Pursuant to Article 78 of the Civil Practice Law Rules
Commissioner of the New York State Department of Health and the Commissioner of the Saratoga County Department of Social Services, Respondents.
This case is not published in a printed volume and its disposition appears in a table in the reporter.
Pierro Law Group, LLC, Attorney for Petitioner, (Louis W. Pierro, of counsel)
Attorney General of the State of New York,
Attorneys for Respondent Commissioner of Health, (Jeffrey M. Dvorin and Shoshanah V. Asnis, of counsel) The Capitol.
Richard M. Platkin, J.
Petitioner Robert Lynch brings this application to overturn a fair hearing decision regarding the Medicaid eligibility of his spouse, June Lynch, rendered by respondent Commissioner of the New York State Department of Health ("Commissioner" or "DOH"). The Commissioner opposes the petition through an answer.
In December 2004, June Lynch was admitted to a residential nursing home. After paying privately for care for approximately 16 months, she filed an application for medical assistance with respondent Commissioner of the Saratoga County Department of Social Services ("SCDSS"). By notice dated July 7, 2006, SCDSS denied Mrs. Lynch's application due to excess resources in the amount of $204,363.79 held by her spouse.
On August 17, 2006, Mrs. Lynch requested a fair hearing to obtain an increased resource allowance for her spouse. The hearing was held on September 25, 2006. By decision dated March 27, 2007, DOH determined that SCDSS's denial was correct when made, but agreed that petitioner was entitled to an increased resource allowance. DOH remanded the matter to SCDSS for a determination of the amount of additional resources required to purchase a single premium immediate life annuity that would generate sufficient monthly income to raise Mr. Lynch to the minimum monthly maintenance needs allowance level. Petitioner objects to the manner by which respondent established such additional allowance, and this petition followed.
"Medicaid, a joint federal-state program established pursuant to Title XIX of the Social Security Act (42 U.S.C. 1396 et seq.), pays for medical care for those unable to afford it, including nursing home care for medically needy older people who become eligible by incurring medical expenses that reduce their monthly income and assets below prescribed levels" ( Matter of Tomeck, 8 N.Y.3d 724, 727-728 ). Thus, as part of evaluating Medicaid eligibility, the state Medicaid agency must calculate an applicant's income and assets, and determine the amount that must be reduced or "spent down" for the applicant to meet the prescribed financial criteria ( see 42 U.S.C. 1396r-5 [c]  [B]; Social Services Law 366-c ; 18 NYCRR 360-4.8 [c]).
The Medicare Catastrophic Coverage Act of 1988 (42 U.S.C. 1396r-5 et seq.) includes spousal impoverishment provisions rules governing the allocation of resources between the spouse residing in a nursing home (the institutionalized spouse) and the spouse residing in the community (the community spouse). "In general, these provisions are designed to insure that the community spouse retains necessary, but not excessive, income and assets . . ." (Tomeck,supra, at 728). "In the MCCA, Congress sought to protect community spouses from 'pauperization' while preventing financially secure couples from obtaining Medicaid assistance" (id., quoting Wisconsin Dept. of Health and Family Servs. v Blumer, 534 U.S. 473, 480 ).
The spousal impoverishment provisions include rules for determining the community spouse's minimum monthly maintenance needs allowance ("MMMNA"), "an amount deemed sufficient for the community spouse to live at a modest level after the institutionalized spouse becomes eligible for Medicaid, subject to a statutory floor and ceiling" (Tomeck, supra, at 728, citing 42 U.S.C. §§ 1396r-5 [b], [d]  and Social Services Law §§ 366-c  [h], [j], ). There also are rules for computing and apportioning the resources of a married couple and allowing the community spouse to retain a portion of such resources, known as the "community spouse resource allowance" ("CSRA") (Tomeck, supra, at 728, citing 42 U.S.C. 1396r-5 [f]  and Social Services Law 366-c  [d]). "All of the institutionalized spouse's countable resources and the community spouse's countable resources exceeding the CSRA may be used to pay for nursing home care, and must be spent down in order for the institutionalized spouse to qualify for Medicaid" (Tomeck, supra, at 728).
Either spouse has the right to a fair hearing to challenge the adequacy of the MMMNA or the CSRA calculated by the local services district ( see 42 U.S.C. 1396r-5 [e]; Social Services Law 366-c ). A hearing examiner is authorized to establish a increased CSRA for the purpose of closing an MMMNA shortfall ( see ...