Could Idaho enforce its Relative Responsibility law (requiring adult children, spouses, and parents to repay Medicaid nursing home costs) consistent with the federal Social Security Act?

Opinion 85-10: Idaho's Medicaid Relative Responsibility law and the federal waiver path

Plain-English summary

Idaho Code § 32-1008A (effective October 1, 1983) required certain "responsible relatives" of Medicaid nursing home patients (spouses, natural and adoptive children) to repay a portion of the medical assistance the state had provided. The AG had concluded in Opinion 84-7 that the law was inconsistent with federal Social Security Act provisions barring relative responsibility beyond spouses and parents of minor children. The legislature responded by directing the Department of Health and Welfare to seek a section 1115 demonstration waiver from the federal Department of Health and Human Services. This 1985 opinion answered four follow-up questions: (1) which Idaho statutes were relevant to the waiver application; (2) how to handle the third-party-liability treatment of relative payments under the waiver; (3) whether the relative responsibility law would still face other federal challenges if a waiver were granted; and (4) what residual collection problems would remain even with a waiver. The AG concluded that significant practical barriers remained: the law did not authorize jurisdiction over non-residents, the Department had to obtain a district court support order before collecting, and pre-rule collections were not authorized.

Currency note

This opinion was issued in 1985. Subsequent statutory amendments, court decisions, or later AG opinions may have changed the analysis. Treat this page as historical context, not current legal advice. Verify current law before relying on any specific rule, deadline, or remedy mentioned here.

Background and statutory framework

Section 1902(a)(17)(D) of the Social Security Act (42 U.S.C. § 1396a(a)(17)(D)) and the Senate Report from 1965 made clear that states could not require contributions from relatives other than a spouse or a parent of a minor child. Idaho's relative responsibility law swept more broadly, reaching adult children of nursing home patients. Section 1115 of the Social Security Act (42 U.S.C. § 1315) gives the Secretary of HHS broad discretion to authorize demonstration projects that depart from standard requirements, provided the project promotes the objectives of the relevant title.

A November 2, 1984 letter from HHS's regional office had described the relative responsibility issue as philosophically interesting and identified section 1115 as the right vehicle. A demonstration project would require a formal application with research design, data plan, and evaluation framework. Approvals are limited to two years.

What the AG concluded at the time

Most other Idaho statutes were not in scope

The Department had asked whether Idaho Code §§ 56-203A, 56-203B, 56-209b(3), 32-1002, 32-1003, 66-414, and 32-901 should be addressed in the waiver application. The AG read each as either narrower than the relative responsibility law (covering child support, county indigency, or community property) or already independently enforced. None needed to be folded into the waiver request, which would target Idaho Code § 32-1008A specifically.

Third-party liability treatment

Under existing federal regulations and the Medicaid Manual Transmittal, third-party liability rules at 42 CFR 433 subpart D do not apply to collections under a statute of general applicability. Because Idaho's relative responsibility law was not a statute of general applicability, the waiver application had to specifically request waiver of 42 CFR 435.602 and 436.602 and ask that relative payments be treated as third-party-liability payments (not as income to the recipient affecting eligibility).

Even with a waiver, the federal validity question rested with HHS

Once the federal government grants a waiver, the state agency must consider those requirements waived for the duration of the project. Aguayo v. Richardson and Crane v. Matthews recognize the Secretary's broad discretion under section 1115, with judicial review limited to arbitrary-and-capricious review.

Practical collection problems remained

The AG flagged three problems even if a waiver issued.

Long-arm jurisdiction over non-residents. Section 32-1008A did not provide long-arm jurisdiction. Idaho Code § 5-514 is the general long-arm statute, but it requires acts in Idaho or contacts that meet due process. Mere parent-child relationship is not enough (Columbia Briargate; Madison Consulting Group). The AG drew an analogy to URESA (the Uniform Reciprocal Enforcement of Support Act) and noted that effective collection across state lines would likely require a federal statute or regulation requiring all states to cooperate.

District court support orders. Voluntary payments could be received under existing rules. But for involuntary collection, the Department would need a district court judgment or support order before executing under §§ 8-505, 506, 528, and 529. The AG read § 56-203D(1)(a) by analogy as requiring a judgment.

Pre-rule collections not authorized. The Idaho Administrative Procedure Act (Idaho Code § 67-5201 et seq.) required the Department to promulgate rules before collecting. The Department could not collect amounts paid by Medicaid before its rules took effect.

Recommended path

The AG suggested the simplest fix was for the legislature to amend § 32-1008A to make it a law of general applicability and address the other concerns. A section 1115 waiver was time-limited to two years, would not insulate the state from third-party suits that could affect federal funding, and would require significant resources to run a credible demonstration project.

Common questions

Did this opinion stop Idaho's program in its tracks?

It identified barriers without halting the program, but it cautioned that even a waiver would not eliminate exposure to private litigation that could threaten federal funding.

Could Idaho still collect from a nursing home patient's spouse who lived in Idaho?

The opinion noted that spousal collections under § 32-901 (community property duties) and § 32-709 (general spousal support) remained authorized in their narrow contexts. Section 32-1008A's broader collection from adult children was the part that triggered the federal conflict.

Did the federal government ever grant the waiver?

The opinion did not say. As a 1985 document, it predates any HHS decision on a formal waiver application.

Citations

• Idaho Code § 32-1008A — relative responsibility statute at issue.
• Idaho Code § 5-514 — Idaho's general long-arm statute.
• Social Security Act § 1115 (42 U.S.C. § 1315) — demonstration project waiver authority.
• Social Security Act § 1902(a)(17)(D) (42 U.S.C. § 1396a(a)(17)(D)) — federal limit on relative contribution requirements.
• Aguayo v. Richardson, 473 F.2d 1090 (2d Cir. 1973) — broad Secretary discretion on section 1115 waivers.
• Idaho Attorney General Opinion No. 84-7 (1984) — earlier opinion finding § 32-1008A inconsistent with federal law.

Source

• Landing page: https://www.ag.idaho.gov/office-resources/opinions/
• Original PDF: https://ag.idaho.gov/content/uploads/2018/04/OP85-10.pdf

Original opinion text

Best-effort transcription from a scanned PDF. Minor errors may remain; the linked PDF is authoritative.

STATE OF IDAHO
OFFICE OF THE ATTORNEY GENERAL

JIM JONES
ATTORNEY GENERAL
BOISE 83720
TELEPHONE (208) 334-2400

ATTORNEY GENERAL OPINION NO. 85-10

TO: Rose Bowman, Director
Idaho Department of Health and Welfare

Per Request for Attorney General's Opinion

QUESTIONS PRESENTED:

I. Idaho's "Relative Responsibility" law, codified at Idaho Code § 32-1008A, is but one of several laws dealing with the liability of parents or spouses for repayment of public assistance, including medical assistance. Which of these laws should be addressed in formulating an application for a waiver under the demonstration program provisions of section 1115 of the Social Security Act?

II. Under Idaho's relative responsibility law, payments collected from parents and spouses are treated by the state as payments from a legally liable third party if they are made after the state has paid Medicaid bills. Should this practice be addressed in applying for a waiver under the demonstration program provisions of section 1115 of the Social Security Act?

III. If the waiver of "general applicability" were received, would Idaho's relative responsibility law still violate the Social Security Act by selecting out only the parents, spouses and adult children of Medicaid nursing home clients?

IV. Assuming that Idaho's relative responsibility program would qualify for a demonstration program waiver under section 1115 of the Social Security Act, the following additional questions must be addressed regarding repayment collections:

Do Idaho's relative responsibility law and other pertinent statutes give the Department of Health and Welfare jurisdiction and authority to collect from non-residents?

Does the Department have to obtain a district court support order prior to obtaining repayment?

Can the Department collect from parents and spouses the amounts paid by Medicaid before the effective date of these rules?

CONCLUSIONS:

I. The intent of the waiver application is to create a demonstration project along the lines of Idaho's relative responsibility law as that law is contained in Idaho Code § 32-1008A. If the application were carefully drafted to incorporate that precise intent, the other statutes in your letter would be irrelevant.

II. A waiver request should state that collections shall be treated as payments from legally liable third parties.

III. It is the responsibility of the federal government to determine whether those provisions of Idaho's relative responsibility law which violate the Social Security Act can be waived pursuant to section 1115 of the same act.

IV. The collection program problems associated with implementing a relative responsibility program are significant:

The relative responsibility law does not give the Department of Health and Welfare jurisdiction or authority to collect from nonresidents.

The Department would have to obtain a district court support order prior to obtaining repayment.

The Department could not collect from responsible relatives any amounts paid by Medicaid before the effective date of promulgation of the Idaho rules.

BACKGROUND:

Idaho's relative responsibility law, Idaho Code § 32-1008A, became effective on October 1, 1983. The law governs Medicaid patients in licensed skilled nursing facilities and licensed intermediate care facilities. It provides that responsible relatives must pay specific portions of the medical assistance provided to such patients and defines "responsible relatives" to include spouses, natural and adoptive children and others.

The Idaho Department of Health and Welfare began to implement this program and adopted appropriate regulations in 1983. However, when the Department began the collection phase of the program, Senator Terry Reilly of the Idaho Legislature requested an Attorney General's opinion as to whether the new relative responsibility law conformed with federal laws and regulations regarding the use of Medicaid funds.

Pursuant to this request, the Attorney General issued Opinion No. 84-7 on March 23, 1984. That Opinion concluded that Idaho's relative responsibility law was "inconsistent with federal law regulating the use of Medicaid funds" and that a "continuation of the statutory scheme may subject Idaho to federal sanctions and/or private court actions . . . ." 1984 Attorney General Opinion No. 84-7 at 67.

In particular, the Opinion found that Idaho's relative responsibility law was not a law of "general applicability" and that its demand for repayment from responsible relatives violates the intent of Congress, which was that "States may not include in their plans provisions for requiring contributions from relatives other than a spouse or a parent of a minor child . . . ." S.Rep. No. 404, 89th Cong. 1st Sess. 78 (1965).

Subsequent to receipt of Attorney General Opinion No. 84-7, the legislative germane committees requested the Idaho Department of Health and Welfare to seek a waiver of the above-quoted prohibitions in the federal Social Security Act, pursuant to section 1115 of that law. The Department inquired into the possibility of such a waiver and, on November 2, 1984, received a response to its inquiry from Norman V. Meyer, Associate Regional Administrator for Policy of the Department of Health and Human Services. The response states that the federal agency "views the relative responsibility program as an important Medicaid issue; one which is of interest philosophically to this administration." This Opinion addresses the questions surrounding any application Idaho might make for such a waiver.

ANALYSIS:

I. Idaho Statutes Pertinent to a Demonstration Program Waiver.

The following Idaho statutes are mentioned in your opinion request as having possible relevance to the waiver request:

Idaho Code § 56-203A — Authority of Department of Health and Welfare to enforce child support.
Idaho Code § 56-203B — Payment of public assistance for child constitutes debt to the Department by natural or adoptive parents.
Idaho Code § 56-209b(3) — Medical assistance.
Idaho Code § 32-1002 — Reciprocal duties of support.
Idaho Code § 32-1003 — Liability of parent for child's necessaries.
Idaho Code § 66-414 — Developmentally disabled persons with assets sufficient to pay expenses, liability of relatives.
Idaho Code § 32-901 — Mutual obligations of husband and wife.

[The opinion proceeds to analyze each of these statutes, concluding that none should be folded into the section 1115 waiver application because they either address narrower contexts (child support, county indigency, community property) or are already enforced under separate frameworks.]

II. Treatment of Collection Procedures Under a Waiver Program

[The opinion addresses third-party liability treatment under 42 CFR 435.602 and 436.602 and the Medicaid Manual Transmittal HFCA Pub. 45-3 No. 3812 (Feb. 1983). The opinion concludes that the waiver application must specifically seek waiver of these regulations and ask that relative payments be treated as third-party-liability payments.]

III. Validity of the Waiver.

[The opinion explains the Secretary of HHS's broad discretion under section 1115 (citing Aguayo v. Richardson and Crane v. Matthews) and the limitations of judicial review (arbitrary and capricious only). It quotes the federal regional administrator's letter on the demonstration project requirements and notes that section 1115 waivers cannot last longer than two years.]

IV. Collection Problems.

A. Long-arm jurisdiction. The AG analyzes Idaho Code §§ 32-1008A and 5-514 and concludes neither provides jurisdiction over non-resident responsible relatives. The mere parent-child relationship does not satisfy due process under Southern Idaho Pipe and Steel, Duignan v. A.H. Robbins, Columbia Briargate, and Madison Consulting Group. The AG draws the analogy to URESA and notes that effective collection across state lines would likely require federal cooperation.

B. District court support order. While voluntary repayments could be obtained, involuntary collection requires a judgment under §§ 8-505, 506, 528, and 529. The AG draws an analogy to § 56-203D(1)(a) which similarly requires repayment to be established by judgment.

C. Pre-rule collections. The Idaho Administrative Procedure Act (§§ 67-5201 et seq.) requires rules before collecting. The Department could not reach back to amounts paid before its rules took effect.

The AG concludes that the simplest path forward would be legislative amendment of § 32-1008A to make it a law of general applicability and address the other identified concerns. The restrictions and limited life of a section 1115 waiver-demonstration experiment would not effectively carry out the legislative purpose. Even a comprehensive waiver could not protect the state from third-party litigation that could affect federal funding (Aguayo v. Richardson). The opinion cannot assure that the Secretary's exercise of discretion in approving a waiver would survive judicial review.

ANALYSIS BY:
MICHAEL DE ANGELO
Deputy Attorney General
Chief, Health and Welfare Division