Judge: Lee W. Tsao, Case: 18STCV06710, Date: 2024-10-31 Tentative Ruling


Case Number: 18STCV06710    Hearing Date: October 31, 2024    Dept: C

MENDEZ v. DOWNEY REGIONAL MEDICAL CENTER

CASE NO.:  18STCV06710

HEARING:  10/31/24

 

#1

 

Third Party Claimant CALIFORNIA DEPARTMENT OF HEALTH CARE SERVICES’s Special Motion to Determine Medi-Cal Lien is GRANTED.  Plaintiff Mason Mendez shall reimburse the Department for the reasonable value of its Medi-Cal lien in the amount of $253,556.81. 

 

Moving Party to give notice.

 

This medical malpractice action was filed on November 30, 2018. On July 8, 2021, the Court issued an order approving the compromise of claim or action or disposition of proceeds of judgment for minor or person with a disability. The Court approved the Settlement in the amount of $1.75 million, allocated as follows: (1) $997,716.24 for a deposit to Plaintiff’s special needs trust; (2) $356,702.22 for attorney’s fees to Plaintiff’s attorneys; (3) $54,251.89 for costs and trust fees; (4) $341,329.65 to be held in the Michels & Lew Client Trust Account pending resolution of the Department’s lien claim.

 

The California Department of Healthcare Services (“Department”) now moves for reimbursement of it’s Medi-Cal lien in the amount of $253,556.81.

 

In Opposition, Plaintiff argues that the Department is barred from asserting a lien against any portion of the settlement that does not represent compensation for past expenses that Medi-Cal paid, and contends that the Department’s net recovery should be $29,653.00.

 

“A State plan for medical assistance must-- …. provide…. that in any case where such 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.” (42 U.S.C. §1396(a)(25)(A)(B).) “The director’s recovery is limited to the amount derived from applying Section 14124.72, 14124.76, or 14124.78, whichever is less, to the total settlement, judgment, or award amount upon resolution of all actions or claims associated with the injury with regard to each and every defendant….” (Cal. Welf. & Inst. Code §14124.785.)  “Although the statutory scheme dealing with third party liability situations [citation omitted] has been revamped since its initial adoption in the 1960’s, the language which so troubled the trial court is virtually identical to that contained in the statute which preceded section 14124.71…. ‘When the state Medi-Cal program pays for medical services rendered to an injured person who has a claim for damages for the injury for which he is treated, the state is granted a lien upon the injured person’s recovery, whether by judgment or settlement, to the extent of the Medi-Cal benefits it has provided. [Citation.]’ [Citation Omitted.]” (Kizer v. Hirata (1993) 20 Cal.App.4th 841, 844.) “[T]he superior court has no discretion to disallow a Medi-Cal lien, filed timely and in accordance with [the] statutory scheme….” (Kizer v. Ortiz (1990) 219 Cal.App.3d 1055, 1061.)

 

Here, the Order Approving the Minor’s Compromise states, in pertinent part: “THE COURT ORDERS a. The petition is granted and the proposed compromise of claim or action or the proposed disposition of the proceeds of the judgment is approved. The gross amount or value of the settlement or judgment in favor of claimant is $1,750,000.00. b. Until further order of the court, jurisdiction is reserved to determine a claim for a reduction of a Medi-Cal lien under Welfare and Intuitions Code section 14124.76. The amount shown payable to the Department of Health Care Services in item 7c(1)(d) of this order is the full amount of the lien claimed by the department but is subject to reduction on further order of the court upon determination of the claim for reduction.” (07/08/21 Order App. Comp..)

 

The Department asserts that it is entitled to a reduced value of its Medi-Cal lien in the amount of $253,566.81 because it is reasonably probable that the Department will pay Plaintiff’s future medical expenses. (Aguilera v. Loma Linda University Medical Center (2015) 235 Cal.App.4th 821.)

 

Declarations in support of the Department’s position “must establish the declarant's expertise in Medi-Cal benefits, funding and eligibility determinations.  The declarations must also be supported with citations to applicable statutes or regulations regarding current Medi-Cal eligibility, the type of health care currently available under Medi-Cal, past funding to pay for such health care, and estimated future funding to pay for the type of health care at issue. Based on the evidence provided, the trial court must make a determination whether it is reasonably probable the Department will pay [Plaintiff’s] future health care expenses.” 

(Aguilera v. Loma Linda University Medical Center, supra, 235 Cal.App.4th at 833)

 

Here, the Department submits evidence of the following:

 

·        Physician services will be provided to Mendez so long as he chooses to receive such services, the services are determined to be medically necessary, and he remains Medi-Cal eligible. (Valdez Decl., 30.)

·        It is reasonably probable that In-Home Supportive Services (“IHSS”) will continue to be provided to Mendez so long as he chooses to receive such services and the services are determined to be medically necessary. The 24-hour in-home caregiving assistance services outlined in the Life Care Plan can be performed by a non-licensed home care provider, such as IHSS. (Garbett Decl., 7.)

·        Should Mendez require additional non-nursing assistance at home beyond the State Plan's IHSS program, he may apply for and, if eligible, enroll in the HCBA Waiver.  Mendez may then choose to request HCBS WPCS to meet his additional needs, pursuant to Welfare and Institutions Code section 14132.97. WPCS services are similar to IHSS as to the type and scope of services. (Id., 8.)

·        Should Mendez choose to sign up for additional hours through the WPCS program, a waiver participant can receive up to, but not more than, 24 hours of direct care and protective supervision services per day. WPCS will be provided to him so long as he chooses to apply to receive such services and the services are determined to be medically necessary. (Id., 9.)

·        Should Mendez choose to apply for in-home services through HCBS Waivers, 24-hour skilled nursing care will be provided to him so long as he chooses to enroll to receive such sen'ices and services are determined to meet applicable medical necessity criteria. (Id., 10.)

·        It is reasonably probable that Mendez will remain eligible for full-scope Medi-Cal so long as his income and/or resources remain at or below Medi-Cal eligibility limits, for the rest of his life. (Allen Decl., 8.)

·        It is reasonably probable that Medi-Cal will pay for all of the medical services and medical items enumerated in Mendez’s Life Care Plan except for services relating to a conservator, fiduciary, and therapeutic recreation. (Saunders Decl., 8.)

·        Examples of services included in the Life Care Plan are dental services, hospital outpatient services, in-home services, inpatient hospitalizations, laboratory and diagnostic services, medical supplies, occupational therapy, orthotic and prosthetic appliances and supplies, physical therapy. physician services, psychology services, and speech therapy. (Id., 9.)

·        Medi-Cal will continue to operate in California and provide services to the population currently served, and that it may expand in the future to provide additional services or to cover additional populations. (Walker Decl., 24.)

 

Based on the above, the Court determines that it is reasonably probable that the Department will pay Plaintiff’s future medical expenses.  The Court makes this finding based upon reasonable assumptions and estimates; absolute certainty is not required. (Aguilera, supra, at 832.) Therefore, the Department is entitled to a reduced value of the Medi-Cal lien in the amount of $253,556.81 calculated as follows:

 

$352,652.56 (value of Medi-Cal benefits already provided)

 

--       $88,163.14 (the Department’s share of attorney’s fees pursuant to Section 14124.76)

 

--       $10,932.61 (the Department’s share of litigation costs pursuant to Section 14124.72)

 

=        $253,556.81

 

The Special Motion to Determine Medi-Cal Lien is GRANTED as set forth above.