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COURT OF APPEALS
NOTICE
DECISION
DATED AND FILED                                                                      This opinion is subject to further editing.   If
published, the official version will appear in
the bound volume of the Official Reports.
July 21, 2011
A party may file with the Supreme Court a
A. John Voelker                                                                                                                                         petition to review an adverse decision by the
Acting Clerk of Court of Appeals                                                                                                                        Court of Appeals.   See WIS. STAT. § 808.10
                                                                                                                                                        and RULE 809.62.
                                                                                                                                                        Cir. Ct. No.   2009CV411
Appeal No.                                                                           2010AP1424
STATE OF WISCONSIN                                                                                                                                      IN COURT OF APPEALS
                                                                                                                                                        DISTRICT IV
EMMETT BERGER,
PETITIONER-APPELLANT,
V.
WISCONSIN DEPARTMENT OF HEALTH SERVICES,
RESPONDENT-RESPONDENT.
APPEAL from an order of the circuit court for La Crosse County:
TODD W. BJERKE, Judge.  Affirmed.
Before Vergeront, P.J., Higginbotham and Blanchard, JJ.
¶1                                                                                   PER  CURIAM.    Emmett  Berger  appeals  an  order  affirming  a
decision by the Department of Health Services (DHS) denying Berger Medicaid
benefits.   Berger contends that DHS’s interpretation of the relevant statutes and
administrative rules is unreasonable.   We disagree, and affirm.




No.   2010AP1424
Background
¶2                                                                                                    Berger entered a nursing home in February 2008.   La Crosse County
determined that Berger was eligible for medical assistance to help pay the costs of
the nursing home.1   See WIS. STAT. § 49.47(4)(b) and (c) (2009-10)2; WIS. ADMIN.
CODE § DHS 103.04(2) and (4) (May 2011).3   The county also determined that
Berger  qualified  for  spousal  impoverishment  protection,  allowing  Berger  to
allocate  a  portion  of  his income  to  his spouse  in  determining the  amount of
Berger’s income that was required to be applied to pay the costs of his care.   See
WIS. STAT. § 49.455(4) and WIS. ADMIN. CODE § DHS 103.075.
¶3                                                                                                    In June 2008, Berger’s condition improved and he transferred to a
community-based  residential  treatment  facility.    The  county  determined  that
Berger no longer qualified for institutional Medicaid based on his transfer to a
community setting, and thus reassessed his eligibility for a different Medicaid
subprogram.   See Medicaid Eligibility Handbook,  §§ 24 to  38  (Feb.  1,  2008).4
The county determined that Berger did not meet the income criteria for any of the
Medicaid subprograms, including Family Care.5   R-15:3.   WIS. STAT. § 46.286;
1  Medical assistance is one of three Medicaid programs in Wisconsin; Medicaid is a
federal/state program.  Estate of Hagenstein ex rel. Klemmer v. DHFS, 2006 WI App 90, ¶3 n.3,
292 Wis. 2d 697, 715 N.W.2d 645.
2  All references to the Wisconsin Statutes are to the 2009-10 version unless otherwise
noted.
3  All references to the Wisconsin Administrative Code are to the May 2011 version.
4  The Medicaid Eligibility Handbook is a policy handbook created by DHS pursuant to
WIS. STAT.  § 49.45(34).   Estate of Hagenstein, ¶5 n.5.   It is designed to assist state and local
agencies, such as the county in this case, in implementing the Medicaid program.  Id.
5  Part of the county’s determination was that, based on the reduced costs of Berger’s care
in the community setting as opposed to the nursing home, Berger did not have sufficient
qualifying medical expenses to reduce his income below the required level.
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No.   2010AP1424
WIS. ADMIN. CODE § DHS 10.32; see Medicaid Eligibility Handbook § 29.   The
county also  determined  that the  spousal  impoverishment protection statute  no
longer applied to the Bergers.   Berger requested a hearing to review the county’s
decision.  See WIS. STAT. § 49.45(5).
¶4                                                                                         An administrative law judge (ALJ) of the Division of Hearings and
Appeals  issued  a  proposed  decision  finding  that  the  spousal  impoverishment
protection continues to apply when a medical assistance recipient moves from
institutional care to a community setting.   The ALJ determined that the recipient’s
income is to be reduced by the amount allocated to the recipient’s spouse before
determining  the  recipient’s  income  for  purposes  of  assessing  eligibility  for  a
Medicaid subprogram.   DHS, however, rejected the ALJ’s proposed decision and
issued  a  final  decision  upholding  the  county’s  determination  that  Berger  is
ineligible for Medicaid benefits or spousal impoverishment protection.    Berger
sought  review  in  the  circuit  court,  which  affirmed  DHS’s  decision.    Berger
appeals.
Standard of Review
¶5                                                                                         On an appeal involving the decision of an administrative agency, we
review the decision of the agency, not the circuit court.   See Estate of Hagenstein
ex rel. Klemmer v. DHFS, 2006 WI App 90, ¶19, 292 Wis. 2d 697, 715 N.W.2d
645.    When  we  review  an  agency’s  statutory  interpretation,  we  accord  the
agency’s decision one of three levels of deference: great weight, due weight, or no
deference.   See id.,  ¶20.   Great weight deference is appropriate where:  (1) the
legislature has charged the agency with the duty of administering the statute;
(2) the agency’s interpretation is long standing; (3) the agency’s interpretation is
based  on  its  specialized  knowledge  or  expertise;  and                                (4)  the  agency’s
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No.   2010AP1424
interpretation provides consistency and uniformity in applying the statute.    Id.
When we accord an agency decision great weight, we uphold the decision if it is
reasonable  and  not  contrary  to  the  intent  of  the  statute,  even  if  another
interpretation is more reasonable.   Hillhaven Corp. v. DHFS, 2000 WI App 20,
¶12 n.6, 232 Wis. 2d 400, 606 N.W.2d 572.
¶6                                                                                          We accord due weight deference when an agency decision does not
meet all of the criteria for great weight deference, or is very nearly one of first
impression.   Estate of Hagenstein, 292 Wis. 2d 697, ¶20.   When we accord due
weight deference, we uphold an interpretation so long as it is reasonable, unless
another interpretation is more reasonable.   Hillhaven, 232 Wis. 2d 400, ¶12 n.6.
De novo review is appropriate where the issue is clearly one of first impression, or
where an agency’s position on an issue has been so inconsistent that it provides no
real guidance.  UFE Inc. v. LIRC, 201 Wis. 2d 274, 285, 548 N.W.2d 57 (1996).
¶7                                                                                          When an agency’s decision is based on the interpretation of its own
rules or regulations, we accord the decision controlling deference.   Hillhaven, 232
Wis. 2d  400,  ¶12  &  n.6.    This  level  of  deference  is  similar  to  great  weight
deference; we defer to an agency’s interpretation of its own rules and regulations
if that interpretation is reasonable and consistent with the meaning or purpose of
the rules and regulations.   Id.   Thus, “an administrative agency’s interpretation of
its own rules or regulations is controlling unless plainly erroneous or inconsistent
with the language of the rule or regulation.”   Id., ¶12.
¶8                                                                                          The parties dispute the level of deference we owe DHS’s decision in
this case.   Berger contends that our review is de novo, because this case presents
an  issue  of  first  impression:  whether  the  spousal  impoverishment  protection
continues to apply when the recipient moves from a nursing home to a community
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No.   2010AP1424
based residential facility under the Medicaid Family Care subprogram.   See WIS.
STAT. § 49.455(4); WIS. ADMIN. CODE § DHS 10.32.   He further contends that de
novo review is appropriate because DHS does not have any particular expertise on
the precise question of how the spousal impoverishment protection applies in the
context of the Family Care subprogram.   See Telemark Dev., Inc. v. DOR, 218
Wis. 2d 809, 820-21, 581 N.W.2d 585 (Ct. App. 1998) (agency’s broad expertise
in area may not be sufficient to accord decision great weight deference, where
agency has not previously addressed precise question presented).   Finally, Berger
contends  de  novo  review  is  appropriate  because  DHS’s  interpretation  of  the
spousal impoverishment statute is inconsistent with its position in the Medical
Eligibility Handbook.    He cites the Handbook’s provisions providing that the
spousal impoverishment protection applies to institutionalized persons and their
spouses, and that when a person transfers from one institutionalized setting to
another, it is considered one continuous period of institutionalization.   See Medical
Eligibility Handbook, §§ 18.1, 18.2.3.   Berger argues that the Handbook expressly
states that the spousal impoverishment protection applies in his situation.
¶9                                                                                             DHS argues that its statutory interpretation is entitled to great weight
deference.    See Estate of Hagenstein,  292 Wis. 2d  697,  ¶20; Hillhaven,  232
Wis. 2d  400,  ¶12 & n.6.   It points out that:  (1) DHS has been charged by the
legislature with the duty of administering the medical assistance statutes; (2) DHS
has a long history of interpreting and applying the medical assistance statutes;
(3) DHS  has  developed  an  expertise  in  interpreting  and  applying  the  medical
assistance statutes; and (4) its interpretation will provide consistency in applying
the statutes and rules.   DHS also argues that, regardless of the level of deference
applied  to  its  statutory  interpretation,  its  decision  in  this  case  turned  on  its
5




No.   2010AP1424
interpretation  of  its  own  rules,  which  we  must  accord  controlling  weight
deference.   See Hillhaven, 232 Wis. 2d 400, ¶12 & n.6.
¶10    We  agree  with  DHS  that  its  decision  in  this  case  turned  on  its
interpretation  of  its  own  rules  and  regulations,  thus  entitling  it  to  controlling
weight  deference.    See  id.    Applying  that  standard  as  explained  below,  we
conclude  that  DHS’s  interpretation  was  reasonable  and  consistent  with  the
language of its rules and regulations, and thus we have no basis to disturb it.
DHS’s Decision
¶11    Berger   contends   that   DHS’s   interpretation   of   the   spousal
impoverishment  statute  is  unreasonable.6    See  Harnischfeger  v.  LIRC,                   196
Wis. 2d 650, 662, 539 N.W.2d 98 (1995) (agency interpretation is unreasonable if
it directly contravenes the words of the statue, is contrary to legislative intent, or
without a rational basis).
¶12    Berger  contends  first  that  DHS’s  interpretation  of  the  spousal
impoverishment statute,  WIS.  STAT.  § 49.455(4)(a),  is unreasonable  because  it
directly contravenes the words of the statute.   Section 49.455(4)(a) provides:
After an institutionalized spouse is determined to be
eligible for medical assistance, in determining the amount
of  that  institutionalized  spouse’s  income  that  must  be
applied  monthly  to  payment  for  costs  of  care  in  the
institution, [DHS] shall deduct the following amounts  …
from the institutionalized spouse’s income:
….
6  Berger did not address controlling weight deference in his initial brief, and declined to
file a reply brief.
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No.   2010AP1424
2.   The   community   spouse   monthly   income
allowance ….
Berger  contends  that  the  statute  is  unambiguous  in  stating  that  after  the
institutionalized spouse qualifies for medical assistance, DHS shall deduct from
the  calculation  of  income  the  community  spouse  monthly  income  allowance.
Thus, Berger contends, after he was found eligible for medical assistance in the
nursing home, DHS was required to apply the spousal impoverishment protection,
regardless of his transfer to a community-based residential facility.   He argues that
nothing in the statute states that a new determination of eligibility must be made
based on a transfer to a different facility.
¶13    Berger  also  contends  that  DHS’s  interpretation  of  the  spousal
impoverishment statute is unreasonable because it clearly contravenes legislative
intent.    He  asserts  that  the  purpose  of  the  Family Care  program  is  to  allow
individuals to choose community-based care over institutional settings.   He points
out that WIS. STAT. § 46.286(1)(b)2m. provides that a person is eligible for Family
Care if that person is eligible for and accepts medical assistance, and asserts that is
what happened here.   He cites legislative history in support of his argument that
drafters  of  the  Family  Care  provisions  intended  the  spousal  impoverishment
protection to apply to Family Care participants.
¶14    Finally,  Berger  argues  that  DHS’s  interpretation  is  unreasonable
because it has no rational basis.    He contends that WIS. ADMIN. CODE  § DHS
10.34(2) provides that an individual who is eligible for medical assistance is also
eligible for Family Care; WIS. ADMIN. CODE § DHS 10.35 states that the spousal
impoverishment provision applies to all Family Care spouses; and WIS. ADMIN.
CODE § DHS 103.075 provides that to allocate income to a community spouse, the
institutionalized spouse need only be eligible for medical assistance.   He contends
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No.   2010AP1424
that while WIS. ADMIN. CODE § DHS 10.32(4) states that Family Care eligibility is
reassessed when a change in circumstances occurs, a move from one facility to
another  should  not  be  viewed  as  such  a  change.    Berger  also  points  to  the
Medicaid Eligibility Handbook,  §§ 18.4.6.2.1. and  18.2.3., as providing that an
institutionalized spouse’s move directly from one institution to another does not
require a reassessment of eligibility for the spousal impoverishment protection.
¶15    DHS responds that Berger’s interpretation is based on an isolated
reading of WIS. STAT. § 49.455(4)(a), rather than viewing it in the context of the
medical assistance  statutes as a whole, and  with corresponding administrative
rules.   It points to its rules requiring it to reassess a participant’s eligibility for
medical assistance at least once a year, and when any change occurs that might
affect the recipient’s eligibility.   See WIS. ADMIN. CODE  §§ DHS  10.32(4) and
102.04(3).   It also points to the Medicaid Eligibility Handbook, § 28.8.1., which
provides  that  a  county  is  to  complete  an  eligibility  worksheet  when  an
institutionalized person is discharged to a community-based program.
¶16    DHS  then  points  to  the  language  of  WIS.  STAT.  § 49.455(4)(a),
which states that the spousal impoverishment protection provision applies after the
institutionalized spouse is determined eligible for medical assistance.   Here, DHS
asserts, its rules provided that it was to reassess Berger’s eligibility for medical
assistance  upon  his  transfer  to  the  community-based  residential  facility  and,
having determined that Berger was not eligible for any subprogram, the statute, by
its  terms,  did  not  apply.    It  argues  that  its  interpretation  is  not  contrary  to
legislative intent of allowing individuals to choose community care over nursing
home care, pointing out that the spousal impoverishment protection would apply
to  Berger  in  the  community setting  if  he  qualified  for  Family Care.    It  also
contends that its interpretation has a rational basis, as it followed its rules in
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No.   2010AP1424
reassessing Berger’s eligibility and determining that, based on Berger’s income
level and the reduced costs of the community-based residential facility, Berger did
not qualify for any Medicaid subprogram.
¶17    We  observe  that  a  threshold  issue  as  to  whether  DHS  properly
determined that Berger is not entitled to the spousal impoverishment protection is
whether DHS properly interpreted its rules as requiring it to reassess Berger’s
eligibility for medical assistance upon his transfer to a different facility.   That is,
all of Berger’s arguments are premised on his assertion that he remained eligible
for  medical  assistance  when  he  transferred  from  the  nursing  home  to  the
community  based  residential  facility,  and  that  DHS  erred  in  reassessing  his
eligibility at that point.    We conclude that DHS’s interpretation of its rules as
requiring it to reassess a recipient’s eligibility for medical assistance upon a move
from a nursing home to a community-based residential facility is a reasonable
interpretation of its rules.
¶18    WISCONSIN ADMIN. CODE § DHS 102.04(3) provides:
A recipient’s eligibility shall be redetermined:
(a)   When information previously obtained by the
agency concerning anticipated changes in the individual’s
situation indicates the need for redetermination;
(b)   Promptly  after  a  report  is  obtained  which
indicates a change in the individual’s circumstances that
may affect eligibility;
….
(e)   At any time the agency has a reasonable basis
for  believing  that  a  recipient  is  no  longer  eligible  for
[medical assistance].
We conclude that DHS’s interpretation of this rule as authorizing it to reassess
Berger’s eligibility for medical assistance upon his transfer from a nursing home
9




No.   2010AP1424
to a community-based residential facility is not plainly erroneous.   A change in
facility, with lower medical costs, may provide a reasonable basis for believing the
recipient no longer qualifies for medical assistance.   See WIS. STAT. § 49.47(4)(b)
and (c); and WIS. ADMIN. CODE § DHS 103.04(2) and (4).
¶19    DHS  also  points  out  that  once  Berger  moved  into  a  residential
facility, which does not qualify as a “medical institution,” he no longer qualified
for institutional Medicaid, and thus the county assessed whether he was eligible
for  any  other  Medicaid  subprogram.7     See  Medicaid  Eligibility  Handbook,
§ 27.1.1. (defining “medical institution” for purposes of Medicaid eligibility).   As
DHS points out, Berger does not challenge the county’s determination that, after
his transfer to the community-based residential facility and absent the community
spouse allocation, his income was above the threshold to qualify for any other
Medicaid subprogram.   Because we have no basis to disturb DHS’s interpretation
of  its  rules  and  regulations  as  allowing  it  to  reassess  Berger’s  eligibility for
medical assistance based on his transfer to a different facility, and Berger has not
set forth an argument that he qualified for medical assistance upon reassessment,
we affirm.
By the Court.—Order affirmed.
7  In his statement of facts, Berger asserts that the county should have assessed his
eligibility for Family Care under “Group A” rather than “Group C” because he remained eligible
for institutional Medicaid upon his transfer from the nursing home to the community-based
treatment facility.   Berger does not provide any record or legal citations to support this assertion,
does not explain why he believes he remained eligible for institutional Medicaid after the transfer,
and does not address this issue in his argument section.  DHS, in its statement of facts, asserts that
while Berger remained an “institutionalized person” in the community-based residential facility,
the residential facility is not a                                                                        “medical institution” for purposes of institutional Medicaid
eligibility.    See Medicaid Eligibility Handbook  § 27.1.1.    Berger has not filed a reply brief
addressing this issue.
10




No.   2010AP1424
                   This  opinion  will  not  be  published.     See  WIS.  STAT.  RULE
809.23(1)          (b)5.
11

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