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What the Courts have said about the Medicaid Program

Medicaid, just one of the sets of rules applicable to most older adults, is one of the most complex laws ever enacted. Even Judges have difficulty understanding it. What follows are a few quotes from court decisions:

“The Social Security Act is among the most intricate ever drafted by Congress. Its Byzantine construction, as Judge Friendly has observed, makes the Act “almost unintelligible to the uninitiated.”Schweiker v. Gray Panthers, 453 U.S. 34 (1981) (The United States Supreme Court quoting and agreeing with a federal district court decision).

“This is a case that does not belong in this court. It involves three governmental agencies — federal, state and city — and centers about regulations so drawn that they have created a Serbonian bog from which the agencies seemingly are unable to extricate themselves. An attorney representing one agency describes the situation as in “a confusing state of flux,” a gross understatement. It is a mess. The city expresses concern that if it complies with the regulations as interpreted by the federal government it may not receive reimbursement from the state because the state differs from that interpretation. It borders on the absurd that federal, state and local officials charged with the administration of the Social Security Act cannot reach an accommodation as to the meaning of the regulations which they drafted themselves but instead force a court action for their interpretation.” Feld v. Berger, 424 F.Supp. 1356 (S.D.N.Y. 1976).

“Far from being plain and unambiguous, the federal medicaid provisions comprise ‘a statutory scheme that is among the most intricate ever drafted by Congress.’ …The hyperbole used to describe the federal medicaid statutes illustrates the difficulty this court now encounters by ‘wad[ing] once again into the virtually impenetrable ‘Serbonian bog’ of federal and state laws governing the Medicaid system.” State v. Peters, 287 Conn. 82 (2008).

“As program after program has evolved, there has developed a degree of complexity in the Social Security Act and particularly the regulations which makes them almost unintelligible to the uninitiated. There should be no such form of reference as ” 45 C.F.R. § 248.3(c)(1)(ii)(B)(2)” discussed below; a draftsman who has gotten himself into a position requiring anything like this should make a fresh start. Such unintelligibility is doubly unfortunate in the case of a statute dealing with the rights of poor people. An indispensable service is performed by attorneys like those representing the plaintiffs here, who advance tenable claims with clarity and courtesy – even if, as in this case, not with success.” Friedman v. Berger, 547 F.2d. 724 (2nd Cir. 1976) (the Medicaid law is embedded within the Social Security Act).

The Medicaid statute (as is true of other parts of the Social Security Act) is an aggravated assault on the English language, resistant to attempts to understand it. The statute is complicated and murky, not only difficult to administer and to interpret but a poor example to those who would like to use plain and simple expressions. The present motion must be decided, however, and what follows is the result of best efforts to find the meaning of the Medicaid statute and other relevant statutes and regulations. Friedman v. Berger, 409 F.Supp. 1225 (S.D.N.Y. 1976).

Program requirements described as a “labyrinthine process.” District of Columbia Hosp. Ass’n v. District of Columbia, 224 F.3d. 776 (D.C. Cir. 2000).

In showing how one change can lead to another, a recent decision, Moore v. Noogle, has this to say about Medicaid:

“Medicaid is a cooperative federal-state program through which the Federal Government provides financial assistance to States so that they may furnish medical care to needy individuals.” Wilder v. Va. Hosp. Ass’n, 496 U.S. 498, 502 (1990). States manage and administer their Medicaid programs through a single agency, and in the State of Georgia, that agency is the Department of Community Health (“DCH”). 42 U.S.C. § 1396a(a)(5); O.C.G.A. § 49-4-142(a). Under federal law, state programs must provide its beneficiaries with “medical assistance,” consisting of certain mandatory and other optional services. 42 U.S.C. §§ 1396a(a)(10)(A), 1396d(a) (defining “medical assistance”). But “when a state elects to provide an optional service, that service becomes part of the state Medicaid plan and is subject to the requirements of federal law.” Tallahassee Mem’l Reg’l Med. Ctr. v. Cook, 109 F.3d 693, 698 (11th Cir. 1997). Pursuant to a waiver from its federal counterpart, the Centers for Medicare and Medicaid Services (“CMS”), a state agency “may include as `medical assistance’ . . . home or community-based services.” 42 U.S.C. § 1396n(c); 42 C.F.R. § 430.25(c)(2). In Georgia, one service provided pursuant to such a waiver is the Independent Care Waiver Program (“ICWP”), which “provides home and community-based services to people such as Plaintiffs with significant physical disabilities” as an alternative to longterm care facilities. (Emphasis added).


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