Siracusa V. ME Dept. of Health & Human Services

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SrATF0F\!Af'Jf Kl:-"i:\EBEC, S~ Sl;PERIOR COlTRT LOC\HON: _\UGCST,\ D~·~KCl :\o_ .-\P -14-l !i MICHAEL .J STRACCS.-'<. JR .. ) ) Petitioner. ORDER ON PETITIONER'S i\-I.R. CIV. P. SOC APPEAL STATE OJ- MAJNL: DEP.-\RTME~T OF HFALTJ-l & lTI_TMA~ SERVJCL:S, ) ) Respondent. ) ) ) Petitioner Ylichael J. Siracusa fi!Gd a M_R_ Ci>-_ P 80C appeal challenging a l·ebruary 3. 2014 ruling t'rom the Department of llealth and Human Services [""DHHS"' or the ""Department") affirming two pnor determmatwn' denying Mr. Siracusa's requests for reimbursement for ccnain non-~mergency medic~l tmnsportation ("NET'") expenses. Mr. Siracusa\ requests were denied because the service' he 'ought reimbursement for were not covered by Yl:am~Car~ and-because the \"isits were not cmcrgcnca:s -he should have contacted the trJ.Ilsportation broker in his area, Coordinated Transportation Solutions ('"CTS"'). Forth~ r~a"ms discussed below, the Court atiirm~ L.':te D~par~nent'< Deci.<ion and denies Petitioner's \1 R_ c,, P SOC appeal. I. Background The Department implemented the current ~ET 'yst~m on August 1, 2013 after working closely with the federal government for several years. See xenerally Record TaO, DHHS-:, MaineCare Benefits Manual (""v!BM'") Chapter Tl. Under the I ~E"l sy~tem. the Department •JTiiins boKers to arra10ge "or Lransponauon to MameCarc cmcreJ ;en-ices for illi di_tnble \L1meCare memhe" that '"''de 'n t'le hroker"s assignee region_ Se~ !d. JI ~ I i 3 02_ Mr Siracusa res' des m Augusta. which is region four. !d_ at § ll3_U3. CTS 10 the ~ET D~pw-tmcm Dec~>wn ("Decision"') broker r(•r .\lr Sikcusa·.l rcgwn_ Id. Rcconl Tab . .-\. 2.'3.- 14 ~-2 trdcrcncing CTS as Ms. Siracusa's broker_>. On l'<ovember 6 and 7. 2013. !VI;:. Siracusa submitted two customer reimbursement forms to CTS seeking reimbur<;ement for his travel i"rom Augusta to th" 11\IA Dentai Health C:inic in Bangor. a' ,,e;l a' Lo Dr. R1chanl Knipping of Gardmcr Famdy ChiropraCtiC, PC. See Record. Tab DHHS-5. The forms contain a section for the medical prov1dcr to complete attcstmg Ihm the person seeking reimbursement, "was seen by the 'vfaineCare covered service pro,·ider'" on the dmes tOr which the individual seeks 1\'FT reimbursement See id On each of the reimhur,em"nt (('rm' submilled hy Mr. :Siracusa the words '".\lmncCarc Provider" wtre crossed out and, on one of them. the tem1 ··MaineCare covered" was crossed out. id CIS denied both of Mr. Siracusa's reques:s for reimbursement because the services Mr. Siracusa obtl.incd \vcrc not \!aincCar~ covered SCTV!CCS_ Record. Tab DIJTIS-4. Mr Siracusa filed a umdJ re<juest \Vllh the Department J(>r an admm"lrative hearing on each of the two 1\tT rcirr:burscmcnt dcmals. Record, Tab DHHS-3 The Rearing Officer held an administrative hearing on December 18, 21)13. Record, Tab B (Administrative Hearing Tr;J.nscript). On February 3. 2014, the lleruing Officer issued the Decision upholdmg CTS 's denial of reimbursement 2 J(>r Mr Siracusa's travel ~~!''""~'- Record. \fR_ ("_ r r" b A. Decision 2-3. ~v!.r Sm.cusa appealed thm dc~1S10n purscmm to goc on Febnar:' 2ii. 2014. A. Standard ofRn-icw !: ml~r the ;l,.dministrat: ve Pro~edure.i Act ("A PA--l, an ,cgency 's decision may be reYersed or modificti by :he Coun il Ll cktermmes that the: Fintiings. inkrcn~C.I, cond LC<ions or deci 'ions are: \ l 1 ln 'iolati on of constitutional or starutory provisions: 1)) In c;..cess of the _,tatutor;; authority of the agency; (3) Made upon unla\\ful procec!ur~. (4) Affected b} bias or error of law; {5"il.lnsupponed b;-· substantial evidence on the "hole recl>rd: or {G) Arbitrary or capricious or charactcnzcd by abuse ot discretion 5 M.R. S. j l l 007( 4 )\C). The Court must g1 ve ·'con.<1der.1hle deference to an agency" s interprew.tion of its rules, regulations. and procedures and v..ill not set n a.>ule, unless the ntk or re~ulation plainly compels a ~ontrary re.<ult_ .. &e Fryeburg Health Care Crr. v Dep 'r of lfuman Servs , 1999 'viE 122, 'I 7, 734 A.2d 114 L The petitioner bears tl1e burden of showing the Dcparuncnt"s Uec~>wn i; arbitrary or baJJed on an error of law. !d. The Court is limited to a review of the administrative record, Vvith I:Ow exceptions that are not applicable to the instant case 5 ld R.:S. § 11006(1). ·' lhe court shall not substitute ib]ud~ment tOr that oft:le agency on questions of !act" 5 \-I R S_ ~ 11 07(_1) 1l1e focus on appeal is not whether t.'-Je appelbte court would have reached the same conclusion as the I {earing Officer, but whether h>e Record crmtain> competent and substantial evidence that .<upport~ the results reached. OYCO, Inc v Supenntendent 6. 703 A2d 1258 3 ~f In1., 1997 lVfE 22G, ~ B. 'Ybdbcrthc \tBM and the Hearing Offic~r'$ Decision Violate State or F ederul Law ll.fr ~irocus~ argues L'l~ He"n"g (lfRcer s Llecioion and the interrreration of the :VlB\1 vmlale Lhe Sociol ~ecurity D~panmcnt"s Act and .\mencan.< with D1 >abili hes Acl (''ADS') or· Llll~ 41 of the U n.ited States Code, regarding Public Ileaith and Wellilre. h;· denying .1.im rc,mbur.,ement ror the transportation expense;: at JS>ue While \lr_ S1racusa i., correct th~tutlc 42 aftOrds h1m cenain rights and protccl!ons, the r'1Zht to reimbursement fe-r LrJnsponation to non-Mamelare cc\e,ed services is not one oi'thenl. In order to r~ce1ve l;oderal funds. the Dcpanmcm'.< MaineCare program must compl)' "lth federal law. See met. staks ha\'e duration '\ub~tantinl limitation~ 4~ U S.C.~ ll9Ga(a). Once the federal discretion to choo~e rcyuir~men!.< are Lhe pmper mix of amount, scope, and on wverage, as long as care anJ scrv1ces are provided in the best mlne-;t' of the recipients" Plcmned Parenthood of indiana, inc. v Comm 'r of fndiantl Swre Dep't of Heaith. 69~ F.Jd 96~. 969 (7th Cir. 20!2) (citing Akwnder v Choate, 41,9 U.S. 2S7. 303 (1985) (quoting42lJ.S.C. § 1396a(a)(l9) Maine, like all smtcs par•.ic!paling in Medicaid. must subm1l proposed Medicaid "stnte pians ., to the Centers for 'vkdicarc & \ledicaid Sen·ices (''C.\IS"), a di v~;wn of Lhe fcdnal Depanment of Health and Human ~enrices. Sec Douglas v Jndep. Uving Ctr of S Cal, Inc., 132 S.Ct. 1204, 1208 1_20>2) AltematiYely. states may apply to CYIS for authority 10 <'perate a 'vledicaid scn·icc pur,uant to a "waiver." in orJcr 10 waive certain of the stole plan requirement< set forth in scctwn 1396a. See 42 C.l'.R. § 430.~5(c)_: Jra 'll1c Department is operanng its },--:ET program pursuant to a waiver. The decision to operate pursuant to a waiver l>..a> no 'ignificance to the present appeal. 4 sTate's ~Jan or '>'m,·er does not comply ,,nh fed~c;J.: requirements. the r:ederal government m:c: withhold Lf:tat stale·' Medicaid fJndmg. See C C.F .R. §~ 4 30.12t c), 4.1 O.:Q, .1.3 0 .3 5. 42 C.f.R f -!31.5< pro\·idcs d!m A St,ue plan :uust· ( u) Spec it:-' that d1e lvkdicmd at!ency wi I! ensurt r.ccc,sary tnmsportati<'ll to bcnctCcmr'es to and from providers; J.nd r,b} Dcscnhe the methods th~t the agenc;· t..le to meet this reqmrcment. "'I' 'j he Department implemc·ntc·d Secticm I :3 of the /villM to r~~ulate the stme· s 1\L ]" services and to :;J.tisfy its rcsponsibiEties under this regulatiOn. S~cllons 11 3.06(C) and (F) o 1 'he 'viR M require vcnficatmn of member eligibility li>rl\"F"'"' services. Record, Tab D!ll!S-2 . .'\lB.\[§§ 113 Obi C). IJ-). -"lET broker>. y,ho act on behalf of the Derartmcnt, must ensure that member> are eligible by detemumng whether the rcq llested trip or requested reimbursement is for a \faineCare-authorized service for thm m~mber. !d at§§ ll3.06(C\ (F)i 1 )(a). l\L 1 scrvic~s are only availohie J(>r trJ.nsportation to MaineCare covered services. :md a broker must deny rc1mbmsement for transportation if a member is detem1ined indJgiblc !d. J.l §§ 11 J. 04(AJ (tnkd, "-"ion~mergency transportation to covered ~!a;neC.tre 1ervices"), 113 .09(A )(I ) (denial of serv1ct,, permitted when a member" ineligible for -"lET ,erv1ces based on the information pw\ ;ded J.nd availa blc to the Broker). ·1he /\' ET bwker.1 may not allow the use of Medicaid- iimded transportatwn J(Jr any purpose other than a' ,,t:>.ted in of Ihe \ffil\1. or for purpose<; in violation of an:-- stale or federal law. !d. at H~re, Maine Care C.F.R. ~ S~cl!on 113 113. I O(B). the :-iBM's ;:eqmrcmenL that reimbursable -"lET expenses are limited to aud!un~.ed oer~ices ~ 431.5~, is not an abu.'e of discretion and docs not violate 42 the Social Securil) i\.ct. the ADA, or 5 an~ mher applicable fedcralldw~. Tin'> 10 becJ~:se section ~ 31 53\ a:' reel u1res the Depar~ment to ··enst;re necessary :ransportmion tOr bc,lctl~iam> L•' ami ii-Pm pre>\· idero [T 42 C.i'.R ~ 4 3 1.53(a)_ Smce oec:ion 4 3 i _53( a) C:oe.' nN define the term providers, :he Department has sub,lantial discrct!On tu mterpret the tem1 -'os long as CQre and services arc provuled in the be't ;nterests of the r~clplenb_., See Planned !'wenrhood oflndiana. inc., 6~~ F.3d m 969 (~lllr.~ Ai~xander v Choare. 469 L' S_ m 303 (quoting 4: C_S_( § 139Go(a)(l'!J)). l'he Department'' interpretation of this requucmcC~t as resLricting '-!FT 'en-ices-ami reimburscm~nt thereof-10 transportation for _lv[aJ,lCCarc covcr~d <ervic~s i' a reasonable exerc1se of the Department" s discretion and does not violate federal law_ See also 42 C .f'.R. § 4 31.4 3 (~xplamin~ that 'ecti<-.r. 1902( aJ(23) of the Social Sec uri~ 1\ct, cmhtle<.l at ~2 1; .S.C. § 13 %aG3 ), quali:icd Medi_~_aid ·'pro-.,-Jd~s ;hat DcncEculrics may obtain sen ice~ from ;!ny prO\·ider \lmt undertakes tO provide the SCtvleCs (() lh~m'' (~mphasis added). Furthermore. the Hcarmg Oliic~r did not abuse hel discretion in denying Mr. Siracusa's reimbursement request [.~" '·' becm.:.~e the services J\lr. Siracusa sought reimbursement ti1r were not MaineCare covcreC scrv1ees and lhu" not ;1vailab!e tOr re1m!mrs~ment under the \iBM_ RecorC, Tab Dlli!S 5 (Reimbursement Request Forms); Tab 4 DHHS 4 (Denials of Reimbursement Requests); 1·ee also Record, Tab Dlli!S-2, MB:Vl §i) 113 04iC). (F)_ The author:ty C1tcd by \lr S1racusa does not compel a different result. For example, 42 C.F R § 440.39C does not apply w the prcs~nt case because it concerns "bench.Jnark" coverage, Y<hid11.; mapplicable to the present situation. See 42 C.F_R_ § 440 305_ Furthermore, even if s~clion 440.390 were applicable, it would cut against Mr. 6 Sirocuoa·s pos1~:on as it provaies Lh:uthe State must assure ··t:ansportat!On :u anC Ji-onc mdically r_ecessary The s~n·1ces covcr~d \,lech~md !\-lr. Siracusa .Jen·iceo."' 42 C.I".R oe~h rennbur~ement ~ -H0.3~U (cmpha.~'-' dJded":o. for were not :>1amcCarc covered >en ices. Record, Tab DHHS 5 r_RelmlmT\ement Request 1-'ormsi; Tab --1 DHHS --1 (De,-,ials of Reimbursement R~queots) \1r Siracusa ~!so directs t!J.c cour-; w Ilurris' Jam~s- l :7 F 3d 99J (11th Cir. 1997}. In that case, the court analyzed whether. pursuant to --12 C F_R_ § 431 35 and 42 'C. S.C. S 1983, thre i <; a pr: vate. entOrceablc right to transponatwn to and ii-ctm Medicaid providers. fd_ m JililR-09 T1e ele\·enth circuit derermmed no such nght nl,Led Jd In Hnrgan v. Cohen, w "-h!ch Mr Siracusa also directs the Court, the United States District Court tor the Fastem Distr:ct of J:'enmyivania dctcrmmed that 42 C F_R_ § 431.53 does create an en!inceJ.hie right to tmnsportalion for Mcdicmd covncd sen-ic~~ li65 F.Supp. 1164. 1167 (L.D.Pa_ I 987)_ In hoth Harris :lnd Morgan, the plainllffs soughr to and enforce their alleg~d prot~Ll right to 1ransuor'.al10n to an<i from Medicaid covered scrv1ces. Hams. l 27 F Jd Jt 1012 {' ... we conclLtcie that plaintiFf, do not have a federal right. entOrc~ablc under ~--12 L'.S.C; § 1983, to trar:.sportarion to and !Tom Morgun, 1;65 F .Supp. at 1165 (plamr:tfs ar~ becau~~ pro,·iders): dig1hle to attend psychiatric serviceo ·•subsidizecl by the medical assistance (Medicaid) prograrn .'.forgan are inapposite M~dicaid ''} Accordingly. Harris and they involved reimbursement for CO\· ere'-' ;e!"-lices. unlike tho<e for which \lr. Siracusa seeks reimbursement. Record, l'ab DHHS:; (Rc!mbunement Request l'orms): 'lab 4 DHHS 4 (Denials of Reimbursement Requests}_l 'The orhcr cases cit~d hy Mr. Siro.cusa are also inapposne: Burduy v Donnelly, 2006 V.· L 381876 (Me_ Super. Jan 27. 2006) mvolved a person;1l injury/negligence case where MameCare was an insurer of one ol the parties and there were issues regarding the proper 7 C. Whether the Hearing Officc_r Entertained Bia~g__ai_ust_~lr. Siracusa :Vl:. Siracusa allcg:~' !haL the Hc:>n,-,5 OtTicer, \E·,-,ndo Ber,edict. emermined ~ J;ias Jgainst lum ant! had C.ctcr.nineJ 'he ..,oulC: ruie apinst :1im before :~earbg his argument. ln urC:cr tu oho\\· bid.,, l\-lr S1ra~u'a must present evidence sufficient if' OYercome a presumption that the fact·findcrs, as state administrators. acted in good tinth_ FnenJ.r oi Jfmm: 's ;'\lounrains v. Bd a_f Lnvrl !'rol, 2013 ML 25, '123, 61 A.Jd 689 (citing Ma/linckmdt ILC v. Liilfil. 616 1· .Supp.2d :zK 142 (D.\1c.2009)} ·'Witholl! a showing w the contrary. -,tale administrators 'Jte ~ssumed to be men land \Vomcnt of COUSC!Cncc and !n!dkctua1 cli.<clpline · :\Iallmckmdi JJC, 016 F Supp.2d at 142. l!ere, ~r. Siracusa docs not prcscm evidence suliiC!cnt to overcome the rrc,umption that \1s. Benedict Cour: =d~rstands ~cted why Mr Siracu.so in good faith and man unb1ascd manner. 'Wbilc the wa~ member of the Dcpanmcm pnor w the di>concerted by J\ls. Benedict meeting with a h~anng, lh~ record presents "'' eviden~e ofbm;;_ As discussed above. the Coun has tound that \Is Benedid properly applied the law to the Jilc~s of Mr. Siracu.su- s case. ln addition. the Court's rcv:ew vf the hearing transcript reveals no cvtdcncc ol impwpndies or hi a.' Cly Ms Be,eciict against :VIr. 'iiracusa. amount of damages and In the Case of Port T-!ud,on T-!ospila/ Provider v. Blu~ Cross Rl1<e Shield Associalwn, 2008 \1/L 646R501 (Dep't of Heulth & lluman Services Sept. 14, 201lR) involved a decision of the Administrawr of C'v!S regarding provider re1m bursement and issues of dual cligJbi1ity. The cases do not addre"' whetheT transporl<tlion expenses to service> not co•·ered by MaineCare-or Medicare or .'vlcd!Ca!d-musl he reimbursed pursuant w state or federal law. Mr. Siracusa's additional references to mhcr sour~es orlaw, mclll<iin~ website links and lists of various >ections of state and federal ;tatutes are 1ikewi;e inapposite_ 8 lll. Conclusion Th~ ~OC1a1 Dcparcment from sec;1ces. Secunt: A:;:. ;he AD.\. ,mel l"ecleral cJse law do nell prohibit the rcsmc~ing lhcr~tOre. oennbursemGr:t ior !'-.'FT e~per.ses to MamcCare J.uthorized s~rviccs hecause the Mr S1mcuoa seeks rcimbur;emenl for were not w \JaineCarc amhon<eC 'e"·ices. the Hcarmg Officer did not err m denying \Jr. Siracllsa ·' reqcest. ]"inally. 'vir. oupport h" daim that the ~iracausa Hemin~ has not pr~serMU >utlicient evidence m Ollicer wos biased against him, or othen•;isc acted m an improper manner. lhc cmr~ wdl be: Petitioner"s .\l.R. C1v P 80C Appeal 1S DENIED. Pursuant to M.R. c;,_ P. 7:J(a). the Clerk.'' hereb;· directed w incorrorate this Order by ,-eference in the docket. Dated: 1\-ovember 1J, 2014 Michaela Murphy. J@U:e :Waine Superior Court 9 Date Filed 2/26/14 Kennebec County Docket No AP-14-16 F Action- Pet1tron for Review J. Murphy 80C Mrcheel Siracusa. Jr Department of Health & Human Serv1ces Plaintiffs Attorney Defendant's Attorney Michael Siracusa, Jr . Pro Se 297 Cony Road Augusta. ME 04330-0502 Hallrday Moncure. AAG 6 State House Station Augusta. ME 04333-0006 Date of Entry 2/27/14 Petition for Judicial Revtew of Final Agency Actior>, filed 2/26/14 s/Srracusa. ProSe Applrcation to Proceed Without Payment of Fees and lndtgency Affidavit. filed 2/26/14. 3/5/14 ORDER Murphy. J. The filing fee rs warved The servrce costs shall be paid as an expense of administration Copy to Pelit10ner 3/19/14 Certified Marl receipts. filed 3/14114 s/Stracusa. ProSe _. DHHS Commtssioner. Administralive Hearings Office, Attn· Miranda Benedict. Esq., delivered 2/18/14 (no signature) · DHHS Commtssioner, Administrattve Heanngs Office_ Attn: G1sele Biron. Supt DHHS, delivered 2118/14 (no signature)_ 3/28/14 Entry of Appearance_ filed 3/27114 s/Moncure, MG 3/28/14 Respondent's Matron For Enlargement Of Time To File The SOC Record, filed 3/27114 s/Moncure, MG 3/28/14 Objectron to "Enlargement of Time." and Request to Seal Certrfied Record, filed s/Srracusa, Pro Se 4/16/14 Respondent's Objectron to Petitroners Matron to Seal Certified Record. filed (4/11114)_ s/Moncure, AAG 4/29/14 Certified Record, filed 4128114 s!Moncure. AAG (Sealed pendmg ruling on Request to Seal filed by Petittoner on 3/28/14) 4/29/14 Notice and Brrefing Schedule rssued_ Copy to Petrtroner and AAG Moncure Page 1 AP-14-16 <!130/14 ORDER, Murphy J (4/29/14) Ire Respondent's Mot1on for Enlargement of Time) The t1me by wh1ch the certified Recore must be filed in thiS matter shall be extended to 519114 Copy to Petitioner and AAG Moncure 4/30114 ORDER Murpl'>y. J. (4;'29114) (re_ Petitioner's Request to Seal Certified Record) Court will defer rul1ng on thiS mot1on until 1t re~1ews record from Respondent Clerk to present record :o Court oefore 11 is docketed and/or placed in public file Copy to Petitioner and AAG Moncure 5/2114 ORDER, Murphy, J The Court has rev1ewec the recora. The Mot1on to Seal is DENIED. Copy to Petitioner and AAG Moncure 5/12114 Brief of Petitioner filed (518/14) s/Siracusa, ProSe 619114 Brref of Respondent, filed siMoncure, AAG 6/25/14 Petitioner's Rebuttal, filed 6/24114 siSiracusa. ProSe 6/25114 Oral Argument scheduled for 913/14 at 1 30 Not1ce of Hearmg sent to Petitioner and AAG Moncure 6/27/14 Letter requesting the matter be subm1tled on the briefs, filed. s/Moncure. AAG 913114 Oral argument held, J Murpfly presiding_ Michael S'1racusa, Jr . Pro Se and Halliday Moncure. AAG Tape 1898 lndex2150-2716 Under advisement 11119114 ORDER ON PETITIONER'S 80C APPEAL. Murphy, J Petitioner's M RCiv P SOC Appeal IS DENIED Copy to Petitioner and AAG Moncure Copy to Repositones 11/19114 Not1ce of removal of Record sent to AAG Moncure Page 2

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