Detgen ex rel. Detgen v. Janek
2013 U.S. Dist. LEXIS 34532
| N.D. Tex. | 2013Background
- Detgen, Barraza, Doyel, and Vargas (the plaintiffs) challenge HHSC, TMHP, and Superior Health Plan for denying Medicaid ceiling lifts to assist in transfers; the requests were denied as “home modifications” not covered DME under Texas Medicaid policy.
- Detgen is a 28-year-old with cerebral palsy and quadriplegia, requiring manual transfers from bed to floor, bath, and stair lift; a ceiling lift was proposed as the solution.
- Barraza is a 45-year-old with severe disabilities requiring transfers with caregiver assistance; a ceiling lift was identified as appropriate and prior authorized in the record but denied.
- Doyel is a 35-year-old with quadriplegia using a power wheelchair; a ceiling lift was requested and denied under the same policy as the others.
- Vargas, 21, with DMD and mobility/ventilation needs, had a ceiling lift identified as necessary; his initial denial was later compensated under waiver services, raising concerns about cost caps.
- The administrative process included TMHP denials, followed by fair hearings and administrative decisions upholding denial under Texas Medicaid policy; the plaintiffs filed suit challenging the policy under the Medicaid Act and the ADA.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether §1983 claims may proceed for due process and Medicaid Act rights. | Plaintiffs argue they have private rights enforceable under §1983. | HHSC argues no federal obligation violation is shown. | §1983 claims may proceed; plaintiff rights are cognizable. |
| Whether the Supremacy Clause precludes Texas policy excluding ceiling lifts. | Plaintiffs contend CMS guidance conflicts with state policy, creating preemption. | CMS guidance authorizes exclusion; no preemption. | Policy exclusion not preempted; no conflict with Medicaid Act. |
| Whether Texas policy excluding ceiling lifts violates Medicaid Act’s reasonable standards or FFP rules. | Exclusion fails DeSario criteria and misclassifies DME. | Categorical exclusion aligns with CMS guidance and state plan. | No violation; policy is consistent with the Act and CMS guidance. |
| Whether plaintiffs have a due process/property interest in ceiling lifts. | Ceiling lifts are medically necessary benefits to which they are entitled. | Guidance shows ceiling lifts are outside the plan; no entitlement. | No property interest; due process not violated. |
| Whether plaintiffs had adequate process under Goldberg v. Kelly. | Hearing officers failed to consider exceptional circumstances. | Notice and a meaningful opportunity to be heard were provided; state judicial review available. | Process provided complied with due process. |
Key Cases Cited
- Gonzaga University v. Doe, 536 U.S. 273 (2002) (whether federal statute creates an individual right enforceable via §1983)
- Blessing v. Freestone, 520 U.S. 329 (1997) (three Blessing factors for implied rights in statutes)
- Harris v. McRae, 448 U.S. 297 (1980) (Medicaid federal/state funding limits; states not required to bear full costs)
- Wright v. City of Roanoke Redevelopment and Housing Authority, 479 U.S. 418 (1987) (§1983 viability and federal statutory rights enforcement)
- Goldberg v. Kelly, 397 U.S. 254 (1970) (due process notice and opportunity to be heard in benefits)