Opinion
No. 12–P–1067.
2013-10-11
Kosal NOU, coadministrator, & others v. EXECUTIVE OFFICE OF HEALTH & HUMAN SERVICES & others.
By the Court (MILKEY, CARHART & SULLIVAN, JJ.).
MEMORANDUM AND ORDER PURSUANT TO RULE 1:28
Leang Kam, a participant in a Medicaid program designed to provide home care to the elderly, sought approval to have her son, Vannara Nou, paid for providing her care. The team of professionals assigned to her case denied that request, as ultimately did a hearing officer of the Medicaid board of hearings. After Kam died, Vannara and the administrators of her estate filed an action pursuant to G.L.c. 30A, § 14, seeking review of the agency's decision. A Superior Court judge dismissed the complaint based on mootness and lack of standing. We affirm.
As the plaintiffs concede, Kam's death renders moot any claim for prospective relief.
The only controversy that remains concerns whether Vannara is paid for the unapproved services he already provided.
Because the propriety of the decision on what care was due is bound up in the particular factual circumstances presented, this case does not meet the exceptions to the mootness doctrine. Compare Lockhart v. Attorney Gen., 390 Mass. 780, 783, 459 N.E.2d 813 (1984), with Guardianship of Nolan, 441 Mass. 1012, 1013, 806 N.E.2d 426 (2004).
We now turn to whether any of the plaintiffs has standing to bring a claim seeking such relief.
Despite the judge's comment to the contrary, it is indisputable that Vannara provided extensive care to his mother during most of the period between her hospitalization in November, 2009, and her death in October, 2010. It is also undisputed that neither Medicaid nor his mother paid him for those services.
Where “an issue involves an area of law governed by a specific statute with a standing requirement, that issue is governed by the standing requirements of the particular statute and not by a general grant of standing.” Centennial Healthcare Inv. Corp. v. Commissioner of the Div. of Med. Assistance, 61 Mass.App.Ct. 320, 328, 810 N.E.2d 1231 (2004) ( Centennial Healthcare ), quoting from Bello v. South Shore Hosp., 384 Mass. 770, 780, 429 N.E.2d 1011 (1981). The governing statute here, G.L .c. 118E, § 47, states with specificity that the only parties who may appeal a decision not to grant particular assistance are applicants for, or recipients of, medical assistance (or their designated legal representatives).
We do not decide whether Kam could have pursued such relief had she lived. At the hearing, the issue of retroactive payment was raised by the private agency provider. No representative of MassHealth participated at the agency level, and the hearing officer did not decide the question in light of his disposition. We are not aware of any regulations that address this question, and neither side has briefed it.
Accordingly, the only party with standing to challenge the denial of Kam's request to participate in the caregiver homes program was Kam herself.
The regulations include parallel provisions regarding administrative and judicial review. See 130 Code Mass. Regs. § 610.035(A)(7)(2006); 130 Code Mass. Regs. § 610.092(A)(2005).
See Centennial Healthcare, supra at 324–325, 810 N.E.2d 1231. The fact that Vannara rendered potentially fundable services with the hope of being paid does not provide him standing to challenge the agency's decision not to approve those services. In the end, Vannara has no legally cognizable interest in seeking a declaration that his mother would have been entitled to any particular services, regardless of whether the resolution of that issue had economic ramifications for him.
None of the plaintiffs has claimed to be Kam's “legal representative” as that term is used in the relevant statute and regulations, or purports to be suing in that capacity.
We acknowledge that our ruling has the effect of leaving Vannara without a remedy despite his vulnerable status.
However, to the extent the Medicaid system may leave unapproved providers without a means of challenging treatment decisions, that appears to be how it has been designed. See ibid. (Medicaid decisions “subject only to limited administrative and judicial review”). Compare G.L.c. 118E, § 38, third par.; 130 Code Mass. Regs. § 450.323 (2003) (appeal procedures for approved providers). We are bound by that legislative judgment.
We further recognize the possibility that Vannara relied on the availability of the appeal procedure when he provided his care.
Nor do the administrators of Kam's estate have standing. There is no evidence before us that the estate has any stake in whether Vannara is paid.
Without a demonstrated interest in the outcome of this litigation, the estate lacks standing to prosecute it. See Care & Protection of Sharlene, 445 Mass. 756, 771, 840 N.E.2d 918 (2006) (“The essence of standing, as it pertains to a private person, is whether the person has alleged a personal stake in the outcome of a controversy”).
This is not a case where, after being denied services, a Medicaid recipient agreed to pay for those services herself. Compare Shaw v. Secretary of the Executive Office of Health & Human Servs., 71 Mass.App.Ct. 218, 221–222, 881 N.E.2d 165 (2008). In that context, if the recipient died before the appeal concluded, the estate might well have standing to continue to seek reimbursement for the monies spent. Cf. 130 Code Mass. Regs. § 507.002(2) (2004). Here, by contrast, the estate has not demonstrated that it would gain anything even if it prevailed.
We recognize that in Sargeant v. Commissioner of Pub. Welfare, 383 Mass. 808, 818, 423 N.E.2d 755 (1981) ( Sargeant ), a recipient was held to have standing to assert a claim on behalf of an approved vendor where “overdue payments are for services already provided and the recipient must depend upon the provider for continued services.” Prior to 1991, no statutory or regulatory mechanism existed by which approved service providers could challenge erroneous denials of claims for payment. See St.1991, c.138, § 185. In Sargeant, supra the Supreme Judicial Court held, in effect, that providers owed money under approved contracts one way or another must have a means of ensuring that Medicaid lives up to its contractual obligations. The question of how approved providers can bring such claims has since been addressed by statutory and regulatory provisions that govern these issues. See G.L.c. 118E, § 38, third par.; 130 Code Mass. Regs. § 450.323 (2003).
The statutes and regulations governing appeals seeking approval of services are different. As is pertinent here, they grant appeal rights to the applicant or recipient, not the vendor, to press the claim. The statutes and regulations do not, in their current form, recognize an appeal by an estate in this context. G.L.c. 118E, § 47; 130 Code Mass. Regs. § 610.035(A)(7)(2006). Contrast G.L.c. 118, §§ 31 & 32 (explicitly referring to an estate). Based on the record before us, the current language of the statute and regulations, and the state of the case law,
we cannot conclude that the estate has standing.
We note that the case law subsequent to Sargeant rejects any “common law remedy for payment of claims under Medicaid.” Athol Memorial Hosp. v. Commissioner of the Div. of Med. Assistance, 437 Mass. 417, 422, 772 N.E.2d 569 (2002).
In sum, because we are compelled to conclude that none of the plaintiffs has standing to press the only remaining aspect of this controversy, we affirm the judgment dismissing the complaint. We do not reach the underlying merits.
Judgment affirmed.