Consejo De Salud De La Comunidad De La Playa De Ponce, Inc. v. González-Feliciano
695 F.3d 83
1st Cir.2012Background
- This appeal concerns Puerto Rico's federally-assisted Medicaid program and wraparound payments owed to FQHCs for Medicaid services.
- The GHIP administratively combines Medicaid, CHIP, Reforma, and other Commonwealth-funded coverage under ASEs control, complicating which costs qualify for wraparound payments.
- Wraparound payments are triggered when MCOs underpay FQHCs and are supposed to supplement to reach PPS-based amounts.
- The district court used a formula including 'Pure Medicaid,' 'State/Other Medicaid,' and 'CHIP' categories, with disputes over whether 'State/Other Medicaid' costs are federally reimbursable.
- The parties dispute whether MCOs' payments to third parties and certain debt obligations to MCOs should reduce wraparound obligations, and whether past (gap-period) payments are permissible relief.
- The Eleventh Amendment and its waiver are central to whether a federal court may order money payments by Puerto Rico for past violations.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether State/Other Medicaid costs belong in wraparound base calculations. | FQHCs argue these costs are federally-matched Medicaid beneficiaries. | Secretary contends these are Reforma-only or non-Medicaid costs and should be excluded. | Remanded for factfinding to determine proper categorization under §1396a(bb). |
| Whether CHIP costs should be included in wraparound calculations. | FQHCs contend CHIP benefits are federally matched and count. | Secretary initially resisted but now accepts CHIP inclusion per CMS guidance. | Included in wraparound calculations; remand still required for other issues. |
| Whether deductions for MCOs’ third-party payments should offset wraparound obligations. | Offsets should be limited to actual payments; phantom payments not deductible. | Offsets may apply for third-party payments to non-FQHC services. | Remanded for further consideration of whether third-party payments to FQHCs’ behalf can be deducted from PPS base rates. |
| Whether debt indemnification to MCOs falls within scope of this litigation. | Debt indemnification should be ordered to protect FQHCs from MCO debts. | Debt indemnification lies outside the scope of this case. | Affirmed district court on scope; indebtedness relief not within this litigation. |
| Whether the Commonwealth waived Eleventh Amendment immunity through conduct in litigation. | Waiver as of mid-2006 through representations and actions in federal court. | Waiver requires unambiguous, voluntary consent; the conduct here does not show clear waiver. | Eleventh Amendment immunity not waived; relief limited to prospective remedies as of November 8, 2010. |
Key Cases Cited
- Edelman v. Jordan, 415 U.S. 651 (U.S. 1974) (state may not be compelled to pay past federal-law violations absent consent)
- Ex parte Young, 209 U.S. 123 (U.S. 1908) (federal courts may enjoin state officers to vindicate federal rights)
- Pennhurst State Sch. & Hosp. v. Halderman, 465 U.S. 89 (U.S. 1984) (limits on federal court power to order retroactive monetary relief against a state)
- Lapides v. Board of Regents, 535 U.S. 613 (U.S. 2002) (state waiver of Eleventh Amendment immunity through voluntary removal to federal court)
- Ramos-Piñero v. Puerto Rico, 453 F.3d 48 (1st Cir. 2006) (unambiguous waiver requirement for Eleventh Amendment consent)
- Belaval I, 397 F.3d 56 (1st Cir. 2005) (Medicaid wraparound rights-created; initial framework for PPS disputes)
- Belaval IV, 551 F.3d 10 (1st Cir. 2008) (remand on compliance with §1396a(bb) methodology; unresolved issues)
- Belaval V, 625 F.3d 15 (1st Cir. 2010) (held district court erred on waiving Eleventh Amendment protections; remanded for consistent proceedings)