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Siracusa v. State, Department of Health & Human Services

Superior Court of Maine, Kennebec

November 19, 2014



Michaela Murphy, Justice Maine Superior Court.

Petitioner Michael J. Siracusa filed a M.R. Civ. P 80C appeal challenging a February 3, 2014 ruling from the Department of Health and Human Services ("DHHS" or the "Department") affirming two prior determinations denying Mr. Siracusa's requests for reimbursement for certain non-emergency medical transportation ("NET") expenses. Mr. Siracusa's requests were denied because the services he sought reimbursement for were not covered by MaineCare and-because the visits were not emergencies-he should have contacted the transportation broker in his area, Coordinated Transportation Solutions ("CTS"). For the reasons discussed below, the Court affirms the Department's Decision and denies Petitioner's M.R. Civ. P. 80C appeal.

I. Background

The Department implemented the current NET system on August 1, 2013 after working closely with the federal government for several years. See generally Record Tab, DHHS-2, MaineCare Benefits Manual ("MBM") Chapter II. Under the NET system, the Department utilizes brokers to arrange for transportation to MaineCare covered services for all eligible MaineCare members that reside in the broker's assigned region. See id. at § 113.02. Mr. Siracusa resides in Augusta, which is region four. Id. at § 113.03. CTS is the NET broker for Mr. Siracusa's region. Id.; Record Tab, A, 2/3/14 Department Decision ("Decision") 1-2 (referencing CTS as Ms. Siracusa's broker).

On November 6 and 7, 2013, Mr. Siracusa submitted two customer reimbursement forms to CTS seeking reimbursement for his travel from Augusta to the UMA Dental Health Clinic in Bangor, as well as to Dr. Richard Knipping of Gardiner Family Chiropractic, PC. See Record, Tab DHHS-5. The forms contain a section for the medical provider to complete attesting that the person seeking reimbursement, "was seen by the MaineCare covered service provider" on the dates for which the individual seeks NET reimbursement. See id. On each of the reimbursement forms submitted by Mr. Siracusa the words "MaineCare Provider" were crossed out and, on one of them, the term "MaineCare covered" was crossed out. Id.

CTS denied both of Mr. Siracusa's requests for reimbursement because the services Mr. Siracusa obtained were not MaineCare covered services. Record, Tab DHHS-4.

Mr. Siracusa filed a timely request with the Department for an administrative hearing on each of the two NET reimbursement denials. Record, Tab DHHS-3. The Hearing Officer held an administrative hearing on December 18, 2013. Record, Tab B (Administrative Hearing Transcript). On February 3, 2014, the Hearing Officer issued the Decision upholding CTS's denial of reimbursement for Mr. Siracusa's travel expenses. Record, Tab A, Decision 2-3. Mr. Siracusa appealed that decision pursuant to M.R. Civ. P. 80C on February 26, 2014.

II. Discussion

A. Standard of Review

Under the Administrative Procedures Act ("APA"), an agency's decision may be reversed or modified by the Court if it determines that the:

Findings, inferences, conclusions or decisions are: (1) In violation of constitutional or statutory provisions; (2) In excess of the statutory authority of the agency; (3) Made upon unlawful procedure; (4) Affected by bias or error of law; (5) Unsupported by substantial evidence on the whole record; or (6) Arbitrary or capricious or characterized by abuse of discretion.

5 M.R.S. § 11007(4)(C). The Court must give "considerable deference to an agency's interpretation of its rules, regulations, and procedures and will not set it aside, unless the rule or regulation plainly compels a contrary result." See Fryeburg Health Care Ctr. v. Dep't of Human Servs., 1999 ME 122, ¶ 7, 734 A.2d 1141. The petitioner bears the burden of showing the Department's decision is arbitrary or based on an error of law. Id. The Court is limited to a review of the administrative record, with few exceptions that are not applicable to the instant case. 5 M.R.S. § 11006(1). "The court shall not substitute its judgment for that of the agency on questions of fact." 5 M.R.S. § 1107(3). The focus on appeal is not whether the appellate court would have reached the same conclusion as the Hearing Officer, but whether the Record contains competent and substantial evidence that supports the results reached. CWCO, Inc. v. Superintendent of Ins., 1997 ME 226, ¶ 6, 703 A.2d 1258.

B. Whether the MBM and the Hearing Officer's Decision Violate State or Federal Law

Mr. Siracusa argues the Hearing Officer's Decision and the Department's interpretation of the MBM violate the Social Security Act and Americans with Disabilities Act ("ADA") of title 42 of the United States Code, regarding Public Health and Welfare, by denying him reimbursement for the transportation expenses at issue. While Mr. Siracusa is correct that title 42 affords him certain rights and ...

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