Davis v. Dep't of Pub. Welfare

In Davis v. Dep't of Pub. Welfare, 776 A.2d 1026 (Pa. Cmwlth. 2001), a CS challenged a denial by a Department hearing officer of the CS's request for an increase in her MMMNA. Based upon an increase in the CS's pension benefits, the Department proposed to decrease her MMMNA. The CS, however, had also experienced an increase in the cost of her health care insurance. At the hearing, the CS produced documents reflecting an unreimbursed medical bill for $ 5,000 and other medical and dental expenses totaling approximately $ 23,000. The payment arrangement the CS had arrived at with the medical provider for the $ 5,000 bill required the CS to make monthly payments of $ 400. The hearing officer concluded that those expenses were not exceptional because such obligations were not out of the ordinary. Before addressing the merits of the case, this Court summarized the purposes behind the MMMNA rules: Prior to 1988, Medicare eligibility rules in this country frequently pauperized married couples by requiring them to virtually deplete their joint assets to allow one to qualify for coverage while the other remained in the "community." To prevent community spousal impoverishment, while ensuring that no one avoided contributing their fair share toward medical care, Congress amended the Social Security Act by enacting the Medical Catastrophe Coverage Act of 1988, 42 U.S.C. 1396r-5, as amended, (MCCA), allowing income for the community spouse above the poverty level. Under the MCCA, the community spouse receives, in addition to an allotted share of the couple's resources (the "protected share"), a minimum monthly maintenance needs allowance, or MMMNA, without rendering the institutionalized spouse ineligible for Medicare assistance. See 42 U.S.C. 1396r-5(d); 55 Pa. Code 181.452(d)(2). When the community spouse feels that the amount is inadequate, or encounters exceptional circumstances, the community spouse may request a hearing to seek revision of that allowance. Id. at 1028. The Court's opinion quoted the regulation containing the expression "exceptional circumstances," 55 Pa. Code 181.452(d)(2)(ix), as follows: The community spouse maintenance need allowance may exceed the amount determined in subparagraph (ii) standard monthly allowance and the amount specified in subparagraph (iv) statutory maximum if a greater amount is determined as a result of a Department hearing decision in which either spouse establishes that the community spouse needs income above the standard due to exceptional circumstances resulting in significant financial duress. The CAO shall review the increased income need established by the Departmental hearing decision at each application/reapplication whenever a change in the circumstances that warranted the increase no longer exist. Id. at 1028-29. This Court in Davis concluded that the hearing officer's approach was erroneous because the "hearing officer . . . mistakenly understood his task to be determining whether an expense was 'exceptional' or 'ordinary;' that is, he required that the nature of the expense itself be exceptional, rather than determining whether or not the expense involved presented exceptional demands on the resources of this particular community spouse. We think this is contrary to the letter and spirit of the statute." Id. at 1029. The Court stated that the regulatory standard required only a showing that "the circumstances and the necessity of the expenses be exceptional." Id. at 1030. The Court then stated that "we contend that the opportunity to increase the MMMNA here is not to 'guarantee the amenities of any current lifestyle' but rather to prevent the impoverishment of a community spouse." Id.