Matter of Tomei v. McDonald

Summary

The New York Appellate Division, Third Department, upheld the denial of a Medicaid recipient’s request for reimbursement of out-of-pocket personal care expenses incurred after she received a Medicaid identification card and was determined eligible for services. The court held that 18 NYCRR 360-7.5 authorizes reimbursement for errors or delays in eligibility determinations, not delays in delivering authorized services, and confirmed the administrative determination.

Holdings

1. The regulation authorizes reimbursement for errors or delays in Medicaid eligibility determinations, including determinations concerning the level or duration of authorized personal care services, but does not authorize reimbursement for delays or failures in delivering services that were already authorized.
2. An administrative agency's rational construction of its own regulation is entitled to deference unless it conflicts with the regulation's plain meaning.
3. The administrative directive does not create a reimbursement right independent of 18 NYCRR 360-7.5, and the regulation prevails to the extent the directive conflicts with it.
4. A petitioner may not avoid available administrative remedies merely by asserting a due process violation when those remedies could provide the requested relief.
5. Arguments based on 42 CFR 431.246 and federal Medicaid comparability requirements were unpreserved because Tomei did not raise them at a fair hearing.

Questions Presented

1. Whether 18 NYCRR 360-7.5 authorizes Medicaid reimbursement for out-of-pocket expenses caused by an agency's delay or inability to provide already-authorized personal care services.
2. Whether the agency's interpretation of 18 NYCRR 360-7.5 was rational and consistent with the regulation's plain language.
3. Whether DOH Administrative Directive 10 OHIP/ADM-9 creates an independent reimbursement right.
4. Whether the agency's determination was arbitrary because it allegedly departed from prior fair hearing decisions.
5. Whether Tomei's due process claim was excused from the exhaustion requirement.
6. Whether Tomei preserved arguments under 42 CFR 431.246 and federal Medicaid comparability requirements.

Disposition

affirmed