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Spring Creek Management, L.P., D/B/A Spring Creek Rehabilitation and v. Department of Public Welfare

June 8, 2012


The opinion of the court was delivered by: Renee Cohn Jubelirer, Judge

Submitted: March 16, 2012



Spring Creek Management, L.P., d/b/a Spring Creek Rehabilitation and Health Care Center (Spring Creek) petitions for review from the Order of the Department of Public Welfare (Department) affirming the Order and Adjudication of an Administrative Law Judge (ALJ) that denied Spring Creek‟s appeal from the denial of Medical Assistance (MA) Long Term Care (MA/LTC) benefits for its patient, W.T., an undocumented alien, by the Dauphin County Assistance Office (CAO). On appeal, Spring Creek argues that W.T. was improperly denied benefits under Section 150.11 of the Department‟s regulations, 55 Pa. Code § 150.11 (pertaining to the availability of MA benefits for undocumented aliens where the benefits are for the care and treatment of an emergency medical condition), because W.T. is suffering from an emergency medical condition.

W.T. suffered a stroke in June 2010, for which she was hospitalized until September 2010. On September 16, 2010, W.T. entered Spring Creek and, on September 29, 2010, Spring Creek submitted, on her behalf, an application for MA/LTC benefits to the CAO. The CAO requested proof of W.T.‟s emergency medical condition by letter dated December 9, 2010, and Spring Creek sent the CAO additional documentation on December 13, 2010. By notice mailed April 13, 2011, the CAO denied the requested MA/LTC benefits because it determined that no emergency medical condition existed and, therefore, W.T. was ineligible for assistance. Spring Creek timely appealed to the Bureau of Hearings and Appeals (BHA), and the ALJ held a hearing. (ALJ‟s Findings of Fact (FOF) ¶¶ 1-8.)

At the hearing, the CAO‟s Income Maintenance Caseworker Supervisor (Supervisor) testified, in relevant part, that once the CAO received the additional documentation of W.T.‟s condition, it forwarded that information to the Bureau of Policy (BOP) and Office of General Counsel (OGC) for a determination of W.T.‟s eligibility. Supervisor explained that, based on the reports from Spring Creek and a report by the CAO‟s own physician, the CAO could not open MA/LTC benefits for W.T. because she is in a stable condition and no emergency medical condition currently exists. (ALJ‟s Adjudication at 3; ALJ Hr‟g Tr. at 19-22, R.R. at 115a-18a.)

Spring Creek‟s Chief Clinical Officer (Clinical Officer), who has been a registered nurse for twenty-seven years, testified about W.T.‟s treatment in the hospital and that, when W.T. entered Spring Creek, she had "an aggregate of very severe chronic conditions, including skin breakdown as a result of her immobility, severely impaired mobility. She‟s incontinent to both bowel and bladder. She‟s severely hypertensive if she doesn‟t take her medications." (ALJ Hr‟g Tr. at 26, R.R. at 122a.) Clinical Officer stated that W.T. was unable to swallow when she entered Spring Creek, but could now swallow pureed food, and that any liquids had to be thickened to avoid choking and aspiration. According to Clinical Officer, W.T. continues to have impaired mobility, but can get around in a wheelchair using one arm, and is at risk for pressure sores, infections, or fractures due to her immobility and "cantankerousness." (ALJ Hr‟g Tr. at 27, R.R. at 123a.) Clinical Officer indicated that W.T. would require indefinite treatment and that, if W.T. did not receive treatment, she would be at risk of another stroke, choking, and additional medical problems, including death.*fn1 (ALJ Hr‟g Tr. at 26-29, R.R. at 122a-25a.)

The ALJ credited Clinical Officer‟s testimony that W.T. required nursing facility level of care, but not Clinical Officer‟s testimony that W.T. needs ongoing treatment for her stroke. (FOF ¶¶ 10-11.) Citing the definition of "emergency medical condition" found at Section 150.2 of the Department‟s regulations, 55 Pa. Code § 150.2, and the Department‟s Operations Memorandum 040301 (Operations Memo), which provides that ongoing treatment may be available in certain circumstances, the ALJ held that "no testimony was provided to show what treatment is still needed directly related to [W.T.‟s] stroke" and that Clinical Officer‟s testimony was regarding the care W.T. "needs as a result of her stroke." (ALJ Adjudication at 5.) The ALJ concluded that Spring Creek‟s treatment and care of W.T. was not ongoing treatment for an emergency medical condition, i.e., the stroke itself, and, therefore, the CAO properly denied the request for MA/LTC benefits. Spring Creek appealed to the BHA, which affirmed the ALJ‟s Order. Spring Creek now petitions this Court for review.*fn2

This case presents an issue of first impression for this Court: under what circumstances does an emergency medical condition continue, and when does the emergency end, such that an undocumented alien‟s treatment is no longer eligible for MA pursuant to federal and state law. In pertinent part, Section 150.11 of the Department‟s regulations sets forth the following:

(a) An alien who has an emergency medical condition as defined in § 150.2 (relating to definitions) and who meets the income, resource and other categorical requirements of the applicable MA program may be eligible for MA for the treatment of the emergency medical condition if the alien:

(3) Is an undocumented alien. . . . .

(d) An alien who had an emergency medical condition is required to provide at application verification of the emergency by presenting a written statement from the medical provider that specifies the following:

(1) The nature of the emergency medical condition.

(2) That the medical treatment was necessary because of the ...

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