965 F. Supp. 2d 834
M.D. Tenn.2013Background
- Jeremy Wilborn, a quadriplegic former TennCare enrollee, received 24/7 private-duty nursing and home-health aide care as a minor under EPSDT; TennCare/BlueCare reduced adult home-care benefits to a 40-hour/week cap and offered CHOICES alternatives.
- Treating physicians and a state ALJ concluded Wilborn medically requires 24/7 care (suctioning, tube feedings, frequent repositioning); nursing homes near him averaged low staff hours per resident.
- Wilborn sought preliminary injunctive relief under Title II of the ADA and Section 504 of the Rehabilitation Act, arguing CHOICES cost caps would force unjustified institutionalization and endanger his health.
- Defendants (Tennessee officials/TennCare and its MCOs) defended CHOICES as a CMS‑approved HCBS waiver program that enforces an individual cost-neutrality cap (home care cost cannot exceed nursing-facility cost) and argued providing Wilborn’s full requested in-home care would fundamentally alter the program and be fiscally unreasonable.
- The court found Wilborn likely to succeed on the merits, that institutionalization would cause irreparable harm, and that limited relief consistent with similarly situated CHOICES enrollees would not constitute a fundamental alteration of the program.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether TennCare’s reduction of Wilborn’s home-care hours violates ADA/Section 504 integration mandate | Wilborn: cutting his 24/7 home care forces unjustified institutionalization, violating ADA/RA; physicians and ALJ confirm medical necessity | TennCare: CHOICES' cost caps and CMS-approved waiver adequately provide community services; exceeding caps would fundamentally alter program and strain resources | Court: Likely success for Wilborn; limits would force institutionalization and violate ADA/RA absent showing of fundamental alteration |
| Whether requested relief is a reasonable modification or a fundamental alteration | Wilborn: limited relief (~$108,137 consumer-directed plan) fits within CHOICES cost parameters for similarly situated enrollees and is reasonable | TennCare: providing 24/7 private-duty nursing at home is prohibitively expensive and would fundamentally alter program implementation | Court: Relief is within cost parameters for comparable CHOICES categories and does not present a fundamental alteration defense warranting denial |
| Irreparable harm from reducing home-care services | Wilborn: loss of medically necessary services will cause severe health risks and institutional confinement with attendant harms | TennCare: offers nursing facility placement and alternative CHOICES options; claims nursing homes can provide needed care | Court: Irreparable harm established — nursing home placement would risk health and be inadequate given staffing and Wilborn’s needs |
| Public interest and potential harm to others from injunction | Wilborn: enforcing ADA/RA serves public interest; requested relief affects few funds and fits program limits | TennCare: granting exceptions undermines budget neutrality and fairness to other enrollees | Court: Public interest favors enforcement of ADA/RA; limited relief unlikely to harm program or other enrollees given CHOICES budget and enrollment data |
Key Cases Cited
- Olmstead v. L.C., 527 U.S. 581 (1999) (integration mandate: unjustified institutionalization is discrimination; community placement required when appropriate, not opposed by individual, and reasonably accommodated)
- Radaszewski v. Maram, 383 F.3d 599 (7th Cir. 2004) (integration mandate may require reasonable modifications to permit 24/7 at‑home care; costs must be compared against similarly situated individuals)
- Fisher v. Okla. Health Care Auth., 335 F.3d 1175 (10th Cir. 2003) (caps that force institutionalization can violate ADA; fiscal concerns do not automatically establish fundamental alteration)
- Frederick L. v. Dep’t of Pub. Welfare, 364 F.3d 487 (3d Cir. 2004) (state must present concrete evidence of fiscal/operational impact to sustain fundamental‑alteration defense; consider waiting lists, comprehensive plan, and ability to meet others’ needs)
- Haskins v. Stanton, 794 F.2d 1273 (7th Cir. 1986) (enjoining a public entity to comply with federal law does not impose impermissible additional burden on government)