Bontrager v. Indiana Family & Social Services Administration, 2012 U.S. App. LEXIS 20157

Background

Indiana participates in the Medicaid program and must comply with federal requirements once it elects coverage.
Medicaid covers dental services that are medically reasonable and necessary within Indiana’s selected coverage, subject to listed exclusions.
Indiana imposes a $1,000 per recipient, per twelve-month cap on reimbursable dental services that are otherwise covered and medically necessary.
Bontrager, an Indiana Medicaid recipient, requires significant dental work (including implants) exceeding the $1,000 cap and cannot pay the excess.
Bontrager asserts a private federal right under 42 U.S.C. § 1983 to challenge the cap as a violation of 42 U.S.C. § 1396a(a)(10).
The district court granted a preliminary injunction preventing enforcement of the cap; the State appeals interlocutorily.

Issues

Issue	Plaintiff's Argument	Defendant's Argument	Held
Whether §1983 provides a private right of action.	Bontrager asserts a private right under §1396a(a)(10) enforceable via §1983.	State contends the statute does not create an enforceable individual right.	Bontrager has an enforceable federal right under §1396a(a)(10) and may pursue §1983 claim.
Whether the district court properly granted a preliminary injunction.	Bontrager shows likely irreparable harm and likely success on the merits due to exclusion of medically necessary care.	State argues cap is a permissible utilization-control or budgetary measure and may not implicate a §1983 remedy.	Preliminary injunction affirmed; cap improperly excludes medically necessary treatments and violates federal law.

Key Cases Cited

Blessing v. Freestone, 520 U.S. 329 (Supreme Court 1997) (private right under federal law requires a rights-creating statute)
Gonzaga Univ. v. Doe, 536 U.S. 273 (Supreme Court 2002) (factors for determining enforceable rights beneath §1983)
Wilder v. Virginia Hospital Ass'n, 496 U.S. 498 (Supreme Court 1990) (Medicaid reimbursement provisions may create enforceable rights)
Miller v. Whitburn, 10 F.3d 1315 (7th Cir. 1993) (affirmed §1983 right under §1396a(a)(10)(A))
Beal v. Doe, 432 U.S. 438 (Supreme Court 1977) (Medicaid coverage questions raise statutory commitments)
Lankford v. Sherman, 451 F.3d 496 (8th Cir. 2006) (state failures to provide coverage for medically necessary treatment)
Thie v. Davis, 688 N.E.2d 182 (Ind. Ct. App. 1997) (state exclusions from Medicaid coverage linked to medical necessity)
Coleman v. Ind. Family & Servs. Admin., 687 N.E.2d 366 (Ind. Ct. App. 1997) (Medicaid coverage defined by medical necessity cannot be excluded)
Davis v. Schrader, 687 N.E.2d 370 (Ind. Ct. App. 1997) (exclusions from coverage conflict with medical necessity definition)
Charleston Mem. Hosp. v. Conrad, 693 F.2d 324 (4th Cir. 1982) (soft limitations may still satisfy coverage unless exclusion is broad)
Curtis v. Taylor, 625 F.2d 645 (5th Cir. 1980) (limits based on degree of medical necessity permissible if non-discriminatory)
Grier v. Goetz, 402 F. Supp. 2d 876 (M.D. Tenn. 2005) (limits may be upheld if not denying necessary treatment en masse)
Montoya v. Johnston, 654 F. Supp. 511 (W.D. Tex. 1987) (arbitrary caps can exclude necessary care from Medicaid)
DeLuca v. Hammons, 927 F. Supp. 132 (S.D.N.Y. 1996) (utilization-control procedures cannot preclude necessary procedures)
Moore ex rel. Moore v. Reese, 637 F.3d 1220 (11th Cir. 2011) (limits based on medical necessity as non-discriminatory are permissible)
Schweiker v. Hogan, 457 U.S. 569 (Supreme Court 1982) (Medicaid program designed to pay for care of the needy)