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SUPREME COURT OF THE UNITED STATES
_________________
No. 12–98
_________________
ALDONA WOS, SECRETARY, NORTH CAROLINA
DEPARTMENT OF HEALTH AND HUMAN SER- VICES, PETITIONER
v.
E. M. A., a minor, by and through her guardian
ad litem, DANIEL H. JOHNSON, et al.
on writ of certiorari to the united states
court of appeals for the fourth circuit
[March 20, 2013]
Justice Kennedy delivered the opinion of the
Court.
A federal statute prohibits States from
attaching a lien on the property of a Medicaid beneficiary to
recover ben-efits paid by the State on the beneficiary’s behalf. 42
U. S. C. §1396p(a)(1). The anti-lien provision pre-empts
a State’s effort to take any portion of a Medicaid beneficiary’s
tort judgment or settlement not “designated as pay-ments for
medical care.”
Arkansas Dept. of Health and Human Servs. v.
Ahlborn,
547 U.S.
268, 284 (2006). North Carolina has enacted a statute requiring
that up to one-third of any damages recovered by a beneficiary for
a tortious injury be paid to the State to reimburse it for
pay-ments it made for medical treatment on account of the in-jury.
See N. C. Gen. Stat. Ann. §108A–57 (Lexis 2011);
Andrews v.
Haygood, 362 N. C. 599, 604–605, 669
S.E.2d 310, 314 (2008). The question presented is whether the North
Carolina statute is compatible with the federal anti-lien
provision.
I
When respondent E. M. A. was born in
February 2000, she suffered multiple serious birth injuries which
left her deaf, blind, and unable to sit, walk, crawl, or talk. The
injuries also cause her to suffer from mental retardation and a
seizure disorder. She requires between 12 and 18 hours of skilled
nursing care per day. She will not be able to work, live
independently, or provide for her basic needs. The cost of her
ongoing medical care is paid in part by the State of North
Carolina’s Medicaid program.
In February 2003, E. M. A. and her
parents filed a medical malpractice suit in North Carolina state
court against the physician who delivered E. M. A. at
birth and the hospital where she was born. The expert witnesses for
E. M. A. and her parents in that proceeding estimated
damages in excess of $42 million for medical and life-care
expenses, loss of future earning capacity, and other assorted
expenses such as architectural renovations to their home and
specialized transportation equipment. App. 91–112. By far the
largest part of this estimate was for “Skilled Home Care,” totaling
more than $37 million over E. M. A.’s lifetime.
Id., at 112. E. M. A. and her parents also sought
damages for her pain and suffering and for her parents’ emotional
distress.
Id., at 64–65, 67–68, 72–73, 75–76. Their experts
did not estimate the damages in these last two categories.
Assisted by a mediator, the parties began
settlement negotiations. E. M. A. and her parents
informed the North Carolina Department of Health and Human Services
of the negotiations. The department had a statutory right to
intervene in the malpractice suit and participate in the settlement
negotiations in order to obtain reimbursement for the medical
expenses it paid on E. M. A.’s behalf, up to one-third of the
total recovery. See N. C. Gen. Stat. Ann. §§108A–57, 108A–59.
It elected not to do so, though its representative informed
E. M. A. and her parents that the State’s Medicaid
program had expended $1.9 million for E. M. A.’s medical
care, which it would seek to recover from any tort judgment or
settlement.
In November 2006, the court approved a $2.8
million settlement. The amount, apparently, was dictated in large
part by the policy limits on the defendants’ medical malpractice
insurance coverage. See Brief for Respondents 5. The settlement
agreement did not allocate the money among the different claims E.
M. A. and her parents had advanced. In approving the
settlement the court placed one-third of the $2.8 million recovery
into an interest-bearing escrow account “until such time as the
actual amount of the lien owed by [E. M. A.] to [the
State] is con-clusively judicially determined.” App. 87.
E. M. A. and her parents then filed
this action under Rev. Stat. §1979, 42 U. S. C. §1983, in
the United States District Court for the Western District of North
Carolina. They sought declaratory and injunctive relief, arguing
that the State’s reimbursement scheme violated the Medicaid
anti-lien provision, §1396p(a)(1). While that litigation was
pending, the North Carolina Supreme Court con-fronted the same
question in
Andrews,
supra. It held that the
irrebuttable statutory presumption that one-third of a Medicaid
beneficiary’s tort recovery is attributable to medical expenses was
“a reasonable method for determining the State’s medical
reimbursements.”
Id., at 604, 669 S. E. 2d, at 314. The
United States District Court, in the instant case, agreed.
Armstrong v.
Cansler, 722 F. Supp. 2d 653 (2010).
The Court of Appeals for the Fourth Circuit
vacated and remanded.
E. M. A. v.
Cansler,
674 F.3d 290 (2012). It concluded that North Carolina’s statutory
scheme could not be reconciled with “
Ahlborn’s clear holding
that the general anti-lien provision in federal Medicaid law
prohibits a state from recovering any portion of a settlement or
judgment not attributable to medical expenses.”
Id., at 310.
In some cases, the court reasoned, the actual portion of a
beneficiary’s tort recovery representing payment for medical care
would be less than one-third. North Caro-lina’s statutory
presumption that one-third of a tort recovery is attributable to
medical expenses therefore must be “subject to adversarial testing”
in a judicial or administrative proceeding.
Id., at 311.
To resolve the conflict between the opinion of
the Court of Appeals in this case and the decision of the North
Carolina Supreme Court in
Andrews, this Court granted
certiorari. 567 U. S. ___ (2012).
II
At issue is the interaction between certain
provisions of the federal Medicaid statute and state law. Congress
has directed States, in administering their Medicaid programs, to
seek reimbursement for medical expenses incurred on behalf of
beneficiaries who later recover from third-party tortfeasors.
States must require beneficiaries “to assign the State any rights .
. . to support (specified as support for the purpose of medical
care by a court or administrative order) and to payment for medical
care from any third party.” 42 U. S. C. §1396k(a)(1)(A).
States receiving Medi-caid funds must also
“ha[ve] in effect laws under which, to the
extent that payment has been made under the State plan for medical
assistance for health care items or services furnished to an
individual, the State is considered to have acquired the rights of
such individual to payment by any other party for such health care
items or services.” §1396a(a)(25)(H).
A separate provision of the Medicaid statute,
however, exists in some tension with these requirements. It says
that, with exceptions not relevant here, “[n]o lien may be imposed
against the property of any individual prior to his death on
account of medical assistance paid or to be paid on his behalf
under the State plan.” §1396p(a)(1).
In
Ahlborn, the Court addressed this
tension and held that the Medicaid statute sets both a floor and a
ceiling on a State’s potential share of a beneficiary’s tort
recovery. Federal law requires an assignment to the State of “the
right to recover that portion of a settlement that represents
payments for medical care,” but it also “precludes attachment or
encumbrance of the remainder of the settlement.” 547 U. S., at
282, 284. This is so because the beneficiary has a property right
in the proceeds of the settlement, bringing it within the ambit of
the anti-lien provision.
Id., at 285. That property right is
subject to the specific statutory “exception” requiring a State to
seek reimbursement for medical expenses paid on the beneficiary’s
behalf, but the anti-lien provision protects the beneficiary’s
interest in the remainder of the settlement.
Id., at
284.
A question the Court had no occasion to resolve
in
Ahlborn is how to determine what portion of a settlement
represents payment for medical care. The parties in that case
stipulated that about 6 percent of respondent Ahlborn’s tort
recovery (approximately $35,600 of a $550,000 settlement)
represented compensation for medical care.
Id., at 274. The
Court nonetheless anticipated the concern that some settlements
would not include an itemized allocation. It also recognized the
possibility that Medicaid beneficiaries and tortfeasors might
collaborate to allocate an artificially low portion of a settlement
to medical expenses. The Court noted that these problems could “be
avoided either by obtaining the State’s advance agreement to an
allocation or, if necessary, by submitting the matter to a court
for decision.”
Id., at 288.
North Carolina has attempted a different
approach. Its statute provides:
“Notwithstanding any other provisions of
the law, to the extent of payments under this Part, the State, or
the county providing medical assistance benefits, shall be
subrogated to all rights of recovery, contractual or otherwise, of
the beneficiary of this assistance . . . . The
county attorney, or an attorney retained by the county or the State
or both, or an attorney retained by the beneficiary of the
assistance if this attorney has actual notice of payments made
under this Part shall enforce this section. Any attorney retained
by the beneficiary of the assistance shall, out of the proceeds
obtained on behalf of the beneficiary by settlement with, judgment
against, or otherwise from a third party by reason of injury or
death, distribute to the Department the amount of assistance paid
by the Department on behalf of or to the beneficiary, as prorated
with the claims of all others having medical subrogation rights or
medical liens against the amount received or recovered, but the
amount paid to the Department shall not exceed one-third of the
gross amount obtained or recovered.” N. C. Gen. Stat. Ann.
§108A–57(a).
Before
Ahlborn was decided, North
Carolina and the state courts interpreted this statute to allow the
State to “recover the costs of medical treatment provided . . .
even when the funds received by the [beneficiary] are not re-
imbursement for medical expenses.”
Campbell v.
North
Carolina Dept. of Human Resources, 153 N. C. App. 305,
307–308, 569 S.E.2d 670, 672 (2002). See also
Ezell v.
Grace Hospital, Inc., 360 N. C. 529, 631 S.E.2d 131
(2006) (
per curiam). Under
Ahlborn, however, this
construction of the statute is at odds with the Medicaid anti-lien
provision, which “precludes attachment or encum- brance” of any
portion of a settlement not “designated as payments for medical
care.” 547 U. S., at 284.
In response to
Ahlborn, the State
advanced—and the North Carolina Supreme Court in
Andrews
accepted— a new interpretation of its statute. Under this
interpretation the statute “defines ‘the portion of the settlement
that represents payment for medical expenses’ as the lesser of the
State’s past medical expenditures or one-third of the plaintiff’s
total recovery.”
Andrews, 362 N. C., at 604, 669
S. E. 2d, at 314. In other words, when the State’s Medicaid
expenditures on behalf of a beneficiary exceed one-third of the
beneficiary’s tort recovery, the statute establishes a conclusive
presumption that one-third of the recovery represents compensation
for medical expenses. Under this reading of the statute the
presumption operates even if the settlement or a jury verdict
expressly allocates a lower percentage of the judgment to medical
expenses. See Tr. of Oral Arg. 10, 16–17. Cf.
Andrews,
supra, at 602–604, 669 S. E. 2d, at 313.
III
A
Under the Supremacy Clause, “[w]here state and
federal law ‘directly conflict,’ state law must give way.”
PLIVA, Inc. v.
Mensing, 564 U. S. ___, ___
(2011) (slip op., at 11). The Medicaid anti-lien provision
prohibits a State from making a claim to any part of a Medicaid
beneficiary’s tort recovery not “designated as payments for medical
care.”
Ahlborn,
supra, at 284. North Carolina’s
statute, therefore, is pre-empted if, and insofar as, it would
operate that way.
And it is pre-empted for that reason. The defect
in §108A–57 is that it sets forth no process for determining what
portion of a beneficiary’s tort recovery is attributable to medical
expenses. Instead, North Carolina has picked an arbitrary
number—one-third—and by statutory command labeled that portion of a
beneficiary’s tort recovery as representing payment for medical
care. Pre-emption is not a matter of semantics. A State may not
evade the pre-emptive force of federal law by resorting to creative
statutory interpretation or description at odds with the statute’s
intended operation and effect.
A similar issue was presented last Term, in
National Meat Assn. v.
Harris, 565 U. S. ___
(2012). That case involved the pre-emptive scope of the Federal
Meat Inspection Act, 21 U. S. C. §601
et seq.
The Act prohibited States from imposing “ ‘[r]equirements
. . . with respect to premises, facilities and
operations’ ” at federally regulated slaughterhouses.
National Meat Assn., 565 U. S., at ___ (slip op., at 4)
(quoting §678). The State of California had enacted a law that
prohibited slaughterhouses from (among other things) selling meat
from nonambulatory ani- mals for human consumption.
Id., at
___ (slip op., at 5) (citing Cal. Penal Code Ann. §599f(b) (West
2010)). California sought to defend the law on the ground that it
did not regulate the activities of slaughterhouses but instead
restricted what type of meat could be sold in the marketplace after
the animals had been butchered. 565 U. S., at ___–___ (slip
op., at 9–10).
The Court rejected that argument. It recognized
that if the argument were to prevail, “then any State could im-pose
any regulation on slaughterhouses just by framing it as a ban on
the sale of meat produced in whatever way the State disapproved.
That would make a mockery of the [Act’s] preemption provision.”
Id., at ___ (slip op., at 10). In a pre-emption case, the
Court held, a proper analysis requires consideration of what the
state law in fact does, not how the litigant might choose to
describe it.
That reasoning controls here. North Carolina’s
argument, if accepted, would frustrate the Medicaid anti-lien
provision in the context of tort recoveries. The argument lacks any
limiting principle: If a State arbitrarily may designate one-third
of any recovery as payment for medical expenses, there is no
logical reason why it could not designate half, three-quarters, or
all of a tort recovery in the same way. In
Ahlborn, the
State of Arkansas, under this rationale, would have succeeded in
claiming the full amount it sought from the beneficiary had it been
more creative and less candid in describing the effect of its
full-reimbursement law.
Here the State concedes that it would be
“difficult . . . to defend” a law purporting to allocate
most or all of a beneficiary’s tort recovery to medical expenses.
Tr. of Oral Arg. 20. That is true; but, as a doctrinal matter, it
is no eas- ier to defend North Carolina’s across-the-board
allocation of one-third of all beneficiaries’ tort recoveries to
medical ex-penses. The problem is not that it is an unreasonable
ap-proximation in all cases. In some cases, it may well be a fair
estimate. But the State provides no evidence to substantiate its
claim that the one-third allocation is reasonable in the mine run
of cases. Nor does the law provide a mechanism for determining
whether it is a reasonable approximation in any particular
case.
In some instances, no estimate will be necessary
or appropriate. When there has been a judicial finding or approval
of an allocation between medical and nonmedical damages—in the form
of either a jury verdict, court decree, or stipulation binding on
all parties—that is the end of the matter.
Ahlborn was a
case of this sort. All parties (including the State of Arkansas)
stipulated that approximately 6 percent of the plaintiff’s
settlement represented payment for medical costs. 547 U. S.,
at 274. In other cases a settlement may not be reached and the
judge or jury, in its findings, may make an allocation. With a
stipulation or judgment under this procedure, the anti-lien
provision protects from state demand the portion of a beneficiary’s
tort recovery that the stipulation or judgment does not attribute
to medical expenses.
North Carolina’s statute, however, operates to
allow the State to take one-third of the total recovery, even if a
proper stipulation or judgment attributes a smaller percentage to
medical expenses. Consider the facts of
Ahlborn. There, only
$35,581.47 of the beneficiary’s settlement “constituted
reimbursement for medical payments made.”
Ibid. North
Carolina’s statute, had it been applied in
Ahlborn, would
have allowed the State to claim $183,333.33 (one-third of the
beneficiary’s $550,000 settlement). A conflict thus exists between
North Carolina’s law and the Medicaid anti-lien provision.
The instant case, to be sure, is not quite so
clear cut; for there was no allocation of the settlement by either
judi- cial decree or binding stipulation of the parties. But the
reasoning of
Ahlborn and the design of the federal statute
contemplate that possibility. When the State and the beneficiary
are unable to agree on an allocation,
Ahlborn noted, the
parties could “submi[t] the matter to a court for decision.”
Id., at 288.
The facts of the present case demonstrate why
Ahlborn anticipated that a judicial or administrative
proceeding would be necessary in that situation. Of the damages
stemming from the injuries E. M. A. suffered at birth, it is
apparent that a quite substantial share must be allocated to the
skilled home care she will require for the rest of her life. See
App. 112. It also may be necessary to consider how much
E. M. A. and her parents could have expected to receive
as compensation for their other tort claims had the suit proceeded
to trial. An irrebuttable, one-size-fits-all statutory presumption
is incompatible with the Medicaid Act’s clear mandate that a State
may not demand any por- tion of a beneficiary’s tort recovery
except the share that is attributable to medical expenses.
B
North Carolina offers responses to this
reasoning, but none is persuasive.
First, the State asserts that it is doing
nothing more than what
Ahlborn said it could do: “adop[t]
special rules and procedures for allocating tort settlements.” 547
U. S., at 288, n. 18. This misreads
Ahlborn. There
the Court, citing an
amicus brief, referred to judicial
proceedings some States had established for allocating tort
settlements where necessary for insurance or tax purposes. See
Brief for Association of Trial Lawyers of America, O. T. 2005, No.
04–1506, pp. 20–21 (citing
Henning v.
Wineman,
306 N.W.2d 550 (Minn. 1981), and
Rimes v.
State Farm
Mut. Auto. Ins. Co., 106 Wis. 2d 263,
316 N.W.2d 348 (1982)). Those examples illustrated the kind of
“special rules and procedures for allocating tort settlements” that
Ahlborn con- sidered. The decision did not endorse
irrebuttable presumptions that designate some arbitrary fraction of
a tort judgment to medical expenses in all cases.
Second, North Carolina contends that its law
falls within the scope of a State’s traditional authority to
regulate tort actions, including the amount of damages that a party
may recover. This argument begins from a correct premise: In our
federal system, there is no question that States possess the
“traditional authority to provide tort remedies to their citizens”
as they see fit.
Silkwood v.
Kerr-McGee Corp.,
464 U.S.
238, 248 (1984). But North Carolina’s law is not an exercise of
the State’s general authority to regulate its tort system. It does
not limit tort plaintiffs’ ability to recover for certain types of
nonmedical damages, and it does not say that medical damages are to
be privileged above other damages in tort suits. All it seeks to do
is to allocate the share of damages attributable to medical
expenses in tort suits brought by Medicaid beneficiaries. A statute
that singles out Medicaid beneficiaries in this manner cannot avoid
compliance with the federal anti-lien provision merely by relying
upon a connection to an area of traditional state regulation.
Third, North Carolina suggests that even though
its allocation of one-third of a tort recovery to medical expenses
may be arbitrary, other methods for allocating a recovery would be
just as arbitrary. In the State’s view there is no “ascertainable
‘true value’ of [a] case that should control what portion of any
settlement is subject to the State’s third-party recovery rights.”
Brief for Petitioner 26–27. As explained earlier, allocations,
while to some extent perhaps not precise, need not be arbitrary.
See
supra, at 9–10. In some cases a judgment or stipulation
binding on all parties will allocate the plaintiff’s recovery
across different claims. Where no such judgment or stipulation
exists, a fair allocation of such a settlement may be difficult to
determine. Trial judges and trial lawyers, however, can find
objective benchmarks to make projections of the damages the
plaintiff likely could have proved had the case gone to trial.
In the instant case, for example, the North
Carolina trial court approved the settlement only after finding
that it constituted “fair and just compensation” to E. M. A.
and her parents for her “severe and debilitating injuries”; for
“medical and life care expenses” her condition will require; and
for “severe emotional distress” from her injuries. App. 82. What
portion of this lump-sum settlement constitutes “fair and just
compensation” for each individual claim will depend both on how
likely E. M. A. and her parents would have been to
prevail on the claims at trial and how much they reasonably could
have expected to receive on each claim if successful, in view of
damages awarded in comparable tort cases.
This relates to North Carolina’s fourth
argument: that it would be “wasteful, time consuming, and costly”
to hold “frequent mini-trials” in order to divide a settlement
between medical and nonmedical expenses. Brief for Petitioner 28.
Even if that were true, it would not relieve the State of its
obligation to comply with the terms of the Medicaid anti-lien
provision. And it is not true as a general proposition. States have
considerable latitude to design administrative and judicial
procedures to ensure a prompt and fair allocation of damages.
Sixteen States and the District of Columbia provide for hearings of
this sort, and there is no indication that they have proved bur-
densome. Brief for United States as
Amicus Curiae 28– 29,
and n. 7. See,
e.g., Cal. Welf. & Inst. Code Ann.
§14124.76(a) (West 2011); Mo. Rev. Stat. §§208.215.9–11 (2012);
Tenn. Code Ann. §§71–5–117(g)–(i) (2012);
In re
E. B., 229 W. Va. 435, ___, 729 S.E.2d 270,
297 (2012). Many of these States have established rebuttable
presumptions and adjusted burdens of proof to ensure that
speculative assessments of a plaintiff’s likely recovery do not
defeat the State’s right to recover medical costs, a concern North
Carolina raises. See,
e.g., Haw. Rev. Stat. §346–37(h) (2011
Cum. Supp.) (rebuttable presumption of a one-third allocation);
Mass. Gen. Laws, ch. 118E, §22(c) (West 2010) (rebuttable
presumption of full reimbursement); Okla. Stat., Tit. 63,
§5051.1(D)(1)(d) (West 2011) (rebuttable presumption of full
reimbursement, “unless a more limited allocation of damages to
medical expenses is shown by clear and convincing evidence”).
Without holding that these rules are necessarily compliant with the
federal statute, it can be concluded that they are more accurate
than the procedure North Carolina has enacted.
The task of dividing a tort settlement is a
familiar one. In a variety of settings, state and federal courts
are called upon to separate lump-sum settlements or jury awards
into categories to satisfy different claims to a portion of the
moneys recovered. See
supra, at 11. See also,
e.g.,
Green v.
Commissioner, 507 F.3d 857, 867–868 (CA5 2007)
(separation of compensatory from noncompensatory damages for tax
purposes);
Donnel v.
United States, 50 Fed. Cl. 375,
386–387 (2001) (separation of employee severance bonus from other
payments for tax purposes);
In re Harrison, 306 B.R.
172, 182–183 (Bkrtcy. Ct. ED Tex. 2003) (separation of
pain-and-suffering damages from other damages for purposes of
bankruptcy exemption);
Colorado Compensation Ins. Auth. v.
Jones,
131 P.3d 1074, 1077–1078 (Colo. App. 2005) (separation of
economic from noneconomic damages for purposes of insurance sub-
rogation);
Spangler v.
North Star Drilling Co., 552
So. 2d 673, 685 (La. App. 1989) (separation of past dam- ages from
future damages for purposes of calculating pre- judgment interest).
Indeed, North Carolina itself uses a judicial allocation procedure
to ascertain the portion of a settlement subject to subrogation in
a workers’ compensation suit. It instructs trial courts to
“consider the anticipated amount of
prospective compensation the employer or workers’ compensation
carrier is likely to pay to the employee in the future, the net
recovery to plaintiff, the likelihood of the plaintiff prevailing
at trial or on appeal, the need for finality in the litigation, and
any other factors the court deems just and reasonable.” N. C.
Gen. Stat. Ann. §97– 10.2(j) (Lexis 2011).
North Carolina would be on sounder footing had
it adopted a similar procedure for allocating Medicaid
beneficiaries’ tort recoveries. It might also consider a different
one along the lines of what other States have done in Medicaid
reimbursement cases.
The State thus has ample means available to
allocate Medicaid beneficiaries’ tort recoveries in an efficient
manner that complies with federal law. Indeed, if States are
concerned that case-by-case judicial allocations will prove
unwieldy, they may even be able to adopt
ex ante
administrative criteria for allocating medical and nonmedical
expenses, provided that these criteria are backed by evidence
suggesting that they are likely to yield reasonable results in the
mine run of cases. What they cannot do is what North Carolina did
here: adopt an arbitrary, one-size-fits-all allocation for all
cases.
Fifth, and finally, North Carolina contends that
in two documents—a July 2006 memorandum and a December 2009 letter
responding to an inquiry from a member of North Carolina’s
congressional delegation—the federal Centers for Medicare and
Medicaid Services approved of North Carolina’s statutory scheme for
Medicaid reimbursement. In the State’s view, these agency
pronouncements are entitled to deference. See Brief for Petitioner
33–36 (citing
Chevron U. S. A. Inc. v.
Natural
Resources Defense Council, Inc.,
467 U.S.
837 (1984)).
The 2006 and 2009 documents, however, no longer
re-flect the agency’s position. See Brief for United States as
Amicus Curiae 8–34. And at any rate, the documents are
opinion letters, not regulations with the force of law. We have
held that “[i]nterpretations such as those in opinion letters—like
interpretations contained in policy statements, agency manuals, and
enforcement guidelines, all of which lack the force of law—do not
warrant
Chevron-style deference.”
Christensen v.
Harris County,
529 U.S.
576, 587 (2000). These documents are “ ‘entitled to
respect’ ” in proportion to their “ ‘power to
persuade.’ ”
Ibid. (quoting
Skidmore v.
Swift
& Co.,
323 U.S.
134, 140 (1944)). Insofar as the 2006 and 2009 documents
approve of North Carolina’s statute, they lack persuasive force for
the reasons discussed above.
* * *
The law here at issue, N. C. Gen. Stat.
Ann. §108A–57, reflects North Carolina’s effort to comply with
federal law and secure reimbursement from third-party tortfeasors
for medical expenses paid on behalf of the State’s Medicaid
beneficiaries. In some circumstances, however, the statute would
permit the State to take a portion of a Medicaid beneficiary’s tort
judgment or settlement not “designated as payments for medical
care.”
Ahlborn, 547 U. S., at 284. The Medicaid
anti-lien provision, 42 U. S. C. §1396p(a)(1), bars that
result.
The judgment of the Court of Appeals for the
Fourth Circuit is affirmed.
It is so ordered.