Sobky v. Smoley

• Decision Date: 14 June 1994
• Docket Number: Civ. No. S-92-613 DFL GGH.
• Citation: 855 F. Supp. 1123
• Parties: Reda Z. SOBKY, M.D., PhD., et al., Plaintiffs, v. Sandra R. SMOLEY, et al., Defendants.
• Court: U.S. District Court — Eastern District of California

855 F. Supp. 1123

Reda Z. SOBKY, M.D., PhD., et al., Plaintiffs, v. Sandra R. SMOLEY,¹ et al., Defendants.

Civ. No. S-92-613 DFL GGH.

United States District Court, E.D. California.

June 14, 1994.

COPYRIGHT MATERIAL OMITTED

COPYRIGHT MATERIAL OMITTED

Amitai Schwartz, San Francisco, CA, for plaintiffs.

Joseph Owens Egan, Attorney General's Office, State of Cal., Sacramento, CA, for defendants.

AMENDED MEMORANDUM OF DECISION AND ORDER

LEVI, District Judge.

Plaintiffs are providers and recipients or potential recipients of Medi-Cal funded drug abuse treatment services.² Plaintiffs claim that the State of California is administering its federally funded Medi-Cal drug abuse program under an administrative and statutory scheme that fails to comply with the requirements of Title XIX of the Social Security Act, 42 U.S.C. ?? 1396 et seq. (the "Medicaid Act"). In particular, plaintiffs object to the State's practice of allowing the counties to determine whether and in what amount to provide Medi-Cal funded methadone maintenance treatment services. Plaintiffs contend that as a result of this system methadone maintenance is wholly unavailable under Medi-Cal for residents of some California counties. Moreover, in counties where treatment is available, plaintiffs aver that the level of service provided is insufficient to meet the need and that patients are placed on waiting lists for Medi-Cal funded "treatment slots." In contrast, other Medi-Cal covered services are available upon presentment of a Medi-Cal card to a licensed provider. Plaintiffs seek injunctive relief through this action brought under 42 U.S.C. ? 1983. This Amended Memorandum of Decision and Order, issued upon plaintiffs' further motion for summary judgment and motion for reconsideration, supersedes the court's previous opinion of October 26, 1993.

I. Background

The federal Medicaid program provides federal funds to states to pay for medical treatment for the needy.³Schweiker v. Gray Panthers, 453 U.S. 34, 36, 101 S.Ct. 2633, 2636, 69 L.Ed.2d 460 (1981). State participation is optional, but states that choose to participate must submit a state plan that fulfills the requirements of the Medicaid Act. 42 U.S.C. ? 1396a(b). For a state plan to be approved, the plan must comply with 58 conditions set forth in 42 U.S.C. ? 1396a(a). California has elected to participate in the federal Medicaid program through its California Medical Assistance Program, known as "Medi-Cal," which provides medical services to the aged, disabled, and indigent.⁴ Citizens Action League v. Kizer, 887 F.2d 1003, 1005 (9th Cir.1989), cert. denied, 494 U.S. 1056, 110 S.Ct. 1524, 108 L.Ed.2d 764 (1990); Cal.Welf. & Inst.Code ?? 14000-14196.

Federal law does not require that states provide methadone maintenance services in their Medicaid plans. It is an optional service. But once a state elects to provide an optional service such as methadone maintenance, that service becomes part of the state Medicaid plan and is subject to the requirements of federal law. Weaver v. Reagen, 886 F.2d 194, 197 (8th Cir.1989); Eder v. Beal, 609 F.2d 695, 701-02 (3d Cir. 1979); Clark v. Kizer, 758 F.Supp. 572, 575 (E.D.Cal.1990), aff'd in part and vacated in part on other grounds sub nom., Clark v. Coye, 967 F.2d 585 (9th Cir.1992) (table); see also King v. Smith, 392 U.S. 309, 316, 88 S.Ct. 2128, 2133, 20 L.Ed.2d 1118 (1968). Methadone maintenance is one of several drug abuse treatment services offered as part of California's "Drug/Medi-Cal" program.⁵ Cal.Welf. & Inst.Code ?? 14021(c), 14021.5 & 14131; Cal.Code Regs. tit. 22, ? 51341; Dep. of Venus Little, 34:24-35:1.

Medi-Cal is generally administered on a "fee-for-service" basis by the California Department of Health Services. To receive services, Medi-Cal recipients present Medi-Cal cards to certified providers of authorized treatments or services. Cal.Welf. & Inst. Code ? 14018; Cal.Code Regs. tit. 22, ?? 50731 & 50733(a); see also Defs.' Statement of Material Facts, ? 7.⁶ The provider then bills the State a pre-established fee for that service. Defs.' Statement of Material Facts, ? 8. The Medi-Cal card is "authorization for payment for Medi-Cal covered services received in any California county." Cal.Code Regs. tit. 22, ? 50735(a). In the fee-for-service scheme, the counties' role is primarily to determine recipients' eligibility in accordance with State regulations. Id. ? 50101.

Methadone maintenance is a method of treating dependence on opiates, including heroin. Methadone is a synthetic drug that relieves the symptoms of opiate withdrawal, and is itself addictive. Maintenance treatment includes prescription of methadone under medical supervision, drug screening, therapy, and vocational and substance abuse counselling. 21 C.F.R. ?? 291.505(a)(2) & 291.505(d)(4)(i)(A); Cal.Health & Safety Code ? 11880. The ultimate goal of the treatment is to eliminate all dependence on drugs. Id. ? 11880. Methadone maintenance providers are licensed for a maximum treatment capacity (called "treatment slots") by the California Department of Alcohol and Drug Programs (the "Department of Alcohol and Drug Programs" or the "Department") which acts after receiving a recommendation from the county in which the provider seeks to operate. Id. ? 11877; Cal.Code Regs. tit. 9, ?? 10026, 10040 & 10045; Decl. of Joy Jarfors, ? 3. No provider may treat more than 300 patients at a time. Cal.Code Regs. tit. 9, ?? 10026(b) & 10145(b). To receive treatment, patients must meet federal and state eligibility criteria, for example, patients must have a documented history of at least two years of narcotic addiction. 21 C.F.R. ? 291.505(d); Cal.Code Regs. tit. 9, ? 10174.

California's Medicaid plan governing the provision of drug abuse treatment services consists of an interagency agreement between the Department of Health Services and the Department of Alcohol and Drug Programs. See Defs.' Ex. 1. Under the agreement, provision of Medi-Cal funded methadone maintenance treatment is integrated into California's separate statutory scheme governing drug abuse services. The key feature of California's drug abuse scheme is that services are administered through locally controlled community drug abuse programs, in which each individual county is vested with the discretion to determine the appropriate mix and level of drug abuse services needed in the community.⁷ Cal.Health & Safety Code ? 11960; Defs.' Opp'n to first Summ.J.Mot. at 9-10. Each county may, but is not required to, seek funds allocated by the Department of Alcohol and Drug Programs for the purpose of alleviating drug abuse problems within its jurisdiction. Cal.Health & Safety Code ? 11981. The Department annually estimates the total amount of State and federal funds available to each county for drug abuse services. Id. ? 11983. Each county then prepares its own drug program plan, subject to State approval, which specifies the particular amount and type of drug abuse services which will be offered in that county. Id. ?? 11983.2 & 11983.1. Counties may choose to include any of the Drug/Medi-Cal services, including methadone maintenance, in their plans. If they do, State "matching" funds for the Drug/Medi-Cal services are deducted from the State general fund monies already allocated to the county for its drug programs. Id. ? 11987.3.⁸ If the county chooses not to include Drug/Medi-Cal services in its plan, then all of the State general fund monies allocated to the county are available for other services specified in the county's drug program plan.⁹Id. ?? 11987.3 & 11987.4; see also Dep. of Dana Kueffner, 30:14-35:15; Dep. of Robert Lefkin, 40:11-47:5, 48:24-49:14.

Based on the amount of money allocated in the county plan to methadone maintenance, the counties contract with methadone maintenance providers for a specific dollar amount of treatment services, which in turn translates into a number of available Medi-Cal funded "treatment slots."¹⁰ Cal.Welf. & Inst.Code ? 14021(c); Decl. of Donald Nikkel, ?? 5-7; Kueffner Dep., 53:1-55:5.

As a result of this system, Medi-Cal methadone maintenance services are available only in those California counties that elect to receive Medi-Cal funds for that purpose.¹¹ Defs.' Statement of Disputed Facts, ? 14. Only 18 of the 58 counties in California have elected to fund Medi-Cal methadone maintenance. Def. Molly Joel Coye's Resp. to Pls.' Second Set of Interrogs., No. 4. In all but eight of the non-participating counties, there is no certified methadone maintenance provider for either Medi-Cal recipients or private pay patients. Jarfors Decl., ? 7.¹² In the eight ?€” which includes Sonoma, San Diego, Ventura, Santa Barbara, Kern, and San Luis Obispo Counties ?€” certified methadone maintenance providers serve private pay patients and patients subsidized under other programs, such as federal block grants, but do not receive any funding through Medi-Cal. Lefkin Dep., 49:5-14, 50:10-13.

If a county does not provide Medi-Cal methadone maintenance services, or if the county provides the service but the available "slots" are filled, then a Medi-Cal eligible individual cannot receive the service in that county under Medi-Cal. Little Dep. at 27-29, 47. Although the practice is contrary to State policy,¹³ see Pls.' Ex. 18, at least two counties include clauses in their provider contracts prohibiting providers from serving Medi-Cal patients who reside in other counties. Decl. of Brian Slattery, ? 7; Dep. of Richard Earle Brown, Jr., 30:21-31:2, 43:22, 65:5-66:7, 111:10-19.¹⁴

Plaintiffs have established that some methadone maintenance providers receive an insufficient number of treatment slots to serve all the Medi-Cal eligible in need of treatment; in response, some providers have created waiting lists for the Medi-Cal funded slots. Nikkel Decl., ?? 8, 9, 11; Slattery Decl., ? 10; Kueffner Dep., 100:13-101:6; Dep. of Reda Z. Sobky, 35:1-6, 37:23-38:1. Plaintiffs also have submitted declarations...