Kathryn Price v. Medicaid Director
838 F.3d 739
| 6th Cir. | 2016Background
- Ohio operates an assisted-living Medicaid waiver that requires a county "passport" agency to approve a written individualized service plan before Medicaid funds may be used for assisted-living services. Ohio regs bar payment for services provided before plan approval.
- Plaintiffs (Hilleger and Saunders, via relatives) received assisted-living care before passport-agency approval; providers/families paid those costs and plaintiffs later sought retroactive Medicaid reimbursement.
- Plaintiffs filed a putative class action under 42 U.S.C. § 1983, contending § 1396a(a)(34) requires States to provide Medicaid coverage retroactively up to three months before application if the beneficiary was eligible when the services were furnished.
- The district court certified a class and granted summary judgment for plaintiffs, ordering prospective injunctive relief (stop denying retroactive coverage) and notice to class members about administrative hearings for retroactive benefits.
- Sixth Circuit reversed: it limited standing to the original retroactivity claim (not later-added notice/promptness claims), held Eleventh Amendment did not bar the prospective injunction/notice, and concluded federal statute § 1396n(c)(1)’s requirement that services be provided "pursuant to a written plan of care" precludes paying for services before plan approval; thus Ohio complied with federal law.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Standing to pursue claims | Plaintiffs had injury and relief (declaration/administrative hearing) could redress retroactive-payment claims | Defendants: declaratory relief cannot redress past injury; named plaintiffs’ administrative hearing windows expired so no standing | Plaintiffs had standing only for the original retroactivity claim filed in Feb. 2013 (Hilleger’s hearing window was open when complaint filed); later-added claims lacked standing |
| Eleventh Amendment sovereign immunity | Prospective injunction and notice remedy are permissible to vindicate federal rights | Defendants: order effectively seeks retroactive payments or to force redoing past determinations (barred by Eleventh Amendment) | Prospective injunction and notice are allowed (Ex parte Young / Quern); Eleventh Amendment does not bar the prospective relief ordered |
| Construction of § 1396a(a)(34) (retroactivity) vs. § 1396n(c)(1) ("pursuant to a written plan") | "Pursuant to" means "consistent with"; services consistent with later-approved plan qualify for retroactive Medicaid reimbursement | "Pursuant to" requires authorization by an existing plan; services before plan approval are not payable under waiver authority | "Pursuant to" means authorization/compliance with an existing plan; § 1396n(c)(1) bars Medicaid payment for assisted-living services provided before passport-agency approval of the service plan; district court erred in ordering retroactive payments |
| Class certification / remedial consequences | Class certification appropriate; remedial classwide relief ordered | Defendants challenged certification and scope of relief | Sixth Circuit vacated the district court’s class-certification order (did not reach merits of certification) and instructed entry of judgment for defendants on merits |
Key Cases Cited
- Armstrong v. Exceptional Child Ctr., Inc., 135 S. Ct. 1378 (discussing Spending Clause conditions on federal funds)
- Lujan v. Defenders of Wildlife, 504 U.S. 555 (standing elements)
- County of Riverside v. McLaughlin, 500 U.S. 44 (inherently transitory-claims rule for class actions)
- Genesis Healthcare Corp. v. Symczyk, 133 S. Ct. 1523 (transitory-claims/class-action context)
- Ex parte Young, 209 U.S. 123 (prospective injunctive relief against state officers)
- Pennhurst State Sch. & Hosp. v. Halderman, 465 U.S. 89 (limits on suits for retroactive monetary relief against states)
- Edelman v. Jordan, 415 U.S. 651 (limits on retroactive relief in federal suits for public benefits)
- Quern v. Jordan, 440 U.S. 332 (permitting notice to class members about state remedies despite retroactivity concerns)
- Youngstown Sheet & Tube Co. v. Sawyer, 343 U.S. 579 (use of "pursuant to" as meaning "authorized by")
- Freeman v. Quicken Loans, Inc., 132 S. Ct. 2034 (statutory interpretation using ordinary meaning of terms)