Years ago, a group of plaintiffs and the Indiana Medicaid program’s administrators agreed to certain terms for the handling of applications to the disability program in Indiana: most relevant for present purposes was a concession that the program would compile a complete twelve-month medical history before reaching a decision on the application. Now, several members of the affected class want to hold the program administrators in civil contempt for violating that portion of the consent decree. They claim that in too many cases the program is relying on summary forms rather than compiling an applicant’s complete medical history.
The district court rejected the motion because the plaintiffs had not demonstrated by clear and convincing evidence that the defendants were in violation of the terms of the consent decree. Appellants now challenge that ruling, citing three errors. First, they claim the district court improperly tasked them with demonstrating that the plaintiffs had not been reasonably diligent in following the demands of the consent decree. Second, they argue that the district court should have held that the evidence proffered below was a clear and convincing demonstration that the program administrators were violating the decree. Third, they argue that the district court erred as a matter of law by holding that 20 C.F.R. § 416.912(d), a pro *932 vision of the regulations for the Supplemental Security Income disability program incorporatеd by reference into the consent decree, did not require a full collection of medical records.
For the following reasons, we affirm the district court’s ruling.
I. Background
The Medicaid for the Disabled program in Indiana provides medical coverage and benefits to individuals who suffer from a qualifying disability. The present case grew out of a class action lawsuit filed against the Indiana Medicaid disability plan in the 1990s. That lawsuit was settled by a consent decree requiring the administrators of the plan to collect certain evidence before making a decision on an application for disability benefits. The consent decree required the Indiana plan to obtain and evaluate evidence used for Medicaid eligibility in the same way that the Code of Federal Regulations requires the Supplemental Security Income administrators to obtain and evaluate evidence. Specifically, the decree provided that, “the State of Indiana must obtain and evaluate evidence in determining Medicaid eligibility in the same way that Supplemental Security Income disability determinations are made under 20 C.F.R. 416.901 through 416.988.”
In fact, the consent decree simply incorporated 20 C.F.R. § 416.901-416.988 as regulations for how the Indiana Medicaid program should go about collecting and evaluating applications. As the district court summarized it, the consent decree required the Indiana Medicaid program to do three things: First, obtain complete histories from a Medicaid applicant’s treatment providers, covering at least the twelve months prior to the application, before making any determination about Medicaid eligibility; second, obtain additional medical information from an applicant’s treating physician or other medical source when necessary; third, ensure that medical records are complete and detailed enough to allow for a proper determination regarding eligibility.
The Indiana Medicaid for the Disabled program is supposed to follow a defined set of procedures when making eligibility determinations. Applicants for Medicaid for the Disabled first meet with an assigned caseworker. The caseworker helps an applicant fill out Form 251B, in which an applicant lists her medical conditions and any information about treatments she’s recеived in the last twelve months, including her treating physicians. The caseworker is responsible for collecting an applicant’s medical history based on the information provided in Form 251B. If the caseworker is unable to collect this information, he is supposed to note that in the applicant’s file. After the caseworker has processed them, applications are forwarded to the Medicaid Medical Review Team (MMRT). The MMRT is responsible for gathering any information that the caseworker has not tracked down.
The Indiana Medicaid plan uses a Form 251A to collect information from a physician about an applicant’s medical history. The Form 251A includes a section asking for information about the patient’s treatments, diagnostic tests, and mеdications going back for at least twelve months, a “Medical Evidence” section asking for information on the patient’s physical systems, and a “Diagnosis/Prognosis” section asking for the doctor’s opinion regarding the applicant’s reported impairment.
On April 13, 1999, plaintiffs filed a petition to hold the defendants in civil contempt for violating the terms of the consent decree. The parties settled by entering into a second consent decree that included the same terms as the original and allowed anyone who had *933 been denied Medicaid benefits in the preceding three years to reapply for benefits.
Seven years later, on September 26, 2006, plaintiffs filed a second petition to hold defendants in civil contempt, alleging that the Indiana Mеdicaid program was again in violation of the consent decree. In response to a discovery request, the Medicaid administrators agreed to produce a representative sample of disability benefit applications. That sample consisted of twenty-six files in all, representing every application from Marion County, Indiana with an applicant whose last name began with “C” and whose application was denied between September 1, 2006 and October 1, 2006. 1 The parties judged twelve of these applications to be complete under any standard, but appellants contend that the remaining fourteen are incomplete and demonstrate the Indiana Medicaid program’s violation of the consent decree.
Appellants contend that in some cases Indiana is improperly using this form as a proxy for the “complete medical history” required in 20 C.F.R. § 416.912. Appellees contend that the consent decree does not always require them to obtain copies of a physician’s medical records and that Form 251A is a “complete” medical history within the meaning of the decree.
The district court conducted its own review of the files. It concluded that five of the fourteen allegedly incomplete files were complete under any standard. With respect to the remaining nine, the district court found that “[flour of these nine applications are clearly less complete than the other five,” and that the other five files contained only the summary Form 251A, but did not find the administrators of Indiana Medicaid in contempt for violating the consent decree. The crux of the district court opinion is that the appellants had not met the burden for a civil contempt petition: Neither side presented adequate evidence on what constituted a “complete” medical history, and thus neither the four arguably incomplete applications nor the five applications containing only the Form 251A was clear and convincing evidence that the appellees violated the consent decree. The district court invited the appellants to re-file their motion, asking them to produce “[ejxpert testimony, or information on how the agency charged with responsibility for compliance with the Decree interрrets the definition Plaintiffs offer” and “factual explication of what precisely the Medicaid system instructs physicians to do and take account of in completing Form 251A.” The appellants instead appealed the district court’s denial of their motion to this court.
II. Discussion
We review the district court’s decision not to hold the state in civil contempt deferentially. “It is well established that the decision by a district court to enter a finding of civil contempt is discretionary and we review it only to determine if there was an abuse of discretion or its entry was clearly erroneous.”
Feltner v. Title Search Co.,
Appellants argue that the district court made three errors. First, it improperly placed upon them the burden of demonstrating that Indiana had not been reasonably diligent in carrying out the consent decree’s requirements. They contend that reasonable diligence is an affirmative defense on which Indiana bears the burden of proof. Second, they argue that the district court abused its discretion by not imposing civil contempt sanctions because of the four applications that the district court characterized as less than complete. Third, they argue that the district court improperly declined to hold that the consent decree requires that Indiana obtain actual copies of a treating physician’s medical records and thus that the five applications with only a Form 251A are evidence of Indiana’s violation of a court order. We take each claim in turn.
A. Whether the district court improperly allocated the burden of proof
The appellants first contend that thе district court abused its discretion because it improperly placed on them the burden of proving that the appellees were not “reasonably diligent” in executing the consent decree. The district court characterized the burden of proof as, “whether Plaintiffs have shown, by clear and convincing evidence, that Defendants have not been ‘reasonably diligent and energetic in attempting to accomplish what was ordered’ in the Consent Decree.” They contend that this was an error of law and necessarily an abuse of the district court’s discretion.
See United States v. Jaderany,
Appellants cite
United States v. Rylander,
Rylander
addressed a case where a party defending against a civil contempt petition for violating a court order requiring a one-time-only action on his part, but in doing so it did not address what evidence a party
seeking
sanctions must produce in the first instance. The parties agree that this circuit’s case law requires the party seeking sanctions to demonstrate that the opposing party is in violation of a court order by clear and convincing evi
*935
dence.
See, e.g., SEC v. Homa,
In
Goluba v. School Dist. of Ripon,
Goluba
does not explicitly say which party bears the burden of demonstrating “reasonable diligence” or the absence thereof. Our discussion of “reasonable diligence” in that case refers to what a court must
find
rather than to what a party to the action must
prove.
However,
Goluba
spelled out what evidence must be before the court before it can impose sanctions: evidence that a party has willfully refused to comply with a court order, or evidence that a party was not “reasonably diligent” in carrying out the terms of the court order. We have subsequently used a test for civil contempt petitions that explicitly requires a petitioner to demonstrate that the alleged contemnor was not reasonably diligent.
See Prima Tek II, LLC v. Klerk’s Plastic Industries, B.V.,
Furthermore, we could reject the contention that the district court erred in stating the burden of proof because it is not clear from reading the opinion that the district court actually placed the burden of demonstrating the lack of reasоnable diligence on appellants. The statement quoted above certainly suggests that the court required as part of the prima facie case evidence that the appellants had not been reasonably diligent. However, the district *936 court ultimately rejected the civil contempt petition because one set of allegedly incomplete applications was in fact complete, and “their completeness shows ‘reasonable diligence’ on the part of Defendants to follow the Court’s order and the regulations that support it.” With respect to the other allegedly incomplete applications, the court declined to impose civil contempt sanctions not because appellants had not demonstrated an absence of reasonable diligence but because “it remains unclear what constitutes a ‘complete’ medical history” and consequently appellants had “failed to meet their burden on the remaining applications, because the standard for contempt requires clear and convincing evidence that Defendants violated the decree.” Appellants did not prevail because they simply failed to produce clear and convincing evidence that Indiana had violated the consent decree. They have now latched onto a single phrase from the opinion and insist that it mandates reversal, but we think this is an uncharitable characterization of the district court’s opinion and, at any ratе, is neither an error nor grounds for reversal.
B. Whether appellants produced sufficient evidence of non-compliance
The burden of proof aside, appellants also contend that the evidence they presented to the district court adequately demonstrated Indiana Medicaid’s non-compliance with the consent decree and justified civil contempt sanctions. As the district court summarized it, appellants made the following factual allegations in the contempt proceeding, based on their random sampling of applications:
(1) In nine, or 35%, of the applications, Defendants failed to request twelvemonth medical histories;
(2) in seven, or 25%, of the applications, Defendants failed to collect information that was “complete and detailed enough” to make a disability determination; (3) in three, or 12%, of the applications, Defendants failed to collect a list of any medical facilities that treated the applicant; (4) in eight, or 53%, of fifteen applications, the county office forwarded the application to the MMRT without any medical records; (5) in four, or 27%, of fifteen applications, the Medicaid application was denied on the same day that the Medicaid Medical Review Team requested additional information about the applicant; (6) in one of fifteen applications, the only medical information included in the application was gathered by a registered nurse, rather than a doctor; (7) in none of the apрlications did the packet contain Form 2032, which is supposed to be present any time an applicant was asked to receive a physical examination; (8) in none of the applications did the county caseworker make a record of requests for medical information; and (9) in neither of the two applications in which a physician requested that the applicant receive further testing was the testing actually performed before the application was denied.
The district court conducted its own review of the files and concluded that at least five of the allegedly incomplete applications in fact contained detailed records. The court did note that of the remaining nine applications, “[flour of these nine applications are clearly less complete than the other five,” either because those files were missing Form 251A altogether or because Form 251A was missing pages or was otherwise incomplete. Appellants claim that this statement regarding the four case files is evidence of Indiana’s noncompliance with the consent decree and a sufficient basis for holding the program’s administrators in civil contempt.
Appellants cite case law from this and other circuits establishing that Medicaid programs are subject to a strict compli
*937
anee standard with respect to regulatory-procedures and deadlines for reaching decisions on individual applications. They rely heavily on
Smith v. Miller,
We are presented, then, with the question of how much non-compliance is needed before a district court can impose civil contempt sanctions. A few preliminary points will sharpen our analysis on this issue. Other courts have observed that in civil contempt proceedings, “context is extremely important to appellate oversight ...”
Langton v. Johnston,
The Supreme Court has also cautioned district courts that in using their contempt powers against a public agency they should select a remedy carefully tailored to the proposed end.
Spallone v. United States,
We conclude that the district court did not abuse its discretion by ruling that appellants had not рroduced clear and convincing evidence of Indiana’s violation of the court order. The first problem for appellants is that the district court did not make a factual finding that any of the applications are incomplete and in violation of the consent decree. The district court did note something that appellants stress in their brief, which is that four of the files are less complete than the others. However, due to the inconclusive nature of the parties’ arguments about what constitutes a “complete” medical history, the district court was unable to make any factual findings about whether the files were or were not in compliance with the regulatory standard incorporated into the consent decree. (The district court’s uncertainty about the applicable regulatory standard is covered in the next section.) Appellants urge us to read the district court’s identification of four less-than-complete applications as an implicit finding that Indiana Medicaid is not collecting complete medical histories and is in violation of the consent decree. 2 We will not base a civil contempt order on an implicit finding when the district court declined to make that finding on the record or base a contempt order upon it, however.
Second, with respect to the legal standard, the case law that appellants cited occurred outside the civil contempt context; those cases sought injunctive or equitable relief for unsettled cases. 3 They are thus swaрping the standard for civil contempt with the standard for initial injunctive relief. Appellants anticipate this objection, and argue in a footnote in then-brief that this court cannot fairly subject motions seeking to enforce the consent decree to a higher burden of proof than the lawsuit seeking relief in the first instance. That argument conflates a standard used to determine an injury with a standard used to measure the efficacy of a remedy, however. The appellants’ position is that the failure to follow regulatory procedures inflicts an injury on them; to the extent that their allegations are true, then-injury does entitle them to equitable relief. The existence of the consent decree in this case, however, means that they already have that relief. The issue at this stage is whether we can hold the Indiana program in civil contempt for not taking adequate steps to implement that remedy and, for the reasons discussed above, a district court is entitled to require clearer and more convincing evidence of non-compliance before imposing coercive sanctions.
*939 Thus, even if we did what appellants ask us to do and took the four “less than complete” applications as an implicit finding that Indiana fell short of the terms of the consent decree in some cases, that finding would not necessarily justify the civil contempt sanctions that appellants seek. We agree with the district court that, given the present context, those sanctions are not warranted based on the еvidence presented.
C. Whether the district court erred by not interpreting “complete medical history” as always requiring copies of a treating physician’s records
Appellants’ final issue in this appeal is whether the district court made an error of law by interpreting the phrase “complete medical history” in the consent decree to mean something less than copies of the medical records of each treatment source of a given applicant. This issue pertains to the five application files that contain completed copies of Form 251A but do not contain copies of the treating physician’s medical record. Appellants argue now that the district court erred by not concluding that those files do not contain the complete medical history required by the regulations.
Once again, the consent decree requires that the administrators of Indiana Medicaid develop records used in eligibility decisions in the same way that the SSI program develops records for eligibility decisions. The Code of Federal Regulations provisions for that program promises applicants that, “we will develop your complete medical history for at least the 12 months preceding the month in which you file your application unless there is a reason to believe that development of an earlier period is necessary or unless you say that your disability began less than 12 months before you filed your application.” 20 C.F.R. § 416.912(d). With respect to the phrase “completе medical history,” the regulations define that as follows:
By complete medical history, we mean the records of your medical source(s) covering at least the 12 months preceding the month in which you file your application. If you say that your disability began less than 12 months before you filed your application, we will develop your complete medical history beginning with the month you say your disability began unless we have reason to believe that your disability began earlier.
20 C.F.R. § 416.912(d)(2). Appellants clearly believe that the phrase “complete medical history” means physical copies of the physician’s own records, going back at least twelve months before the date of the application. Indiana clearly operates under the incomрatible belief that Form 251A suffices as a complete medical history, since it gathers information from each of the applicants’ treatment providers for at least the previous twelve months. The district court was unable to sort out this disagreement based on the parties’ presentations. It invited appellants to re-file their contempt petition along with evidence elaborating on the meaning of “complete medical history.” Specifically, the district court was interested in receiving expert or other testimony on “whether the applications that included only Form 251A, or the other applications that were otherwise less comprehensive, are ‘complete’ enough to conform to the consent decree. Furthermore, we require a factual explication of what precisely the Medicaid system instructs physicians to do and take account of in completing Form 251A.”
The appellants urge us to reverse this part of the decision, claiming that this interpretation of the consent decree violates the plain meaning of the terms as well as the decisions of courts that have
*940
reviewed the meaning of the relevant C.F.R. provisions. They cite, among other things, the dictionary definition of complete (meaning “having all parts or elements; lacking nothing”), and two opinions from the Second Circuit reversing an agency’s eligibility determination because some medical records were missing.
See Rosa v. Callahan,
A court interprets the meaning of a consent decree in the same way it interprets the meaning of a contract, and a reviewing court examines that interpretation de novo.
Goluba,
The regulations also place at least part of the burden for gathering the relevant medical records on the applicant rather than on the agency. “In general, you have to prove to us that you are blind or disabled. This means that you must furnish medical and other evidence that we can use to reach conclusions about your medical impairment(s).” 20 C.F.R. § 416.912(a). While the regulations task the agency with the responsibility to develop an applicant’s medical history, they discuss this in terms of a duty to make a “reasonable effort” to do this. “We will make every reasonable effort to help you get medical reports from your own medical sources when you give us permission to request the reports.” 20 C.F.R. § 416.912(d) (emphasis added). Indiana, in reliance on these portions of the regulations, interprets the consent decree much more narrowly, and argues that by training case workers to interview Medicaid applicants and requesting an applicant’s medical history they fulfill their burden under the regulations with respect to the collection of a physician’s records.
Appellants’ position that a Form 251A does not suffice as an applicant’s “complete medical history” within the meaning of 20 C.F.R. § 416.912(d)(2) is based on an assumption that the document is deficient in some respect, or that a physician’s records contain material information not captured in Form 251A. 4 As the district court noted, *941 however, there is not enough information before the court to reach a determination on that issue. The regulations require both the applicant and the agency to develop a record sufficient for the agency to make an informed determination about the applicant’s disability. Based on this record we are not prepared to hold categorically that an agency can never use a summary form when developing that record or that the absence of any document from a physician within the last twelve months, whatever its relevance, is a violation of the regulations.
While the case is simply underdeveloped on this point, our ruling does not foreclose all future claims on this issue from appellants. The district court indicated a willingness to entertain further petitions and to engage in greater fact-finding on the meaning of “complete medical history” under the terms of the consent decree, including gathering information about how thorough health care providers have been when filling out Form 251A. This matter presently comes before us as a contempt petition, however, where the salient issue is whether appellants have presented sufficient evidence that the Indiana Medicaid program has violated a court order. We agree with the district court that they have not satisfied that burden at this point.
III. Conclusion
For the foregoing reasons, we Affirm the decision of the district court.
Notes
. This procedure raises some obvious concerns about sample size and concentration, but appellants contend that appellees stipulated that they would not raise those issues in defense of the action, and they have not.
. One problem complicating this categorization is that those four files are all at various stages of incompleteness. One file, designated File M, contains no medical history outside of a copy of a prescription refill; File E contains a Form 251A that is missing pages; File L contains only one incomplete Form 251A and nothing from other mediсal providers; and File H was denied on the same day that the MMRT requested additional records which they apparently never received.
.
Withrow
is a particularly problematic citation for appellants, as the Ninth Circuit specifically distinguished between the initial remedy and enforcement of that remedy in contempt proceedings.
Withrow,
. Appellants argue that a Form 251A is deficient because it is not a “record” under Indiana law, becаuse the Indiana Code defines "medical records” as files "possessed” by health care providers before they are turned over to the state. Ind.Code. § 1 — 1—4— 5(6). First, appellants do not explain why Indiana law should inform the meaning of a term used in the federal regulations. We understand that looking at the Indiana Code may illuminate how the parties understood the term, but appellants otherwise urge this court to adopt a strict reading of the term as it is construed by courts interpreting the federal regulations themselves. The Indiana Code would be of limited value in that exercise. Second, appellants do not explain how the fact of possession makes a substantive *941 difference in the completeness of an applicant’s file if, for instance, the file contained a form completed by a health care provider containing all of the relevant information in the provider’s files.