116 F. Supp. 3d 334
S.D.N.Y.2015Background
- Three named plaintiffs (Angie Cruz, Ar’es Kpaka, Riya Christie) are New York Medicaid "categorically needy" recipients diagnosed with Gender Dysphoria who allege medically necessary transition-related treatments were denied under NY Medicaid rules.
- New York DOH enacted 18 N.Y.C.R.R. § 505.2(i) (1998) banning payment for gender-reassignment treatment; DOH adopted an amended § 505.2(i) in 2015 permitting some care but excluding (a) "cosmetic" procedures (e.g., breast augmentation, electrolysis, chondrolaryngoplasty, facial surgery) and (b) certain youth treatments (the "Cosmetic Procedures Exclusion" and the "Youth Exclusion").
- Plaintiffs brought a class action asserting: violations of the Medicaid Act (Availability, Comparability, Reasonable Standards, EPSDT), Section 1557 of the ACA (sex discrimination), and the New York State Constitution.
- Defendant moved to dismiss. The court treated Availability, Comparability, and EPSDT claims as brought under 42 U.S.C. § 1983; the Reasonable Standards claim was raised under the Supremacy Clause.
- The court denied dismissal of Counts I (Availability), II (Comparability), and VI (EPSDT), dismissed Count III (Reasonable Standards) under Armstrong, dismissed Count IV (state equal protection) as barred by the Eleventh Amendment, and dismissed Count V (Section 1557) as to the Youth Exclusion for failure to plead disparate treatment or impact facts, but allowed claims challenging the Cosmetic Procedures Exclusion to proceed as ripe.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether the Medicaid Availability Requirement (42 U.S.C. § 1396a(a)(10)(A)) creates an individual right enforceable via § 1983 | Availability requires states to provide medically necessary services listed in the statute and regs; plaintiffs entitled to coverage for medically necessary transition procedures | § 1396a(a)(10)(A) sets programmatic standards, not an individually enforceable right; Casillas supports dismissal | Court: Availability creates an individual right enforceable under § 1983; denied dismissal of Count I |
| Whether the Medicaid Comparability Requirement (42 U.S.C. § 1396a(a)(1)(B)(i)) is privately enforceable | Plaintiffs: denying treatments to transgender recipients while providing same procedures to others violates comparability | Def.: Comparability does not create individual entitlement; allowing claims would chill states from offering optional services (Rodriguez) | Court: Comparability creates an individual right under § 1983; denied dismissal of Count II |
| Whether the Reasonable Standards Requirement (42 U.S.C. § 1396a(a)(17)) is enforceable by private suit under the Supremacy Clause/§ 1983 | Plaintiffs: state standards must be consistent with Medicaid objectives and are subject to judicial enforcement | Def.: Armstrong bars private enforcement where statute has express administrative remedy and is programmatic/judgment-laden | Court: Dismissed Count III — Reasonable Standards is not privately enforceable (Armstrong controls) |
| Whether Section 1557 (ACA) prohibits the Youth Exclusion as sex discrimination | Plaintiffs: Youth Exclusion discriminates by denying services to transgender youth or has disparate impact | Def.: Youth Exclusion is age-based and not a sex-based distinction; plaintiffs fail to allege services are available to non‑transgender youth | Court: Dismissed Section 1557 challenge to Youth Exclusion for failure to plead facts showing sex-based denial or disparate impact |
Key Cases Cited
- Maine v. Thiboutot, 448 U.S. 1 (statutory rights cognizable under § 1983)
- Blessing v. Freestone, 520 U.S. 329 (three-prong test for when federal statute creates enforceable individual right under § 1983)
- Gonzaga Univ. v. Doe, 536 U.S. 273 (requirement of unambiguously conferred individual right for § 1983 enforcement)
- Beal v. Doe, 432 U.S. 438 (Medicaid need/nonneed distinction; denial of unnecessary procedures permissible)
- Casillas v. Daines, 580 F. Supp. 2d 235 (S.D.N.Y. 2008) (held Availability and Comparability did not create § 1983 rights; court respectfully disagreed)
- Armstrong v. Exceptional Child Center, Inc., 135 S. Ct. 1378 (private enforcement precluded where statute provides administrative remedy and is programmatic)
- Rodriguez v. City of New York, 197 F.3d 611 (2d Cir. 1999) (limits on comparability claims where plaintiff seeks services state has not chosen to provide)
- Sabree ex rel. Sabree v. Richman, 367 F.3d 180 (3d Cir. 2004) (Availability requirement creates enforceable individual right)
- Watson v. Weeks, 436 F.3d 1152 (9th Cir. 2006) (Availability and related regs supply concrete, enforceable standards)