M.G. v. Armijo, 117 F.4th 1230

Background

M.G. and C.V. are medically fragile children under New Mexico’s Medicaid program and entitled to a specified amount of private duty nursing (PDN) hours approved through the EPSDT budgeting process.
M.G. and C.V. alleged that the New Mexico Human Services Department (HSD) consistently failed to provide them the full required PDN hours, putting them at risk of severe medical harm or institutionalization.
The children and their guardians sought a preliminary injunction obligating HSD to undertake good faith efforts to provide the approved PDN hours during the litigation.
The district court granted the injunction; HSD appealed, challenging the children’s standing, the likelihood of success on the merits, the specificity of the injunction, and the legal basis for injunctive relief under Armstrong v. Exceptional Child Ctr., Inc.
The Tenth Circuit reviewed and affirmed the district court’s injunction, finding the requirements for injunctive relief met and rejecting HSD’s procedural and substantive arguments.

Issues

Issue	Plaintiff's Argument	Defendant's Argument	Held
Standing	M.G./C.V. suffer ongoing harm from denied PDN hours; injunction can remedy it.	No redressability due to nurse shortage; HSD can’t guarantee remedy.	Plaintiffs have standing; HSD’s argument is a merits defense, not jurisdictional.
Likelihood of Success	HSD violated Medicaid Act by not providing approved PDN hours; relief is due.	Hours not always medically necessary; nurse shortage makes compliance impossible.	Plaintiffs are likely to succeed; EPSDT budget hours are presumptively necessary, and HSD didn’t prove impossibility.
Irreparable Harm	Absence of PDN hours risks life-threatening injury and institutionalization.	One plaintiff was briefly receiving full hours; harm is not ongoing.	Historic and likely ongoing shortfalls cause irreparable harm; harm shown.
Public Interest/Balance of Harms	Injunction enforces legal entitlements for two children, with limited state burden.	Injunction risks scarce resources, limits HSD’s discretion, could hurt others.	Public interest favors injunction; it enforces existing law, tailored to minimize state disruption.
Vagueness of Injunction	Order specifies required steps and allows HSD flexibility.	Injunction lacks specific instructions, too vague to enforce.	Order is sufficiently detailed for compliance and review; flexibility is justified.
Armstrong Preclusion	Not seeking rate changes; only enforcement of medical services entitlement.	Armstrong bars injunctive relief when statutory remedy exists or text is unadministrable.	Armstrong doesn’t bar this action; case is about services, not rates.

Key Cases Cited

Armstrong v. Exceptional Child Ctr., Inc., 575 U.S. 320 (2015) (Medicaid providers cannot enforce §1396a(a)(30)(A) via Supremacy Clause; addressed limits on injunctive relief against state Medicaid agencies)
O.B. v. Norwood, 838 F.3d 837 (7th Cir. 2016) (summarized statutory basis and rights for medically fragile children to receive in-home PDN services under Medicaid, affirmed similar district court relief)
Winter v. Natural Resources Defense Council, Inc., 555 U.S. 7 (2008) (sets standard for preliminary injunctions: likelihood of success, irreparable harm, balance of equities, and public interest)
Planned Parenthood of Kan. v. Andersen, 882 F.3d 1205 (10th Cir. 2018) (set forth framework for private right of action under the Medicaid Act)