Alabama Medicaid Agency v. Betty Jane Kerby, by and through her next friend, Brenda Montgomery

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REL: 10/28/2011 Notice: T h i s o p i n i o n i s s u b j e c t t o formal r e v i s i o n b e f o r e p u b l i c a t i o n i n t h e advance s h e e t s o f Southern R e p o r t e r . R e a d e r s a r e r e q u e s t e d t o n o t i f y t h e R e p o r t e r o f D e c i s i o n s , Alabama A p p e l l a t e C o u r t s , 300 D e x t e r A v e n u e , M o n t g o m e r y , A l a b a m a 3 6 1 0 4 - 3 7 4 1 ((334) 2 2 9 - 0 6 4 9 ) , o f a n y t y p o g r a p h i c a l o r o t h e r e r r o r s , i n o r d e r t h a t c o r r e c t i o n s may b e made b e f o r e t h e o p i n i o n i s p r i n t e d i n Southern R e p o r t e r . ALABAMA COURT OF CIVIL APPEALS OCTOBER TERM, 2011-2012 2100874 Alabama M e d i c a i d Agency v. B e t t y Jane Kerby, by and through h e r next f r i e n d , Montgomery Appeal from Morgan C i r c u i t (CV-09-900382) Brenda Court THOMAS, J u d g e . In Kerby, 2008, sought Retardation Brenda Montgomery, services f o r Kerby the cousin of Betty under t h e Alabama Jane Mental Home a n d Community B a s e d W a i v e r p r o g r a m ( " w a i v e r 2100874 s e r v i c e s " ) from the Alabama M e d i c a i d Agency ("the Agency"). The w a i v e r s e r v i c e s a r e a d m i n i s t e r e d by t h e A l a b a m a Department of Mental ("the suffering persons Health from Department Kerby, an and Montgomery intellectual sought review who, at that provided disability. from t i m e , was M a r t i n upheld the d e n i a l of waiver Montgomery t h e n s o u g h t was are the 1 to The Associate f o r the D i v i s i o n of Mental R e t a r d a t i o n the Department, which and d e n i e d Montgomery's r e q u e s t f o r w a i v e r s e r v i c e s f o r Commissioner of Department") held b e f o r e an a fair Patricia Services Martin. services. h e a r i n g from the Agency, administrative law judge Although the A L J determined t h a t Kerby q u a l i f i e d ("ALJ"). f o r waiver s e r v i c e s and recommended t h a t t h e d e n i a l o f w a i v e r s e r v i c e s be overturned, the Agency's Commissioner, d i s a g r e e d and u p h e l d t h e d e n i a l waiver s e r v i c e s f o r Kerby. Carol Steckel, o f Montgomery's r e q u e s t f o r Montgomery s o u g h t j u d i c i a l r e v i e w A l t h o u g h most o f t h e s t a t u t e s and a d m i n i s t r a t i v e r u l e s governing t h e A l a b a m a D e p a r t m e n t o f M e n t a l H e a l t h use t h e terms " m e n t a l l y r e t a r d e d " or "mental retardation," the Department i s i n the p r o c e s s of changing the t e r m i n o l o g y i n t h e s t a t u t e s and t h e r u l e s t o " p e o p l e w i t h an i n t e l l e c t u a l d i s a b i l i t y " o r " i n t e l l e c t u a l d i s a b i l i t y . " See A l a . Code 1975, § 22-50-2.1(d). Thus, we w i l l u s e t h e t e r m " i n t e l l e c t u a l d i s a b i l i t y " or a p p r o p r i a t e phrases to r e f e r to the c o n d i t i o n f o r m e r l y r e f e r r e d t o as " m e n t a l r e t a r d a t i o n . " 1 2 2100874 of C o m m i s s i o n e r S t e c k e l ' s d e n i a l o f w a i v e r s e r v i c e s , and circuit court concluding to the overturned t h a t i t was Agency and the the Commissioner's n o t s u p p o r t e d by t h e e v i d e n c e ALJ and that d e c i s i o n t o deny w a i v e r s e r v i c e s was The Agency Commissioner Code provided Steckel's appeals. 1975, administrative limited. decision, a r b i t r a r y and c a p r i c i o u s . Under the Alabama A d m i n i s t r a t i v e P r o c e d u r e A c t Ala. the See § 40-22-1 et seq., review d e c i s i o n t o deny w a i v e r A l a . Code 1975, § of the ("AAPA") Agency's s e r v i c e s to Kerby i s 41-22-20(k). " S e c t i o n 41-22-20(k) p r o v i d e s t h a t i n the c i r c u i t c o u r t ' [ t ] h e a g e n c y o r d e r s h a l l be t a k e n as p r i m a f a c i e j u s t and r e a s o n a b l e and t h e c o u r t s h a l l n o t s u b s t i t u t e i t s j u d g m e n t f o r t h a t o f t h e a g e n c y as t o t h e w e i g h t o f t h e e v i d e n c e on q u e s t i o n s o f f a c t , e x c e p t where o t h e r w i s e a u t h o r i z e d by s t a t u t e . ' U n d e r t h i s l i m i t e d standard of review, the c i r c u i t c o u r t must give the Agency's determination of n o n e l i g i b i l i t y a presumption of c o r r e c t n e s s . See B e n t o n v. A l a b a m a B o a r d o f M e d i c a l E x a m i n e r s , 4 67 So. 2d 234 ( A l a . 1 9 8 5 ) . "In f a c t , under § 41-22-20(k) the c i r c u i t c o u r t may r e v e r s e o r m o d i f y an a g e n c y ' s d e c i s i o n o n l y i f i t d e t e r m i n e s t h a t t h e a g e n c y a c t i o n i s due t o be s e t a s i d e or m o d i f i e d under s t a n d a r d s s e t f o r t h i n a p p e a l or review s t a t u t e s a p p l i c a b l e t o the agency (not a p p l i c a b l e i n t h i s case) or ' i f s u b s t a n t i a l rights of the p e t i t i o n e r have b e e n prejudiced because the agency a c t i o n i s : 3 2100874 "'(1) I n v i o l a t i o n o f c o n s t i t u t i o n a l or s t a t u t o r y p r o v i s i o n s ; "'(2) In excess of a u t h o r i t y of the agency; "'(3) In agency r u l e ; the statutory any pertinent v i o l a t i o n of "'(4) Made upon u n l a w f u l "'(5) A f f e c t e d by procedure; other e r r o r of law; "'(6) C l e a r l y e r r o n e o u s i n v i e w o f t h e reliable, probative, and substantial e v i d e n c e on t h e w h o l e r e c o r d ; o r "'(7) Unreasonable, arbitrary or c a p r i c i o u s o r c h a r a c t e r i z e d by an a b u s e o f discretion or a clearly unwarranted e x e r c i s e of d i s c r e t i o n . ' "This court has held that § 41-22-20(k) ' r e c o g n i z e s the general r u l e t h a t j u d i c i a l review of administrative decisions i s l i m i t e d i n scope to whether the order i s s u p p o r t e d by substantial evidence, whether the agency's decision is r e a s o n a b l e and n o t a r b i t r a r y , and w h e t h e r t h e a g e n c y a c t e d w i t h i n i t s power c o n f e r r e d upon i t by l a w and the constitution.' Ferlisi v. Alabama Medicaid A g e n c y , 481 So. 2d 400 ( A l a . C i v . App. 1985)." Alabama (Ala. Medicaid Civ. v. App. interpretation reasonable, Agency 1986). of i t s own Norred, even though In 497 4 not 2d addition, regulation i t may So. must appear 176, 176-77 "an agency's stand i f i t is as reasonable as 2100874 some other A g e n c y , 481 At waiver persons interpretation." So. 2d 400, issue i n this services to under the be 403 case Ferlisi v. Alabama ( A l a . C i v . App. i s the provided 1985). eligibility to as A l a . A d m i n . Code (Alabama M e d i c a i d A g e n c y ) , R u l e e t seq. Ala. The Admin. .02(3) ( a ) . qualifications Code (Dep't of f o r waiver Mental That a d m i n i s t r a t i v e r u l e of intellectually w a i v e r - s e r v i c e s program, Medicaid Kerby disabled described Rule "(3) State-Operated Developmental Center. I n d i v i d u a l s w i t h m e n t a l r e t a r d a t i o n who r e s i d e i n t h e S t a t e o f A l a b a m a , and who meet t h e c r i t e r i a f o r admission to a developmental center, will be a d m i t t e d f o r e v a l u a t i o n f o r s e r v i c e s (or as r e q u i r e d by a C o u r t O r d e r ) , o r may be a d m i t t e d f o r s h o r t - t e r m r e s p i t e s e r v i c e s or c r i s i s s t a b i l i z a t i o n s e r v i c e s . "(a) A d m i s s i o n C r i t e r i a : I n d i v i d u a l s who meet t h e f o l l o w i n g s p e c i f i c c r i t e r i a may be eligible for residence in the developmental center/Intermediate Care Facility for Persons with Mental R e t a r d a t i o n (ICF/MR) f o r t h e p r o v i s i o n o f i d e n t i f i e d s e r v i c e s and s u p p o r t s : 5 in 580-5-30- reads: "1. The individual has s i g n i f i c a n t l y sub-average g e n e r a l intellectual functioning (IQ l o w e r t h a n 70 on a s t a n d a r d i z e d intelligence test), existing concurrently with deficits in adaptive behavior that manifested in the developmental period in 560-X-35-.01 s e r v i c e s are found Health), for 2100874 ( b e f o r e t h e age o f 18 mental r e t a r d a t i o n ) . years, for "2. Community-based services, both generic and s p e c i a l i z e d , can n o t a f f o r d t h e p e r s o n a d e q u a t e and appropriate services for h a b i l i t a t i o n . "3. Residence in a state-operated developmental c e n t e r i s the l e a s t r e s t r i c t i v e environment adequate for the person's habilitation at the time. "4. In order for an individual to be admitted to ICF/MR A c t i v e T r e a t m e n t S e r v i c e s the individual must meet the c r i t e r i a s t a t e d i n #1 t h r o u g h 3 above. Additionally, the individual will benefit from s p e c i a l i z e d or g e n e r i c t r a i n i n g , treatment, health and related s e r v i c e s i n t h r e e o r more o f t h e f o l l o w i n g areas of l i f e a c t i v i t y : Self-care, Receptive and Expressive Language, Learning, Self Direction, Mobility, and C a p a c i t y f o r Independent L i v i n g . These services are directed towards: " ( i ) t h e a c q u i s i t i o n of behaviors necessary for the individual to function w i t h as much self-determination and independence as capable; and/or 6 2100874 "( i i ) t p r e v e n t i o n r e g r e s s i o n or l o s s current optim functional status." Commissioner Steckel recommendation services under determined requirements that, despite the d i d not o t h e r w i s e , Kerby the h e of of al qualify f o r waiver stated in Rule ALJ's 580-5-30- .02(3)(a)(1). The evidence record contains both establishing prematurely the i n Arkansas documentary (around 1960). and another facts. Kerby was i n November 1946. Kerby moved and relative, deceased, never to A c c o r d i n g t o t h e t e s t i m o n y o f Montgomery high school, she has born a p p r o x i m a t e l y 14 y e a r s Carolyn Turner, at the b e f o r e t h e A L J , K e r b y h a d n e v e r been " n o r m a l . " complete testimonial following A l a b a m a w i t h h e r m o t h e r when K e r b y was old and fair Kerby d i d not she does n o t have a d r i v e r ' s lived independently. and she h a d b e e n l i v i n g e i t h e r w i t h r e l a t i v e s , who Kerby's license, parents are f o r the l a s t s e v e r a l years h a d a s s i s t e d h e r and h a d p r o v i d e d f o r h e r , o r i n a g r o u p home f o r t h e i n t e l l e c t u a l l y I n 1973, when K e r b y was hearing disabled. 26 y e a r s o l d , t h e Morgan P r o b a t e C o u r t 7 2100874 d e t e r m i n e d t h a t K e r b y was Key, was "of unsound mind." A cousin, Hadley a p p o i n t e d as K e r b y ' s g u a r d i a n . M e d i c a l records i n d i c a t e t h a t Kerby's p h y s i c i a n , Nixon Gillespie, intellectual behalf, believes disability. Dr. G i l l e s p i e that In a Kerby letter suffers written surmises t h a t Kerby t i m e " and did brain intellectual Gillespie on S. an Kerby's ... and p r o b a b l y o f h e a l t h c a r e and m o t h e r ' s p r e n a t a l c a r e a t t h e then concludes that suffer from "[m]ost l i k e l y d i d have a b r a i n i n j u r y f r o m t h e p r e m a t u r e b i r t h complications Dr. injury from disability] indicates " [ i ] t i s obvious that birth, " that In Kerby's a [Kerby] resulting in [an note, Dr. including her medical history, p r e m a t u r e b i r t h and h e r e d u c a t i o n a l h i s t o r y o f f a i l i n g g r a d e s , "indicates disabled] absolutely that [Kerby] and n o t demented...." i n d i c a t e t h a t Dr. G i l l e s p i e f r o m an i n t e l l e c t u a l Anecdotal intellectual was [intellectually Other m e d i c a l notes further has d e t e r m i n e d t h a t K e r b y s u f f e r s disability. evidence indicating that Kerby's d i s a b i l i t y e x i s t e d before Kerby's 18th alleged birthday was p r o v i d e d by t h e t e s t i m o n y o f Montgomery and T u r n e r . testimony revealed that Kerby d i d n o t have 8 friends or Their have 2100874 social i n t e r a c t i o n s w i t h peers throughout her teenage Montgomery n o t e d t h a t K e r b y , never given without herself received a as f a r as Montgomery knew, m e d i c a t i o n and supervision. Montgomery telephone c a l l years. from could said Kerby not that and handle she that had she had money never doubted K e r b y c o u l d remember a t e l e p h o n e number; Montgomery d i d a d m i t that she d i d not independently Montgomery, bathing; cook. i f Kerby i f Kerby Kerby can Parts of could perform Montgomery's ever do basic used so. a telephone According hygiene that tasks Kerby Turner testified not testimony concerning Kerby's of the f a i r that, to like could are d i f f i c u l t t o f o l l o w because of apparent the audio r e c o r d i n g visited had h o w e v e r , Montgomery m e n t i o n e d abilities with or know hearing. when K e r b y i n Alabama, Kerby had acted issues was "like younger a spoiled and had brat." T u r n e r a l s o r e c a l l e d t h a t K e r b y h a d made p o o r g r a d e s w h i l e i n s c h o o l ; T u r n e r s a i d t h a t when K e r b y ' s m o t h e r h a d a t t e m p t e d t o assist Kerby with homework, K e r b y clue." A c c o r d i n g t o T u r n e r , Kerby's mother p i c k e d out Kerby's A letter " d i d not from Turner a l s o seem t o have clothes f o r her. record. I n t h a t l e t t e r , T u r n e r e x p l a i n e d t h a t h e r memories o f 9 appears a i n the 2100874 K e r b y d u r i n g h e r t e e n a g e y e a r s were t h a t K e r b y d i d n o t d e v e l o p close f r i e n d s h i p s or e x h i b i t pursuits, like fashionable "social interest i n typical activities, career c l o t h e s , make up, h a i r s t y l e s teenage interests, and boys." Turner f u r t h e r n o t e d t h a t K e r b y ' s g a i t was s i m i l a r t o t h a t o f a young c h i l d and t h a t h e r h a n d w r i t i n g had n o t developed beyond t h a t of a f i v e - y e a r - o l d c h i l d . The evidence i n the record regarding Kerby's schooling i n d i c a t e s t h a t K e r b y was p r o v i d e d " s p e c i a l c l a s s e s " a t A u s t i n H i g h S c h o o l i n t h e 1963-64 a n d 1964-65 s c h o o l y e a r s , when she was a p p r o x i m a t e l y 17 a n d 18 y e a r s old. This also i n d i c a t e s t h a t she was a d m i n i s t e r e d 1962 on w h i c h beside "High she s c o r e d 67. Written an IQ t e s t Level." The s c h o o l record i n July on t h e s c h o o l h e r c l a s s e s f o r t h e 1963-64 s c h o o l y e a r Elementary school record record i s the phrase reflects that K e r b y e a r n e d a m i x o f "A," "B," a n d "C" g r a d e s f o r h e r c l a s s e s both i n t h e 1963-64 s c h o o l y e a r Notations on t h e same s c h o o l a n d t h e 1964-65 s c h o o l year. r e c o r d appear t o i n d i c a t e t h a t K e r b y s c o r e d w e l l b e l o w h e r g r a d e l e v e l on a c h i e v e m e n t g i v e n i n S e p t e m b e r 1963 a n d i n May 1964. tests The s e c o n d page o f t h a t s c h o o l r e c o r d c o n t a i n s a s t a t e m e n t t h a t K e r b y "needs h e l p 10 2100874 for mental contain illness!" any A second features school identifying indicates that i t reflects record the that school 5 "D" g r a d e s and The n o t a t i o n denotes Kerby because the repeating same school course record l a b e l e d " R e p e a t Work" t h a t c o n t a i n s I n 1995, when K e r b y was test who According administered IQ full-scale IQ was Kerby "significant had 70. Kerby Borderline "would to intellectual test and Loftin Mild be g i v e n services work or contains that not a is column information. Stewart Center i n evaluated Kerby, Loftin, Kerby's also noted i n h i s report weaknesses classified [intellectual functioning." rehabilitation should be received. a u t h o r e d by J o e l E. i n adaptive r e l a t i v e t o h e r age p e e r s i n t h e community." that only 48 y e a r s o l d , she t o o k a n o t h e r IQ to a report the earning no r e c o r d e d when she s o u g h t p l a c e m e n t i n t h e B i l l Moulton. which a p p e a r s on t h a t r e c o r d ; w h e t h e r was not y e a r shows g r a d e o u t o f t h e 16 g r a d e s "2nd y e a r " that unclear, 1 "C" but K e r b y ' s 1961-62 s c h o o l t h a t K e r b y f a i l e d most o f h e r c l a s s e s t h a t y e a r , does Loftin as 11 functioning L o f t i n concluded functioning disability] recommended f o r K e r b y and n o t e d t h a t t o development that in the range of vocational"attention of independent l i v i n g skills 2100874 and work activity skills along s o c i a l i z a t i o n and interpersonal LaGretta the with Ratliff, development of better skills." D i r e c t o r o f Community S e r v i c e s the Department, t e s t i f i e d at the f a i r hearing before the at ALJ. R a t l i f f t e s t i f i e d t h a t she had d e n i e d w a i v e r s e r v i c e s t o K e r b y b a s e d on was the f a c t t h a t K e r b y had therefore According not qualified scored to 70 on receive an IQ t e s t waiver t o R a t l i f f , had K e r b y n e v e r s c o r e d and services. 70 on an IQ test, R a t l i f f w o u l d have a p p r o v e d K e r b y f o r w a i v e r s e r v i c e s . When asked whether the test f a c t t h a t Kerby scored a 62 on an administered i n 2009 w o u l d change R a t l i f f ' s d e c i s i o n , answered the IQ in negative, explaining that i n d i c a t e d t h a t , a t some p o i n t , K e r b y had the intellectual-disability Dr. Behavioral Disability Susan Ford, Services at the the for of 70 functioned outside of Director the of Division Psychological of Dr. Ford explained that she Dr. had reviewed a l l the 12 the ALJ. appeals from the d e n i a l of properly denied waiver services. she and Intellectual Department, a l s o t e s t i f i e d b e f o r e t h a t K e r b y was Ford, score range. Dr. F o r d ' s d u t i e s i n c l u d e r e v i e w i n g waiver services. the Ratliff had concluded According documentation to originally 2100874 p r o v i d e d t o t h e A g e n c y and had Kerby's counsel to determine impact the d e c i s i o n reviewed and the appeal reviewed later whether those t o deny K e r b y w a i v e r assessed Kerby's submissions submissions services; eligibility by might Dr. three times Ford during process. Dr. F o r d s a i d t h a t she b a s e d h e r c o n c l u s i o n , i n p a r t , on the fact t h a t K e r b y had once s c o r e d 70 on an F o r d e x p l a i n e d t h a t a s c o r e on an ability than factors a test affecting however, she subject's true the said, Dr. been affected other of the test; that test than the t e s t s u b j e c t a c t u a l l y has. received earlier intelligence that waiver and life in level; other, services. cannot because a by her throughout fact of Ford admitted t h a t Kerby's have s c o r e o f 70 on an IQ t e s t services that life reflect she the might may lower better have Kerby reflect her h o w e v e r , Dr. F o r d d i d n o t a g r e e lower scores According existed t o Dr. Ford, qualified a person s e r v i c e s i f he o r she had true t h a t the Kerby for receiving disqualified s c o r e d 70 on an IQ t e s t . 13 may received score w a i v e r s e r v i c e s w o u l d be r e e v a l u a t e d and c o u l d be for be test IQ s u b j e c t has more a b i l i t y Dr. s u b j e c t at the time test an test. at times, IQ t e s t may, lower IQ Although 2100874 she admitted that error the for o f measurement, Department's score scores on an IQ t e s t h a d a +/- Dr. F o r d s t a t e d administrative that rules to Dr. consider Kerby's eligibility services. Ford regarding standard she was bound by o f 70 on t h e 1995 IQ t e s t t o d e t e r m i n e h e r waiver further explained Kerby's claimed that other t h e 1962 information i n t e l l e c t u a l d i s a b i l i t y was l a c k i n g i n t h e d o c u m e n t a t i o n t h a t she h a d r e v i e w e d . Ford, 3 t o Dr. o f 67 n o t e d on K e r b y ' s IQ t e s t s c o r e According school r e c o r d s d i d meet t h e r e q u i r e m e n t o f " s i g n i f i c a n t l y s u b - a v e r a g e general intellectual functioning." a l t h o u g h Kerby had s c o r e d as f a r as the problem" Although the "normal," special a 67 on t h e IQ t e s t , she h a d n e v e r , the documentation i n t e l l e c t u a l l y disabled. leading record to the classes i n school, Ford of adaptive of waiver that Kerby had grades and as services. never been and h a d b e e n p l a c e d that testified a v a i l a b l e was n o t s u f f i c i e n t level diagnosed denial reflected she h a d p o o r Dr. r e f l e c t e d , been T h i s , Dr. F o r d s t a t e d , "was p a r t o f that independently, However, Dr. F o r d n o t e d , she that had the never in lived information f o r her to determine the a c t u a l f u n c t i o n i n g t h a t Kerby had had b e f o r e 14 she 2100874 turned 18 y e a r s old. According t o Dr. Ford, the information l i s t e d d e f i c i t s i n Kerby's a b i l i t i e s but d i d not e s t a b l i s h the skills t h a t Kerby d i d have. provide a solid basis Without information for age functioning l e v e l before determining 18, Dr. that Kerby's could adaptive- Ford explained, she was u n a b l e t o d e t e r m i n e w h e t h e r s e r v i c e s t h a t had been p r o v i d e d Kerby had testified, waiver increased she had her IQ concluded s e r v i c e s under Rule The score over she qualify for 580-5-30-.02(3)(a). r e c o r d c o n t a i n s o t h e r documents, i n c l u d i n g l e t t e r s t o and e x p l a i n i n g the and Dr. Ford memoranda personnel from outlining documentation a Thus, t h a t Kerby d i d not Montgomery c o n v e y i n g In time. to November her relating 2008 to Department's d e n i a l Department and/or recommendations a f t e r to Kerby p r o v i d e d letter, Patricia her to the Martin, Agency review of Department. who A s s o c i a t e Commissioner f o r the D i v i s i o n of M e n t a l was then Retardation S e r v i c e s of the Department, e x p l a i n e d the v a r i o u s reasons t h e D e p a r t m e n t had d e t e r m i n e d t h a t K e r b y was waiver services. waiver s e r v i c e s : "(1) deficits in First, adaptive an Martin IQ score set b e l o w 70; functioning 15 out skills not e l i g i b l e the (2) criteria why for for significant measured by a 2100874 standardized tool; AND (3) evidence p r e s e n t p r i o r t o the person's 18th t h a t the p r i m a r y reason f o r the K e r b y was the which, Martin fact that stated, s e r v i c e s under the to scored her & 2 Martin were stated 70 on an IQ to test, for consideration for a l s o mentioned that Martin the 1 d e n i a l of waiver s e r v i c e s "eliminates documentation provided both birthday." K e r b y had waiver." that the Department c o n t a i n e d a letter r e q u e s t i n g an a s s e s s m e n t t h a t s t a t e d t h a t K e r b y " p o s s e s s e s a l l her self-care skills," suggest that multiple areas of well." [the Finally, presence adaptive Martin "insufficient evidence met for a age of criteria prior to letter, the Martin which, of] Martin, significant "might in f u n c t i o n i n g were q u e s t i o n a b l e as the to v e r i f y diagnosis further to deficits stated, ... 18 according of years." documentation that [ K e r b y ] w o u l d have [intellectual In the provided disability] conclusion of explained: " A l t h o u g h [ K e r b y ] may have been g i v e n a d i a g n o s i s o f [ i n t e l l e c t u a l d i s a b i l i t y ] e a r l y i n l i f e , t h a t does n o t g u a r a n t e e t h a t she meets t h e s t r i c t e l i g i b i l i t y criteria required. Not everyone with [an intellectual disability] qualifies for services u n d e r t h e W a i v e r i n A l a b a m a b e c a u s e t h e r e must a l s o be e v i d e n c e t h a t , e x c e p t f o r t h o s e s e r v i c e s , t h e p e r s o n w o u l d have t o be i n s t i t u t i o n a l i z e d i n the n e a r f u t u r e . The r e p o r t i s s u e d i n 1995 indicated t h a t [ K e r b y ] was e s t i m a t e d t o be f u n c t i o n i n g w i t h i n 16 her 2100874 the B o r d e r l i n e to M i l d [ i n t e l l e c t u a l disability] range of i n t e l l i g e n c e . Persons f u n c t i o n i n g i n the B o r d e r l i n e range of i n t e l l i g e n c e are not considered t o have a d i a g n o s i s o f [ i n t e l l e c t u a l d i s a b i l i t y ] and t h o s e w i t h m i l d [ i n t e l l e c t u a l d i s a b i l i t i e s ] do n o t t y p i c a l l y r e q u i r e an i n s t i t u t i o n a l l e v e l o f c a r e . Therefore, t h e y w o u l d most l i k e l y n o t q u a l i f y f o r [ i n t e l l e c t u a l d i s a b i l i t y ] waiver s e r v i c e s . " A f t e r the c o n c l u s i o n the ALJ made a Department's written of the recommendation denial of "substantiat[es] sought." The t h e age o f 18 and Turner regarding reach his conclusion her the to opined [Kerby's] letter that on Dr. Ford's In waiver school record administered on t h e t e s t i m o n y f r o m Montgomery that Kerby skills met his the to the the record the i n order and to eligibility services. rejecting the ALJ's recommendation, scored 70 t e s t , which, Commissioner S t e c k e l s t a t e d , d i s q u a l i f i e d found ALJ, the s c o r e d 67 on an IQ t e s t C o m m i s s i o n e r S t e c k e l n o t e d t h a t K e r b y had waiver services. the Kerby. right relied before Agency o v e r t u r n Kerby's l a c k of adaptive requirements for waiver In ALJ s t a t e d t h a t he i n d i c a t i n g t h a t K e r b y had hearing services the evidence before that waiver recommendation, ALJ fair on an IQ her for C o m m i s s i o n e r S t e c k e l a l s o n o t e d t h a t she had testimony m a t t e r of Kerby's e l i g i b i l i t y and opinions persuasive for waiver services. 17 on the Finally, 2100874 Commissioner S t e c k e l p o i n t e d that the w a i v e r - s e r v i c e s diagnostic criteria, o u t t h a t Dr. F o r d had r e q u i r e m e n t s were more s t r i n g e n t t h a n indicating diagnosed might be person might not q u a l i f y with an that, even intellectual f o r waiver the testimony Steckel and upheld the waiver services to evidence As noted judicial Kerby before Department's though a person disability, services that i f that person B a s e d on h e r were t o s c o r e 70 o r above on an IQ t e s t . of explained review the ALJ, original Commissioner decision denying Kerby. above, Montgomery, on Kerby's behalf, sought r e v i e w of the Agency's d e n i a l of w a i v e r s e r v i c e s i n t h e Morgan C i r c u i t C o u r t . The circuit court, after c o n s i d e r i n g t h e a d m i n i s t r a t i v e r e c o r d and s u b m i s s i o n s by parties, e n t e r e d a judgment o r d e r i n g waiver services circuit court reliance on rejection found fault the testimony of the determinations. court's t o Kerby. The and ALJ's the of i t s judgment, Commissioner opinion of findings concluding paragraph Dr. and of the Steckel's Ford and her credibility the circuit judgment r e a d s : "The Court concludes that the Agency Commissioner rejected the findings and 18 both t h a t the Agency p r o v i d e In support with to 2100874 r e c o m m e n d a t i o n s o f t h e A d m i n i s t r a t i v e Law Judge i n f a v o r o f t h e w r i t t e n o p i n i o n s o f one w i t n e s s , Dr. Susan F o r d . The C o m m i s s i o n e r i n e s s e n c e i g n o r e d a l l o t h e r e v i d e n c e , i n c l u d i n g c e r t a i n t e s t i m o n y t h a t was e l i c i t e d f r o m Dr. F o r d d u r i n g t h e a d m i n i s t r a t i v e hearing, and overruled the credibility d e t e r m i n a t i o n s t h a t were made by t h e A d m i n i s t r a t i v e Law Judge. The Court is satisfied that the Commissioner's r e j e c t i o n of the f i n d i n g s of the Administrative Law Judge was done without substantial justification, that the substantial r i g h t s o f Ms. K e r b y were p r e j u d i c e d , that the Commissioner adopted l e g a l o p i n i o n s or c o n c l u s i o n s t h a t are not p a r t of the r e g u l a t i o n s governing eligibility for [waiver] s e r v i c e s and that her d e c i s i o n d e n y i n g e l i g i b i l i t y f o r Ms. K e r b y u n d e r t h e [waiver-services] p r o g r a m was not substantially justified and was unreasonable, arbitrary or capricious." From t h a t j u d g m e n t , t h e A g e n c y First, when the Agency i t overruled argues appeals. that Commissioner the circuit Steckel's court denial of erred waiver s e r v i c e s t o K e r b y i n l i g h t o f t h e d e f e r e n c e t o be a f f o r d e d Agency's d e t e r m i n a t i o n . interpreted Kerby and that, e x a m i n e d by K e r b y was the other and a p p l i e d the based the expert not The on hand, Agency contends t h a t i t p r o p e r l y criteria a review e m p l o y e d by eligible argues the for waiver of the a l l the the evidence e s t a b l i s h e d " u n e q u i v o c a l l y " t h a t K e r b y was 19 to evidence as D e p a r t m e n t , Dr. for wavier services. that services Ford, Montgomery, before the on ALJ e l i g i b l e for waiver 2100874 services and s e r v i c e s was that Commissioner Steckel's u n s u p p o r t e d by t h e e v i d e n c e denial and was of those arbitrary and capricious. This c o u r t , l i k e the c i r c u i t c o u r t , i s r e q u i r e d to with the presumption reasonable. circuit that Norred, court's 497 the So. judgment Agency circuit court give review of the standard of review. The more deference to the d e t e r m i n a t i o n and t o f a u l t C o m m i s s i o n e r S t e c k e l f o r the evidence at the f a i r hearing deny w a i v e r s e r v i c e s t o K e r b y . the Agency, a c t i n g through deference, not the determination for to support the her has of the App. d e c i s i o n to ALJ. "It is t h e a u t h o r i t y t o make t h e Agency, and the hearing b i n d i n g upon t h e 1987). As this court So. 2d final 1329, explained "For aught t h a t appears, the c i r c u i t c o u r t d i d a p p l y t h e AAPA's l i m i t e d s t a n d a r d o f r e v i e w i n 20 the officer's Norred: not due commissioner." A l a b a m a M e d i c a i d A g e n c y v. B e v e r l y E n t e r s . , 521 (Ala. Civ. reweighing Commissioner S t e c k e l , t h a t i s r e c o m m e n d a t i o n s a r e i n no way 1333 ALJ's However, i t i s t h e d e c i s i o n o f recommendation A g e n c y ' s c o m m i s s i o n e r who the regarding c o u r t ' s a p p l i c a t i o n of t h i s to Our and questions circuit appears decision i s just 2d a t 176-77. raises begin in 2100874 t h i s case, b u t , r a t h e r , s u b s t i t u t e d i t s judgment f o r t h a t o f t h e A g e n c y as t o t h e w e i g h t t o be g i v e n t h e evidence presented at the a d m i n i s t r a t i v e hearing. In this regard, we note that the findings and recommendations of the administrative hearing o f f i c e r , with which the c i r c u i t court concurred, were n o t b i n d i n g upon t h e A g e n c y . R a t h e r , i t i s t h e Agency's commissioner who makes the final d e t e r m i n a t i o n o f M e d i c a i d e l i g i b i l i t y b a s e d upon t h e evidence presented at the a d m i n i s t r a t i v e hearing. Rule 560-X-3-.01(2), Alabama Medicaid Agency A d m i n i s t r a t i v e Code." N o r r e d , 497 So. 2d a t 177. indicating that was i m p r o p e r l y court failed By f a v o r i n g t h e A L J ' s f i n d i n g s a n d the weight given ignored to apply t o t h e e v i d e n c e by t h e A L J by C o m m i s s i o n e r S t e c k e l , the appropriate standard the c i r c u i t of review t o the Agency's d e c i s i o n . However, the c i r c u i t court Commissioner adopted l e g a l also opinions determined that or conclusions that are not p a r t o f t h e r e g u l a t i o n s g o v e r n i n g e l i g i b i l i t y f o r services." In another p o r t i o n "the [waiver] o f i t s judgment, t h e c i r c u i t c o u r t e x p l a i n e d t h a t i t h a d c o n c l u d e d t h a t Dr. F o r d gave l e g a l opinions that stringent obtains than the "[w]aiver diagnostic an IQ s c o r e eligibility criteria" o f 70 o r h i g h e r i s d e t e r m i n e d t o be ... i n e l i g i b l e if there have b e e n o t h e r IQ s c o r e s 21 r e q u i r e m e n t i s more and t h a t " i f a person a t any p o i n t , t h e p e r s o n f o r [w]aiver s e r v i c e s even t h a t were b e l o w 70." The 2100874 circuit court went on t o s t a t e t h a t , b a s e d on i t s review of t h e A g e n c y ' s b r i e f and t h e a p p l i c a b l e a d m i n i s t r a t i v e r u l e s , no law s u p p o r t e d Dr. explained that criteria for Ford's " l e g a l " o p i n i o n s . i t appeared to the intellectual court disability The that and c r i t e r i a f o r w a i v e r s e r v i c e s were " p a r a l l e l . " the circuit s c o r e o f 70 court stated that or higher a t any [ w a i v e r s e r v i c e s ] may does n o t have t h e The be misinterpreting eligibility by the the eligibility In conclusion, Ford's o p i n i o n point disqualifies diagnostic t h a t an a person failing IQ for law." f u r t h e r d e t e r m i n e d t h a t the Agency first s t a t e of i n t e l l e c t u a l the court a p r o f e s s i o n a l r u l e o f thumb, b u t i t f o r c e of c i r c u i t court "Dr. circuit to criterion focus on the presently t h e p r i n c i p l e t h a t words i n a r e g u l a t i o n s h o u l d be g i v e n their Enters., 521 So. circuit existing using and The waiver-services court, plain, ordinary, functioning. for was commonly u n d e r s t o o d m e a n i n g , see 2d at 1332 ("The language a d m i n i s t r a t i v e r e g u l a t i o n s h o u l d be g i v e n used Beverly in an i t s natural, plain, o r d i n a r y , and commonly u n d e r s t o o d m e a n i n g , j u s t as l a n g u a g e i n a s t a t u t e . " ) , c o n c l u d e d t h a t t h e use o f t h e w o r d "has" a p p l i c a b l e a d m i n i s t r a t i v e r u l e r e q u i r e d the Agency t o 22 in the consider 2100874 o n l y t h e most r e c e n t e v i d e n c e r e g a r d i n g K e r b y ' s IQ a n d n o t t h e e v i d e n c e f r o m 1995 e s t a b l i s h i n g t h a t K e r b y h a d s c o r e d 70 on an IQ t e s t . to See R u l e 5 8 0 - 5 - 3 0 - . 2 ( 3 ) ( a ) ( 1 ) ( s t a t i n g , i n p a r t , t h a t qualify "[t]he f o r waiver individual intellectual s e r v i c e s p r o o f must be p r e s e n t e d has significantly f u n c t i o n i n g (IQ l o w e r t h a n intelligence test)"). sub-average that general 70 on a s t a n d a r d i z e d B e c a u s e K e r b y h a d s c o r e d 62 on t h e most r e c e n t IQ t e s t a d m i n i s t e r e d t o h e r i n 2009, t h e c i r c u i t reasoned, waiver K e r b y met t h e f i r s t p a r t o f t h e f i r s t services. Although the c i r c u i t court criterion for court's attempt to apply the p r i n c i p l e s of s t a t u t o r y c o n s t r u c t i o n t o the language of Rule agree 580-5-30-.2(3)(a)(1), that the c i r c u i t i s understandable, court was permitted we cannot to reject the Agency's reasonable i n t e r p r e t a t i o n of the c r i t e r i a f o r waiver services set eligibility Again, out in f o r those the administrative rule governing services. i t appears t h a t the c i r c u i t court misunderstands b o t h t h e a p p r o p r i a t e s t a n d a r d o f r e v i e w and t h e w e l l principle that "an agency's interpretation of settled i t s own r e g u l a t i o n must s t a n d i f i t i s r e a s o n a b l e , e v e n t h o u g h i t may not appear as reasonable as 23 some other interpretation." 2100874 Ferlisi, 481 So. 2d a t 403. The i n t e r p r e t a t i o n of the D e p a r t m e n t ' s a n d t h e A g e n c y ' s g o v e r n i n g c r i t e r i a was e x p l a i n e d by M a r t i n waiver i n h e r l e t t e r t o Montgomery r e g a r d i n g services, Ratliff's hearing i n Dr. testimony before memorandum, and Dr. Ford's the ALJ. waiver-services Ford's the denial of and testimony at the criteria significant fair The c o n s i s t e n t i n t e r p r e t a t i o n o f t h e a d v a n c e d by t h e D e p a r t m e n t a n d t h e A g e n c y i s t h a t a p e r s o n must have " ( 1 ) an IQ s c o r e (2) i n both deficits measured by a s t a n d a r d i z e d i n adaptive t o o l ; AND b e l o w 70; functioning skills (3) e v i d e n c e t h a t b o t h 1 & 2 were p r e s e n t p r i o r t o t h e p e r s o n ' s 1 8 t h b i r t h d a y . " Both R a t l i f f and Dr. F o r d e x p l a i n e d that a person r e c e i v i n g waiver s e r v i c e s w o u l d be r e e v a l u a t e d and c o u l d s e r v i c e s i fthat person scored The 70 o r h i g h e r i s s u p p o r t e d by t h e f a c t t h a t federal criteria for i n t e l l e c t u a l l y disabled. services Sullivan, U.S.C. on an IQ t e s t . Department's and t h e Agency's i n t e r p r e t a t i o n o f t h e criteria offer be d i s q u a l i f i e d f o r §§ provision of Supp. i s no m a n d a t e d services Alabama i s p e r m i t t e d f o r the i n t e l l e c t u a l l y 776 F. there 645, 651 1396a(a)(10)(C)(iv) & 24 1991) 1396a(a)(31) the to decline to disabled. (D.R.I. to King v. (citing 42 (1988)) ("A 2100874 participating state [intermediate care mix of c o v e r a g e , as option persons not with to offer mental Alabama i s a l s o p e r m i t t e d amount, long the for s e r v i c e s at a l l . " ) . proper has as scope, care and and are retardation] "to choose the limitations duration services ICF-MR on provided in 'the b e s t i n t e r e s t s o f t h e r e c i p i e n t s . ' " A l e x a n d e r v. C h o a t e , 469 U.S. 287, see also S u l l i v a n , 776 303 (1985) ICF-MR [ i n t e r m e d i a t e (quoting F. 42 U.S.C. § 13 9 6 a ( a ) ( 1 9 ) ) ; Supp. at 651 ("If a state care f o r persons w i t h mental r e t a r d a t i o n ] s e r v i c e s i n i t s S t a t e P l a n , as Rhode I s l a n d has s t a t e i s f r e e t o s e t w h i c h l e v e l o f ICF-MR c a r e above the includes minimal requirements of done, t h e n the i t w i l l offer 42 U.S.C. §§ 1396a(a)(10)(C)(iv)."). No evidence Department's was the and presented Agency's e l i g i b i l i t y c r i t e r i a was any indicating interpretation that the of the unreasonable or t h a t i t c o n t r a d i c t e d o t h e r i n t e r p r e t a t i o n o f t h e same o r s i m i l a r c r i t e r i a . D e p a r t m e n t ' s and force of law, regulations by the and Agency's a d m i n i s t r a t i v e the reasonable those o f f i c i a l s r u l e s have i n t e r p r e t a t i o n of entrusted with The applying the those them a r e n o t mere " p r o f e s s i o n a l r u l e [ s ] o f thumb" and a r e , i n f a c t , 25 2100874 the law. 2d Ex p a r t e W i l b a n k s 422, 424 orders of H e a l t h C a r e S e r v s . , I n c . , 986 (Ala. 2007)("'Rules, administrative r e g u l a t i o n s , and authorities pursuant So. general to powers d e l e g a t e d t o them have t h e f o r c e and e f f e c t o f l a w s when t h e y are of Dep't statewide of 1988))). application Human Res., Therefore, 548 the (quoting So. 2d circuit 171, 173 i s the State (Ala. Civ. c o u r t was App. not p e r m i t t e d to of t h e c r i t e r i a f o r w a i v e r s e r v i c e s w i t h i t s own Agency v. the Agency's i n t e r p r e t a t i o n s u p p l a n t t h e D e p a r t m e n t ' s and The Hand agency to which interpretation. decisions regarding e l i g i b i l i t y f o r waiver s e r v i c e s are u l t i m a t e l y e n t r u s t e d . Ala. Code 1975, Alabama § 22-6-7 ("The [is] the single See M e d i c a i d Agency of the S t a t e of state agency charged with r e s p o n s i b i l i t y f o r a d m i n i s t e r i n g the Alabama M e d i c a i d Program "). The r e c o r d c o n t a i n s no e v i d e n c e indicating that the D e p a r t m e n t ' s and t h e A g e n c y ' s i n t e r p r e t a t i o n o f R u l e 580-5-30.02(3)(a) to i s unreasonable, interpret that rule and t h e c i r c u i t c o u r t was differently. However, we not f r e e must still c o n s i d e r whether Commissioner S t e c k e l ' s d e c i s i o n t o uphold denial of waiver justification, s e r v i c e s t o K e r b y was arbitrary, or capricious. 26 without We the substantial have explained 2100874 t h a t , even i n l i g h t of the are not binding determination, unbridled. on She Beverly so commissioner, however, the that Enters., B a s e d on f i n d i n g s of the " [ i ] n making i t will So. not be 2d a t capricious." Commissioner Steckel's d e n i a l of waiver s e r v i c e s to Kerby i s the Agency's i n t e r p r e t a t i o n o f R u l e 5 8 0 - 5 - 3 0 - . 0 2 ( 3 ) ( a ) and t h e a p p l i c a t i o n o f t h e in arbitrary, Therefore, Commissioner justification, or rule to capricious. Kerby. criteria d e c i s i o n i s not w i t h o u t s u b s t a n t i a l Steckel's that The determinations of Dr. Ford, R a t l i f f , M a r t i n , and C o m m i s s i o n e r S t e c k e l were c o n s i s t e n t the Department's criteria s e t out Ford t e s t i f i e d provided, test, for 1333. s u p p o r t e d by t h e D e p a r t m e n t ' s and out not justification a r b i t r a r y or evidence of r e c o r d , d e c i s i o n to uphold the set final o r b a s e i t upon a d e q u a t e p r i n c i p l e s o r f i x e d 521 the [a] ALJ commissioner's d i s c r e t i o n i s must have some r e a s o n a b l e her d e t e r m i n a t i o n standards the f a c t t h a t the and i n the the Agency's of the applicable administrative rule. Dr. t h a t , b a s e d on interpretation a l l the d o c u m e n t a t i o n she she had d e t e r m i n e d t h a t K e r b y had i n d i c a t i n g that intelligence. with Kerby had, in scored fact, 70 on an that Dr. F o r d a l s o n o t e d t h a t t h e e v i d e n c e 27 level was IQ of regarding 2100874 Kerby's a d a p t i v e - f u n c t i o n i n g not skills before t h e age o f 18 was d e v e l o p e d enough f o r h e r t o c o n c l u d e t h a t K e r b y f r o m an i n t e l l e c t u a l d i s a b i l i t y b e f o r e she t u r n e d suffered 18. B e c a u s e o f t h e s e f a c t s , D r . F o r d c o n c l u d e d , K e r b y was n o t e n t i t l e d t o waiver services. Dr. Ford's detailed explanation of the i s s u e s s h e e n c o u n t e r e d when a s s e s s i n g K e r b y ' s e l i g i b i l i t y a n d her testimony Kerby on that three she r e v i e w e d occasions c o n s i d e r a t i o n was g i v e n Steckel was e n t i t l e d information indicates pertaining to that t o Kerby's e l i g i b i l i t y . to rely on D r . F o r d ' s sufficient Commissioner analysis e l i g i b i l i t y c r i t e r i a a n d Dr. F o r d ' s d e c i s i o n r e g a r d i n g of the whether K e r b y met t h o s e c r i t e r i a ; t h e c o m m i s s i o n e r ' s d e c i s i o n t o do s o i s i n no way a r b i t r a r y o r c a p r i c i o u s . the judgment o f t h e c i r c u i t proceedings consistent with court this Accordingly, we reverse a n d remand t h e c a u s e f o r opinion. REVERSED AND REMANDED WITH INSTRUCTIONS. Thompson, P . J . , and Pittman, J . , concur. B r y a n , J . , c o n c u r s s p e c i a l l y , w i t h w r i t i n g , w h i c h Moore, J., joins. 28 2100874 BRYAN, J u d g e , c o n c u r r i n g specially. Given the d e f e r e n t i a l s t a n d a r d of review i n t h i s case, I must c o n c l u d e t h a t the circuit court erred in reversing d e c i s i o n by t h e A l a b a m a M e d i c a i d A g e n c y ("the Betty Jane Kerby waiver unfortunate result. cannot services. independently function and A g e n c y " ) t o deny However, Evidence i n d i c a t e s that that this is currently she could greatly I believe that Agency and have discretion to applicants interpreted grant waiver i t s rules Kerby and services; because interpretation, Moore, J . , I am of the bound t o f o r K e r b y and deference concur. concurs. 29 exercised similarly unfortunately C o n s e q u e n t l y , t h i s i s a s a d day However, any due i t the its situated has others l i k e the an Kerby b e n e f i t from the Agency's w a i v e r s e r v i c e s . could the not. her. Agency's

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