Arkansas Department of Health & Human Services v. Ahlborn

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SERVICES et al. v. AHLBORN

certiorari to the united states court of appeals for the eighth circuit

No. 04–1506. Argued February 27, 2006—Decided May 1, 2006

Federal Medicaid law requires participating States to “ascertain the legal liability of third parties . . . to pay for [an individual benefits recipient’s] care and services available under the [State’s] plan,” 42 U. S. C. § 1396a(a)(25)(A); to “seek reimbursement for [medical] assistance to the extent of such legal liability,” § 1396a(a)(25)(B); to enact “laws under which, to the extent that payment has been made . . . for medical as­ sistance 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); to “provide that, as a condition of [Medicaid] eligibility . . . , the individual is required . . . (A) to assign the State any rights . . . to payment for medical care from any third party; . . . (B) to cooperate with the State . . . in obtaining [such] payments . . . and . . .

(C) . . . in identifying, and providing information to assist the State in pursuing, any third party who may be liable,” § 1396k(a)(1). Finally, “any amount collected by the State under an assignment made” as de­ scribed above “shall be retained by the State . . . to reimburse it for [Medicaid] payments made on behalf of ” the recipient. § 1396k(b). “[T]he remainder of such amount collected shall be paid” to the recipi­ ent. Ibid. Acting pursuant to its understanding of these provisions, Arkansas passed laws under which, when a state Medicaid recipient ob­ tains a tort settlement following payment of medical costs on her behalf, a lien is automatically imposed on the settlement in an amount equal to Medicaid’s costs. When that amount exceeds the portion of the settle­ ment representing medical costs, satisfaction of the State’s lien requires payment out of proceeds meant to compensate the recipient for damages distinct from medical costs, such as pain and suffering, lost wages, and loss of future earnings.

Following respondent Ahlborn’s car accident with allegedly negligent third parties, petitioner Arkansas Department of Health and Human Services, then named Arkansas Department of Human Services (ADHS), determined that Ahlborn was eligible for Medicaid and paid providers $215,645.30 on her behalf. She filed a state-court suit against the alleged tortfeasors seeking damages for past medical costs and for

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other items including pain and suffering, loss of earnings and working time, and permanent impairment of her future earning ability. The case was settled out of court for $550,000, which was not allocated be­ tween categories of damages. ADHS did not participate or ask to par­ ticipate in the settlement negotiations, and did not seek to reopen the judgment after the case was dismissed, but did intervene in the suit and assert a lien against the settlement proceeds for the full amount it had paid for Ahlborn’s care. She filed this action in Federal District Court seeking a declaration that the State’s lien violated federal law insofar as its satisfaction would require depletion of compensation for her inju­ ries other than past medical expenses. The parties stipulated, inter alia, that the settlement amounted to approximately one-sixth of the reasonable value of Ahlborn’s claim and that, if her construction of fed­ eral law was correct, ADHS would be entitled to only the portion of the settlement ($35,581.47) that constituted reimbursement for medical payments made. In granting ADHS summary judgment, the court held that under Arkansas law, which it concluded did not conflict with federal law, Ahlborn had assigned ADHS her right to recover the full amount of Medicaid’s payments for her benefit. The Eighth Circuit reversed, holding that ADHS was entitled only to that portion of the settlement that represented payments for medical care.

Held: Federal Medicaid law does not authorize ADHS to assert a lien on Ahlborn’s settlement in an amount exceeding $35,581.47, and the federal anti-lien provision affirmatively prohibits it from doing so. Arkansas’ third-party liability provisions are unenforceable insofar as they compel a different conclusion. Pp. 280–292.

(a) Arkansas’ statute finds no support in the federal third-party liabil­ ity provisions. That ADHS cannot claim more than the portion of Ahlborn’s settlement that represents medical expenses is suggested by § 1396k(a)(1)(A), which requires that Medicaid recipients, as a condition of eligibility, “assign the State any rights . . . to payment for medical care from any third party” (emphasis added), not their rights to payment for, e. g., lost wages. The other statutory language ADHS relies on is not to the contrary, but reinforces the assignment provision’s implicit limitation. First, statutory context shows that § 1396a(a)(25)(B)’s re­ quirement that States “seek reimbursement for [medical] assistance to the extent of such legal liability” refers to “the legal liability of third parties . . . to pay for care and services available under the plan,” § 1396a(a)(25)(A) (emphasis added). Here, because the tortfeasors ac­ cepted liability for only one-sixth of Ahlborn’s overall damages, and ADHS has stipulated that only $35,581.47 of that sum represents com­ pensation for medical expenses, the relevant “liability” extends no fur­

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ther than that amount. Second, § 1396a(a)(25)(H)’s requirement that the State enact laws giving it the right to recover from liable third parties “to the extent [it made] payment . . . for medical assistance for health care items or services furnished to an individual” does not limit the State’s recovery only by the amount it paid out on the recipient’s behalf, since the rest of the provision makes clear that the State must be assigned “the rights of [the recipient] to payment by any other party for such health care items or services.” (Emphasis added.) Finally, § 1396k(b)’s requirement that, where the State actively pursues recovery from the third party, Medicaid be reimbursed fully from “any amount collected by the State under an assignment” before “the remainder of such amount collected” is remitted to the recipient does not show that the State must be paid in full from any settlement. Rather, because the State’s assigned rights extend only to recovery of medical payments, what § 1396k(b) requires is that the State be paid first out of any dam­ ages for medical care before the recipient can recover any of her own medical costs. Pp. 280–282.

(b) Arkansas’ statute squarely conflicts with the federal Medicaid law’s anti-lien provision, § 1396p(a)(1), which prohibits States from im­ posing liens “against the property of any individual prior to his death on account of medical assistance paid . . . on his behalf under the State plan.” Even if the State’s lien is assumed to be consistent with federal law insofar as it encumbers proceeds designated as medical payments, the anti-lien provision precludes attachment or encumbrance of the re­ mainder of the settlement. ADHS’ attempt to avoid the anti-lien provi­ sion by characterizing the settlement proceeds as not Ahlborn’s “prop­ erty,” but as the State’s, fails for two reasons. First, because the settlement is not “received from a third party,” as required by the state statute, until Ahlborn’s chose in action has been reduced to proceeds in her possession, the assertion that any of the proceeds belonged to the State all along lacks merit. Second, the State’s argument that Ahl­ born lost her property rights in the proceeds the instant she applied for medical assistance is inconsistent with the creation of a statutory lien on those proceeds: ADHS would not need a lien on its own property.

Pp. 283–286.

(c) The Court rejects as unpersuasive ADHS’ and the United States’ arguments that a rule permitting a lien on more than medical damages ought to apply here either because Ahlborn breached her duty to “coop­ erate” with ADHS or because there is an inherent danger of manipula­ tion in cases where the parties to a tort case settle without judicial oversight or input from the State. As § 1396k(a)(1)(C) demonstrates, the duty to cooperate arises principally, if not exclusively, in proceedings initiated by the State to recover from third parties. In any event, the

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aspersions cast upon Ahlborn are entirely unsupported; all the record reveals is that ADHS neither asked to be nor was involved in the settle­ ment negotiations. Whatever the bounds of the duty to cooperate, there is no evidence that it was breached here. Although more color­ able, the alternative argument that a rule of full reimbursement is needed generally to avoid the risk of settlement manipulation also fails.

The risk that parties to a tort suit will allocate away the State’s interest can 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. Pp. 287–288.

(d) Also rejected is ADHS’ contention that the Eighth Circuit ac­ corded insufficient weight to two decisions by the Departmental Appeals Board (Board) of the federal Department of Health and Human Services (HHS) rejecting appeals by two States from denial of reimbursement for costs they paid on behalf of Medicaid recipients who had settled tort claims. Although HHS generally has broad regulatory authority in the Medicaid area, the Court declines to treat the Board’s reasoning in those cases as controlling because they address a different question from the one posed here, make no mention of the anti-lien provision, and rest on a questionable construction of the federal third-party liability provi­ sions. Pp. 289–292.

397 F. 3d 620, affirmed.

Stevens, J., delivered the opinion for a unanimous Court.

Lori Freno, Assistant Attorney General of Arkansas, ar­ gued the cause for petitioners. With her on the briefs was Mike Beebe, Attorney General.

Patricia A. Millett argued the cause for the United States as amicus curiae urging reversal. With her on the brief were Solicitor General Clement, Assistant Attorney Gen­ eral Keisler, Deputy Solicitor General Kneedler, William Kanter, and Anne Murphy.

H. David Blair argued the cause for respondent. With

him on the brief was Phillip Farris.*

*A brief of amici curiae urging reversal was filed for the State of Wash­ ington et al. by Rob McKenna, Attorney General of Washington, William

Assistant Attorney General, and by the Attorneys General for their re­ spective jurisdictions as follows: David W. Ma´ rquez of Alaska, Terry God­

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Opinion of the Court Justice Stevens delivered the opinion of the Court.

When a Medicaid recipient in Arkansas obtains a tort set­ tlement following payment of medical costs on her behalf by Medicaid, Arkansas law automatically imposes a lien on the settlement in an amount equal to Medicaid’s costs. When that amount exceeds the portion of the settlement that rep­ resents medical costs, satisfaction of the State’s lien requires payment out of proceeds meant to compensate the recipient for damages distinct from medical costs—like pain and suf­ fering, lost wages, and loss of future earnings. The Court of Appeals for the Eighth Circuit held that this statutory lien contravened federal law and was therefore unenforce­ able. Ahlborn v. Arkansas Dept. of Human Servs., 397

F. 3d 620 (2005). Other courts have upheld similar lien pro­

visions. See, e. g., Houghton v. Department of Health, 2002 UT 101, 57 P. 3d 1067; Wilson v. Washington, 142 Wash. 2d 40, 10 P. 3d 1061 (2000) (en banc). We granted certiorari to resolve the conflict, 545 U. S. 1165 (2005), and now affirm.

On January 2, 1996, respondent Heidi Ahlborn, then a 19­ year-old college student and aspiring teacher, suffered se­

dard of Arizona, John W. Suthers of Colorado, Richard Blumenthal of Connecticut, Robert J. Spagnoletti of the District of Columbia, Thurbert

E. Baker of Georgia, Mark J. Bennett of Hawaii, Lawrence G. Wasden of

Idaho, Lisa Madigan of Illinois, Phill Kline of Kansas, Gregory D. Stumbo of Kentucky, G. Steven Rowe of Maine, J. Joseph Curran, Jr., of Maryland, Thomas F. Reilly of Massachusetts, Michael A. Cox of Michigan, Jeremiah

W. (Jay) Nixon of Missouri, Mike McGrath of Montana, Kelly A. Ayotte

of New Hampshire, Peter C. Harvey of New Jersey, Eliot Spitzer of New York, Wayne Stenehjem of North Dakota, Jim Petro of Ohio, Hardy Myers of Oregon, Patrick Lynch of Rhode Island, Henry McMaster of South Carolina, Lawrence E. Long of South Dakota, Mark L. Shurtleff of Utah, Peggy A. Lautenschlager of Wisconsin, and Patrick J. Crank of Wyoming.

Louis M. Bograd, Ned Miltenberg, and Kenneth M. Suggs filed a brief for the Association of Trial Lawyers of America as amicus curiae urg­ ing affirmance.

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Opinion of the Court vere and permanent injuries as a result of a car accident.

She was left brain damaged, unable to complete her college education, and incapable of pursuing her chosen career. Al­ though she possessed a claim of uncertain value against the alleged tortfeasors who caused her injuries, Ahlborn’s liquid assets were insufficient to pay for her medical care. Peti­ tioner Arkansas Department of Health and Human Services (ADHS) 1 accordingly determined that she was eligible for medical assistance and paid providers $215,645.30 on her be­ half under the State’s Medicaid plan.

ADHS required Ahlborn to complete a questionnaire about her accident, and sent her attorney periodic letters advising him about Medicaid outlays. These letters noted that, under Arkansas law, ADHS had a claim to reimburse­ ment from “any settlement, judgment, or award” obtained by Ahlborn from “a third party who may be liable for” her injuries, and that no settlement “shall be satisfied without first giving [ADHS] notice and a reasonable opportunity to establish its interest.” 2 ADHS has never asserted, how­ ever, that Ahlborn has a duty to reimburse it out of any other subsequently acquired assets or earnings.

On April 11, 1997, Ahlborn filed suit against two alleged tortfeasors in Arkansas state court seeking compensation for the injuries she sustained in the January 1996 car accident.

She claimed damages not only for past medical costs, but also for permanent physical injury; future medical expenses; past and future pain, suffering, and mental anguish; past loss of earnings and working time; and permanent impairment of the ability to earn in the future.

ADHS was neither named as a party nor formally notified of the suit. Ahlborn’s counsel did, however, keep ADHS informed of details concerning insurance coverage as they became known during the litigation.

1 ADHS was then named Arkansas Department of Human Services.

2 Affidavit of Wayne E. Olive, Exhs. 5 and 6 (Mar. 6, 2003).

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In February 1998, ADHS intervened in Ahlborn’s lawsuit to assert a lien on the proceeds of any third-party recovery Ahlborn might obtain. In October 1998, ADHS asked Ahl­ born’s counsel to notify the agency if there was a hearing in the case. No hearing apparently occurred, and the case was settled out of court sometime in 2002 for a total of $550,000.

The parties did not allocate the settlement between catego­ ries of damages. ADHS did not participate or ask to partici­ pate in settlement negotiations. Nor did it seek to reopen the judgment after the case had been dismissed. ADHS did, however, assert a lien against the settlement proceeds in the amount of $215,645.30—the total cost of payments made by ADHS for Ahlborn’s care.

On September 30, 2002, Ahlborn filed this action in the United States District Court for the Eastern District of Ar­ kansas seeking a declaration that the lien violated the fed­ eral Medicaid laws insofar as its satisfaction would require depletion of compensation for injuries other than past medi­ cal expenses. To facilitate the District Court’s resolution of the legal questions presented, the parties stipulated that Ah lborn’s entire claim was reasonably valued at $3,040,708.12; that the settlement amounted to approxi­ mately one-sixth of that sum; and that, if Ahlborn’s construc­ tion of federal law was correct, ADHS would be entitled to only the portion of the settlement ($35,581.47) that con­ stituted reimbursement for medical payments made. See App. 17–20.

Ruling on cross-motions for summary judgment, the Dis­ trict Court held that under Arkansas law, which it concluded did not conflict with federal law, Ahlborn had assigned to ADHS her right to any recovery from the third-party tort­ feasors to the full extent of Medicaid’s payments for her benefit. Accordingly, ADHS was entitled to a lien in the amount of $215,645.30.

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The Eighth Circuit reversed. It held that ADHS was entitled only to that portion of the judgment that repre­ sented payments for medical care. For the reasons that fol­ low, we affirm.

The crux of the parties’ dispute lies in their competing constructions of the federal Medicaid laws. The Medicaid program, which provides joint federal and state funding of medical care for individuals who cannot afford to pay their own medical costs, was launched in 1965 with the enactment of Title XIX of the Social Security Act (SSA), as added, 79 Stat. 343, 42 U. S. C. § 1396 et seq. (2000 ed. and Supp. III).

Its administration is entrusted to the Secretary of Health and Human Services (HHS), who in turn exercises his au­ thority through the Centers for Medicare and Medicaid Serv­ ices (CMS).3

States are not required to participate in Medicaid, but all of them do. The program is a cooperative one; the Federal Government pays between 50% and 83% of the costs the State incurs for patient care,4 and, in return, the State pays its portion of the costs and complies with certain statutory requirements for making eligibility determinations, collect­ ing and maintaining information, and administering the pro­ gram. See § 1396a.

One such requirement is that the state agency in charge of Medicaid (here, ADHS) “take all reasonable measures to as­ certain the legal liability of third parties . . . to pay for care and services available under the plan.” § 1396a(a)(25)(A)

3 Until 2001, CMS was known as the Health Care Financing Administra­ tion or HCFA. See 66 Fed. Reg. 35437.

4 The exact percentage of the federal contribution is calculated pursuant to a formula keyed to each State’s per capita income. See 42 U. S. C. § 1396d(b).

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(2000 ed.).5 The agency’s obligation extends beyond mere identification, however;

“in any case where such a legal liability is found to exist after medical assistance has been made available on be­ half of the individual and where the amount of reim­ bursement 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.” § 1396a(a)(25)(B).

To facilitate its reimbursement from liable third parties, the State must,

“to the extent that payment has been made under the State plan for medical assistance in any case where a third party has a legal liability to make payment for such assistance, [have] 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 serv­ ices.” § 1396a(a)(25)(H).

The obligation to enact assignment laws is reiterated in an­

“(a) For the purpose of assisting in the collection of medical support payments and other payments for medi­ cal care owed to recipients of medical assistance under the State plan approved under this subchapter, a State plan for medical assistance shall—

“(1) provide that, as a condition of eligibility for medi­ cal assistance under the State plan to an individual who

5 A “third party” is defined by regulation as “any individual, entity or program that is or may be liable to pay all or part of the expenditures for medical assistance furnished under a State plan.” 42 CFR § 433.136 (2005).

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has the legal capacity to execute an assignment for him­ self, the individual is required—

“(A) 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;

“(B) to cooperate with the State . . . in obtaining sup­ port and payments (described in subparagraph (A)) for himself . . . ; and

“(C) to cooperate with the State in identifying, and providing information to assist the State in pursuing, any third party who may be liable to pay for care and services available under the plan . . . .” § 1396k(a).

Finally, “any amount collected by the State under an assign­ ment made” as described above “shall be retained by the State as is necessary to reimburse it for medical assist­ ance payments made on behalf of ” the Medicaid recipient. § 1396k(b). “[T]he remainder of such amount collected shall be paid” to the recipient. Ibid.

Acting pursuant to its understanding of these third-party liability provisions, the State of Arkansas passed laws that purport to allow both ADHS and the Medicaid recipient, either independently or together, to recover “the cost of ben­ efits” from third parties. Ark. Code Ann. §§ 20–77–301 through 20–77–309 (2001). Initially, “[a]s a condition of eligi­ bility” for Medicaid, an applicant “shall automatically assign his or her right to any settlement, judgment, or award which may be obtained against any third party to [ADHS] to the full extent of any amount which may be paid by Medicaid for the benefit of the applicant.” § 20–77–307(a). Accordingly, “[w]hen medical assistance benefits are provided” to the re­ cipient “because of injury, disease, or disability for which an­ other person is liable,” ADHS “shall have a right to recover from the person the cost of benefits so provided.” § 20–77–

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301(a).6 ADHS’ suit “shall” not, however, “be a bar to any action upon the claim or cause of action of the recipient.” § 20–77–301(b). Indeed, the statute envisions that the recip­ ient will sometimes sue together with ADHS, see § 20–77– 303, or even alone. If the latter, the assignment described in § 20–77–307(a) “shall be considered a statutory lien on any settlement, judgment, or award received . . . from a third party.” § 20–77–307(c); see also § 20–77–302(a) (“When an action or claim is brought by a medical assistance recipient . . . , any settlement, judgment, or award obtained is sub­ ject to the division’s claim for reimbursement of the bene­ fits provided to the recipient under the medical assistance program”).7

The State, through this statute, claims an entitlement to more than just that portion of a judgment or settlement that represents payment for medical expenses. It claims a right to recover the entirety of the costs it paid on the Medicaid recipient’s behalf. Accordingly, if, for example, a recipient sues alone and settles her entire action against a third-party tortfeasor for $20,000, and ADHS has paid that amount or more to medical providers on her behalf, ADHS gets the whole settlement and the recipient is left with nothing.

This is so even when the parties to the settlement allocate damages between medical costs, on the one hand, and other injuries like lost wages, on the other. The same rule also

6 Under the Arkansas statute, ADHS’ right to recover medical costs ap­ pears to be broader than that of the recipient. When ADHS sues, “no contributory or comparative fault of a recipient shall be attributed to the state, nor shall any restitution awarded to the state be denied or reduced by any amount or percentage of fault attributed to a recipient.” § 20–77– 301(d)(1) (2001).

7 The Arkansas Supreme Court has held that ADHS has an independent, nonderivative right to recover the cost of benefits from a third-party tort­ feasor under § 20–77–301 even when the Medicaid recipient also sues for recovery of medical expenses. See National Bank of Commerce v.

Quirk, 323 Ark. 769, 792–794, 918 S. W. 2d 138, 151–152 (1996).

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would apply, it seems, if the recovery were the result not of a settlement but of a jury verdict. In that case, under the Arkansas statute, ADHS could recover the full $20,000 in the face of a jury allocation of, say, only $10,000 for medical expenses.8

That this is what the Arkansas statute requires has been confirmed by the State’s Supreme Court. In Arkansas Dept. of Human Servs. v. Ferrel, 336 Ark. 297, 984 S. W. 2d 807 (1999), the court refused to endorse an equitable, nontex­ tual interpretation of the statute. Rejecting a Medicaid re­ cipient’s argument that he ought to retain some of a settle­ ment that was insufficient to cover both his and Medicaid’s

“Given the clear, unambiguous language of the statute, it is apparent that the legislature intended that ADHS’s ability to recoup Medicaid payments from third parties or recipients not be restricted by equitable subrogation principles such as the ‘made whole’ rule stated in [Franklin v. Healthsource of Arkansas, 328 Ark. 163, 942 S. W. 2d 837 (1997)]. By creating an automatic legal assignment which expressly becomes a statutory lien, [Ark. Code Ann. § 20–77–307 (1991)] makes an unequivo­ cal statement that the ADHS’s ability to recover Med­ icaid payments from insurance settlements, if it so chooses, is superior to that of the recipient even when the settlement does not pay all the recipient’s medical costs.” Id., at 308, 984 S. W. 2d, at 811.

Accordingly, the Arkansas statute, if enforceable against Ahlborn, authorizes imposition of a lien on her settlement proceeds in the amount of $215,645.30. Ahlborn’s argument before the District Court, the Eighth Circuit, and this Court

8 ADHS denies that it would actually demand the full $20,000 in such a case, see Brief for Petitioners 49, n. 13, but points to no provision of the Arkansas statute that would prevent it from doing so.

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has been that Arkansas law goes too far. We agree. Ar­ kansas’ statute finds no support in the federal third-party liability provisions, and in fact squarely conflicts with the anti-lien provision of the federal Medicaid laws.

We must decide whether ADHS can lay claim to more than the portion of Ahlborn’s settlement that represents medical expenses.9 The text of the federal third-party liability pro­ visions suggests not; it focuses on recovery of payments for medical care. Medicaid recipients must, as a condition of eli­ gibility, “assign the State any rights . . . to payment for med­ ical care from any third party,” 42 U. S. C. § 1396k(a)(1)(A) (emphasis added), not rights to payment for, for example, lost wages. The other statutory language that ADHS relies upon is not to the contrary; indeed, it reinforces the limita­ tion implicit in the assignment provision.

First, ADHS points to § 1396a(a)(25)(B)’s requirement that States “seek reimbursement for [medical] assistance to the extent of such legal liability” (emphasis added) and suggests that this means that the entirety of a recipient’s settlement is fair game. In fact, as is evident from the context of the emphasized language, “such legal liability” refers to “the legal liability of third parties . . . to pay for care and serv­ ices available under the plan.” § 1396a(a)(25)(A) (emphasis added). Here, the tortfeasor has accepted liability for only one-sixth of the recipient’s overall damages, and ADHS has stipulated that only $35,581.47 of that sum represents com­ pensation for medical expenses. Under the circumstances,

9 The parties here assume, as do we, that a State can fulfill its obligations under the federal third-party liability provisions by requiring an “assign­ ment” of part of, or placing a lien on, the settlement that a Medicaid recipi­ ent procures on her own. Cf. §§ 1396k(a)(1)(B)–(C) (the recipient has a duty to identify liable third parties and to “provid[e] information to assist the State in pursuing” those parties (emphasis added)).

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Opinion of the Court the relevant “ liability” extends no further than that amount.10

Second, ADHS argues that the language of § 1396a(a) (25)(H) favors its view that it can demand full reimburse­ ment of its costs from Ahlborn’s settlement. That provi­ sion, which echoes the requirement of a mandatory assign­ ment of rights in § 1396k(a), says that the State must have in effect laws that, “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,” give the State the right to recover from liable third parties. This must mean, says ADHS, that the agency’s recovery is limited only by the amount it paid out on the recipient’s behalf— and not by the third-party tortfeasor’s particular liability for medical expenses. But that reading ignores the rest of the provision, which makes clear that the State must be assigned “the rights of [the recipient] to payment by any other party for such health care items or services.” § 1396a(a)(25)(H) (emphasis added). Again, the statute does not sanction an assignment of rights to payment for anything other than medical expenses—not lost wages, not pain and suffering, not an inheritance.

Finally, ADHS points to the provision requiring that, where the State actively pursues recovery from the third party, Medicaid be reimbursed fully from “any amount col­ lected by the State under an assignment” before “the re­ mainder of such amount collected” is remitted to the recipi­ ent. § 1396k(b). In ADHS’ view, this shows that the State must be paid in full from any settlement. See Brief for Peti­ tioners 13. But, even assuming the provision applies in cases where the State does not actively participate in the litigation, ADHS’ conclusion rests on a false premise: The

10 The effect of the stipulation is the same as if a trial judge had found that Ahlborn’s damages amounted to $3,040,708.12 (of which $215,645.30 were for medical expenses), but because of her contributory negligence, she could only recover one-sixth of those damages.

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Opinion of the Court .

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“amount recovered . under an assignment” is not, as ADHS assumes, the entire settlement; as explained above, under the federal statute the State’s assigned rights extend only to recovery of payments for medical care. Accordingly, what § 1396k(b) requires is that the State be paid first out of any damages representing payments for medical care before the recipient can recover any of her own costs for medical care.11

At the very least, then, the federal third-party liability provisions require an assignment of no more than the right to recover that portion of a settlement that represents pay­ ments for medical care.12 They did not mandate the enact­ ment of the Arkansas scheme that we have described.

11 Implicit in ADHS’ interpretation of this provision is the assumption that there can be no “remainder” to remit to the Medicaid recipient if all the State has been assigned is the right to damages for medical expenses.

That view in turn seems to rest on an assumption either that Medicaid will have paid all the recipient’s medical expenses or that Medicaid’s ex­ penses will always exceed the portion of any third-party recovery ear­ marked for medical expenses. Neither assumption holds up. First, as both the Solicitor General and CMS acknowledge, the recipient often will have paid medical expenses out of her own pocket. See Brief for United States as Amicus Curiae 12 (under § 1396k(b), “the beneficiary retains the right to payment for any additional medical expenses personally incurred either before or subsequent to Medicaid eligibility and for other dam­ ages”); CMS, State Medicaid Manual § 3907, available at https://www.lexis. com>Legal>Secondary Legal>CCH>Health Law>CMS Program Manu­ als>CCH CMS Program Manuals P 3907 (as updated Mar. 25, 2006, and available in Clerk of Court’s case file) (envisioning that “medical insurance payments,” for example, will be remitted to the recipient if possible).

Second, even if Medicaid’s outlays often exceed the portion of the recovery earmarked for medical expenses in tort cases, the third-party liability pro­ visions were not drafted exclusively with tort settlements in mind. In the case of health insurance, for example, the funds available under the policy may be enough to cover both Medicaid’s costs and the recipient’s own medical expenses.

12 ADHS concedes that, had a jury or judge allocated a sum for medical payments out of a larger award in this case, the agency would be entitled to reimburse itself only from the portion so allocated. See Brief for Peti­

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If there were no other relevant provisions in the federal statute, the State might plausibly argue that federal law sup­ plied a recovery “floor” upon which States were free to build.

In fact, though, the federal statute places express limits on the State’s powers to pursue recovery of funds it paid on the recipient’s behalf. These limitations are contained in 42

U. S. C. §§ 1396a(a)(18) and 1396p. Section 1396a(a)(18) re­

quires that a state Medicaid plan comply with § 1396p, which in turn prohibits States (except in circumstances not relevant here) from placing liens against, or seeking recovery of bene­

“(a) Imposition of lien against property of an individ­ ual on account of medical assistance rendered to him under a State plan

“(1) No 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, except—

“(A) pursuant to the judgment of a court on account of benefits incorrectly paid on behalf of such individual, or

“(B) [in certain circumstances not relevant here] . .

.

.

.

“(b) Adjustment or recovery of medical assistance correctly paid under a State plan

“(1) No adjustment or recovery of any medical assist­ ance correctly paid on behalf of an individual under the

tioners 49, n. 13; see also Brief for United States as Amicus Curiae 22,

n. 14 (noting that the Secretary of HHS “ordinarily accepts” a jury alloca­

tion of medical damages in satisfaction of the Medicaid debt, even where smaller than the amount of Medicaid’s expenses). Given the stipulation between ADHS and Ahlborn, there is no textual basis for treating the settlement here differently from a judge-allocated settlement or even a jury award; all such awards typically establish a third party’s “liability” for both “payment for medical care” and other heads of damages.

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State plan may be made, except [in circumstances not relevant here].” § 1396p.

Read literally and in isolation, the anti-lien prohibition con­ tained in § 1396p(a) would appear to ban even a lien on that portion of the settlement proceeds that represents payments for medical care.13 Ahlborn does not ask us to go so far, though; she assumes that the State’s lien is consistent with federal law insofar as it encumbers proceeds designated as payments for medical care. Her argument, rather, is that the anti-lien provision precludes attachment or encumbrance of the remainder of the settlement.

We agree. There is no question that the State can require an assignment of the right, or chose in action, to receive pay­ ments for medical care. So much is expressly provided for by §§ 1396a(a)(25) and 1396k(a). And we assume, as do the parties, that the State can also demand as a condition of Med­ icaid eligibility that the recipient “assign” in advance any payments that may constitute reimbursement for medical costs. To the extent that the forced assignment is expressly authorized by the terms of §§ 1396a(a)(25) and 1396k(a), it is an exception to the anti-lien provision. See Washington State Dept. of Social and Health Servs. v. Guardianship Estate of Keffeler, 537 U. S. 371, 383–385, and n. 7 (2003).

But that does not mean that the State can force an assign­ ment of, or place a lien on, any other portion of Ahlborn’s property. As explained above, the exception carved out by

13 Likewise, subsection (b) would appear to forestall any attempt by the State to recover benefits paid, at least from the “individual.” See, e. g., Martin ex rel. Hoff v. Rochester, 642 N. W. 2d 1, 8, n. 6 (Minn. 2002); Wallace v. Estate of Jackson, 972 P. 2d 446, 450 (Utah 1998) (Durham, J., dissenting) (reading § 1396p to “prohibi[t] not only liens against Medicaid recipients but also any recovery for medical assistance correctly paid”).

The parties here, however, neither cite nor discuss the antirecovery provi­ sion of § 1396p(b). Accordingly, we leave for another day the question of its impact on the analysis.

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§§ 1396a(a)(25) and 1396k(a) is limited to payments for medi­ cal care. Beyond that, the anti-lien provision applies.

ADHS tries to avoid the anti-lien provision by characteriz­ ing the settlement proceeds as not Ahlborn’s “property.” 14 Its argument appears to be that the automatic assignment effected by the Arkansas statute rendered the proceeds the property of the State.15 See Brief for Petitioners 31 (“[U]nder Arkansas law, the lien does not attach to the recip­ ient’s ‘property’ because it attaches only to those proceeds already assigned to the Department as a condition of Med­ icaid eligibility”). That argument fails for two reasons.

First, ADHS insists that Ahlborn at all times until judgment retained her entire chose in action—a right that included her claim for medical damages. The statutory lien, then, cannot have attached until the proceeds materialized. That much is clear from the text of the Arkansas statute, which says that the “assignment shall be considered a statutory lien on any settlement . . . received by the recipient from a third party.” Ark. Code Ann. § 20–77–307(c) (2001) (emphasis added). The settlement is not “received” until the chose in action has been reduced to proceeds in Ahlborn’s possession.

Accordingly, the assertion that any of the proceeds belonged to the State all along lacks merit.

Second, the State’s argument that Ahlborn lost her prop­ erty rights in the proceeds the instant she applied for medi­ cal assistance is inconsistent with the creation of a statutory

14 “Property” is defined by regulation as “the homestead and all other personal and real property in which the recipient has a legal interest.”

42 CFR § 433.36(b) (2005).

15 The United States as amicus curiae makes the different argument

that the proceeds never became Ahlborn’s “property” because “to the ex­ tent the third party’s payment passes through the recipient’s hands en route to the State, it comes with the State’s lien already attached.” Brief as Amicus Curiae 18. Even if that reading were consistent with the Ar­ kansas statute (and it is not, see infra this page), the United States’ char­ acterization of the “assignment” simply reinforces Ahlborn’s point: This is a lien that attaches to the property of the recipient.

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lien on those proceeds. Why, after all, would ADHS need a lien on its own property? A lien typically is imposed on the property of another for payment of a debt owed by that other. See Black’s Law Dictionary 922 (6th ed. 1990).

Nothing in the Arkansas statute defines the term otherwise.

That the lien is also called an “assignment” does not alter the analysis. The terms that Arkansas employs to describe the mechanism by which it lays claim to the settlement pro­ ceeds do not, by themselves, tell us whether the statute vio­ lates the anti-lien provision. See United States v. Craft, 535

U. S. 274, 279 (2002); Drye v. United States, 528 U. S. 49,

58–61 (1999). Although denominated an “assignment,” the effect of the statute here was not to divest Ahlborn of all her property interest; instead, Ahlborn retained the right to sue for medical care payments, and the State asserted a right to the fruits of that suit once they materialized. In effect, and as at least some of the statutory language recognizes, Arkansas has imposed a lien on Ahlborn’s property.16 Since none of the federal third-party liability provisions excepts that lien from operation of the anti-lien provision, its imposi­ tion violates federal law.

16 Because ADHS insists that “Arkansas law did not require Ahlborn to assign her claim or her right to sue,” Brief for Petitioners 33 (emphasis in original), we need not reach the question whether a State may force a recipient to assign a chose in action to receive as much of the settlement as is necessary to pay Medicaid’s costs. The Eighth Circuit thought this would be impermissible because the State cannot “circumvent the restric­ tions of the federal anti-lien statute simply by requiring an applicant for Medicaid benefits to assign property rights to the State before the appli­ cant liquidates the property to a sum certain.” App. to Pet. for Cert. 6.

Indeed, ADHS acknowledges that Arkansas cannot, for example, require a Medicaid applicant to assign in advance any right she may have to re­ cover an inheritance or an award in a civil case not related to her injuries or medical care. This arguably is no different; as with assignment of those other choses in action, assignment of the right to compensation for lost wages and other nonmedical damages is nowhere authorized by the federal third-party liability provisions.

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ADHS and its amici urge, however, that even if a lien on more than medical damages would violate federal law in some cases, a rule permitting such a lien ought to apply here either because Ahlborn breached her duty to “cooperate” with ADHS or because there is an inherent danger of ma­ nipulation in cases where the parties to a tort case settle without judicial oversight or input from the State. Neither argument is persuasive.

The United States proposes a default rule of full reim­ bursement whenever the recipient breaches her duty to “co­ operate,” and asserts that Ahlborn in fact breached that duty.17 But, even if the Government’s allegations of ob­ struction were supported by the record, its conception of the duty to cooperate strays far beyond the text of the statute and the relevant regulations. The duty to cooperate arises principally, if not exclusively, in proceedings initiated by the State to recover from third parties. See 42 U. S. C. § 1396k(a)(1)(C) (recipients must “cooperate with the State in identifying . . . and providing information to assist the State in pursuing” third parties). Most of the accompanying fed­ eral regulations simply echo this basic duty; all they add is that the recipient must “[p]ay to the agency any support or medical care funds received that are covered by the assign­ ment of rights.” 42 CFR § 433.147(b)(4) (2005).

In any event, the aspersions the United States casts upon Ahlborn are entirely unsupported; all the record reveals is that ADHS, despite having intervened in the lawsuit and

17 See, e. g., Brief for United States as Amicus Curiae 14 (alleging that Ahlborn “omitt[ed] or understat[ed] the medical damages claim from her lawsuit and attempt[ed] to horde for herself the third-party liability pay­ ments”); id., at 15 (“[H]aving forsaken her federal and state statutory duties of candid and forthcoming cooperation[,] respondent, rather than the taxpayers, must bear the financial consequences of her actions”); id., at 21, 24 (referring to Ahlborn’s “backdoor settlement” and “obstruction and attrition,” as well as her “calculated evasion of her legal obligations”).

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asked to be apprised of any hearings, neither asked to be nor was involved in the settlement negotiations. Whatever the bounds of the duty to cooperate, there is no evidence that it was breached here.

ADHS’ and the United States’ alternative argument that a rule of full reimbursement is needed generally to avoid the risk of settlement manipulation is more colorable, but ultimately also unpersuasive. The issue is not, of course, squarely presented here; ADHS has stipulated that only $35,581.47 of Ahlborn’s settlement proceeds properly are designated as payments for medical costs. Even in the ab­ sence of such a postsettlement agreement, though, the risk that parties to a tort suit will allocate away the State’s inter­ est can 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.18 For just as there are risks in underestimating the value of readily calculable damages in settlement negotiations, so also is there a countervailing concern that a rule of absolute priority might preclude set­ tlement in a large number of cases, and be unfair to the recip­ ient in others.19

18 As one amicus observes, some States have adopted special rules and procedures for allocating tort settlements in circumstances where, for ex­ ample, private insurers’ rights to recovery are at issue. See Brief for Association of Trial Lawyers of America 20–21. Although we express no view on the matter, we leave open the possibility that such rules and procedures might be employed to meet concerns about settlement manipulation.

19 The point is illustrated by state cases involving the recovery of work­ ers’ compensation benefits paid to an employee (or the family of an em­ ployee) whose injuries were caused by a third-party tortfeasor. In Flani­ gan v. Department of Labor and Industry, 123 Wash. 2d 418, 869 P. 2d 14 (1994), for example, the court concluded that the state agency could not satisfy its lien out of damages the injured worker’s spouse recovered as compensation for loss of consortium. The court explained that the depart­ ment could not “share in damages for which it has provided no compensa­ tion” because such a result would be “absurd and fundamentally unjust.” Id., at 426, 869 P. 2d, at 17.

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Finally, ADHS contends that the Court of Appeals’ deci­ sion below accords insufficient weight to two decisions by the Departmental Appeals Board of HHS (Board) rejecting appeals by the States of California and Washington from de­ nial of reimbursement for costs those States paid on behalf of Medicaid recipients who had settled tort claims. See App. to Pet. for Cert. 45–67 (reproducing In re Washington State Dept. of Social & Health Servs., Dec. No. 1561, 1996 WL 157123 (HHS Dept. App. Bd., Feb. 7, 1996)); App. to Pet. for Cert. 68–86 (reproducing In re California Dept. of Health Servs., Dec. No. 1504, 1995 WL 66334 (HHS Dept.

App. Bd., Jan. 5, 1995)). Because the opinions in those cases address a different question from the one posed here, make no mention of the anti-lien provision, and, in any event, rest on a questionable construction of the federal third-party lia­ bility provisions, we conclude that they do not control our analysis.

Normally, if a State recovers from a third party the cost of Medicaid benefits paid on behalf of a recipient, the Federal Government owes the State no reimbursement, and any funds already paid by the Federal Government must be re­ turned. See 42 CFR § 433.140(a)(2) (2005) (federal financial participation “is not available in Medicaid payments if . . . [t]he agency received reimbursement from a liable third party”); § 433.140(c). Washington and California both had adopted schemes according to which the State refrained from claiming full reimbursement from tort settlements and in­ stead took only a portion of each settlement.

(In California, the recipient typically could keep at least 50% of her settle­ ment, see App. to Pet. for Cert. 72; in Washington, the pro­ portion varied from case to case, see id., at 48–51.) Each scheme resulted in the State’s having to pay a portion of the recipient’s medical costs—a portion for which the State sought partial reimbursement from the Federal Government.

CMS (then called HCFA) denied this partial reimbursement

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on the ground that the States had an absolute duty to seek full payment of medical expenses from third-party tortfeasors.

The Board upheld CMS’ determinations. In California’s appeal, which came first, the Board concluded that the State’s duty to seek recovery of benefits “from available third party sources to the fullest extent possible” included demanding full reimbursement from the entire proceeds of a Medicaid recipient’s tort settlement. Id., at 76. The Board acknowledged that § 1396k(a) “refers to assignment only of ‘payment for medical care,’ ” but thought that “the statutory scheme as a whole contemplates that the actual recovery might be greater and, if it is, that Medicaid should be paid first.” Ibid. The Board gave two other reasons for siding with CMS: First, the legislative history of the third-party liability evinced a congressional intent that “the Medicaid program . . . be reimbursed from available third party sources to the fullest extent possible,” ibid.; and, second, Cal­ ifornia had long been on notice that it would not be reim­ bursed for any shortfall resulting from failure to fully recoup Medicaid’s costs from tort settlements, see id., at 77. The Board also opined that the State could not escape its duty to seek full reimbursement by relying on the Medicaid recipi­ ent’s efforts in litigating her claims. See id., at 79–80.

Finally, responding to the State’s arg ument that its scheme gave Medicaid recipients incentives to sue third­ party tortfeasors and thus resulted in both greater recovery and lower costs for the State, the Board observed that “a state is free to allow recipients to retain the state’s share” of any recovery, so long as it does not compromise the Fed­ eral Government’s share. Id., at 85.

The Board reached the same conclusion, by the same means, in the Washington case. See id., at 53–64.

Neither of these adjudications compels us to conclude that Arkansas’ statutory lien comports with federal law. First, the Board’s rulings address a different question from the one

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presented here. The Board was concerned with the Federal Government’s obligation to reimburse States that had, in its view, failed to seek full recovery of Medicaid’s costs and had instead relied on recipients to act as private attorneys gen­ eral. The Board neither discussed nor even so much as cited the federal anti-lien provision.

Second, the Board’s acknowledgment that the assignment of rights required by § 1396k(a) is limited to payments for medical care only reinforces the clarity of the statutory lan­ guage. Moreover, its resort to “the statutory scheme as a whole” as justification for muddying that clarity is nowhere explained. Given that the only statutory provisions CMS relied on are §§ 1396a(a)(25), 1396k(a), and 1396k(b), see id., at 75–76; id., at 54–55, and given the Board’s concession that the first two of these limit the State’s assignment to pay­ ments for medical care, the “statutory scheme” must mean § 1396k(b). But that provision does not authorize the State to demand reimbursement from portions of the settlement allocated or allocable to nonmedical damages; instead, it gives the State a priority disbursement from the medical expenses portion alone. See supra, at 282. In fact, in its adjudication in the Washington case, the Board conceded as much: “[CMS] may require a state to assert a collection pri­ ority over funds obtained by Medicaid recipients in [third­ party liability] suits even though the distribution methodol­ ogy set forth in section [1396k(b)] refers only to payments collected pursuant to assignments for medical care.” App.

to Pet. for Cert. 54 (emphasis added). The Board’s reason­ ing therefore is internally inconsistent.

Third, the Board’s reliance on legislative history is mis­ placed. The Board properly observed that Congress, in crafting the Medicaid legislation, intended that Medicaid be a “payer of last resort.” S. Rep. No. 99–146, p. 313 (1985).

That does not mean, however, that Congress meant to au­ thorize States to seek reimbursement from Medicaid recipi­ ents themselves; in fact, with the possible exception of a lien

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on payments for medical care, the statute expressly prohibits liens against the property of Medicaid beneficiaries. See 42

U. S. C. § 1396p(a). We recognize that Congress has dele­

gated “broad regulatory authority to the Secretary [of HHS] in the Medicaid area,” Wisconsin Dept. of Health and Fam­ ily Servs. v. Blumer, 534 U. S. 473, 496, n. 13 (2002), and that agency adjudications typically warrant deference. Here, however, the Board’s reasoning couples internal inconsist­ ency with a conscious disregard for the statutory text.

Under these circumstances, we decline to treat the agency’s reasoning as controlling.

Federal Medicaid law does not authorize ADHS to assert a lien on Ahlborn’s settlement in an amount exceeding $35,581.47, and the federal anti-lien provision affirmatively prohibits it from doing so. Arkansas’ third-party liability provisions are unenforceable insofar as they compel a differ­ ent conclusion. The judgment of the Court of Appeals is affirmed.

It is so ordered.