KATIE A., by & through her next friend Michael LUDIN; Mary B., by & through her next friend Robert Jacobs; Janet C., by & through her next friend Dolores Johnson; Henry D., by & through his next friend Gillian Brown; Gary E., by & through his next friend Michael Ludin, individually & on behalf of others similarly situated, Plaintiffs-Appellees, v. LOS ANGELES COUNTY; Los Angeles County Department of Children and Family Services; Does, I thru 100 inclusive; David Sanders, Defendants, and Diana Bontá, Director of CA Dept of Health Services; Rita Saenz, Director of CA Dept of Social Services, Defendants-Appellants.
No. 06-55559
United States Court of Appeals, Ninth Circuit
March 23, 2007
481 F.3d 1150
Filed March 23, 2007.
sponte, we do not reach the Warden‘s argument that Robbins did not meet the new standards laid out in Rhines for applying the procedure. We also do not address whether the Rhines requirements apply to the specific type of stay-and-abeyance procedure at issue in Kelly, see Jackson, 425 F.3d at 661, and we do not alter the “strong preference” in favor of granting the Kelly procedure, if requested by the petitioner, “when an outright dismissal will render it unlikely or impossible for the petitioner to return to federal court within the one-year limitation period,” Kelly, 315 F.3d at 1070. Nor do we reach Robbins’ uncertified argument that all claims in his habeas petition were exhausted and thus that his petition was not “mixed.” Finally, we deny Robbins’ motion before this court to hold his habeas petition in abeyance while he seeks exhaustion in state court. Because we affirm the district court‘s dismissal of his petition, this motion is now moot.
Robert D. Newman, Esq., Western Center for Law and Poverty, Los Angeles, CA, for the plaintiffs-appellees.
Before EUGENE E. SILER, JR.,* TASHIMA, and BEA, Circuit Judges.
TASHIMA, Circuit Judge.
Defendants, the Director of the California Department of Health Services (“DHS“) and the Director of the California Department of Social Services (“DSS“), appeal from the district court‘s grant of a preliminary injunction ordering them to screen members of a statewide class of foster children1 and, where medically neсessary, provide the children with the forms of mental health care known as wraparound services and therapeutic foster care. The district court found that “the early and periodic screening, diagnostic, and treatment services” (“EPSDT“) provisions of the Medicaid Act obligate the State of California (“State“) to provide wraparound services and therapeutic foster care to Medicaid-eligible children under 21, and that the State does not currently provide those forms of assistance, “as such.”
On appeal, defendants argue that the district court abused its discretion in granting a preliminary injunction against them and in denying their motion for reconsideration. Specifically, they contend that the court: (1) failed to make findings of fact and conclusions of law, as required by
Because the district court applied an erroneous interpretation of the Medicaid Act, we reverse and remand. We reject defendants’ remaining contentions of error regarding the factual findings and legal standard relied on by the district court.
BACKGROUND
I. The Katie A. Class Action
In July 2002, a class of children who were in Los Angeles County foster care or at risk of being placed into foster care (Katie A., et al.) filed a complaint seeking declaratory and injunctive relief against the Director of DHS and the Director of DSS,2 as well as Los Angeles County, the Los Angeles County Department of Children and Family Services (“DCFS“), and the Director of DCFS (“LA County Defendants“). The complaint alleged that the class was entitled to and had not received “medically necessary mental health services in a home-like setting.” Separate claims were alleged under
The complaint was later amended to include a state-wide class of children in foster care or at risk of being placed in foster care. The district court certified the class under
Plaintiffs then moved for a preliminary injunction to require the Director of DHS and the Director of DSS (“defendants“) to provide wraparound services (“wraparound“) and therapeutic foster care (“TFC“) to members of the class. Plaintiffs described wraparound and TFC as highly effective “integrated community-based interventions for children with emotional, behavioral, and mental health disorders.” Plaintiffs argued that the EPSDT provisions obligate the State to provide wraparound and TFC to them. In particular, they alleged that Medi-Cal policies impeding access to wraparound services or TFC violated the Medicaid statute. They alleged that Medi-Cal covered only some components of wraparound and TFC, and that State policies made it difficult to аccess either type of care.
Defendants argued that the Medicaid statute does not require them to provide services in the wraparound or TFC forms demanded by plaintiffs,4 and that Medi-Cal
provides all required services. They characterized wraparound and TFC as processes or approaches, rather than services, and argued that the Medicaid Act does not create obligations to provide either. Defendants also disputed plaintiffs’ contention that all of the components of wraparound and TFC are health care services properly covered by Medicaid.
On March 14, 2006, the district court entered an order granting a mandatory preliminary injunction against defendants, ordering them to provide medically necessary wraparound services5 and TFC6 to class members on a consistent, statewide basis within 120 days of the order‘s entry. Stating that defendants did not dispute that they did not provide wraparound and TFC as such, the court found that “wraparound services and therapeutic foster care fall within the EPSDT obligations of Medicaid-participating states.”7 The court also cited what it described as plaintiffs’ undisputed evidence that wraparound and TFC are medically necessary for children with serious mental health needs. On this basis, the court concluded that plaintiffs had shown a strong likelihood of succeeding on the merits of their Medicaid Act claim. The court also described the potential for irreparable harm to plaintiffs in the form of unnecessary institutionalization and unmet mental health needs, if the injunction were not issued.
The court denied defendants’ motions for clarification and reconsideration, but subsequently issued an Addendum to the order, which contained short answers to defendants’ questions from their motion for clarification. The Addendum also contained appendices (“Appendices A and B“) listing the components of wraparound and TFC for purposes of compliance with the order.
II. The Medicaid Framework and the EPSDT Obligation
Medicaid is a cooperative federal-state program that directs federal funding to states to assist them in providing medical
To participate in Medicaid, a state must submit and have approved by the Secretary of Health and Human Resources a state plan for medical assistance.
Thus, California, like all other states participating in Medicaid, is required to provide EPSDT care to eligible children under the age of 21.9 EPSDT services are defined in
Under
The EPSDT obligation is thus extremely broad. The federal agency charged with administering the Medicaid Act, the Centers for Medicare and Medicaid Services (“CMS“), has described EPSDT as a “comprehensive child health program of prevention and treatment.” CMS, U.S. Dep‘t of Health & Human Servs., Pub. No. 45,
STANDARD OF REVIEW
We review the district court‘s grant or denial of a preliminary injunction for abuse of discretion. Earth Island Inst. v. U.S. Forest Serv., 442 F.3d 1147, 1156 (9th Cir. 2006). “The district court necessarily abuses its discretion when it bases its decision on an erroneous legal standard or on clearly erroneous findings of fact.” Rodde v. Bonta, 357 F.3d 988, 994 (9th Cir.2004) (citations and internal quotation marks omitted); see also Stanley v. Univ. of S. Cal., 13 F.3d 1313, 1319 (9th Cir.1994) (“An order [granting a preliminary injunction] is reversible for legal error if the court did not apply the correct preliminary injunction standard, or if the court misapprehended the law with respect to the underlying issues in litigation.“) (citation and internal quotation marks omitted).12 Where an injunction is issued against state officials, a district court will “be deemed to have committed an abuse of discretion ... if its injunction requires any more of state officers than demanded by federal constitutional or statutory law.” Clark v. Coye, 60 F.3d 600, 604 (9th Cir.1995) (citation omitted).
DISCUSSION
I. The District Court‘s Factual Findings
Defendants argue that the district court clearly erred in a number of its findings of fact. We review a district court‘s factual findings for clear error, and this court will not reverse “if the district court‘s findings are plausible in light of the record viewed in its entirety ... even if it is convinced it would have found differently.” Husain v. Olympic Airways, 316 F.3d 829, 835 (9th Cir.2002), aff‘d, 540 U.S. 644 (2004).
First, defendants argue that the court erred in stating that “Defendants do not dispute that currently they are not providing these forms of assistance [wraparound and TFC], as such, to members of the plaintiff class.” However, defendants immediately follow this contention with this statement: “‘Wraparound services’ and ‘therapeutic foster care’ are not Medicaid-covered services as such and are therefore not covered as such under the Medi-Cal program.” (Emphasis added.) This statement coincides almost exactly with the district court‘s description of defendants’ position. It is therefore difficult to see how defendants can argue that the court‘s finding was clearly erroneous, while
Defendants also argue that the court overlooked or mis-characterized several of their legal arguments (whether they disputed plaintiffs’ categorization of which statutory provisions encompass the components of wraparound and TFC, and the nature of their contentions regarding the coverage of
Defendants further argue that the court erred in finding that other states fund wraparound and TFC programs under Medicaid. The district court cited those states’ practices as support for its conclusion that wraparound and TFC are Medicaid-covered services. Evidence in the record supports the court‘s findings, and defendants have not presented any strong evidence to the contrary. For example, evidence that some states’ programs use blended funding is not inconsistent with the fact that such programs use Medicaid funding. Nor did defendants point to any specific evidence that other states are only able to fund wraparound and TFC through waivers allowing them to offer services not otherwise covered by Medicaid.
II. The Mandatory Preliminary Injunction
Defendants contend that the district cоurt failed to apply the appropriate legal standard for issuance of a mandatory preliminary injunction. We disagree. First, the district court correctly described the applicable test for the granting of a preliminary injunction, see Rodde, 357 F.3d at 994 (describing test), as well as the heightened standard that applies to mandatory injunctive relief, see Stanley, 13 F.3d at 1320 (stating that, when issuing a mandatory preliminary injunction, the court must find that the “facts and law clearly favor” plaintiffs).
Second, in concluding that plaintiffs were entitled to a mandatory preliminary injunction, the district court correctly applied these tests. The court found that plaintiffs had a strong likelihood of success on the merits of their Medicaid Act claims. It also discussed the possibility that plaintiffs would face unnecessary institutionalization without the preliminary injunction, recognized that such harms were “grave,” and rejected defendants’ arguments that plaintiffs failed to show that they faced irreparable harm. It is evident that the court concluded that plaintiffs faced the potential for irreparable injury without the injunction. This is sufficient to meet the general requirement of “probable success
Defendants also argue that the district court did not make any explicit findings showing that it considered the federalism principles that require federal courts to grant each state “the widest latitude in the dispatch of its оwn internal affairs” and to find “a threat of immediate and irreparable harm” before enjoining a state agency‘s operations. See Rizzo, 423 U.S. at 378-79; Gomez v. Vernon, 255 F.3d 1118, 1128 (9th Cir.2001); Hodgers-Durgin v. de la Vina, 199 F.3d 1037, 1042 (9th Cir.1999). The district court, however, did describe plaintiffs’ vulnerability, complex needs, and ongoing “unmet mental health needs and the harms of unnecessary institutionalization.” That description suffices to show that the court found a threat of immediate and irreparable harm to plaintiffs. As for the deference accorded to state agencies in their internal affairs, the court appropriately allowed defendants an opportunity jointly to develop the remedial plan needed to implement the injunction. No further deference was required; the order itself required only that defendants supply the services that the court found to be required under federal law. It did not mandate detailed or burdensome procedures for compliance. See Clark, 60 F.3d at 604.
III. The Medicaid Act
The district court‘s determination that the EPSDT provisions of the Medicaid Act require the State to provide wraparound and TFC was the foundation for its ruling that plaintiffs have a strong likelihood of success on the merits. Whether the district court correctly interpreted the EPSDT provisions of the Medicaid Act is a question of statutory interpretation that we review de novo. Bay Area Addiction Research & Treatment, Inc. v. City of Antioch, 179 F.3d 725, 730 (9th Cir.1999).
Defendants contend that the district court erred in determining that the EPSDT provisions of the Medicaid Act require the State to provide wraparound and TFC. They argue that, even assuming all the components are covered under
We conclude that the district court applied an erroneous legal standard in concluding that the EPSDT provisions require the State to provide wraparound and TFC. The district court mistakenly assumed that if all the components of wraparound and TFC fall within categories listed in
In general, the EPSDT provisions require only that the individual services listed in
The district court first determined that wraparound and TFC are mental health “services,” rather than simply processes, approaches, or philosophiеs. The court then noted that a service may fall under one of the 28 categories of
The court did not explore the pоssibility that the State might only have an obligation to fund the component services of wraparound and TFC, rather than to offer the coordinated complex of services in a single package. This is clear from the way that the court addressed whether the State was violating its EPSDT obligations—which is to say that the court did not address the question beyond stating that defendants did not dispute that they were not providing wraparound and TFC “as such” to members of the plaintiff class.
But defendants had stated in their opposition to plaintiffs’ motion for a preliminary injunction that “Medi-Cal already covers the services that Plaintiffs are entitled to under Medicaid” and that plaintiffs were seeking a “bundled rate.”16 There was also evidence in the record that MediCal currently reimburses providers for at least some components of wraparound and TFC. Therefore, the court should have examined whether all required component services under
B. The EPSDT provisions require that a specified set of health services be provided in an effective manner to eligible children
As stated above, under the EPSDT provisions, states have an obligation to cover every type of health care or service necessary for EPSDT corrective or ameliorative purposes that is allowable under
States also must ensure that the EPSDT services provided are reasonably effective. Thus, the State Medicaid Manual states at several points that EPSDT services must be sufficient “to achieve their purpose.” See State Medicaid Manual § 5110 (“Services provided under EPSDT must be sufficient in amount, duration, or scope to reasonably achieve their purpose.“); id. § 5123 (while “42 C.F.R. 440.230 allows [states] to establish the amount, duration and scope of services provided under the EPSDT benefit ... services must be sufficient to achieve their purpose (within the context of serving the needs of individuals under age 21)“). Other statutory provisions and regulations under the Medicaid Act reinforce this obligation. See, e.g.,
Federal courts have scrutinized state Medicaid systems to be sure that those systems are adequately designed to provide EPSDT services. See, e.g., Chisholm v. Hood (“Chisholm II“), 133 F.Supp.2d 894, 899-901 (E.D.La.2001) (stating that in not allowing psychologists directly to enroll as Medicaid providers and not providing alternative avenues of care, system foreclosed access to necessary psychological services for EPSDT-eligible children); John B., 176 F.Supp.2d at 791-92, 800-05 (finding that the structure of the Tennessee Medicaid managed care system “makes it impossible to fully comply with federal mandates” including EPSDT).
C. As long as a State provides all EPSDT services in an effective manner, the Medicaid statute does not dictate that services must be “bundled”
While the states must live up to their obligations to provide all EPSDT services, the statute and regulations afford them discretion as to how to do so. There is nothing in the EPSDT statutory provisions or regulations that indicates that the state must generally design its Medicaid system to fund “packages” of EPSDT services.17 The legislative history of the EPSDT provisions simply indicates a Congressional purpose to provide a broad program of health care to poor children, one that would include all the forms of care listed in
In a number of cases, courts have held that particular types of health services must be provided to Medicaid-eligible children under a state‘s EPSDT obligations. Those cases, however, did not require a state to fund distinct services covered under separate categories of
The issue of whether the state must provide “bundled” EPSDT services was raised in a recent case quite similar to this one in Massachusetts, in which a class of children with serious emotional disturbances claimed a right under the EPSDT provisions to “intensive home-based services,” which would have included components falling under various categories of
The conclusion that as a general rule, states may fund or provide medically necessary EPSDT services as separate components is consistent with the overall structure and principles of the Medicaid program. Medicaid is a cooperative federal-state program. Wilder v. Va. Hosp. Ass‘n, 496 U.S. 498, 502 (1990),
IV. The Approach on Remand
Here, the district court assumed that if each component of a given type of care falls within the State‘s EPSDT obligations, this necessarily implies that that form of care itself must be funded and provided by the State as a single package.20 Under that assumption, because MediCal does not fund wraparound or TFC as distinct types of care, the district court concluded that the State was violating this obligation.
In analyzing the issue in this way, the court conflated a two-step analysis into one; as a result, it applied a legal interpretation of the Medicaid Act that is too sweeping. The court should have first determined whether the State is meeting its legal obligation under the EPSDT provisions to provide all individual health services that fall under the categories listed in
V. Other Claims of Error
We reject defendants’ remaining contentions of error.21 First, defendants contend
Defendants also contend that the district court erroneously required that thеy provide services to class members, rather than simply make such services available. The order required the State to screen class members and provide wraparound and TFC to members where medically necessary. Requiring the State actually to provide EPSDT services that have been found to be medically necessary is consistent with the language of the Medicaid Act, which requires that each state plan “provide for ... arranging for (directly or through referral to appropriate agencies, organizations, or individuals) corrective treatment the need for which is disclosed by such child health screening services....”
Finally, in their reply brief, defendants argue that plaintiffs’ first amended complaint fails to cite the actual provision of the Medicaid Act which creates the EPSDT entitlement enforceable under
In any event, it is clear that defendants had fair notice of the nature of plaintiffs’ claims. See Conley v. Gibson, 355 U.S. 41, 47 (1957) (defendant must have fair notice of the nature of plaintiff‘s claim); see also Crull v. GEM Ins. Co., 58 F.3d 1386, 1391 (9th Cir.1995) (“The pleadings need not identify any particular legal theory under which recovery is sought.“).
Because we vacate the preliminary injunction, we need not address defendants’ contentions that the form of the ordеr violated
CONCLUSION
The district court abused its discretion by relying on an erroneous legal interpretation of the federal Medicaid statute in granting plaintiffs’ motion for a preliminary injunction. The preliminary injunction is reversed and the case is remanded for furthеr proceedings consistent with this opinion.
REVERSED and REMANDED.
Cornelio Arcos MEMIJE; Maria Del Rosario Rendon Velez, Petitioners, v. Alberto R. GONZALES, Attorney General, Respondent.
No. 06-71282.
United States Court of Appeals, Ninth Circuit.
March 26, 2007.
Cornelio Arcos Memije, Corona, CA, pro se.
Maria Del Rosario Rendon Velez, Corona, CA, pro se.
CAC–District Counsel, Office of the District Counsel Department of Homeland Security, Los Angeles, CA, Ronald E. Lefevre, Chief Counsel, Office of the District Counsel Department of Homeland Security, San Francisco, CA, William C. Minick, Leslie McKay, DOJ–U.S. Department of Justice Civil Div./Office of Immigration Lit., Washington, DC, for Respondent.
Before HARRY PREGERSON, RICHARD C. TALLMAN and CONSUELO M. CALLAHAN, Circuit Judges.