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KATELYN ANDREWS, a minor, through her Guardian ad Litem, DAVID
ANDREWS; and DAVID ANDREWS and ANDREA ANDREWS, individually
VANESSA P. HAYGOOD, M.D., individually; CENTRAL CAROLINA
OBSTETRICS AND GYNECOLOGY, P.A., a North Carolina Corporation;
THE WOMEN'S HOSPITAL OF GREENSBORO, a North Carolina Not-for-
Profit Corporation; KIM RICHEY, R.N., individually; and JENNIFER
DALEY, R.N., individually
NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES, DIVISION
OF MEDICAL ASSISTANCE, Intervenor
Appeal pursuant to N.C.G.S. § 7A-30(2) from the
decision of a divided panel of the Court of Appeals, ___ N.C.
App. ___, 655 S.E.2d 440 (2008), affirming an order entered on 27
July 2006 by Judge Steve A. Balog in Superior Court, Alamance
County. On 10 April 2008, the Supreme Court allowed appellant's
petition for discretionary review of additional issues. Heard in
the Supreme Court 13 October 2008.
Wishart, Norris, Henninger & Pittman, P.A., by Pamela S. Duffy and Molly A. Orndorff, for trustee-appellant Charlie D. Brown.
Roy Cooper, Attorney General, by Susannah P. Holloway, Assistant Attorney General, for intervenor-appellee North Carolina Department of Health and Human Services, Division of Medical Assistance.
Glenn, Mills, Fisher & Mahoney, P.A., by Carlos E. Mahoney, Counsel for North Carolina Academy of Trial Lawyers, amicus curiae.
This case presents the question of whether the
statutory framework governing the State's subrogation claim for
medical expenses on a Medicaid recipient's tort claim settlement
complies with federal Medicaid law as interpreted by the Supreme
Court of the United States in Arkansas Department of Health &
Human Services v. Ahlborn, 547 U.S. 268, 126 S. Ct. 1752, 164 L.
Ed. 2d 459 (2006). Because Ahlborn does not mandate a specific
method for determining the medical expense portion of a
plaintiff's settlement, we uphold North Carolina's reasonable
statutory scheme and accordingly affirm the Court of Appeals.
Although I agree with the majority that [Arkansas
Department of Health & Human Services v.] Ahlborn does not
mandate a specific method for determining the medical expense
portion of a plaintiff's settlement, the United States Supreme
Court nevertheless did explicitly hold in Ahlborn that a State
may not violate the anti-lien provisions of 42 U.S.C. §§
1396a(a)(18) and 1396p by requiring a Medicaid recipient to
reimburse it out of settlement funds designated for purposes
other than medical care. 547 U.S. 268, 284-85, 164 L. Ed. 2d
459, 474 (2006). The terms of the settlement at issue here
provide insufficient detail to allow us to determine whether the
application of N.C.G.S. § 108A-57(a) would violate the anti-lien
provisions of the federal Medicaid statutes, pursuant to the
holding in Ahlborn. Because I conclude that we are bound to
follow Ahlborn, I must respectfully dissent.
As observed by the United States Supreme Court, the federally funded and administered Medicaid program is a cooperative one, with participating states compl[ying] with certain statutory requirements for making eligibility determinations, collecting and maintaining information, and administering the program in exchange for the federal funding. Id. at 275, 164 L. Ed. 2d at 468-69. Among these requirements is that the state agency in charge of Medicaid . . . 'take all reasonable measures to ascertain the legal liability of third parties . . . to pay for care and services available under theplan.' Id. at 275, 164 L. Ed. 2d at 469 (quoting 42 U.S.C. § 1396a(a)(25)(A) (2000) (alteration in original)). Further,
The [state] agency's obligation extends beyond mere identification, however; in any case where such a legal liability is found to exist after medical assistance has been made available on behalf of the individual and where the amount of reimbursement the State can reasonably expect to recover exceeds the costs of such recovery, the State or local agency will seek reimbursement for such assistance to the extent of such legal liability.
Id. at 276, 164 L. Ed. 2d at 469 (quoting 42 U.S.C. § 1396a(a)(25)(B)). The federal Medicaid statutes obligate participating states to enact so-called assignment laws to provide for such reimbursement. Id. at 276-77, 164 L. Ed. 2d at 469-70 (citing 42 U.S.C. §§ 1396a(a)(25)(H), 1396k(a)).
In enacting section 108A-57(a), our General Assembly fulfilled this requirement while also explicitly limiting the percentage of a settlement that the State could recover through assignment:
Notwithstanding any other provisions of the law, to the extent of payments under this Part, the State, or the county providing medical assistance benefits, shall be subrogated to all rights of recovery, contractual or otherwise, of the beneficiary of this assistance, or of the beneficiary's personal representative, heirs, or the administrator or executor of the estate, against any person. The county attorney, or an attorney retained by the county or the State or both, or an attorney retained by the beneficiary of the assistance if this attorney has actual notice of payments made under this Part shall enforce this section. Any attorney retained by the beneficiary of the assistance shall, out of the proceeds obtained on behalf of the beneficiary bysettlement with, judgment against, or otherwise from a third party by reason of injury or death, distribute to the Department the amount of assistance paid by the Department on behalf of or to the beneficiary, as prorated with the claims of all others having medical subrogation rights or medical liens against the amount received or recovered, but the amount paid to the Department shall not exceed one-third of the gross amount obtained or recovered.
N.C.G.S. § 108A-57(a) (2005) (emphases added). Moreover, the General Assembly specifically provided that the provisions of this Part shall be liberally construed in relation to [the federal Social Security Act providing grants to the states for medical assistance] so that the intent to comply with it shall be made effectual. Id. § 108A-56 (2005). In my view, the majority's interpretation runs contrary to this directive by risking violations of the federal anti-lien provisions, which would render our State out of compliance with Medicaid requirements and thereby jeopardize the funding our State receives.
The General Assembly's explicit direction that we defer to the federal provisions as necessary guides our consideration of the interaction of these federal and state statutes. In addition, because this case involves questions of federal statutory law, we are bound by the United States Supreme Court's interpretation of the federal Medicaid statutes. As this Court has stated:
It is elementary that an act of Congress, in pursuance of the Constitution of the United States, is the supreme law of the land. Constitution of the United States, Article VI, Clause 2. Thus, in case of a conflict between such an act and the law ofNorth Carolina, the act of Congress controls and, so long as it remains in effect, modifies the law of this State and the authority of its courts to render judgment in accordance therewith. It is equally well settled that a decision of the Supreme Court of the United States, construing an act of Congress, is conclusive and binding upon this Court.
R.H. Bouligny, Inc. v. United Steelworkers, 270 N.C. 160, 173-74, 154 S.E.2d 344, 356 (1967). The United States Supreme Court decision in Ahlborn directly addresses and determines the question presented by this case, as our state statute is similar to the one at issue in Ahlborn and the factual situations are analogous. Therefore, I conclude that Ahlborn is binding upon this Court, and its reasoning and holding compel the conclusion that the application of N.C.G.S. § 108A-57(a) here, without any further determination of how the settlement proceeds were allocated among the different types of damages alleged by plaintiff, would be contrary to federal law.
In delivering the opinion of a unanimous Court in Ahlborn, Justice John Paul Stevens framed the issue as follows:
When a Medicaid recipient in Arkansas obtains a tort settlement following payment of medical costs on her behalf by Medicaid, Arkansas law automatically imposes a lien on the settlement in an amount equal to Medicaid's costs. When that amount exceeds the portion of the settlement that represents medical costs, satisfaction of the State's lien requires payment out of proceeds meant to compensate the recipient for damages distinct from medical costs--like pain and suffering, lost wages, and loss of future earnings. The Court of Appeals for the Eight Circuit held that this statutory lien contravened federal law and was therefore unenforceable. Other courts have upheld similar lien provisions. We grantedcertiorari to resolve the conflict and now affirm.
547 U.S. at 272, 164 L. Ed. 2d at 467 (internal citations omitted). Thus, contrary to the majority's assertion that the Ahlborn holding controls only in situations in which there has been a prior determination or stipulation as to the medical expense portion of a plaintiff's settlement, the Supreme Court in no way rested its analysis on whether a settlement had been so allocated.
Rather, the Supreme Court in Ahlborn express[ed] no view on how such allocation should be determined [e]ven in the absence of such a postsettlement agreement, id. at 547 at 288 & n.18, 164 L. Ed. 2d at 476 & n.18, emphasizing instead simply that, regardless of how an allocation is made, the exception carved out by [the anti-lien provisions laid out in 42 U.S.C. §§ 1396a(a)(18) and 1396p] is limited to payments [by the third party to the plaintiff-beneficiary] for medical care. Beyond that, the anti-lien provision applies, id. at 284-85, 164 L. Ed. 2d at 474. Indeed, the Court repeatedly emphasized this point as to whether [a state agency] can lay claim to more than the portion of [the plaintiff-beneficiary's] settlement that represents medical expenses:
The text of the federal third-party liability provisions suggests not; it focuses on recovery of payments for medical care. Medicaid recipients must, as a condition of eligibility, assign the State any rights . . . to payment for medical care from any third party, 42 U.S.C. § 1396k(a)(1)(A) (emphasis added), not rights to payment for, for example, lost wages.Id. at 280, 164 L. Ed. 2d at 471 (alteration in original). More explicitly, under the federal statute the State's assigned rights extend only to recovery of payments for medical care. Id. at 282, 164 L. Ed. 2d at 472. Likewise, assignment of the right to compensation for lost wages and other nonmedical damages is nowhere authorized by the federal third-party liability provisions. Id. at 286 n.16, 164 L. Ed. 2d at 475 n.16.
These statements broadly prohibit a state's claim to reimbursement from any funds not earmarked solely for medical expenses under any circumstances. Accordingly, to the extent that the terms of a settlement are unclear as to the portion designated for medical expenses, the Ahlborn analysis requires states to fashion a method to make those determinations and protect their right to reimbursement, for example, by obtaining the State's advance agreement to an allocation or, if necessary, by submitting the matter to a court for decision. Id. at 288, 164 L. Ed. 2d at 476. Simply put, an indispensable step in calculating the amount of a State's right to reimbursement for medical expenses is establishing how much of a third-party settlement has been allocated to the medical expenses of the plaintiff-beneficiary.
The majority would hold that in N.C.G.S. § 108A-57(a), the General Assembly attempted to do just that and that the statute comports with Ahlborn by providing a reasonable method for determining the State's medical reimbursements, namely, capping the reimbursement at no more than one-third of a beneficiary's settlement with a third party. However,application of the bright-line rule articulated by the majority in a case like this one, in which there has been no allocation, could allow precisely the result that is explicitly barred by Ahlborn. In fact, this would be the outcome with any settlement in which the amount actually paid by the Division of Medical Assistance (DMA) is greater than the amount of the settlement designated for medical expenses, but less than the one-third cap specified in N.C.G.S. § 108A-57(a).
A hypothetical example illustrates this point. (See footnote 2) Suppose a plaintiff--a past beneficiary of Medicaid assistance--settles with a tortfeasor for $2 million following an automobile accident. She initially alleged damages totaling $5 million, including $500,000 in past medical expenses, $1 million in future medical expenses, $1.5 million in pain and suffering, and $2 million in lost future earnings income. Medicaid, through DMA, paid the full $500,000 in actual past medical costs for the beneficiary's treatment following the accident. Under the majority's holding and application of N.C.G.S. § 108A-57(a), DMA would be entitled to $500,000 of the settlement. However, without knowing more about how the parties allocated the settlement among the different types of damages sought, the amounts might suggest that the parties, as in Ahlborn, reached a settlement that prorated the beneficiary's damages, awarding her forty percent of what she sought in each category of damages. In that scenario, of the $2 million settlement, $200,000 would bedesignated for past medical expenses, $400,000 for future medical expenses, $600,000 for pain and suffering, and $800,000 for lost future earnings income. Awarding the full $500,000 to DMA would thus exceed the $200,000 designated for past medical expenses and clearly violate the explicit holding of Ahlborn.
Likewise, N.C.G.S. § 108A-57(a) and the majority opinion make no distinction between past medical expenses paid by DMA that relate directly to the injury that is the basis of the settlement and expenses that were paid for treatment of a preexisting, ongoing condition. For example, in the scenario outlined above, suppose DMA had paid $500,000 in medical costs for the beneficiary, but only $300,000 of that amount related to the automobile accident, with the balance of $200,000 spent on treatment for the beneficiary's leukemia. Under the majority's holding, DMA could still claim the full $500,000 from the beneficiary, as that amount does not exceed the one-third statutory limitation in N.C.G.S. § 108A-57(a)--even though that recovery would include reimbursement for medical expenses totally unrelated to the accident or the settlement. This result, permitted by this Court's earlier holding in Ezell v. Grace Hospital, Inc., 360 N.C. 529, 631 S.E.2d 131, rev'g per curiam for reasons stated in the dissent 175 N.C. App. 56, 623 S.E.2d 79 (2005), reh'g denied, 361 N.C. 180, 641 S.E.2d 4 (2006), would clearly violate the anti-lien provisions of the federal Medicaid statutes, contrary to the holding of Ahlborn. As such, I also believe we should overrule that decision. Here, as in Ahlborn, plaintiff's civil suit sought damages including, but not limited to, past medical expenses paid by Medicaid and others; the complaint also alleged damages for mental and physical pain and anguish, severe and permanent injury, future medical expenses, loss of future earnings, disfigurement and loss of normal use of her body, her parents' expenses for education and life care, and her parents' emotional distress and derivative claims. These claims were settled among all parties, with proceeds held in a single account and no allocations made as to which specific amounts represented damages for which particular type of claim. Nevertheless, the parties clearly intended the settlement to account for all of the different types of damages alleged not just by plaintiff, but also by her parents. The parties concede that the amount of the settlement here allows DMA to be fully reimbursed for the entire $1,046,681.94 it had paid through October 2005 for plaintiff's medical care, without violating the one-third cap of N.C.G.S. § 108A-57(a). However, the lack of stipulation or other determination as to the allocation of the settlement funds among the damages leaves us unable to conclude whether a DMA lien for full reimbursement would impermissibly entitle DMA to an amount greater than the medical expenses portion of the settlement, as is prohibited by Ahlborn.
In addition, the majority misinterprets N.C.G.S. § 108A-57(a) as being the General Assembly's blanket determination that the full one-third of any settlement amount between aplaintiff and a third party is for medical expenses. (See footnote 3) In my view, that is neither what the statute says nor what it does. According to the plain language of the statute, the legislature envisioned both that a beneficiary could have a private attorney representing her in an action against a third party, see N.C.G.S. § 108A-57(a) (referring to [a]ny attorney retained by the beneficiary of the assistance), and that for most settlements, damages for medical expenses would be prorated among the various providers, see id. (requiring the recipient's attorney to distribute to the Department the amount of assistance paid by the Department on behalf of or to the beneficiary, as prorated with the claims of all others having medical subrogation rightsor medical liens against the amount received or recovered). Thus, the General Assembly itself recognized that either stipulations by the parties or evidentiary hearings would be necessary to determine the amount of recovery by DMA and others seeking reimbursement for payment of medical expenses. Moreover, as with other lien statutes, see, e.g., N.C.G.S. § 97-10.2(f) (2005) (Workers' Compensation Act), the General Assembly acknowledged that the beneficiary's attorney would likely be entitled to a large percentage of the settlement as a contingent fee; as such, the one-third cap represents a reasonable ceiling on the amount paid to DMA while also ensuring that the beneficiary would still recover a meaningful proportion of the settlement.
This reading of the statute is supported by the public policy rationale that underpins the federal requirements for assignment laws adopted by the states to seek reimbursement for the Medicaid payments they make. Such assignments prevent double recovery by a beneficiary: because the beneficiary is required to repay Medicaid from the medical expenses portion of his settlement with a third-party tortfeasor, he does not keep both the State's money and damages recovered from the tortfeasor. However, both the federal and state statutory schemes rely on the beneficiary--not the State or county--to bring a civil action against the third-party tortfeasor. Indeed, without the beneficiary's action to bring the suit, the State may enjoy no recovery at all for the Medicaid payments it made to the beneficiary as a result of the injury or accident. Thus, theState seeks to encourage beneficiaries to bring such suits. Accordingly, the statute is designed to protect the State's interest in having the suit brought by providing an incentive for the beneficiary to bring the suit--namely, by safeguarding some portion of the settlement for the beneficiary rather than allowing all of the proceeds to be paid to the attorneys and to DMA and other medical lienholders. Without this guarantee of some return, beneficiaries would be unlikely to go through the time and inconvenience associated with pursuing a civil action, and the State or DMA would be left with no recovery at all.
Application of N.C.G.S. § 108A-57(a) in a manner consistent with this rationale likewise comports with the reasoning relied upon by the United States Supreme Court in Ahlborn to ensure that a state Medicaid agency does not force an assignment of, or place a lien on, any other portion of [the beneficiary's] property or settlement proceeds designated to compensate a beneficiary for other types of damages. 547 U.S. at 284, 164 L. Ed. 2d at 474. Specifically, Ahlborn compels our State to apply N.C.G.S. § 108A-57(a) in compliance with the following language:
Federal Medicaid law does not authorize [the state agency] to assert a lien on [a beneficiary's] settlement in an amount exceeding [the pro rata portion designated as reimbursement for medical payments made], and the federal anti-lien provision affirmatively prohibits it from doing so. [The State's] third-party liability provisions are unenforceable insofar as they compel a different conclusion.
Id. at 292, 164 L. Ed. 2d at 479. Thus, I would not find that N.C.G.S. § 108A-57(a) violates the federal anti-lien provisionson its face, as it could be applied to factual situations in which the parties have stipulated, or an evidentiary hearing has determined, how to allocate the settlement proceeds among medical expenses and other damages. Nevertheless, I conclude that here, when the settlement proceeds have not been so allocated, the only way to ensure that the application of the statute complies with Ahlborn is to provide for such an allocation. (See footnote 4)
I would therefore reverse the Court of Appeals with instructions to remand to the trial court to hold an evidentiary hearing to ensure that the DMA lien is not applied to settlement proceeds aside from those designated to reimburse medical expenses.
Justices BRADY and TIMMONS-GOODSON join in this dissenting opinion.
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