A. JOE FISH, Senior District Judge.
Before the court are the cross-motions for summary judgment of the plaintiffs and the defendant (docket entries 37 and 39). For the reasons stated below, the plaintiffs' motion is denied and the defendant's motion is granted.
Scott Detgen ("Detgen"), Juanita Barazza ("Barazza"), Brandon Doyel ("Doyel"), and Joshua Vargas ("Vargas") (collectively, the "plaintiffs") bring this suit because the defendant, Dr. Kyle Janek ("Janek"), acting in his official capacity as the Executive Commissioner of the Texas Health and Human Services Commission ("HHSC"), and his agents, the Texas Medicaid and Healthcare Partnership ("TMHP") and Superior Health Plan, denied the plaintiffs' claims for Medicaid benefits for a particular type of ceiling lift, an item of medical equipment used to transfer a patient to and from bed, bath, wheelchair, and other surfaces.
Detgen is a 28 year old resident of Rockwall County, Texas. See Second Amended Complaint ("Complaint") ¶ 11 (docket entry 25); Plaintiffs' Sealed Appendix in Support of Motion for Summary Judgment ("Plaintiffs' Sealed Appendix 1"), Ex. 27 Detgen Affidavit ("Aff.") ¶ 5 at 83 (docket entry 42). He receives Supplemental Security Income ("SSI") due to his disability and is categorically-eligible for the Texas Medicaid program. See Complaint ¶ 11. Detgen was diagnosed with cerebral palsy at birth and has numerous medical conditions including quadriplegia, legal blindness, seizure disorder, severe contractures, and a history of hip dislocation. Plaintiffs' Sealed Appendix 1, Ex. 27 Detgen Aff. ¶ 2 at 83. He is incontinent of bowel and bladder and is dependent upon his caregivers to meet his personal care needs. Id. ¶¶ 3-4 at 83. He is 5 feet 2 inches tall and weighs approximately 95 pounds. Id. ¶ 5 at 83. Detgen is unable to walk, bear weight, sit independently, or assist with repositioning or transferring, and he must be manually transferred by one or both of his parents from his bed to the floor, to and from the bathtub, and to a stair lift that is used to move him between the first and second floors of his house. Id. ¶¶ 4, 6 at 83. These transfers are necessary for Detgen to maintain his hygiene and to prevent skin breakdown. Id. ¶ 3 at 83.
To assist with the process of transfers, Detgen's mother contacted a lifting specialist with a Medicaid-enrolled equipment provider to find a patient lift that would best alleviate Detgen's total dependence on caregivers for transfers. Id. ¶ 9 at 84. A ceiling lift was identified as the type of lift that could meet Scott's transfer needs in the three locations of his home for which transfers were required (bedroom, bathroom, and stairway). Id. The provider specifically identified a ceiling lift known as the "Roomer 5200," which moves along a track that runs across the ceiling and allows the user to move from bedroom to bathroom or other designated locations in the home without additional transfers. Id. ¶ 10 at 84.
On October 26, 2010, United Rehab Specialists, Inc., the provider of the Roomer 5200, submitted a request for prior authorization of the recommended ceiling lift to TMHP. Id. Exhibit 28 at 86-92. On October 29, 2010, TMHP issued a denial notice that stated, in relevant part:
Id. Exhibit 29 at 93-94.
A Medicaid fair hearing was requested on Detgen's behalf on November 15, 2010, to challenge TMHP's application of this policy exclusion to Detgen's request. Id. Ex. 27, Detgen Aff. ¶ 15 at 84. The hearing was held on April 13, 2011, before an HHSC hearing officer. The hearing decision was issued by HHSC on August 25, 2011, and concluded that "TMHP correctly denied Appellant's request for an overhead lift system" in accordance with agency policy. Id. Ex. 30 at 95-111.
Barraza is a 45 year old Medicaid recipient in the state of Texas. Id. Ex. 31, Villareal Aff. ¶ 3 at 112. She has a history of long-standing medical conditions and disabilities, beginning at age 2 when she contracted measles and sustained brain damage. Id. As a result of this, Barraza lost the ability to walk and talk and was later diagnosed with a significant intellectual disability. Id. Several years later, she regained the ability to walk and continued to be ambulatory, albeit with a somewhat impaired gait. Id. In 2010,
Barraza lives at home with her mother who is her primary caregiver. Id. ¶ 2 at 112. Following Barraza's return home from hospitalization in late 2010, and after Villareal's assessment that the floor lift the hospital had ordered could not be used safely, a lifting specialist with a Medicaid-enrolled provider met with Barraza and her mother. Id. ¶¶ 7-8 at 112. The purpose of the meeting was to determine a lifting solution that would best address Barraza's transfer needs, given her complete dependence on her caregiver during transfers to and from her bed and bath and the physical limitations of her living space. Id. ¶ 8 at 112. A ceiling lift was identified as an appropriate solution for safely transferring Barraza both in and out of bed and bath. Id.
In February 2011, a request for prior authorization of a ceiling lift was submitted to TMHP on Barraza's behalf. Id. Ex. 32 at 114-123. On February 11, 2011, TMHP denied Barraza's request for a ceiling lift, using precisely the same language quoted above from its letter to Detgen. Id. Ex. 33 at 127. A Medicaid fair hearing was requested on Barraza's behalf in March 2011 to challenge the application of HHSC's policy to Barraza's prior authorization request for a ceiling lift. Id. Ex. 31 Villareal Aff. ¶ 11. The hearing was held on July 11, 2011, and a decision was issued on August 31, 2011. Id. ¶¶ 11-12. The hearing officer issued a single conclusion of law, stating that:
Id. Ex. 34 at 143 (emphasis in original).
Doyel is a 35 year old Texas resident and Medicaid recipient, born prematurely and, at 18 years old, diagnosed with quadriplegia, secondary to cerebral palsy. Id. Ex. 35, Doyel Aff. ¶ 2 at 145. As a result of his medical condition, Doyel is unable to walk and has used a power wheelchair for mobility since he was 4 years old. Id.
Doyel lives alone and requires assistance with activities of daily living from personal care providers, including physical assistance with all transfers throughout the day. Id. ¶ 4. Doyel's daily transfer needs include transfers from bed to wheelchair, wheelchair to toilet, wheelchair to bathtub, and wheelchair to standing frame. Id. These numerous transfers are performed manually by Doyel's personal care providers. Id. Doyel has taken steps to reduce his daily number of transfers, including the use of a catheter to avoid transfers to the toilet. Id. ¶ 7. He also has foregone the use of a "stander" on a daily basis, because his care providers cannot safely transfer him into the device. Id.
In December 2010, a lifting specialist with a Medicaid-enrolled provider met with Doyel to determine a lifting solution that would best address his transfer needs. Id. ¶ 8. A ceiling lift was identified as an appropriate solution for transferring Doyel throughout the day. Id. In early February 2011, a request for prior authorization of a ceiling lift was submitted to TMHP on Doyel's behalf. Id. ¶ 10 at 146. On February 9, 2011, TMHP denied Doyel's request, using precisely the same language as in its denial of Detgen's request, quoted above. Id. Ex. 37 at 160. On April 11, 2011, a Medicaid fair hearing was requested on Doyel's behalf, to challenge TMHP's denial of the request for a ceiling lift. Id. Ex. 35 ¶ 11 at 146. The hearing was held on July 20, 2011. Id. On March 7, 2012, the hearing officer issued a decision upholding TMHP's denial, finding the ceiling lift was an "expense that is not a benefit of Home Health services." Id. Ex. 38 at 164-65. The hearing officer relied on TMHP's policy exclusion of lifts requiring attachment to walls, ceilings, or floors. Id.
Vargas is a 21 year old Texas resident and Medicaid recipient diagnosed with Duschenne Muscular Dystrophy at age 6. Id. Ex. 39 at 168-170, 176-78; see also Plaintiffs' Motion at 11. Due to the progressive nature of this condition, Vargas uses a custom power wheelchair for mobility and relies on a ventilator to assist with breathing. Plaintiffs' Appendix 1 Ex. 39 at 168-170, 176-78. In addition, Vargas has severe scoliosis and contractures in his upper and lower extremities. Id. This complicates the process of manual transfers in and out of his bed and wheelchair and into the bathtub. Id. Vargas has a history of decubiti, which puts him at high risk for ongoing skin breakdown. Id. Vargas is 5 feet 6 inches tall and weighs approximately 140 pounds. Id. His mother or father manually transfer him when necessary, because space limitations in his bedroom and bathroom prevent use of a floor lift. Id. He has apparently previously been injured during transfers. Id. After an extended hospitalization in the summer of 2011, a home health agency met with Vargas and his mother to discuss his daily nursing and personal care needs. Id.; see also Plaintiffs' Motion at 12. The agency referred the Vargases to a Medicaid-enrolled provider to assist with determining an appropriate lifting solution for Vargas. Id. A ceiling lift was identified as the only patient lift that would effectively meet Vargas's transfer needs. Id.
In October 2011, a request for prior authorization for a ceiling lift was submitted on Vargas's behalf. Plaintiffs' Appendix 1 Ex. 39 at 167. On October 21, 2011, the request was denied on the basis of the same policy under which Detgen's, Barraza's, and Doyel's requests had been denied. Id. Ex. 40 at 179-81. On November 30, 2011, Vargas was added as a plaintiff in this suit. See First Amended Complaint
The plaintiffs Detgen and Barraza filed a complaint against Thomas Suehs (at that time the Executive Commissioner of HHSC) on October 31, 2011, alleging that Texas Medicaid's policies are in violation of the Medicaid Act and the Americans with Disabilities Act ("ADA") and that they (Detgen and Barraza) were denied due process in violation of the Fourteenth Amendment and the fair hearing provisions of the Medicaid Act. See Complaint ¶¶ 61-71 (docket entry 1). On November 30, 2011, the plaintiff Vargas was added to the litigation in the plaintiffs' amended complaint. See First Amended Complaint. On April 13, 2012, the plaintiff Doyel was added to the litigation in a second amended complaint. See Second Amended Complaint. In all other relevant respects, particularly with regard to the claims alleged against Texas Medicaid's executive commissioner, this second amended complaint mirrors the initial complaint. The defendant filed an answer to the second amended complaint on April 26, 2012. See Defendant's Answer to Second Amended Complaint (docket entry 28). On October 1, 2012, the parties filed the instant motions for summary judgment.
Summary judgment is proper when the pleadings, depositions, admissions, disclosure materials on file, and affidavits, if any, "show[ ] that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law." FED. R. CIV. P. 56(a), (c)(1).
When evaluating a motion for summary judgment, the court views the evidence in the light most favorable to the nonmoving
HHSC
42 U.S.C. § 1983 states that
42 U.S.C. § 1983.
The statute by its terms authorizes private suits against government officials for the "deprivation of any rights, privileges, or immunities." Id. HHSC makes the creative suggestion that "a section 1983 lawsuit cannot get off the ground unless a litigant first shows that a state officer has violated a federal legal obligation." See Defendant's Brief in Support of Motion for Summary Judgment ("Defendant's Motion") at 13 (docket entry 37-1). It cites Wright v. City of Roanoke for this suggestion, which states that "Maine v. Thiboutot, 448 U.S. 1, 100 S.Ct. 2502, 65 L.Ed.2d 555 (1980), held that § 1983 was available to enforce violations of federal statutes by agents of the State." See Wright v. City of Roanoke Redevelopment and Housing Authority, 479 U.S. 418, 423, 107 S.Ct. 766, 93 L.Ed.2d 781 (1987).
First, the court notes that there is no mention in the statute of a potential defendant's "violation" of his or her legal obligations.
HHSC also relies on the Supreme Court's Gonzaga decision for its argument, see Defendant's Motion at 15-16, but all that Gonzaga held was that where a federal statute does not unambiguously create an individual "right" in a plaintiff, no Section 1983 suit can be maintained. See Gonzaga University v. Doe, 536 U.S. 273, 283, 122 S.Ct. 2268, 153 L.Ed.2d 309 (2002). The Court in Gonzaga focused on whether certain provisions of the Family Educational Rights and Privacy Act of 1974 ("FERPA") contain "rights-creating language" and whether those provisions have an "aggregate" or an "individual" focus. Id. at 287-90, 122 S.Ct. 2268.
Here, the only claims the plaintiffs bring that are rooted in § 1983 are claims of violations of due process under the Fourteenth Amendment and the Medicaid Act. See Complaint ¶¶ 91, 94. Clearly, the Fourteenth Amendment confers an individual right enforceable in a § 1983 suit. See, e.g., Arnaud v. Odom, 870 F.2d 304, 307 (5th Cir.), cert. denied, 493 U.S. 855, 110 S.Ct. 159, 107 L.Ed.2d 117 (1989). The language of the fair hearing provision of the Medicaid Act also unambiguously confers individual rights. 42 U.S.C. § 1396a(a)(3) states that
(emphasis added). The language is mandatory, the provision contains rights-creating language, and there is an individual focus. This is enough to show that, in conformity with Gonzaga, the statute unambiguously confers a private individual right that may be enforced under § 1983.
The court also notes that the fair-hearing provision easily satisfies the three-factor Blessing test, namely, (1) whether Congress intended that the provision in question benefit the plaintiff; (2) whether the right protected by the statute is so "vague and amorphous" that its enforcement would strain judicial competence; and (3) whether the statute unambiguously imposes a binding obligation on the States. See Blessing v. Freestone, 520 U.S. 329, 340-41, 117 S.Ct. 1353, 137 L.Ed.2d 569 (1997). Congress clearly intended that any individual whose claim for Medicaid benefits was denied would be benefitted by the fair hearing provision. The right to a
HHSC's threshold argument that all of the plaintiffs' claims can be disposed of on a finding that the defendant violated "no legal obligation" fails.
The plaintiffs rely on the Supremacy Clause to support their claim that HHSC's rules, policies, and practices conflict with the "reasonable standards" and "amount, duration, and scope" provisions and regulations of the Medicaid Act and are thus preempted. See Complaint ¶ 88. The court notes as an initial matter that it is clear from the case law that "the federal courts have jurisdiction under 28 U.S.C. § 1331 over a preemption claim seeking injunctive and declaratory relief." Planned Parenthood of Houston and Southeast Texas v. Sanchez, 403 F.3d 324, 331 (5th Cir.2005). In addition, the Fifth Circuit has held that the Supremacy Clause provides plaintiffs with a valid implied cause of action. Id. at 333. Thus, none of HHSC's threshold arguments will prevent the court from considering the merits of the plaintiffs' Supremacy Clause claim. The question the court must proceed to answer is whether there is conflict between the Medicaid Act's provisions (and regulations implementing those provisions) and HHSC's rules, policies, and practices with respect to the ceiling lift at issue in this case, such that HHSC's rules and policies are preempted.
Medicaid is a cooperative federal-state program that provides medically necessary health care to low income families and individual with disabilities. See 42 U.S.C. § 1396 et seq. The Centers for Medicare & Medicaid Services ("CMS") administers the federal program, and participating states are required to designate a single state agency to administer their Medicaid program. See 42 U.S.C. § 1396a(a)(5). HHSC is the single state agency responsible for administering Texas's Medicaid program. See Defendant's Appendix in Support of its Motion for Summary Judgment ("Defendant's App. 1"), Declaration of Robert Perez ("Perez Decl.") ¶ 3 at 1-2 (docket entry 38).
Title XIX of the Social Security Act identifies a set of services that all states that participate in Medicaid must provide to eligible persons, including but not limited to inpatient and outpatient hospital services, Early Periodic Screening, Diagnosis, and Treatment ("EPSDT") services for persons under age 21, physician services, home health care, and pregnancy-related services. See 42 U.S.C. § 1396a et seq. Title XIX also requires that services provided under a Medicaid state plan be: (1) available statewide; (2) the same or comparable for all individuals eligible for the program; and (3) available to individuals determined financially eligible through a single standard for determining income and resource eligibility. Id. If a state elects to participate in Medicaid, it creates and submits for federal approval a State Medicaid Plan ("the State plan"). Id. In order to be eligible for continuing federal
The State plan must, among other things, specify the categories of services available to eligible beneficiaries. 42 U.S.C. § 1396a(a). One such category is home health services, which includes items known as durable medical equipment ("DME"). 42 U.S.C. § 1396a(a)(10)(D); 42 C.F.R. § 440.70. Federal statutes do not define DME, but individual state plans often provide specific guidelines for what constitutes covered DME. Some states, including Texas, identify a list of pre-approved DME items. See, e.g., 1 Tex. Admin. Code § 354.1039(a)(4). In response to a Second Circuit opinion, DeSario v. Thomas, 139 F.3d 80 (2d Cir.1998), cert. granted, judgment vacated by Slekis v. Thomas, 525 U.S. 1098, 119 S.Ct. 864, 142 L.Ed.2d 767 (1999), addressing the required extent of DME coverage, CMS's predecessor agency (the Health Care Financing Administration) wrote a September 4, 1998 letter providing guidance clarifying its position on DME coverage under Medicaid (the "DeSario letter"). Letter from Sally K. Richardson, Director of Centers for Medicaid and State Operations, September 4, 1998, available at http://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/SMD090498.pdf (last visited Jan. 29, 2012). The letter advised that states limiting DME coverage must meet three conditions:
Texas Medicaid provides guidance as to the extent of its DME coverage. The Texas Medicaid Provider Procedures Manual ("TMPPM") states:
Texas Medicaid Provider Procedures Manual § 2.2.2.
Section 2.2.24 of the TMPPM further states that Texas Medicaid cannot reimburse a beneficiary "for any service, supply or equipment for which FFP is not available." Id. at § 2.2.24. Because of this, Texas Medicaid Home Health Services coverage under the State Plan does not include, among other things, "[s]tructural changes to homes, domiciles, or other living arrangements," as those items are not eligible for FFP. Id. Furthermore, section 2.2.14.26 of the TMPPM states that "[p]atient lifts requiring attachment to walls,
Texas Medicaid requires claimants to obtain "prior authorization" for most DME items in order to be reimbursed through Medicaid. See 1 Tex. Admin. Code §§ 354.1035(b)(1) and 354.1039(a). The Texas Medicaid and Healthcare Partnership ("TMHP") is an agency with whom HHSC contracts to administer aspects of the Medicaid program, including the prior authorization process. See, e.g., Koenning v. Suehs, 897 F.Supp.2d 528, 533-34 (S.D.Tex.2012). TMHP makes an initial prior authorization determination in response to a request for an item of DME. When a request is denied, TMHP must send a notice of denial to the claimant. 1 Tex. Admin. Code § 357.11(b). HHSC also provides administrative hearings to claimants who are denied items of DME, and the regulations governing these hearings require hearing officers to sustain TMHP's denial if it is supported by agency policy. Id. § 357.23(e).
The plaintiffs argue that the ceiling lift at issue in this case clearly meets Texas Medicaid's definition of DME. See Plaintiffs' Memorandum in Opposition to Defendant's Motion for Summary Judgment ("Plaintiffs' Response") at 11-13 (docket entry 48). Consequently, they argue, HHSC's categorical exclusion of the lift violates the DeSario letter's guidance, because the DeSario letter's criteria (referenced above) are supposed to be applied to any individual request for an item of DME. Id. at 9. A categorical exclusion thus violates the individualized inquiry the letter requires. Id. Furthermore, the plaintiffs argue, in prior case law, states' categorical exclusions of items of DME have never been upheld as consistent with the Medicaid Act or the DeSario letter's requirements. See Plaintiffs' Memorandum in Support of Motion for Summary Judgment ("Plaintiffs' Motion") at 2 (docket entry 40).
HHSC argues that the DeSario letter's requirements do not apply to ceiling lifts, because both State and Federal Medicaid guidance and policies show that ceiling lifts are considered to be "home modifications" and not DME. See Defendant's Motion at 20. Furthermore HHSC argues that, even if ceiling lifts are considered DME, the Texas policies sufficiently comply with the DeSario letter. Id. at 20-21.
HHSC also contends that it cannot be in violation of the Medicaid Act's requirements where its categorical exclusion of a purported benefit (DME or not) is in accord with explicit and implicit guidance from CMS that FFP will not be available for that purported benefit. Id. at 9, 18. HHSC points out that the most recent explicit guidance it has received from CMS about ceiling lifts is that FFP is unavailable for them. Id. It also points out that CMS has implicitly accepted recent Texas plans that: (1) categorically exclude ceiling lifts from the "home health benefit" portion of its Medicaid program, but (2) provide ceiling lifts to patients under 21 via the EPSDT program and to patients over 21 via Medicaid's waiver services provisions. Id. at 2-6.
To this argument, the plaintiffs respond that HHSC is improperly imposing an "FFP assurance" standard on claimants in the prior authorization process. See Plaintiffs' Response at 14. In other words, the plaintiffs maintain, HHSC's argument means a claimant will have the burden to assure HHSC that, for any requested item of DME, FFP is available. Id. This, the plaintiffs argue, is too great a burden for
The court agrees that claimants ought not to be required to assure HHSC during the prior authorization process that FFP will be available for items they request. However, the court is of the opinion that this "FFP assurance standard" is not a necessary result of accepting HHSC's argument with respect to FFP availability for ceiling lifts. Rather, the court understands HHSC to be arguing that, where the state has explicit guidance that FFP will not be available for a particular item (DME or not), the state is not required by the Medicaid Act to provide such an item. Furthermore, since the state is not required to provide the item, a categorical exclusion is perfectly appropriate and consistent with the efficient administration of the state's Medicaid program.
In none of the "categorical exclusion" cases cited by the plaintiffs does a court address the argument being advanced by HHSC here. See, e.g., Koenning v. Suehs, 897 F.Supp.2d 528, 549-50 (S.D.Tex.2012) (declaring that HHSC's categorical exclusion of powered wheelchairs with "standers" violated the Medicaid Act's "reasonable standards" provision); Fred C. v. Texas Health and Human Services Commission, 167 F.3d 537 (5th Cir.1998) (upholding a district court's summary judgment in favor of a Medicaid claimant who argued that he must be provided with an augmentative communicative device, because Texas Medicaid provided such devices for patients under 21 years of age); Hope Medical Group For Women v. Edwards, 63 F.3d 418 (5th Cir.1995), cert. denied, 517 U.S. 1104, 116 S.Ct. 1319, 134 L.Ed.2d 471 (1996) (holding that Louisiana's Medicaid restrictions on abortion funding, which would not allow for Medicaid funding of abortions in cases of rape or incest, violated Title XIX); Mitchell v. Johnston, 701 F.2d 337, 340-41 (5th Cir.1983) (affirming the district court's finding that Texas's cutbacks in Medicaid dental benefits for children violated Title XIX); Rush v. Parham, 625 F.2d 1150 (5th Cir.1980) (holding that a Georgia Medicaid policy excluding funding for transsexual surgery would be appropriate if the policy was meant to exclude experimental procedures and if transsexual surgery was determined to be such an experimental procedure). In none of these cases did a state claim that it had explicit guidance that FFP would not be available for the benefit in question. In that respect, this case appears to present a question of first impression, at least in this circuit.
Neither party cites it, but this court finds the rule articulated in Harris v. McRae to be dispositive with regard to this question. See generally Harris v. McRae, 448 U.S. 297, 100 S.Ct. 2671, 65 L.Ed.2d 784 (1980). There the Court considered whether Title XIX required a participating state to pay for medically necessary abortions for which federal reimbursement was unavailable under the Hyde Amendment. Id. at 301, 100 S.Ct. 2671. The Court determined that the scheme of cooperative federalism Congress enacted in the Medicaid Act evinced no intent to require a participating state to shoulder the full costs of any health service provided in a state Medicaid plan. Id. at 308, 100 S.Ct. 2671. In addition, the Court found that the Hyde Amendment's legislative history contained no indication that Congress intended to shift the entire cost of certain medically necessary abortions to participating states. Id. at 310, 100 S.Ct. 2671. As the Court stated:
Id. at 308, 100 S.Ct. 2671.
The most apparent difference between that case and this is that congressional intent not to provide funding for certain abortions via the Medicaid program was clearly expressed in the legislation at issue in Harris, i.e., the Hyde Amendment. Id. at 310, 100 S.Ct. 2671. Here, CMS, the agency charged with administration of the Medicaid statute, has expressed in its guidance to HHSC the view that funding is unavailable for certain items of DME (including ceiling lifts) via the Medicaid program.
The rule the court employs is this: where a State has explicit guidance from CMS that FFP will not be available for an item of DME, that State acts reasonably when it categorically excludes such an item from coverage in its Medicaid policies. This is because, as the Supreme Court has held, the Medicaid Act never requires States to shoulder the full burden of the cost of services provided under the State's Medicaid plan. See Harris, 448 U.S. at 308, 100 S.Ct. 2671.
The court finds that Texas Medicaid's policy categorically excluding ceiling lifts from coverage does not conflict with the Medicaid Act's "reasonable standards" requirement, the "amount, duration, and scope" regulation, or the DeSario letter's guidance. It is therefore not preempted by the Supremacy Clause.
The Fourteenth Amendment prevents States from depriving citizens of property without due process of law. U.S. Const. Amend. XIV § 1. This has been termed "procedural due process." See, e.g., Mathews v. Eldridge, 424 U.S. 319, 332, 96 S.Ct. 893, 47 L.Ed.2d 18 (1976).
The plaintiffs here cannot make out a procedural due process claim, for the simple reason that they cannot show "a legitimate claim of entitlement" to the ceiling lift which was denied them by HHSC. The contours of the plaintiffs' property interests under the Medicaid Act are clarified by CMS in its guidance to HHSC that FFP is not available for ceiling lifts. This guidance shows that ceiling lifts do not fall within the scope of the services provided by the statute. There can be no "legitimate claim of entitlement" to a benefit that the agency charged with administration of a benefit statute has determined is not within the ambit of that statute.
For the same reason, the plaintiffs' due process claims under the Medicaid Act's "fair hearing" provision fail. That provision, by its terms, applies only to an individual "whose claim for medical assistance under the plan is denied." Here, the plaintiffs' claims for ceiling lifts are not claims "under the plan." Indeed, CMS has provided guidance to HHSC that suggests that ceiling lifts are outside the plan. Thus, the plaintiffs in this case have no claim to which the Medicaid Act's fair hearing provision applies.
Even were the court to conclude that these plaintiffs did have a property interest,
What process is due depends on the circumstances of each case. See Mathews, 424 U.S. at 334, 96 S.Ct. 893. In Goldberg, the fact that a welfare recipient depends for his or her continued existence on the uninterrupted provision of benefits weighed in favor of the Court demanding a robust pre-termination hearing. See Goldberg, 397 U.S. at 264, 90 S.Ct. 1011. Here, the plaintiffs' current benefits have not in any sense been terminated or reduced by TMHP's decision to deny their claim based on the policy that the ceiling lift is not a benefit of Texas Medicaid. Rather, the plaintiffs' claims for this extra benefit were denied consistent with HHSC's reasonable policy. The plaintiffs were provided notice of the denial and
For the reasons stated above, the defendant's motion for summary judgment is
Judgment will be entered for the defendant.
