The opinion of the court was delivered by: Judge Brobson
Submitted: August 13, 2010
BEFORE: HONORABLE RENÉE COHN JUBELIRER, Judge, HONORABLE P. KEVIN BROBSON, Judge, HONORABLE ROCHELLE S. FRIEDMAN, Senior Judge.
Petitioner Sonja Kuznick (Kuznick) petitions for review of an order of the Department of Public Welfare (Department), Bureau of Hearings and Appeals (Bureau). The Chief Administrative Law Judge of the Bureau affirmed the decision of an Administrative Law Judge (ALJ) that denied Kuznick's appeal from a decision by the Bucks County Assistance Office (CAO). The CAO concluded that Kuznick is not eligible to retain part of her institutionalized*fn1 husband's monthly income because her own income is sufficient to enable her to live in the community without being impoverished. We affirm the Department's order.
The facts, as revealed in the ALJ's decision and the record, can be summarized as follows. Kuznick's husband resides in Buckingham Valley Nursing Facility. Mr. Kuznick applied to the CAO for Medical Assistance and Long Term Care (LTC) benefits. The CAO notified Mr. Kuznick on July 9, 2009, that it had approved his application with an effective date of February 25, 2009.*fn2
In making its determination regarding Mr. Kuznick's eligibility, the CAO (1) calculated the monthly amount Mr. Kuznick would be required to contribute to his nursing care costs based upon his monthly income, and (2) calculated the amount of monthly income Kuznick, as a community spouse (CS),*fn3 would need to live in the community in a non-impoverished manner. This latter calculation is known as a CS's minimum monthly maintenance need allowance (MMMNA).*fn4 If a CS's MMMNA is insufficient to prevent impoverishment, the CS is entitled to a modification of her institutionalized spouse's monthly contribution for long-term care, such that his contribution is reduced and the CS essentially retains a portion of the institutionalized spouse's monthly income, thereby increasing her MMMNA.
The CAO determined that Kuznick's MMMNA was $3,289.93. The CAO, using the above-noted regulatory formula, arrived at this figure by adding together Kuznick's excess monthly shelter allowance of $1,467.93 to the federally-established minimum monthly maintenance needs allowance of $1,822.00. The CAO concluded that because Kuznick's gross monthly income, which it determined to be $5,600.12, exceeded her MMMNA, she was not entitled to an increase in her MMMNA and corresponding reduction of Mr. Kuznick's monthly contribution for his nursing facility care.
Kuznick challenged this determination and the Bureau assigned the matter to an ALJ, who conducted a telephonic hearing on September 15, 2009. During that hearing, an Income Maintenance Caseworker (IMCW), Pamela Moteles, presented evidence that Kuznick's gross monthly income is $5,600.12, which reflects a gross monthly salary of $3,313.60, gross monthly social security payments of $1,802, a gross monthly pension of $340.74, and monthly interest income calculated to be $143.78. The IMCW explained that she examines a CS's total shelter costs, including rent or mortgage, insurance, taxes and a utility standard. The IMCW acknowledged that the utility standard may or may not bear any relationship to actual utility expenses. In Kuznick's case, the IMCW used the highest utility standard allowance of $491 per month. Kuznick's counsel offered "testimony" on behalf of Kuznick and also submitted to the ALJ documents, consisting mainly of credit card, mortgage, utility, pharmaceutical, and medical bills.
The ALJ determined that Kuznick's gross monthly income is $5,612.00 and that this income exceeded the MMMNA calculated by the CAO. The ALJ concluded that the CAO had fully complied with the regulatory directions for arriving at Kuznick's MMMNA and determining whether Kuznick is entitled to an increase in her MMMNA. The ALJ acknowledged that the purpose of the law is to prevent the impoverishment of a CS and that a county assistance office may increase a CS's MMMNA to prevent such impoverishment if "exceptional circumstances" warrant an increase. Davis v. Dep't of Pub. Welfare, 776 A.2d 1026 (Pa. Cmwlth. 2001). Nevertheless, the ALJ concluded that the expenses and bills upon which Kuznick relied did not support her assertions that exceptional circumstances exist with regard to her income.
Kuznick petitioned for review of the ALJ's order.*fn5 Kuznick does not contend that the CAO erred in its calculations. Rather, she contends that the ALJ erred as a matter of law in her application of this Court's holding in Davis. Kuznick suggests that the ALJ in this case erred by (1) addressing Kuznick's expenses individually, rather than in the aggregate, and (2) characterizing the services or commodities identified in the bills as reflecting lifestyle amenities instead of obligations that could be a precursor to impoverishment.*fn6
In Davis, 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. §1369r-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 ...