Bontrager v. Indiana Family & Social Services Administration
829 F. Supp. 2d 688
N.D. Ind.2011Background
- Sandra Bontrager, Indiana Medicaid recipient, needs medically necessary dental implants and abutments for the mandible.
- Indiana restricts Medicaid dental reimbursements to $1,000 per recipient per year, regardless of medical necessity determinations.
- Bontrager’s preauthorization through Advantage eventually found the services covered and medically necessary, but remained subject to the $1,000 cap.
- Plaintiffs sue as a class to enjoin the cap, arguing it violates Indiana and federal law requiring coverage of medically necessary treatments.
- Court analyzes whether Indiana must fully cover medically necessary dental services versus permitting partial coverage under the cap.
- Court grants preliminary injunction, holds a private right of action exists under 42 U.S.C. § 1396a(a)(10), and that the cap violates federal and state Medicaid law.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Private right of action viability | 1396a(a)(10) creates enforceable right under Blessing/Gonzaga. | Right not unambiguously conferred due to ‘utilization control procedures’ and variability. | Plaintiffs may proceed; private right of action exists. |
| Whether $1,000 cap violates Medicaid law | Cap prevents full coverage of medically necessary services. | Cap provides some coverage and complies with law. | Cap violates federal and state Medicaid law; not permissible. |
| Characterization of cap under 440.230(d) and (b) | Cap acts as a forbidden categorical exclusion and fails ‘amount, duration, scope’ for each service. | Cap is a permissible utilization control/limits measure. | Cap impermissible; does not satisfy the requirements for “amount, duration, and scope” of each service. |
Key Cases Cited
- Blessing v. Freestone, 520 U.S. 329 (1997) (establishes Blessing three-factor test for enforcing federal rights via §1983)
- Gonzaga University v. Doe, 536 U.S. 273 (2002) (clarifies rights-enforcement under Blessing standards)
- Miller ex rel. Miller v. Whitburn, 10 F.3d 1315 (7th Cir.1993) (applies Blessing framework in Seventh Circuit)
- Clark v. Coye, 60 F.3d 600 (9th Cir.1995) (interprets §1396a(a)(10) baseline provisions)
- Ball v. Rodgers, 492 F.3d 1094 (9th Cir.2007) (confirms Blessing/Gonzaga approach to enforceability)
- Thie v. Davis, 688 N.E.2d 182 (Ind.Ct.App.1997) (federal/state Medicaid require coverage of medically necessary treatments)
- Davis v. Schrader, 687 N.E.2d 370 (Ind.Ct.App.1997) (state must cover medically necessary treatments within a covered category)
- Coleman v. Indiana Family and Social Services Administration, 687 N.E.2d 366 (Ind.Ct.App.1997) (once state opts to provide coverage, must cover medically necessary treatments)
- Moore ex rel. Moore v. Reese, 637 F.3d 1220 (11th Cir.2011) (Medicaid law requires coverage of medically necessary services)
- Lankford v. Sherman, 451 F.3d 496 (8th Cir.2006) (non-experimental medically necessary services must be covered)
- Hope Medical Group for Women v. Edwards, 63 F.3d 418 (5th Cir.1995) (protection of medical necessity in coverage decisions)
- Hern v. Beye, 57 F.3d 906 (10th Cir.1995) (coverage for medically necessary abortions analyzed under Medicaid)
- Dexter v. Kirschner, 984 F.2d 979 (9th Cir.1992) (federal law requires payment for medically necessary in-patient services)
- Beal v. Doe, 432 U.S. 438 (1977) (statutory questions regarding Medicare/Medicaid coverage)
- University of Washington Medical Center v. Sebelius, 634 F.3d 1029 (9th Cir.2011) (interpretation of federal Medicaid funding and coverage limits)
- Phoenix Memorial Hospital v. Sebelius, 622 F.3d 1219 (9th Cir.2010) (definition of medical assistance and funding constraints)