Salazar v. District of Columbia

• Decision Date: 16 October 1996
• Docket Number: Civil Action No. 93-452 (GK).
• Citation: 954 F.Supp. 278
• Parties: Oscar SALAZAR, Jr. et al., on behalf of themselves and all others similarly situated, Plaintiffs, v. DISTRICT OF COLUMBIA et al., Defendants.
• Court: U.S. District Court — District of Columbia

Page 278

954 F.Supp. 278

Oscar SALAZAR, Jr. et al., on behalf of themselves and all others similarly situated, Plaintiffs, v. DISTRICT OF COLUMBIA et al., Defendants.

Civil Action No. 93-452 (GK).

United States District Court, District of Columbia.

October 16, 1996.

COPYRIGHT MATERIAL OMITTED

Nancy S. Schultz, Assistant Corporation Counsel, Washington, D.C., for defendants.

Kathleen L. Millian, Terris, Pravlik & Wagner, Washington, D.C., for plaintiffs.

AMENDED FINDINGS OF FACT AND CONCLUSIONS OF LAW¹

KESSLER, District Judge.

Plaintiffs² bring this action pursuant to 42 U.S.C. § 1983 on behalf of themselves and a class of needy children and adults who have applied for Medicaid³ in the District of Columbia. After three years of pretrial litigation, including extensive, complex discovery generally conducted in good faith by both sides, several dispositive motions, and exhaustive settlement efforts,⁴ this case proceeded to trial.

This Court conducted a seven-day bench trial on the four remaining claims⁵ in the Complaint: Claim 4, which alleges that Defendants⁶ do not issue decisions and provide Medicaid coverage within 45 days after initial applications are submitted; Claim 5, which alleges that Defendants do not provide advance notice of the discontinuance or suspension of Medicaid benefits; Claim 6, which alleges that Defendants do not provide or arrange for the provision of early and periodic screening, diagnostic and treatment ("EPSDT") services to Medicaid recipients who request such services; and Claim 7, which alleges that Defendants do not effectively notify individuals of the availability of EPSDT services. During the trial, the Court heard testimony from 38 witnesses for Plaintiffs and 16 witnesses for Defendants; over 500 exhibits were admitted into evidence.

* * *

This case is about people—children and adults who are sick, poor, and vulnerable— for whom life, in the memorable words of poet Langston Hughes, "ain't been no crystal stair". It is written in the dry and bloodless language of "the law"—statistics, acronyms of agencies and bureaucratic entities, Supreme Court case names and quotes, official governmental reports, periodicity tables, etc. But let there be no forgetting the real people to whom this dry and bloodless language gives voice: anxious, working parents who are too poor to obtain medications or heart catheter procedures or lead poisoning screens for their children, AIDS patients unable to get treatment, elderly persons suffering from chronic conditions like diabetes and heart disease who require constant monitoring and medical attention. Behind every "fact" found herein is a human face and the reality of being poor in the richest nation on earth.

I. INTRODUCTION

Medicaid is the largest public assistance program in the District of Columbia, serving slightly over 25% of all District residents. From April 1995 to April 1996, an average of approximately 115,000 people per month were eligible for Medicaid. For example, in February 1996, 111,644 people were eligible for Medicaid. Of this total, 73,337, or 65.7%, qualified as categorically eligible for Medicaid through the Aid to Families with Dependent Children ("AFDC") program; 23,903, or 21.4%, qualified for Medicaid as a result of nursing home care, their enrollment in the General Public Assistance ("GPA") program, or their enrollment in the Supplemental Security Income ("SSI") program; 11,321, or 10.1%, qualified through the Non-Public Assistance ("NPA") program; and 3,083, or 2.8%, qualified because they were foster care children. Within NPA, the Multinational Program serves approximately 3,000 people, who constitute slightly over 2.5% of all Medicaid-eligible persons.⁷ However, of the entire monthly Medicaid application workload, which is approximately 2,150 cases, the Multinational Program normally accounts for approximately 8% of all applications.⁸ Testimony of John M. Bayne ("Bayne Test."), ¶ 6.

Upon Plaintiffs' motion, the court certified the following class pursuant to Fed.R.Civ.P. 23(b)(2):

All persons who have applied, have attempted to apply, or will apply in the future during the pendency of this litigation, for medical assistance pursuant to Title 19 of the Social Security Act ("Medicaid"), and all persons who have received, are receiving, or will receive in the future during the pendency of this litigation, Medicaid in the District of Columbia with respect to the following claims:

. . . . .

Any claims for declaratory, injunctive, or other relief premised on an alleged delay in excess of 45 days in the processing of Medicaid applications [Sub-class III]

Any claims for declaratory, injunctive, or other relief premised on an alleged lack of advance notice of the discontinuance, suspension or obligation to recertify Medicaid benefits, after being found eligible [Sub-class IV]

Any claims for declaratory, injunctive, or other relief premised on an alleged lack of effective notice of the availability of early and periodic screening, diagnostic and treatment ("EPSDT") services for children under 21 years of age, and/or an alleged lack of EPSDT services for eligible children under 21 years of age [Sub-class V].

See Orders of October 6, 1994 and November 3, 1994 (Kessler, J.).

The NPA program encompasses different categories of eligible persons, including non-SSI disabled and multinational persons and children in foster care. As the litigation developed, and as a result of obtaining discovery, Plaintiffs focused more and more narrowly on NPA applicants and recipients. At trial, Plaintiffs asserted Claim 4, regarding untimely processing of initial Medicaid applications, only on behalf of certain NPA applicants, i.e., non-disabled, non-foster care applicants. As to Claim 5,⁹ Plaintiffs asserted the recertification component of that claim on behalf of all non-foster care NPA recipients. As to the EVS component of Claim 5 and the request for reimbursement for Plaintiffs' out-of-pocket expenses, Plaintiffs sued on behalf of all Medicaid applicants and recipients. As to Claims 6 and 7, Plaintiffs continued to seek relief on behalf of all Medicaid applicants and recipients.

On April 1, 1994, Defendants started implementing the District's Medicaid Managed Care Program, a health care delivery system for the 65.7% of all Medicaid recipients who receive AFDC benefits. Testimony of Terri Thompson ("T. Thompson Test."), ¶ 15. The Medicaid Managed Care Program allows patients to choose between prepaid, capitated managed care organizations and fee-for-service primary care providers. Id. Testimony of Paul Offner ("Offner Test."); Testimony of Jane E. Thompson ("J. Thompson Test.").

Mr. Paul Offner, Commissioner of Health Care Finance for the District of Columbia, and Ms. Jane Thompson, Chief of the Managed Care Program in the Commission on Health Care Finance ("CHCF"), testified at length regarding their plans for a major overhaul of the Medicaid Managed Care Program. This massive restructuring of the delivery of health care to poor people in the District of Columbia was to begin with a Request for Proposals ("RFP"), which was issued shortly before trial, in early April 1996. Both Mr. Offner and Ms. Thompson testified that this restructuring of the Medicaid Managed Care Program would alleviate many of the problems they conceded existed in the District's EPSDT program. Defendants repeatedly relied upon the reforms embodied in the RFP to assure the Court that concrete steps were being taken to correct a system which was admittedly failing to operate efficiently, economically, and in accordance with federal law. After trial, however, the Court learned that this RFP has been withdrawn. See Pls.' Post-Trial Brief at 2, n. 1.¹⁰

II. FINDINGS OF FACT

A. Timeliness of Initial Application Processing

Defendants are required to send notices of decision on Medicaid applications within 45 days of receiving the applications. See 42 U.S.C. § 1396a(a)(8); 42 C.F.R. § 435.911(a); D.C.Code Ann. § 3-205.26. However, as discussed below, the record clearly establishes that NPA Medicaid applications are not processed in a timely manner.

1. Initial Medicaid applications are accepted and processed by the Income Maintenance Administration ("IMA"), a division of the Commission on Social Services within the D.C. Department of Human Services ("DHS"), at IMA's central intake offices at 645 H Street, N.E., Washington, D.C. ("645 H Street"), and at IMA's nine decentralized service centers located at various community locations. Bayne Test., ¶¶ 5 and 7. At 645 H Street, there are two separate sections that handle NPA applications: the Multinational Section and the NPA Intake Section. Bayne Cross-Exam. Test.¹¹

2. Medicaid applications are processed by IMA social service representatives ("SSRs"), who in turn rely upon the Automated Client Eligibility Determination System ("ACEDS"), a computer system used to determine eligibility for the many public assistance programs administered by IMA. Testimony of Arlene Conover ("Conover Test."), ¶¶ 3-4. An IMA SSR enters the application into ACEDS, determines from the automated ACEDS checklist which information is still needed to complete the application process, and gives the applicant that checklist with instructions to provide any missing, required information to the SSR. Id., ¶ 6.

3. As the applicant provides the required information, the SSR updates the automated record of the checklist. Id. On the 10th and 30th days after an application is submitted, notices requesting any outstanding information are issued to the applicant automatically, without intervention by the SSR, to remind the applicant of the date of application and the data still needed to determine eligibility. Id. On the 15th day or on the next available workday following the issuance of the 30-day notice, ACEDS denies the application automatically if the checklist still contains outstanding items. If the applicant requests additional time to...