Bontrager v. Ind. Family & Soc. Servs. Admin.

• Decision Date: 26 September 2012
• Docket Number: No. 11–3710.,11–3710.
• Citation: 697 F.3d 604
• Parties: Sandra M. BONTRAGER, on her own behalf and on behalf of a class of those similarly situated, Plaintiff–Appellee, v. INDIANA FAMILY AND SOCIAL SERVICES ADMINISTRATION, Michael A. Gargano, and Patricia Casanova, Defendants–Appellants.
• Court: U.S. Court of Appeals — Seventh Circuit

697 F.3d 604

Sandra M. BONTRAGER, on her own behalf and on behalf of a class of those similarly situated, Plaintiff–Appellee,

v.INDIANA FAMILY AND SOCIAL SERVICES ADMINISTRATION, Michael A. Gargano, and Patricia Casanova, Defendants–Appellants.

No. 11–3710.

United States Court of Appeals, Seventh Circuit.

Argued June 4, 2012.

Decided Sept. 26, 2012.

Jacquelyn Bowie Suess(argued), Attorney, Indianapolis, IN, for Plaintiff–Appellee.

David L. Steiner(argued), Attorney, Office of the Attorney General, Indianapolis, IN, for Defendants–Appellants.

Before KANNE, WOOD, and TINDER, Circuit Judges.

KANNE, Circuit Judge.

On May 5, 2011, Sandra M. Bontrager filed a putative class action complaint challenging Indiana's $1,000 annual limit for dental services covered by Medicaid.The district court granted Bontrager's request for a preliminary injunction, holding that Indiana is required to cover all medically necessary dental services, irrespective of the monetary cap.We affirm.

I.Background

The Medicaid program, 42 U.S.C. § 1396 et seq., allows states to provide federally subsidized medical assistance to low-income individuals and families.Collins v. Hamilton,349 F.3d 371, 374(7th Cir.2003).“Although participation in Medicaid is optional, once a state has chosen to take part ... it must comply with all federal statutory and regulatory requirements.”Miller ex rel. Miller v. Whitburn,10 F.3d 1315, 1316(7th Cir.1993).Indiana participates in the Medicaid program and is therefore bound by its rules and regulations.SeeInd.Code § 12–15–1–1 et seq.

Under federal Medicaid law, “[a] State plan for medical assistance must ... provide ... for making medical assistance available ... to all [eligible] individuals.”42 U.S.C. § 1396a(a)(10).“Medical assistance” includes “dental services,” but coverage for these services is not required.42 U.S.C. §§ 1396a(a)(10)(A),1396d(a)(10).Under its Medicaid plan, Indiana elects to cover certain dental services, see405 Ind. Admin. Code 5–14–1 et seq., that are “medically reasonable and necessary” and not listed as “noncovered” or otherwise excluded, id.at 5–2–17(1)–(2).Whether a service is “medically reasonable and necessary” is determined by utilizing “generally accepted standards of medical or professional practice.”Id.at 5–2–17(1).Even if medically necessary, “covered services routinely provided in a dental office will be limited to one thousand dollars ($1,000) per recipient, per twelve (12) month period.”Id.at 5–14–1(b).This $1,000 limit, a cost-cutting measure for Indiana, went into effect on January 1, 2011.

Bontrager is an Indiana Medicaid recipient in need of significant dental services, including two endosteal implants and two implant abutments for her lower jaw.Bontrager sought payment of these services through Medicaid, but her claim, although covered and medically necessary, was denied to the extent her requested treatment exceeded the $1,000 annual limit.Bontrager's medically necessary procedures, considered separately or in combination, exceed this cap and she is unable to pay for the services on her own.

Bontrager's lawsuit alleges that the Indiana Family and Social Services Administration, which administers Indiana's Medicaid program, and its individually named administrators (collectively, the “State”), violated state and federal Medicaid laws by instituting the $1,000 annual cap on dental services, even when such services are covered and medically necessary.Bontrager's federal claim seeks injunctive and declaratory relief under 42 U.S.C. § 1983 for the State's violation of 42 U.S.C. § 1396a(a)(10).On November 4, 2011, the district court granted a preliminary injunction, preventing the State from enforcing its $1,000 cap on dental services.This matter is now before us on interlocutory appeal.See28 U.S.C. § 1292(a)(1).

II.Analysis

The State presents two issues for our consideration: (1) whether Bontrager has a private right of action under 42 U.S.C. § 1983 for a violation of 42 U.S.C. § 1396a(a)(10), and (2) whether the district court erred in granting the preliminary injunction.We consider each of these questions in turn.

A.Private Right of Action

First we must consider, as the district court did, whether Bontrager has a private right of action to challenge Indiana's $1,000 annual limit on dental services covered by Medicaid under 42 U.S.C. § 1983.“In order to seek redress through § 1983, ... a plaintiff must assert the violation of a federal right, not merely a violation of federal law.”Blessing v. Freestone,520 U.S. 329, 340, 117 S.Ct. 1353, 137 L.Ed.2d 569(1997).“Once a plaintiff demonstrates that a statute confers an individual right, the right is presumptively enforceable by § 1983.”Gonzaga Univ. v. Doe,536 U.S. 273, 284, 122 S.Ct. 2268, 153 L.Ed.2d 309(2002).Generally, we consider three factors to determine if a statute creates an enforceable right: (1) whether Congress intended the provision to benefit the plaintiff, as evidenced by “rights-creating” language, seeid.;(2) whether the right is not so “vague and amorphous” that its enforcement would strain judicial competence; and (3) whether the statute unambiguously imposes a binding obligation on the States, such that the provision is “couched in mandatory, rather than precatory, terms.”Blessing,520 U.S. at 340–41, 117 S.Ct. 1353.

Bontrager's § 1983 claim is based upon an implied right of action conferred by the federal Medicaid statute, 42 U.S.C. § 1396a(a)(10)(A).In Miller,we considered whether this same provision creates an enforceable federal right under § 1983. 10 F.3d at 1319.We answered that question in the affirmative, and held that § 1396a(a)(10)(A) satisfies the standard set forth in Wilder v. Virginia Hospital Association,496 U.S. 498, 509, 110 S.Ct. 2510, 110 L.Ed.2d 455(1990), and permitted the plaintiff to challenge Wisconsin's classification of a liver-bowel transplant as “experimental.”10 F.3d at 1319–20.In Wilder,the Supreme Court determined that a portion of the Medicaid Act governing reimbursement of health care providers was enforceable pursuant to § 1983. 496 U.S. at 509–10, 110 S.Ct. 2510.In doing so, the Court found that the provision at issue was intended to benefit the putative plaintiff, the statute created a binding obligation on the governmental unit, and the plaintiff's interests were not too vague and amorphous for courts to enforce.Id. at 509, 110 S.Ct. 2510.

The State argues that Miller no longer governs because the post-Wildercases of Blessing and Gonzaga changed the standard for determining whether a private right of action exists.Although we have acknowledged that Gonzaga“may have taken a new analytical approach,”Bertrand ex rel. Bertrand v. Maram,495 F.3d 452, 456(7th Cir.2007), Wilder has not been overruled, id.;cf.State Oil Co. v. Khan,522 U.S. 3, 20, 118 S.Ct. 275, 139 L.Ed.2d 199(1997)(“[I]t is [the Supreme Court's] prerogative alone to overrule one of its precedents.”).Further, post-Blessing and Gonzaga, several circuit courts have held that the Medicaid provision at issue creates an enforceable federal right.See, e.g., Watson v. Weeks,436 F.3d 1152, 1159–61(9th Cir.2006);Sabree ex rel. Sabree v. Richman,367 F.3d 180, 189–92(3d Cir.2004);S.D. ex rel. Dickson v. Hood,391 F.3d 581, 604–06(5th Cir.2004).We find the reasoning of these courts persuasive and reaffirm Miller's holding.Accordingly, Bontrager has an enforceable federal right capable of redress through § 1983, and her claim may proceed.

B.Preliminary Injunction

We next consider whether the district court properly granted Bontrager's motion for a preliminary injunction.On appeal, we review the district court's grant of a preliminary injunction by considering its legal rulings de novo, its factual determinations for clear error, and its balancing of the factors for an abuse of discretion.Pro's Sports Bar & Grill, Inc. v. City of Country Club Hills,589 F.3d 865, 870(7th Cir.2009).To justify a preliminary injunction, Bontrager must show that she is “likely to succeed on the merits, ... likely to suffer irreparable harm without the injunction, that the harm [she] would suffer is greater than the harm that the preliminary injunction would inflict on the defendants, and that the injunction is in the public interest.”Judge v. Quinn,612 F.3d 537, 546(7th Cir.2010).

To determine Bontrager's likelihood of success, we must take a closer look at the applicable state and federal Medicaid statutes and regulations.As noted previously, Indiana voluntarily participates in the Medicaid program and provides Medicaid coverage for dental services.Ind.Code § 12–15–5–1.This coverage includes only those dental services listed in Indiana's Administrative Code. 405 Ind. Admin. Code 5–14–1(a), 5–14–2.The dental service must be a “medically reasonable and necessary service,” which is defined as “a covered service ... that is required for the care or well being of the patient and is provided in accordance with generally accepted standards of medical or professional practice.”Id. at 5–2–17.¹To be reimbursable, a service must be “medically reasonable and necessary,” a determination made by utilizing “generally accepted standards of medical or professional practice,”id.at 5–2–17(1), and not listed as a noncovered service or otherwise excluded from coverage, id.at 5–2–17(2).

Neither party disputes that the State is required to provide Medicaid coverage for medically necessary treatments in those service areas that the State opts to provide such coverage (such as dental services).The district court thoroughly discussed this issue, Bontrager v. Ind. Family & Soc. Servs. Admin.,829 F.Supp.2d 688, 696–98(N.D.Ind.2011), and its opinion is well-supported by state and federal case law.See, e.g., Beal v. Doe,432 U.S. 438, 444, 97 S.Ct. 2366, 53 L.Ed.2d 464(1977)(“[S]erious statutory questions might be presented if a state Medicaid plan excluded...