Diaz v. Division of Soc. Servs., 360 NC 384 (523PA04) 04/07/2006

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HECTOR DIAZ, Petitioner v. DIVISION OF SOCIAL SERVICES and DIVISION OF MEDICAL ASSISTANCE, NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES, Respondent

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- appellee/appellant.

    Roy Cooper, Attorney General, by Richard J. Votta, Assistant Attorney General, for respondent- appellant/appellee.

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.

    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 serious jeopardy,
        (B) serious impairment to bodily functions, or
        (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 medical condition.
    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 Szewczyk.
    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.