A.M.T. v. Gargano
| Decision Date | 10 February 2011 |
| Docket Number | No. 1:10–cv–0358–JMS–TAB.,1:10–cv–0358–JMS–TAB. |
| Parties | A.M.T., et al., Plaintiffs,v.Michael A. GARGANO, in his official capacity as Secretary of the Indiana Family and Social Services Administration, et al., Defendants. |
| Court | U.S. District Court — Southern District of Indiana |
OPINION TEXT STARTS HERE
Gavin Minor Rose, Kenneth J. Falk, ACLU of Indiana, Indianapolis, IN, for Plaintiffs.Betsy M. Isenberg, Erica Sue Sullivan, Indiana Office of the Attorney General, Indianapolis, IN, for Defendants.
DECISION ON PENDING MOTIONS
Presently before the Court are Plaintiffs' Motion for Summary Judgment, [dkt. 64], Defendants' Motion for Partial Judgment on the Pleadings, [dkt. 78], and Defendants' Alternative Motion Pursuant to Federal Rule of Civil Procedure 56(d),1 [dkt. 91].
Plaintiffs sued Defendants Michael A. Gargano and Patricia Casanova (collectively, “ Defendants”) in their official capacities with the Indiana Family and Social Services Administration (“ FSSA”). In their Amended Complaint, Plaintiffs allege that Defendants' enforcement of 405 I.A.C. 5–22–6(b)(6) and (b)(7) (respectively, “ § (b)(6)” and “ § (b)(7)”) violates federal Medicaid law. [Dkt. 60 at 18.] The Court previously certified Plaintiffs' claims as a class action, and Plaintiffs now ask that summary judgment and a permanent injunction be entered in favor of the class.
The class representatives—A.M.T., J.J.M., and J.M.G.—are disabled minors ages seven, nine, and twelve who are enrolled in the Medicaid program. Two of them have been diagnosed with cerebral palsy and one has been diagnosed with a type of mitochondrial metabolic myopathy. All three suffer from functional limitations and have received physical and occupational therapies pursuant to the recommendations of their treating physicians for most of their lives.2
In late 2009 or early 2010, each of the Plaintiffs, through their respective medical providers, sought authorization for their therapies to continue at the previous rates prescribed by their treating physicians for an additional six months. It is undisputed that Defendants invoked § (b)(6) and/or § (b)(7) to deny Plaintiffs' requests in substantial part by limiting the prescribed treatment. [ See dkts. 60–2 to 60–4 (denial notices).] At least two of the named Plaintiffs had their requested treatments denied or modified pursuant to both § (b)(6) and § (b)(7). [Dkts. 60–2 at 3 (); 60–3 at 3 ().]
In November 2010, this Court designated A.M.T., J.J.M., and J.M.G. as representative plaintiffs for the following certified class:
Any and all persons in Indiana who are or will be enrolled in the Medicaid program and who are or will be under the age of twenty-one (21) who have been or will be denied coverage for physical therapy, occupational therapy, respiratory therapy, and/or speech pathology (“therapies”), or who have had or will have coverage for these therapies otherwise limited, which denial or limitation is based upon 405 IAC 5–22–6(b)(6) and/or 405 IAC 5–22–6(b)(7), notwithstanding the fact that a physician acting within the scope of his or her practice under Indiana law has or will recommend and/or prescribe these therapies for the Medicaid recipient.
[Dkt. 87 at 12 (emphasis added).] 3
The parties make no distinction between § (b)(6) and § (b)(7), treating these “coextensive” rules together under the term “maintenance therapy.”
[Dkts. 65 at 2 n.
2; 93 at 2 n. 1.] Although only certain types of services are at issue—physical therapy, occupational therapy, respiratory therapy, and/or speech pathology—the parties do not distinguish between the types of treatment in their arguments. The Court will refer to the services at issue collectively as “therapies.”
In addition to their response to Plaintiffs' summary judgment motion, Defendants filed an “Alternative Motion” pursuant to Rule 56(d) motion, requesting that the Court not rule on Plaintiffs' motion for summary judgment until the completion of discovery. [Dkt. 91.] Contemporaneously with that request, and as required by Rule 56(d), counsel for Defendants submitted an affidavit detailing six categories of discovery counsel plans to conduct to dispute Plaintiffs' claims. [Dkt. 91–1 at 1.] These categories include obtaining expert testimony regarding the medical necessity of therapy services for children with chronic illnesses; obtaining testimony and documentation from the agencies contracting with FSSA regarding the criteria used to determine medical necessity of therapy services for children with chronic illnesses; determining the veracity of the allegations of the named Plaintiffs' medical providers; determining the veracity of the allegations of the named Plaintiffs' guardians; obtaining expert testimony regarding the ability of unskilled individuals to provider therapy services for children with chronic illnesses; and obtaining expert testimony regarding medical therapies, including alternatives, that can be used for children with chronic conditions. [Dkt. 91–1 at 1–2.]
The discovery that Defendants identify is irrelevant to the Court's determination of the Plaintiffs' narrow legal challenge. Specifically, the veracity of the allegations of the medical providers and the named Plaintiffs' guardians is irrelevant because Defendants did not deny the prescribed services because of guardian or provider fraud, overbilling, or because an unskilled individual could provide the service.4 Testimony and documentation from the agencies contracting with the FSSA regarding the criteria used to determine medical necessity of therapies for children with chronic illnesses are irrelevant because Defendants already admit that they do not consider potential regression when making the determination. [Dkt. 37–1 at 9, 12–13.] Finally, expert testimony regarding medical necessity, alternative therapies, and the ability of unskilled individuals to provide therapies for children with chronic illnesses is inappropriate because Plaintiffs' narrow legal challenge is a question of law for the Court, not for a testimonial expert. See United States v. Caputo, 517 F.3d 935, 942 (7th Cir.2008) ().
The only question at issue is whether Defendants' ban on maintenance therapy, without considering potential regression, violates federal Medicaid law. This is a legal question for the Court that is appropriate to decide on the current record. For these reasons, the Court denies Defendants' alternative Rule 56(d) motion.
Defendants also filed a Motion for Partial Judgment on the Pleadings, arguing that no private right of action exists for Plaintiffs to bring their claim under 42 U.S.C. § 1983 for alleged violations of 42 U.S.C. §§ 1396a(a)(8), (a)(17), and 42 CFR 440.230. [Dkt. 78.] Defendants do not challenge Plaintiffs' right to bring a private cause of action under 42 U.S.C. § 1396a(a)(10). [Dkt. 79 at 2 ().] Because the Court ultimately finds that Defendants' policy violates 42 U.S.C. § 1396a(a)(10) and Defendants do not challenge Plaintiffs' right to bring a private cause of action under that provision, Defendants' Motion for Partial Judgment on the Pleadings is denied as moot.5
A motion for summary judgment asks that the Court find that a trial based on the uncontroverted and admissible evidence would, as a matter of law, conclude in the moving party's favor and is thus unnecessary. See Fed. R. Civ. Pro. 56(c). When evaluating a motion for summary judgment, the Court must give the non-moving party the benefit of all reasonable inferences from the evidence submitted and resolve “any doubt as to the existence of a genuine issue for trial ... against the moving party.” Celotex Corp. v. Catrett, 477 U.S. 317, 330 n. 2, 106 S.Ct. 2548, 91 L.Ed.2d 265 (1986). Nevertheless, “the Court's favor toward the non-moving party does not extend to drawing inferences that are supported by only speculation or conjecture.” Singer v. Raemisch, 593 F.3d 529, 533 (7th Cir.2010). The non-moving party must set forth specific facts showing that there is a material issue for trial. Fed. R. Civ. Pro. 56(e); Celotex, 477 U.S. at 323, 106 S.Ct. 2548. The key inquiry is the existence of evidence to support a plaintiff's claims or a defendant's affirmative defenses, not the weight or credibility of that evidence, both of which are assessments reserved to the trier of fact. See Schacht v. Wis. Dep't of Corrections, 175 F.3d 497, 504 (7th Cir.1999).
The Medicaid Act allows states to provide federally-subsidized medical assistance to eligible individuals and families with insufficient income or resources to pay for necessary medical services. Collins v. Hamilton, 349 F.3d 371, 374 (7th Cir.2003); 42 U.S.C. § 1396. A state's participation in the Medicaid program is voluntary; however, if a state elects to participate, “it must abide by all federal requirements and standards” set forth in the Medicaid Act. Collins, 349 F.3d at 374.
Indiana participates in the Medicaid program and, therefore, is bound by its requirements. [Dkt. 93 at 5.] One of the mandatory service categories requires an early and periodic...
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