125 F. Supp. 3d 1099
D. Haw.2015Background
- Plaintiffs (J.E., through his mother, and Hawaii Disability Rights Center) sued DHS, alleging Medicaid-eligible children with autism are being denied medically necessary applied behavioral analysis (ABA) under EPSDT.
- Plaintiffs claim DHS long maintained a policy excluding ABA from coverage and, despite a 2015 memorandum indicating coverage, has not implemented a federally compliant program or informed beneficiaries/providers.
- Plaintiffs seek declaratory and injunctive relief under 42 U.S.C. § 1983 for violations of EPSDT-related provisions of the Medicaid Act (notably §§ 1396a(a)(10)(A), 1396a(a)(43), 1396d(a), and 1396d(r)(5)).
- DHS moved to dismiss arguing plaintiffs lack a private right of action to enforce the cited Medicaid provisions (relying on Armstrong and related reasoning).
- The sole legal question decided: whether Medicaid beneficiaries have a private cause of action under § 1983 to enforce EPSDT entitlements to medically necessary services such as ABA.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether Medicaid beneficiaries have a private right under § 1983 to enforce EPSDT entitlements | Beneficiaries have a § 1983 cause to enforce EPSDT rights ( §§1396a(a)(10)(A), 1396a(a)(43), 1396d(r)(5) ); ABA alleged as medically necessary | Armstrong and related authority limit private enforcement; plaintiffs cannot sue to enforce Medicaid program details | Court held beneficiaries do have a private § 1983 right to enforce EPSDT services and denied dismissal |
| Whether Armstrong forecloses a § 1983 remedy here | Armstrong concerned providers and §1396a(a)(30); does not control cases where beneficiaries seek EPSDT services | DHS argued Armstrong undermines private enforcement generally | Court distinguished Armstrong (provider, different provision) and found it inapplicable |
| Whether the question of ABA’s medical necessity is ripe on motion to dismiss | Plaintiffs plead ABA is medically necessary for class members and allege lack of access | DHS asserts ABA is not an enumerated EPSDT service or that coverage depends on individual medical necessity findings | Court declined to resolve medical-necessity merits at dismissal; plaintiffs may pursue claims under §1983 |
| Whether DHS’s January 2015 memorandum cured alleged violations | Plaintiffs say memo lacks operational details, outreach, provider lists, and state-plan amendments needed for compliance | DHS contends memo acknowledges coverage and cures exclusion | Court found memo insufficient to defeat §1983 claim at pleading stage |
Key Cases Cited
- Westside Mothers v. Haveman, 289 F.3d 852 (6th Cir. 2002) (holds EPSDT provisions create privately enforceable rights under §1983)
- Pediatric Specialty Care, Inc. v. Arkansas Dep’t of Human Servs., 293 F.3d 472 (8th Cir. 2002) (recognizes private §1983 cause to enforce EPSDT entitlements)
- Miller v. Whitburn, 10 F.3d 1315 (7th Cir. 1993) (same: EPSDT provisions enforceable under §1983)
- S.D. ex rel. Dickson v. Hood, 391 F.3d 581 (5th Cir. 2004) (EPSDT creates enforceable rights for ameliorative services)
- Watson v. Weeks, 436 F.3d 1152 (9th Cir. 2006) (Ninth Circuit recognizes private right under §1396a(a)(10)(A) to enforce certain Medicaid services)
- Sanchez v. Johnson, 416 F.3d 1051 (9th Cir. 2005) (distinguishes provider-focused Medicaid provisions from recipient-focused provisions for §1983 enforcement)
- Armstrong v. Exceptional Child Ctr., Inc., 135 S. Ct. 1378 (U.S. 2015) (holds Supremacy Clause does not create a private cause of action and limits ability of providers to enforce certain Medicaid provisions)
- Blessing v. Freestone, 520 U.S. 329 (U.S. 1997) (announces three-part test for whether federal statute creates enforceable rights under §1983)