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HECTOR DIAZ, Petitioner
DIVISION OF SOCIAL SERVICES and
DIVISION OF MEDICAL ASSISTANCE, NORTH CAROLINA DEPARTMENT OF
HEALTH AND HUMAN SERVICES, Respondent
FILED 7 APRIL 2006
Public Assistance--Medicaid--illegal alien--emergency medical treatment
Medicaid coverage was properly denied for chemotherapy for an illegal alien with
acute lymphocytic leukemia after his condition stabilized and no longer constituted an
emergency (although there was testimony that he would have regressed into an emergency
condition without the treatments). There is an emergency treatment provision in the federal
Medicaid statutes, but petitioner did not meet the statutory definition for an emergency medical
condition when he received the treatments in question.
Justice TIMMONS-GOODSON did not participate in the consideration or
decision of this case.
On discretionary review pursuant to N.C.G.S. § 7A-31 of
a unanimous decision of the Court of Appeals, 166 N.C. App. 209,
600 S.E.2d 877 (2004), affirming a judgment and order entered on
23 May 2003 by Judge James W. Webb in Superior Court, Guilford
County. On 3 March 2005, the Supreme Court allowed petitioner's
conditional petition for discretionary review as to an additional
issue. Heard in the Supreme Court 14 November 2005.
Ott Cone & Redpath, P.A., by Melanie M. Hamilton,
Thomas E. Cone, and Wendell H. Ott, for petitioner-
Roy Cooper, Attorney General, by Richard J. Votta,
Assistant Attorney General, for respondent-
This case requires determination of the scope of
coverage and reimbursement for a nonqualifying alien's medical
treatment under federal and North Carolina Medicaid law. Becausewe hold the relevant treatment provided to petitioner did not
qualify as treatment for an emergency medical condition, we
reverse the decision of the Court of Appeals.
Petitioner Hector Diaz, a native of Guatemala, is an
alien who is not lawfully admitted for permanent residence or
otherwise permanently residing in the United States under color
of law. 42 U.S.C. § 1396b(v)(1) (2000). In October of 2000,
Diaz began experiencing sore throat, nausea, vomiting, bleeding
gums, and increasing lethargy, which were later diagnosed as
symptoms of acute lymphocytic leukemia (ALL).
(See footnote 1)
Doctors at Moses
Cone Memorial Hospital in Greensboro, North Carolina treated
petitioner beginning on or about 21 October 2000. Chemotherapy
treatments commenced shortly thereafter and continued
intermittently until July of 2002.
At some time during his treatment, petitioner
authorized the medical service provider to seek Medicaid coverage
on his behalf. In the applications for Medicaid coverage
relevant to this appeal, respondent Division of Medical
Assistance (DMA) approved payment for emergency medical services
from 21-22 October 2000 and 9-11 February 2002. DMA denied all
other coverage dates relevant to this appeal as nonemergencyservices, and this denial was affirmed on administrative appeal
by a final decision of the Chief Hearing Officer of the North
Carolina Department of Health and Human Services. Consequently,
none of petitioner's chemotherapy treatments at issue were
reimbursed by Medicaid.
Petitioner appealed the final agency decision to the
Guilford County Superior Court, which reversed respondent's
decisions, finding the treatment was provided for an emergency
medical condition and that payment by Medicaid is not limited to
emergency services; rather, Medicaid shall pay for all care and
services as are medically necessary for the treatment of an
emergency medical condition. Respondent then appealed to the
North Carolina Court of Appeals, which unanimously affirmed the
decision of the trial court. This Court allowed respondent's
petition for discretionary review and petitioner's conditional
petition for discretionary review, and we now reverse the
decision of the Court of Appeals.
STANDARD OF REVIEW
In cases appealed from administrative tribunals, we
review questions of law de novo and questions of fact under the
whole record test. See N.C. Dep't of Env't & Natural Res. v.
Carroll, 358 N.C. 649, 659, 599 S.E.2d 888, 894-95 (2004).
CONSTRUCTION OF 42 U.S.C. § 1396b(v)
Medicaid is a joint program between participating
states and the federal government. North Carolina chose toparticipate and therefore must abide by federal statutory law
governing Medicaid reimbursement by the federal government. See
42 U.S.C. § 1396a (2000). If a state does not follow federal
Medicaid statutes in providing coverage for a patient, that state
risks losing Medicaid reimbursement from the federal government
for that payment. The relevant statute in this case provides the
federal government will not make payment to a state for medical
assistance furnished to an alien who is not lawfully admitted for
permanent residence or otherwise permanently residing in the
United States under color of law. Id. § 1396b(v)(1). There is
one exception to this broad rule, and that is for treatment of an
emergency medical condition, not related to an organ transplant
procedure, of an alien who would qualify but for his or her
immigration status. Id. § 1396b(v)(2) (2000). Subsection (v)(3)
defines an emergency medical condition as:
a medical condition (including emergency
labor and delivery) manifesting itself by
acute symptoms of sufficient severity
(including severe pain) such that the absence
of immediate medical attention could
reasonably be expected to result in--
(A) placing the patient's health in
(B) serious impairment to bodily
(C) serious dysfunction of any
bodily organ or part.
Id. § 1396b(v)(3) (2000). The relevant federal and North
Carolina administrative codes are in accord with this definition.
See 42 C.F.R. § 440.255(b)(1) & (c)(1) (2005); 10A NCAC 21B
.0302(c) (June 2004). We must now interpret this statute anddetermine whether petitioner's treatments were for an emergency
When the language of a statute is clear and without
ambiguity, it is the duty of this Court to give effect to the
plain meaning of the statute, and judicial construction of
legislative intent is not required. See Burgess v. Your House
of Raleigh, Inc., 326 N.C. 205, 209, 388 S.E.2d 134, 136 (1990).
However, when the language of a statute is ambiguous, this Court
will determine the purpose of the statute and the intent of the
legislature in its enactment. See Coastal Ready-Mix Concrete Co.
v. Bd. of Comm'rs of Town of Nags Head, 299 N.C. 620, 629, 265
S.E.2d 379, 385 (1980) (The best indicia of that intent are the
language of the statute or ordinance, the spirit of the act and
what the act seeks to accomplish.). We find the statute in
question to be clear and unambiguous; therefore, we will give
effect to its plain meaning.
In the leading case on this issue, Greenery
Rehabilitation Group, Inc. v. Hammon, the United States Court of
Appeals for the Second Circuit held that continuous and
regimented care provided for nonqualified aliens who suffered
sudden and serious head injuries that necessitated immediate
treatment and ultimately left the patients with long-term
debilitating conditions was not covered under the Medicaid
program. 150 F.3d 226, 228 (2d Cir. 1998). One of these
patients, Izeta Ugljanin, was [b]edridden and quadriplegic,
requiring a feeding tube and extensive nursing care. See id. Another, Leon Casimir, was unable to walk and required continual
monitoring and medication. He was unable to bathe, dress, eat,
or use the toilet without assistance. See id. at 228-29. A
third patient, Yik Kan, was legally blind. See id. at 229. The
United States District Court for the Northern District of New
York found Ugljanin and Casimir's treatments were for emergency
medical conditions, but that Yik Kan's treatment was not. See
id. at 231. In reversing the District Court as to the treatments
for Ugljanin and Casimir, the Second Circuit wrote: The
patients' sudden and severe head injuries undoubtedly satisfied
the plain meaning of § 1396b(v)(3). However, after the patients
were stabilized and the risk of further direct harm from their
injuries was essentially eliminated, the medical emergencies
ended. Id. at 232.
In arriving at this stabilization construction of
subsection 1396b(v)(3), the Second Circuit noted when determining
whether a condition is an emergency medical condition, the key
words are emergency, acute, manifest, and immediate. See
id. Using the common definitions of those words, that court
concluded: [T]he statutory language unambiguously conveys the
meaning that emergency medical conditions are sudden, severe and
short-lived physical injuries or illnesses that require immediate
treatment to prevent further harm. Id. This analysis closely
adheres to the clear and unambiguous language of subsection
1396b(v)(3). Accordingly, we find the Greenery decision
persuasive. Petitioner contends that once a patient presents with
an emergency medical condition, any and all treatment necessary
for the cure of the underlying cause of the emergency medical
condition must be covered, even when the condition is no longer
an emergency. We disagree. Petitioner's contention, in our
view, is contrary to the plain meaning of the statute. Under
subsection 1396b(v)(3), in order for a nonqualifying alien to be
entitled to Medicaid coverage, his or her condition must require
immediate intervention to prevent the occurrence of any of the
three statutorily enumerated results. See 42 U.S.C. §
1396b(v)(3). The word immediate is commonly defined as:
occurring, acting, or accomplished without loss of time : made
or done at once : INSTANT. Webster's Third New International
Dictionary 1129 (16th ed. 1971). Therefore, treatment is not for
an emergency medical condition under subsection 1396b(v)(3)
unless one of the statutorily enumerated results is reasonably
expected if immediate treatment is withheld.
We are cognizant the Supreme Court of Connecticut has
decided a case factually similar to this one and has held
contrary to our decision today. See Szewczyk v. Dep't of Soc.
Servs., 275 Conn. 464, 881 A.2d 259 (2005). However, in our
opinion, the Connecticut decision applied a much broader
interpretation of the word immediate than intended by Congress.
The divided Szewczyk court seemed to rest much of its decision
upon evidence in the record indicating that the nonqualifying
alien in the case would have rapidly died if not providedtreatment. See id. at 468, 881 A.2d at 262. In the case at bar,
while there is no dispute Diaz received appropriate care in the
standard medical course of treatment, there is nothing in the
record that indicated the prolonged chemotherapy treatments must
have been immediate to prevent the statutorily enumerated
results. The record in the case sub judice and the record in
Szewczyk differ as to whether immediate treatment was required to
treat the respective conditions of the patients.
Additionally, while the Szewczyk court purported to
follow the Second Circuit's decision in Greenery for the sake of
uniformity between federal and state law in Connecticut, it added
to the holding in Greenery: Beyond the analysis of Greenery . .
. we also note that the plain language of § 1936b(v) indicates
that the statute encompasses payment for care beyond that which
is immediately necessary to stabilize a patient. Id. at 482-83,
881 A.2d at 271. The reasoning behind this statement is the
requirement that the treatment for an emergency medical condition
not be related to an organ transplant procedure. 42 U.S.C. §
1396b(v)(2)(C). Because Congress chose to not provide coverage
for emergency medical services related to organ transplant
procedures, the Szewczyk court reasoned that Congress intended
for treatment under the statute to encompass more than
stabilization because organ transplants are undoubtedly . . .
time-consuming and entail relatively lengthy hospitalizations.
Id. at 483, 881 A.2d at 271. Presuming Congress would not enact
superfluous legislation, the Szewczyk court assumed it wasunnecessary to exempt coverage for organ transplant procedures if
only short-term stabilization is required. Id. at 483-84, 881
A.2d at 271-72.
However, the construction of the statute by the Second
Circuit in Greenery and this Court in the case sub judice does
not render subsection (v)(2)(C) a superfluity. Congress simply
provided that even if the only appropriate treatment for an
emergency medical condition was an organ transplant, it had made
a policy decision that the federal government would not reimburse
state Medicaid payments for such a procedure. We are not
persuaded the restriction found in subsection (v)(2)(C) changes
the plain meaning of the word immediate found in (v)(3).
Therefore, we follow the federal appellate court's interpretation
of 42 U.S.C. § 1396b in Greenery and decline to follow the
divided fellow state appellate court's interpretation in
By giving effect to the plain meaning of the statute,
we acknowledge '[t]he role of the Court is not to sit as a super
legislature and second-guess the balance struck by the elected
officials.' State v. Bryant, 359 N.C. 554, 565, 614 S.E.2d 479,
486 (2005) (quoting Henry v. Edmisten, 315 N.C. 474, 491, 340
S.E.2d 720, 731 (1986)); see also State v. Revis, 193 N.C. 192,
195, 136 S.E. 346, 347 (1927) (The Legislature alone may
determine the policy of the State . . . .). Therefore we defer
to the broad public policy statement of Congress found in
subsection 1396b(v): [N]o payment may be made to a State underthis section for medical assistance furnished to an alien who is
not lawfully admitted for permanent residence or otherwise
permanently residing in the United States under color of law.
42 U.S.C. § 1396b(v)(1). The narrow exception to this broad
statement appears in subsection (v)(2), which provides for
treatment of emergency medical conditions if the alien would
qualify but for his immigration status and the care and services
are not related to an organ transplant procedure. This
exception is consistent with the public policy clearly
articulated by Congress in 8 U.S.C. § 1601(6): It is a
compelling government interest to remove the incentive for
illegal immigration provided by the availability of public
benefits. The Second Circuit's analysis in Greenery follows the
plain meaning of 42 U.S.C. § 1396b, and our holding is consistent
with both the statute and Greenery.
Therefore, we hold an emergency medical condition is
one which manifests itself by acute symptoms at the time of
treatment and requires immediate treatment to stabilize the
condition, such that the absence of this treatment would
reasonably be expected to cause any of the three results listed
in 42 U.S.C. § 1396b(v)(3)(A), (B), or (C). The State is not
required to make payment for services provided to treat a
nonqualifying alien's condition, unless it meets the definition
of an emergency medical condition.
APPLICATION OF SECTION 1396b(v)
Acute lymphocytic leukemia (ALL) is an acute leukemia
characterized by replacement of normal bone marrow by blast
cells of a clone arising from malignant transformation of a
hematopoietic stem cell. The Merck Manual of Diagnosis and
946 (Mark H. Beers, M.D. & Robert Berkow, M.D., eds.,
17th ed. 1999). The presenting symptoms of ALL are fatigue,
fever, malaise, weight loss, and other nonspecific symptoms.
at 947. When petitioner sought emergency treatment on or
about 21 October 2000, he presented with severe symptoms, namely
sore throat, nausea and vomiting, bleeding gums, and lethargy.
At the time of his initial treatment in the emergency room, there
is no dispute petitioner presented with an emergency medical
condition. However, soon after his admission to the facility,
petitioner's condition dramatically improved. During
petitioner's chemotherapy treatments, his condition was stable
and, therefore, he was no longer entitled to Medicaid coverage.
As testified to by a medical doctor under contract to review
cases for the Medicaid program, if petitioner had not received
chemotherapy treatments, he would have eventually regressed into
a state of an emergency medical condition. However, as also
testified to by that same physician, at the time the chemotherapy
treatments at issue were provided to petitioner, he did not meet
the requirement of having an emergency medical condition. Thus,
it was error for the trial court to reverse the final agency
decision denying coverage for the dates denied. Accordingly, we
reverse the decision of the Court of Appeals and remand the caseto that court with instructions to remand to the trial court for
further proceedings not inconsistent with this opinion.
REVERSED AND REMANDED.
Justice TIMMONS-GOODSON did not participate in the
consideration or decision of this case.
Footnote: 1 This disease is also referred to as acute lymphoblastic
leukemia in medical literature and in portions of the record.
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