Blanchard v. ForrestBlanchard v. Forrest
- Reporters:
- , ,
- Before:
- Reynaldo G. Garza, King, Higginbotham (per curiam)
Phillip Bruce Waters, Department of Health and Hospitals for the State of Louisiana.
Before REYNALDO G. GARZA, KING and HIGGINBOTHAM, Circuit Judges.
PER CURIAM:
Rose Forrest, as Secretary of the Louisiana Department of Health and Hospitals, appeals from the district court‘s partial summary judgment for the plaintiffs. Finding no error, we affirm.
I. BACKGROUND
Myrtle W. Blanchard (“Blanchard“) and Patrice A. Dumas (“Dumas“) brought this class action on behalf of Louisiana Medicaid applicants to challenge certain policies of the Louisiana Department of Health and Hospitals (“LDHH“) — the state agency that administers Louisiana‘s Medicaid plan. Specifically, the plaintiffs argued that LDHH‘s retroactive coverage policy violates the federal Medicaid statute. That statute requires that Medicaid assistance be made available to an eligible Medicaid applicant for covered medical services furnished to the applicant during the three months preceding the month in which he or she applied for Medicaid, if the applicant had been eligible for Medicaid when the services were furnished.
The experiences of the named plaintiffs exemplify the dilemma1 created by Louisiana‘s retroactive coverage policy. Blanchard is a 65-year-old insulin-dependent diabetic who has a fixed income of $477 per month in Social Security benefits. In February 1994, she was found eligible for retroactive Medicaid coverage for the period from February 20, 1993 to April 1993. Thereafter, Blanchard requested that the pharmacy from which she had purchased medication refund her payments totaling $197.28 and submit a claim to Medicaid. The pharmacy refused to do so. Similarly, in July 1994, Dumas‘s minor son was found eligible for Medicaid effective February 1, 1992. Dumas then sought refunds from pharmacies from which she had purchased $40 worth of medications for her son during the retroactive coverage period. The pharmacies denied her requests, and explained to her that such a denial was their standard policy when Medicaid clients had paid for supplies before the clients were found eligible for Medicaid.
On May 8, 1995, the district court granted the plaintiffs’ motion for partial summary judgment,1 concluding that LDHH‘s retroactive coverage policy violates
posed
II. STANDARD OF REVIEW
We review a grant of summary judgment de novo, applying the same criteria used by the district court in the first instance. Norman v. Apache Corp., 19 F.3d 1017, 1021 (5th Cir.1994); Conkling v. Turner, 18 F.3d 1285, 1295 (5th Cir.1994). Summary judgment is proper “if the pleadings, depositions, answers to interrogatories, and admissions on file, together with the affidavits, if any, show that there is no genuine issue of material fact and that the moving party is entitled to judgment as a matter of law.”
III. DISCUSSION
Medicaid, enacted as Title XIX of the Social Security Act (codified at
Under federal Medicaid law, a state plan must provide that “the medical assistance made available to any individual ... shall not be less in amount, duration, or scope than the medical assistance made available to any other individual....”
make eligibility for Medicaid effective no later than the third month before the month of application if the individual—
(1) Received Medicaid services, at any time during that period, of a type covered under the plan; and
(2) Would have been eligible for Medicaid at the time he received the services if he had applied (or someone had applied for him), regardless of whether the individual is alive when application for Medicaid is made.
LDHH is the state agency which administers Louisiana‘s state Medicaid plan. LDHH‘s policy on retroactive coverage, purporting to implement the requirements of
When retroactive payment shall not be made
(1) for services received in any period prior to the third month preceding that of application. (2) for services for which payment has already been made [by] a source other than the Division of Family Services (predecessor to the Louisiana Medicaid Program), even though the person was eligible at the time of the service, except when the provider refunds all payment received and accepts the division‘s payment as payment in full (except in long term care facilities). The refund must be clearly established on the bill the provider submits to state office (now UNISYS).
This policy provides coverage for Medicaid-coverable bills paid privately (by the recipient, not an insurer), in whole or in part, during the retroactive coverage period, only if the medical provider first, before submitting the claim to LDHH‘s Medicaid program, voluntarily refunds the money paid by the recipient, and then after making the refund, submits the bill to LDHH for payment at Medicaid rates. Because Medicaid rates are usually much lower than the rates providers charge private patients, Medicaid providers in Louisiana have a disincentive to provide voluntary refunds to patients determined to be Medicaid-eligible after the services or supplies were furnished. Even if a recipient has only partially paid the medical provider for a service rendered during the three-month retroactive coverage period, LDHH will not pay the provider the balance unless the provider first voluntarily refunds the recipient‘s payment. Ironically, a Medicaid applicant who fails or refuses to pay for services rendered during the three month retroactive coverage period, will receive medical assistance from LDHH for that period, because LDHH will pay directly a provider who submits a claim for the full amount.
In sum, federal law requires state Medicaid plans to make available medical assistance during the retroactive coverage period. Under the federal statute and regulations, a Medicaid recipient must meet three requirements to obtain retroactive medical assistance: (1) medical services or supplies covered under the Medicaid plan must have been furnished; (2) during the three months prior to the month in which the recipient filed his Medicaid application; and (3) the recipient must have been eligible for Medicaid at the time the services or supplies were furnished. For Medicaid applicants who pay the provider at the time of service,4 the Louisiana policy adds a fourth requirement — that the medical provider first voluntarily refund payments made by the Medicaid applicant, and then submit a claim to LDHH for repayment at the lower Medicaid rate. Undoubtedly, few medical providers seeking to maximize their profits will volunteer such charity, as evidenced by the experiences of Blanchard and Dumas.
The district court concluded that Louisiana‘s retroactive coverage policy violated the requirements of
Nothing in either provision permits a state to refuse to make assistance available for such care and services if the recipient has already paid for them. The statutory intent of these two provisions is to make Medicaid coverage during this period just as effective as it would have been if the individual had already been certified for Medicaid. The defendant‘s policy of leaving the availability of such coverage to the discretion of the medical provider who has interests adverse to the recipient‘s, clearly violates this intent.
We agree with the district court‘s reasoning. Under Louisiana‘s policy, Medicaid applicants who fail to pay their medical bills incurred during the retroactive period receive a greater amount of medical assistance than Medicaid applicants who privately pay for medical supplies or services during the retroactive coverage period. This unequal treatment violates the requirement of
LDHH, and amicus the Louisiana State Medical Society, argue that: (a) genuine issues of material fact exist precluding summary judgment; (b) Louisiana‘s current policy is fair and equitable; (c) the remedy requested by the plaintiffs and ordered by the district court — that providers be required to refund private payment and obtain substitute payment from Medicaid — violates
LDHH argues that a material fact dispute exists as to “whether the Louisiana Medicaid plan for providing retroactive coverage for medical services provided to Medicaid eligible recipients is in violation of the Equal Protection Clause of the Fourteenth Amendment.” However, the district court‘s grant of summary judgment did not rest upon the Equal Protection Clause; rather, the district court concluded that Louisiana‘s policy conflicted with the statutory requirements of
LDHH additionally argues that the district court erred in granting summary judgment because its current retroactive coverage policy is fair and equitable. LDHH asserts that Medicaid applicants are notified, both in a flyer given to all applicants and in the “Notice of Decision” letter sent to eligible applicants, that Medicaid cannot reimburse applicants for payments already made to a medical provider in the three months prior to the month of application, unless the provider first refunds their payment and then submits a claim. LDHH apparently misapprehends the relevant question. A State‘s Medicaid plan need not only be fair and equitable, it must comply with federal statutes and regulations. See Wilder, 496 U.S. at 502, 110 S.Ct. at 2513-14. Even if LDHH provides notice to applicants that they cannot obtain retroactive assistance unless their provider chooses to refund payment, the voluntary refund policy still fails to make available and effective medical assistance to all Medicaid applicants for supplies and services furnished during the retroactive coverage period, as required by section
Additionally, LDHH, mistakenly believing that the district court ordered it to “require providers to refund payments ... and to then submit their claims to Medicaid,” contends, for the first time on appeal (although this remedy was recommended by the plaintiffs in their motion for partial summary judgment), that this remedy “interfere[s] with the contract between the patient and the health care provider.” Indeed, only the amicus, Louisiana State Medical Society, presented argument and authority in its appellate brief that the remedy violates the Contracts Clauses of the United States and Louisiana Constitutions. Additionally, LDHH argued at oral argument, although not in its appellate brief, that this remedy also violates
Finally, in light of LDHH‘s apparent misunderstanding, we wish to clarify what the district court ordered. The district court‘s Judgment orders that LDHH “shall establish a mechanism to provide coverage for bills for medical care, supplies and services during the retroactive coverage period established by
LDHH argues at length that the first suggested remedy — requiring providers to refund private payments and submit claims to Medicaid — is unfair to medical providers because it limits their ability to choose which Medicaid patients to treat. However, it must be remembered that this suggested remedy would affect only those medical providers who have already elected to participate in the Medicaid program, as only their services would be “covered” under the Medicaid plan. See
IV. CONCLUSION
Louisiana‘s retroactive coverage policy, which provides medical assistance for Medicaid recipients who privately paid their Medicaid-coverable bills incurred during the retroactive coverage period only if the provider first voluntarily refunds their payment and then submits a Medicaid claim, violates the mandates of