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State Medicaid Program Must Pay For Woman’s Knee Surgery

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Indiana resident Petricia Day seemed to be caught in a bureaucratic Catch-22. She needed help paying for her medical treatment. Her problem: Indiana’s interpretation of federal Medicaid rules prevented her from getting the treatment because it might be successful.

Medicaid is a federal program partially paid for and administered by individual states, and so the rules vary somewhat depending on the state of residence. Indiana’s Medicaid eligibility rules at the time of Ms. Day’s problem required that the applicant suffer from a condition that is “reasonably certain to continue throughout the lifetime” of the applicant.

Ms. Day’s medical problem was not that untreatable. She needed surgery to completely replace her right knee, but physicians believed that after the surgery she would recover nicely and no longer experience medical problems with her knee.

Ms. Day could not afford to pay for her knee surgery. Because of her limited resources she met the financial qualifications for Medicaid coverage. Her application was denied, however, because the state agency determined that her condition was treatable. In other words Ms. Day could not afford medical care she needed, but Indiana’s Medicaid program would not provide the treatment precisely because it would cure Ms. Day’s condition.

Ms. Day filed a class action against the State of Indiana on behalf of all patients denied treatment under the state rules. Her case wound through the Indiana courts for several years, including one trip to the Court of Appeals and the state Supreme Court in 1997. The case was sent back to the trial court for further hearings, and the judge in the case granted a judgment in favor of Ms. Day. Although Indiana had changed its rules in the intervening years, the State appealed for the second time to the Court of Appeals.

Indiana’s argument hinged on a provision of federal law which permits states to have restrictive Medicaid eligibility rules. That law, usually referred to as “section 209(b),” allows states to utilize restrictive eligibility rules provided that they are no more restrictive than the state’s rules in 1972, when the federal Supplemental Security Income (SSI) program’s national eligibility standards were implemented.

The logical question in Ms. Day’s case might have been whether she needed medical care she could not afford to pay for. That was not, however, the question addressed by the Indiana Medicaid agency or the courts. The court had good news for Ms. Day, however: it held that Indiana law in 1972 would have covered Ms. Day’s medical needs, and so she had to be covered under current rules. Indiana Family and Social Services Administration v. Day, September 29, 2000.

Arizona does not apply the so-called “209(b)” rules, and Ms. Day’s eligibility would have been determined under federal standards had she lived in Arizona. Only a handful of states utilize Indiana’s approach to Medicaid eligibility.

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Robert B. Fleming


Robert Fleming is a Fellow of both the American College of Trust and Estate Counsel and the National Academy of Elder Law Attorneys. He has been certified as a Specialist in Estate and Trust Law by the State Bar of Arizona‘s Board of Legal Specialization, and he is also a Certified Elder Law Attorney by the National Elder Law Foundation. Robert has a long history of involvement in local, state and national organizations. He is most proud of his instrumental involvement in the Special Needs Alliance, the premier national organization for lawyers dealing with special needs trusts and planning.

Robert has two adult children, two young grandchildren and a wife of over fifty years. He is devoted to all of them. He is also very fond of Rosalind Franklin (his office companion corgi), and his homebound cat Muninn. He just likes people, their pets and their stories.

Elizabeth N.R. Friman


Elizabeth Noble Rollings Friman is a principal and licensed fiduciary at Fleming & Curti, PLC. Elizabeth enjoys estate planning and helping families navigate trust and probate administrations. She is passionate about the fiduciary work that she performs as a trustee, personal representative, guardian, and conservator. Elizabeth works with CPAs, financial professionals, case managers, and medical providers to tailor solutions to complex family challenges. Elizabeth is often called upon to serve as a neutral party so that families can avoid protracted legal conflict. Elizabeth relies on the expertise of her team at Fleming & Curti, and as the Firm approaches its third decade, she is proud of the culture of care and consideration that the Firm embodies. Finding workable solutions to sensitive and complex family challenges is something that Elizabeth and the Fleming & Curti team do well.

Amy F. Matheson


Amy Farrell Matheson has worked as an attorney at Fleming & Curti since 2006. A member of the Southern Arizona Estate Planning Council, she is primarily responsible for estate planning and probate matters.

Amy graduated from Wellesley College with a double major in political science and English. She is an honors graduate of Suffolk University Law School and has been admitted to practice in Arizona, Massachusetts, New York, and the District of Columbia.

Prior to joining Fleming & Curti, Amy worked for American Public Television in Boston, and with the international trade group at White & Case, LLP, in Washington, D.C.

Amy’s husband, Tom, is an astronomer at NOIRLab and the Head of Time Domain Services, whose main project is ANTARES. Sadly, this does not involve actual time travel. Amy’s twin daughters are high school students; Finn, her Irish Red and White Setter, remains a puppy at heart.

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Matthew M. Mansour


Matthew is a law clerk who recently earned his law degree from the University of Arizona James E. Rogers College of Law. His undergraduate degree is in psychology from the University of California, Santa Barbara. Matthew has had a passion for advocacy in the Tucson community since his time as a law student representative in the Workers’ Rights Clinic. He also has worked in both the Pima County Attorney’s Office and the Pima County Public Defender’s Office. He enjoys playing basketball, caring for his cat, and listening to audiobooks narrated by the authors.