Opinion
23-0046
02-21-2024
JANELLE B. WILCOX, Petitioner-Appellant, v. IOWA DEPARTMENT OF HUMAN SERVICES, Respondent-Appellee.
Rebecca A. Brommel of Dorsey & Whitney, LLP, Des Moines, for appellant. Brenna Bird, Attorney General, and Robert J. Thole, Assistant Attorney General, for appellee.
Appeal from the Iowa District Court for Polk County, Robert B. Hanson, Judge.
Janelle Wilcox appeals the denial of her petition for judicial review of final agency action.
Rebecca A. Brommel of Dorsey & Whitney, LLP, Des Moines, for appellant.
Brenna Bird, Attorney General, and Robert J. Thole, Assistant Attorney General, for appellee.
Heard by Bower, C.J., Chicchelly, J., and Doyle, [*] S.J.
CHICCHELLY, JUDGE
A recipient of Medicaid waiver services appeals the denial of her petition for judicial review. The question is whether the Iowa Administrative Code authorizes stand-alone transportation services for program members receiving supported community living services that include transportation costs. Because the Iowa Department of Human Services properly determined that it does not, we affirm.
In 2022, the Iowa Department of Human Services and the Iowa Department of Public Health merged into the Iowa Department of Health and Human Services.
I. Background Facts and Proceedings.
Janelle Wilcox receives Medicaid benefits under the home- and community-based services (HCBS) brain injury waiver program. Members of the brain injury waiver program have two options for receiving their program benefits: (1) reimbursement for the cost of services covered by the program or (2) a community choice option (CCO), which provides a monthly budget for use toward covered expenses. Wilcox chose the CCO, which allows her to directly purchase goods and services or hire providers to meet her needs.
In June 2021, Wilcox asked Iowa Total Care, the managed care organization providing Wilcox with Medicaid services, to add 2835 miles of standalone transportation expenses to her monthly budget. Iowa Total Care denied the request for two reasons. First, it cited administrative rules that prevent reimbursement for transportation when the transportation costs are included as part of another covered service. Second, Iowa Total Care determined that added transportation is not medically necessary to meet Wilcox's needs. Wilcox launched an internal appeal of the decision, which Iowa Total Care also denied.
Wilcox asked the department to review Iowa Total Care's denial. An administrative law judge entered a proposed ruling that upheld the denial, and the final decision of the department accepted the proposed ruling. Wilcox petitioned for judicial review, which the district court denied. She now appeals.
II. Scope and Standard of Review.
"We review a district court's dismissal of a petition for judicial review for correction of errors at law." Irland v. Iowa Bd. of Med., 939 N.W.2d 85, 89 (Iowa 2020). Iowa Code section 17A.19 (2022) sets out our standard of review, which depends on the grounds raised by the petitioner. Tyson Foods, Inc. v. Hedlund, 740 N.W.2d 192, 195 (Iowa 2007). The question is whether the appellate court can reach the same conclusions as the district court when applying those standards. Id. If so, the court can affirm; if not, it must reverse or modify. Id.
III. Discussion.
Wilcox contends the district court erred by determining that she is not entitled to reimbursement for stand-alone transportation expenses. She also contends the district court erred by rejecting her arguments about medical necessity.
Iowa Administrative Code rule 441-83.86 (2021) outlines the services allowed under the brain injury waiver program. These services include supported community living (SCL) and transportation services. Iowa Admin. Code r. 44183.86. A detailed description of these services, criteria for coverage, and general service standards are set out in rule 441-78.43. The program pays only for services identified in a member's service plan. Iowa Admin. Code r. 441-78.43; see also id. r. 441-83.87 (detailing service plans under the brain injury waiver program).
The last five services listed in rule 441-83.86 are "financial management, independent support brokerage, self-directed personal care, self-directed community supports and employment, and individual-directed goods and services." Those services are only available to members who choose the CCO reimbursement, as detailed in rule 441-78.34(13)(c)-(e). Although rule 441-78.34 describes HCBS health and disability waiver services, subrule 78.34(13) is incorporated by reference in rules describing the services available to members of five other HCBS Medicaid waiver program members, including the brain injury waiver program members. See Iowa Admin. Code rr. 441-78.37(16) (elderly waiver services), 78.38(9) (AIDS/HIV waiver services), 78.41(15) (intellectual disability waiver services), 78.43(15) (brain injury waiver services), 78.46(6) (physical disability waiver services).
Wilcox's service plan identifies a need for "24-7 supervision to ensure safety and that needs are being met with assistance" with a goal "to access the community and integrate with others in [her] community." She is approved for SCL services, which include "personal and home skill training services, individual advocacy services, community skills training services, personal environment support services, transportation, and treatment services." Id. r. 441-78.43(2)(a). SCL transportation services "are activities and expenditures designed to assist the member to travel from one place to another to obtain services or carry out life's activities," excluding nonemergency medical transportation. Id. r. 441-78.43(2)(a)(5). SCL provider budgets must "reflect costs associated with members' specific support needs for travel and transportation." Id. r. 441-78.43(2)(e). Rule 441-78.43(2)(h) prohibits double billing or "double dipping" by stating that SCL services cannot "be simultaneously reimbursed with other residential services or with . . . transportation . . . services provided through Medicaid or the HCBS brain injury waiver." Id. r. 441-78.43(2)(h).
Rule 441-78.43(7) addresses other transportation services covered by the program, including transportation "for members to conduct business errands and essential shopping, to travel to and from work or day programs, and to reduce social isolation." Iowa Admin. Code r 441-78.43(7). As with reimbursement for SCL services, the rule prevents double dipping by prohibiting reimbursement for transportation services simultaneous with "HCBS brain injury waiver [SCL] service when the transportation costs are included within the [SCL] reimbursement rate." Id.
Wilcox elects to receive her program benefits under the CCO, which provides a monthly budget based on her assessed needs and the services authorized in their service plan. Id. r. 441-78.34(13)(b). SCL and transportation services are among the services that may be included in determining the individual budget amount for members of the brain injury waiver program. See id. r. 441-78.34(13)(b)(5). After the budget is set, a member can buy self-directed personal care services, self-directed community supports and employment services, and individual-directed goods and services. Id. r. 441-78.34(13)(d).
Wilcox's service plan provides for 2806 SCL units per month (twenty-three hours of SCL services per day), the maximum amount allowed. So the amount of her monthly budget provides for the cost of 2806 SCL units at the approved rate of $5.39 per unit. Wilcox requests an increase in her monthly budget to cover the cost of 2835 additional "stand alone" miles of transportation per month at the approved rate of $2.57 per mile.
For members who do not receive on-site staff supervision for an average of eight or more hours per day, a unit of service is fifteen minutes. Iowa Admin. Code r. 441-78.43(2)(e)(2). Up to 33,580 units are available per year, id. r. 441-78.43(2)(f)(2), which equals twenty-three units per day.
The department determined that Wilcox cannot be reimbursed for more transportation services based on the rules prohibiting double dipping.
The plain language states that, when the transportation costs are included in the SCL rate, those costs are not separately billable. Here, the evidence in the record indicates that some ([]frankly unknown) amount of the SCL rate is comprised of . . . transportation costs, as evidenced in part by DHS's spreadsheet entered into this record and the credible testimony of its program manager. While there may be a desire to quibble with some the precise phrasing [in] the DHS's program manager's testimony over the course of his extensive questioning, the general gist of his testimony was consistent and credible. This ends the case on some level, as how Wilcox structures her CCO budget and actual SCL time is irrelevant. The governing rules [tie] reimbursement to the inclu[sion] of [transportation] costs in the [SCL] rate itself, which occurred. Thus, the denial was appropriate, and Wilcox may wish follow DHS's program manager's suggestion and submit a new request that separates out transportation costs from her SCL rate, which would then allow her to bill such costs separately. As this would require a fundamental restructuring of Wilcox's services and as the record does not contain all such information, the Tribunal cannot simply do this now with the record made, particularly since the issue certified to it is relatively narrow.
Wilcox denies that she is double dipping, claiming that she wants her budget increased to account for transportation expenses that are not currently included rather than asking for reimbursement for expenses already reimbursed. She also argues that the CCO allows reimbursement for both SCL and transportation services. The district court rejected her arguments:
The Court concludes [Wilcox] is incorrect that transportation expense reimbursement entitlement is provided under two different authorizing programs and/or that the alleged two types of transportation expenses are distinct. "[SCL] services shall not be reimbursed simultaneously with other residential services or with . . . transportation . . . services provided through the HCBS injury waiver." Iowa Admin. Code r. 441-78.43(2)(h). Therefore, the question that must be answered is whether transportation expenses described under the CCO reimbursement mechanism in Iowa Administrative Code rule 441-78.34(13) are also "transportation services provided through the HCBS injury waiver." Id. Iowa
Administrative Code rule 441-78.34(13) is located under the heading, "HCBS health and disability waiver services." The Court does not need to resort to tools of interpretation to infer that "HCBS health and disability waiver services," under which the guidelines for calculation of a CCO monthly budget are provided, are reimbursement of the same transportation expenses provided for in Iowa Administrative Code rule 441-78.43(2)(a). The guidelines within rule 441-78.34(13) and their reference to transportation expenses address how those expense reimbursements are to be calculated in the scenario where the recipient elects the CCO and is entitled to a monthly budget.
[Wilcox] argues that allowing reimbursement for medical expenses under rules 441-78.34 and 441-78.43 does not implicate "double-dipping" of Medicaid benefits. The Court concludes this is incorrect as the former addresses the calculation of a monetary budget provided to a recipient to account for the same services as provided by [SCL] services where no monetary budget needs to be calculated. Therefore, the Court can return to an analysis of the disputed provision:
Transportation may not be reimbursed simultaneously with HCBS brain injury waiver [SCL] service when transportation costs are within the [SCL] reimbursement rate.
Iowa Admin. Code r. 441-78.43(7). This language is unambiguous based on how Medicaid waiver program benefits are addressed in the Iowa Administrative Code. Further, the word "within" substantiates the Court's conclusion. Here, the [SCL] reimbursement rate provides reimbursement of transportation expenses. However, that conclusion does not foreclose the possibility of reimbursement for transportation expenses outside of the waiver program altogether. The requirement is that the transportation expenses are not "within" the waiver program as applied through SCL reimbursement rates. Id. Hence, the Court concludes reimbursement expenses may be awarded when they are not provided for by SCL benefits as determined by the recipient's personal service care plan.
We reach the same conclusion as the district court. Simply put, Wilcox wants a bigger monthly budget. The amount of her budget depends on the services authorized in her service plan. Wilcox's service plan approves the maximum amount of SCL services allowed. Her SCL services include transportation. Because the department's administrative rules do not allow simultaneous stand-alone transportation when SCL services include transportation, Iowa Total Care properly denied the request for additional transportation mileage.
The proposed agency ruling states that a DHS manager "provided extensive and credible testimony about the SCL rate and the structure of the waiver program. In essence, DHS takes an average of certain reported transportation costs and uses that to calculate a portion of the SCL rate." "It is the agency's duty as the trier of fact, not the reviewing court, to determine the credibility of witnesses, to weigh the evidence, and to decide the facts in issue." Taylor v. Iowa Dep't of Hum. Servs., 870 N.W.2d 262, 266 (Iowa Ct. App. 2015). We give its credibility findings significant deference. See id.
The CCO rules list services that may be considered in determining the amount of a member's monthly budget. That list includes both SCL and transportation services. But it only states which brain injury waiver services could be covered in the CCO budget; it does not authorize the receipt of both. Which services are considered depends on the member's service plan. As noted above, the service plan must follow the rules for brain injury waiver services, including the prohibitions on double dipping. See Iowa Admin. Code r. 441-78.43(2)(h), (7).
Because the department reached the correct result by affirming Iowa Total Care's denial of Wilcox's request for stand-alone transportation, we affirm the denial of Wilcox's petition for judicial review without reaching the question of whether stand-alone transportation is medically necessary for Wilcox.
AFFIRMED.
[*] Senior judge assigned by order pursuant to Iowa Code section 602.9206 (2024).