The U.S. Department of Justice Submits Statement of Interest in DC Jail case

On April 9, 2021, TPM, along with co-counsel at the Washington Lawyers’ Committee and School Justice Project, filed a class action on behalf of students with disabilities at the DC Jail complex challenging the District of Columbia’s failure to provide special education services and a free and appropriate public education (FAPE) throughout the COVID-19 pandemic. On April 12, we filed a motion for a preliminary injunction which shows that the District’s failure to provide any direct instruction throughout the pandemic, and only providing students with work packets, is not FAPE and the Court should order effective injunctive relief. 

On May 26, 2021, the United States Department of Justice filed a Statement of Interest in the case, explaining that the United States “has an interest in ensuring the appropriate and consistent interpretation of the [Individuals with Disabilities Education Act (IDEA)] and its implementing regulations . . . . [and] also has an interest in ensuring that the IDEA protections continue to apply during emergencies such as the COVID-19 pandemic.”

The United States explained that students with disabilities in adult correctional facilities are entitled to special education and related services under the IDEA and the responsibility of state and local education agencies to provide special education and related services exists during the COVID-19 pandemic despite challenges. The United States further explained that special education and related services must be designed to meet a student’s unique needs and cited cases in which courts have found packet-based instruction to be insufficient under the IDEA, particularly when it is the sole method of instruction.

The United States emphasized the federal resources available to state and local education agencies which can be used to overcome the challenges posed by remote learning in correctional settings. The Statement noted that the Department of Education has explained that educational agencies have “considerable flexibility” in how they use federal IDEA funds during the COVID-19 pandemic.

Lastly, the United States stated that compensatory education may be required when a school district denies students special education and related services, including during the COVID-19 pandemic. The Statement of Interest is available here.

TPM Wins Affirmance in Federal Appeals Court that District of Columbia Underserves Preschoolers with Disabilities

D.L. v. District of Columbia is a class action brought by the firm seeking to remedy the District of Columbia’s failure to provide and timely provide special education services to preschoolers with disabilities in violation of the Individuals with Disabilities Education Act (IDEA) and other laws.

On Friday, June 23, 2017, the court of appeals, in a unanimous decision, affirmed the lower court decision in all respects.  The lower court found that the District of Columbia violates the rights of preschoolers with disabilities by failing to provide and timely provide services required by the IDEA and District law.  The lower court issued an injunction requiring numerous corrective actions to prevent further violations.

U.S. District Court Judge Royce C. Lamberth, who has presided over the case since 2005, described the case as follows: “This case concerns the District of Columbia’s obligations, under both federal and local law, to provide special education to some of our most vulnerable citizens at a very early and critical stage in their lives.  In the first few years of a child’s life, there exists a narrow window of opportunity in which special education, tailored to the child’s particular needs, can work a miracle.  ‘[S]omewhere in the neighborhood of 75 to 80 percent’ of the disabled children who are found in the community and served by quality early intervention programs will go on to kindergarten alongside every other ordinary five-year-old—without needing further supplemental special education. * * * So that’s what’s at stake here.”   

The court of appeals rejected all arguments made by the District in its appeal of Judge Lamberth’s ruling.  Addressing the District’s argument that the IDEA precludes comprehensive injunctions and allows only for relief on an individual child basis, the court of appeals stated that “the District’s argument would eviscerate the very purpose of IDEA.”  Congress enacted the IDEA in response to the “pervasive and tragic” failure to serve all children with disabilities.  In exchange for federal funding, the IDEA imposes on states, including the District, the obligation of identifying and evaluating all preschoolers with disabilities.  The court of appeals found that although the District had “enthusiastically accepted millions of dollars in IDEA funding,” it was now proposing to shift back to parents the burden of determining whether a child was eligible for special education services.  The court of appeals stated: “Given the purpose of IDEA, we cannot imagine a more preposterous argument.”

Plaintiffs and their counsel are very pleased with the ruling.  This decision will have a positive and lasting impact on children with disabilities in the District.  We hope and expect that the District will now focus its full attention and resources on complying with the injunction and bringing about the improvements needed to ensure that special education services are timely delivered to all preschoolers with disabilities.

This decision was featured in the Washington Post on June 23, 2017.

Click here for the decision.

TPM Wins Ruling that Plaintiffs Have Stated a Claim that Due Process Requires Individualized Written Notice When Prescribed Drugs Denied Medicaid Coverage at Pharmacy

On March 26, 2017, the United States District Court for the District of Columbia issued a decision in N.B. v. District of Columbia in favor of plaintiffs represented by Terris, Pravlik & Millian, LLP, and the National Health Law Program.  Plaintiffs allege that the District of Columbia has systematically failed to provide Medicaid recipients with due process when a prescribed medication is denied Medicaid coverage at the pharmacy.  Defendants, the District of Columbia and the Department of Health Care Finance, had filed a renewed motion to dismiss on a second remand from the United States Court of Appeals for the District of Columbia Circuit (“the D.C. Circuit”).  The district court partially denied defendants’ renewed motion to dismiss, finding that plaintiffs have stated a claim that the District’s current system violates the Fifth Amendment’s Due Process Clause by not providing individualized written notice to Medicaid recipients.  

Plaintiffs filed their complaint on September 7, 2010.  On August 8, 2011, the district court granted defendants’ first motion to dismiss on the ground that plaintiffs lacked standing.  On June 8, 2012, the D.C. Circuit reversed the district court’s decision and remanded the case for further proceedings.  In March 2014, the district court granted defendants’ second motion to dismiss because, inter alia, it determined that the plaintiffs lacked a protected property interest (i.e., a legitimate claim of entitlement to the prescribed medication) and therefore had no protections under the Due Process Clause.

In July 2015, the D.C. Circuit reversed in part, holding that under the U.S. Constitution plaintiffs have a protected property interest in Medicaid coverage of any prescribed medication not completely excluded from coverage under Medicaid.  The D.C. Circuit cited the “mandatory, non-discretionary terms” used in the District’s Medicaid regulations (29 D.C.M.R. 2700, et seq.).  The D.C. Circuit remanded the case to the district court.

On March 23, 2016, defendants filed a third motion to dismiss, arguing, inter alia, that plaintiffs failed to state a Due Process Clause claim because the District’s current Medicaid pharmacy program provides sufficient notice to Medicaid recipients.  Defendants argued, inter alia, that Medicaid recipients who are denied prescription drug coverage could learn the reason for the denial by asking the pharmacist or calling District officials.  Plaintiffs contended that the system’s reliance on affirmative inquiry was inadequate to protect the due process rights of Medicaid recipients under the Constitution.

The district court agreed with the plaintiffs. The court found that requiring Medicaid recipients to ask the pharmacist or call District officials to learn the reason for the prescription denial “is constitutionally insufficient, and thus, the fact that a Medicaid plaintiff could conduct such an inquiry is irrelevant to the constitutional analysis” (emphasis in original).  The district court concluded that plaintiffs have stated a claim under the Due Process Clause of the Fifth Amendment and that the District’s current practice “simply cannot constitute adequate notice.  * * * [I have] concluded that defendants have failed to provide adequate initial written notice that reasonably apprises plaintiffs of the reasons for the prescription denial.”  The case now proceeds to discovery and a determination on class certification.

Click here for the decision.

Notice to Plaintiff Subclasses in D.L. v. District of Columbia

Plaintiffs’ counsel filed a motion for an award of litigation costs, including attorneys’ fees and related expenses, in DL v. District of Columbia, a class action related to special education services for preschool-aged children in the District of Columbia.  Defendants are scheduled to file an opposition to that motion.  In addition, subclass members may file objections to that motion.  For additional detail, click here for a copy of the notice related to this motion.  Click here for additional information regarding this case.

District of Columbia Responds to FOIA Request Concerning the Implementation of Federal Court Order Providing Relief to Medicaid Applicants and Beneficiaries

On July 12, 2016, the U.S. District Court entered an Order in the long-running Salazar v. District of Columbia class action case providing immediate relief to self-identified Medicaid applicants and beneficiaries who cannot access their benefits as a result of the District of Columbia’s delays and errors in processing eligibility applications and renewals.  More information about the July 12, 2016, Order and how to obtain relief under it is provided in our August 25 and September 28 posts. 

On September 27, 2016, Terris, Pravlik & Millian, LLP, class counsel for the Salazar v. District of Columbia plaintiff class of Medicaid applicants and beneficiaries, submitted a request under the District of Columbia’s Freedom of Information Act (FOIA) for policies, procedures, and training materials developed by the District of Columbia to implement the relief in the Order entered by the U.S. District Court on July 12, 2016.

In its FOIA Response, the District provided 68 pages of documents detailing how it processes requests for provisional Medicaid, in the case of applications, and for extended Medicaid, in the case of renewals, under the July 12 Order.  The District also provided sample notices for applicants and beneficiaries who submit a claim for relief under the July 12 Order.  

If you or someone you represent is a non-disabled applicant who has been waiting longer than 45 days for a Medicaid eligibility determination and have submitted a claim seeking relief under the Court’s July 12 Order, be sure to request a notice from the District of Columbia informing you whether the relief has been granted.  

If you or someone you represent is a Medicaid beneficiary of any kind, including a QMB, EPD-HCBS, IDD, and Long-Term Care Nursing Home beneficiary, and whose benefits are about to be terminated at renewal or recertification or have already been terminated, even though you did not receive advance notice of the need to renew or you timely submitted all required forms and supporting documents, and have submitted a claim seeking relief under the Court’s July 12 Order, be sure to request a notice from the District of Columbia informing you whether the relief has been granted.

If you disagree with District’s determination, please call Terris, Pravlik & Millian, LLP at 202-682-0578 for free legal help or email us at medicaidhelp@tpmlaw.com.

Terris, Pravlik & Millian, LLP Will Provide Free Legal Help for Delayed Medicaid Applications or Problems with Medicaid Renewals

If you or a client is waiting more than 45 days for a decision on a District of Columbia Medicaid application or has lost or is threatened with the loss of Medicaid coverage at renewal (also known as recertification), either without notice or after having turned in all required forms, call Terris, Pravlik & Millian, LLP at 202-682-0578 for free legal help or a referral. You may also email us at medicaidhelp@tpmlaw.com.

Terris, Pravlik & Millian, LLP, class counsel for the Salazar v. District of Columbia plaintiff class of Medicaid applicants and beneficiaries, provides free legal help for many problems involving Medicaid applications and renewals.  We provided more information about a July 12, 2016, Order providing relief to Medicaid applicants and beneficiaries here.

The District of Columbia Medicaid agency has forms to be submitted if you wish to submit a claim for relief concerning a Medicaid application or renewal without a lawyer.  Fill out a renewal or application claim form and submit it to dpo.deputy@dc.gov, at any Department of Human Services (DHS) service center* or make a claim by telephone at the Medicaid customer service line: (202) 727-5355.   Keep a record of what you submit.  If you have any problems, please call us for help:  202-682-0578. 

Information for DHS service centers is as follows: 

Anacostia

2100 Martin Luther King Avenue, SE

(202) 645-4614 (phone)

(202) 727-3527 (fax)

Congress Heights

4001 South Capitol Street, SW

(202) 645-4525 (phone)

(202) 645-4524 (fax)

Fort Davis

3851 Alabama Avenue, SE

(202) 645-4500 (phone)

(202) 645-6205 (fax)

H Street

645 H Street, NE

(202) 698-4350 (phone)

(202) 724-8964 (fax)

Taylor Street

1207 Taylor Street, NW

(202) 576-8000 (phone)

(202) 576-8740 (fax)

Federal Court Ruling Provides Immediate Relief to District of Columbia Medicaid Applicants and Beneficiaries

On July 12, 2016, the District Court entered an Order in the long-running Salazar v. District of Columbia class action case providing immediate relief to self-identified Medicaid applicants and beneficiaries who cannot access their benefits as a result of the District of Columbia government’s delays and errors in processing Medicaid eligibility applications and renewals. 

First, the District must grant provisional eligibility to all individuals who inform the government that more than 45 days have elapsed without a determination on their non-disability application for Medicaid benefits. The District must grant provisional eligibility to such individual applicants until it makes an eligibility determination on the application and provides them written notice of the decision.

Second, the District must provide continued eligibility to all Medicaid beneficiaries who inform the government that their Medicaid benefits are about to be terminated at renewal or recertification or have already been terminated, even though they did not receive advance notice that they needed to renew or they timely submitted all required forms and supporting documents. The District must continue these beneficiaries’ eligibility until it makes a determination on their renewal or recertification and provides them written notice of the decision. 

Individuals who believe they have one of these claims should contact plaintiffs’ counsel, Terris, Pravlik & Millian, LLP at (202) 682-0578 for free legal assistance, or the District government through the Medicaid customer service at line at (202) 727-5355, at any of its Service Centers, or at dpo.deputy@dc.gov.  

The July 2016 relief is a partial win for Medicaid applicants and beneficiaries, who first sought a preliminary injunction in December 2015.  They later sought, in February 2016, a modification of an existing consent decree seeking permanent relief for Medicaid applicants and beneficiaries without access to Medicaid benefits as a result of the District’s systemic failure timely and adequately to process applications and renewals.  In their papers, plaintiffs presented evidence of severe backlogs in the processing of thousands of applications and systemic delays and mishandling of paperwork at the time of renewal or recertification, arguing that the District was depriving these individuals of their constitutional and statutory rights. With the support of some of the major Medicaid advocacy and health organizations in the District, including the District of Columbia Legal Aid Society, Bread for the City, Whitman Walker Health, and Legal Counsel for the Elderly, plaintiffs presented dozens of examples of individuals who were denied health care and incurred out-of-pocket expenses through no fault of their own.

On April 4, 2016, the District Court granted in large part the relief sought by the plaintiff class, with some modifications, finding that “severe and technical and logistical problems in the processing of initial Medicaid applications and in the Medicaid benefits renewal process * * * have affected thousands of Medicaid beneficiaries and have deprived many District residents of necessary medical care to which they are entitled.”  However, shortly after the entry of the Court’s Order, the District of Columbia obtained a stay of the order and sought an appeal of it in the court of appeals.  The appeal of the April 4, 2016 Order is pending.

In the meantime, individuals who come forward with one of the claims described above can obtain immediate relief provided by the Court’s July 12, 2016 Order.  

Washington Post Addresses Decision in DL v. District of Columbia

On June 24, 2016, the Washington Post addressed the decision in DL v. District of Columbia, and the District of Columbia's appeal of that decision, in an article titled, “Court rules D.C. underserves and under-identifies preschoolers with disabilities.”  Click here to link to that article.

For more information about this case, click here.

TPM Wins Injunction Requiring Improvements to District of Columbia’s Provision of Special Education and Related Services for Preschoolers in the District

In DL v. District of Columbia, on May 18, 2016, the district court found the District of Columbia liable for violating children’s rights under the Individuals with Disabilities Education Act (IDEA) and District law through November 12, 2015, and the Rehabilitation Act until March 22, 2010, and issued an injunction.  The district court enjoined the District of Columbia from further violations of the IDEA and District law, and ordered specific corrective actions, including that the District ensure that (1) at least 8.5 percent of children between the ages of three and five who reside in the District or are wards of the District receive necessary special education and related services, (2) at least 95 percent of all children between the ages of three and five referred for special education services receive a timely eligibility determination, and (3) at least 95 percent of all children receiving Part C services (early intervention services for children up to three years of age) that are found eligible for Part B services (special education and related services for children ages three and older) receive a smooth and effective transition to those Part B services by their third birthdays.

The injunction also includes specific provisions related to the measurement and monitoring of compliance.  Specifically, the District of Columbia was ordered to correct several metrics that it uses to measure compliance with these benchmarks, which had made it appear that it was performing much better than it actually was.

The District of Columbia is required to provide annual reports on its compliance with the numerical benchmarks and semi-annual reports regarding compliance with other programmatic requirements.  The injunction will remain in effect until the District has demonstrated sustained compliance with its requirements.

The district court wrote that “The District’s lack of effective Child Find and transition policies is particularly troubling in light of the intense scrutiny and seemingly constant admonishment it has received over the last decade.  In 2011, this Court stated, ‘Defendant’s persistent failure to live up to their statutory obligations, a failure that works a severe and lasting harm on one of society’s most vulnerable populations—disabled preschool children—is deeply troubling to this Court.’ * * * Moreover, as discussed, OSEP [the U.S. Department of Education Office of Special Education Programs] informed OSSE [the District of Columbia Office of the State Superintendent of Education] in 2015 that it ‘needs intervention in implementing the requirements of Part B of the IDEA’ for the ‘ninth consecutive year,’ which is the longest period in the country. * * * Although OSEP’s long-running ‘needs intervention’ determination does not deal exclusively with the statutory obligations at issue in this litigation, it contributes to the overarching narrative that the District requires strong, outside involvement to produce even minimally acceptable results.  And critically, this litigation has been ongoing for more than ten years, providing the District with ample time and robust incentives to come into full compliance with the law.  It is for these reasons that a structural injunction is necessary.”

The district court concluded by stating that “The District has come a long way since 2005 when this lawsuit was initiated, but it has not come far enough.  Indeed, while its progress has been in some ways impressive, the District started at such a low base that the advances it has made are insufficient to bring it into compliance with its legal obligations. The Court today makes clear that the implementation and outcomes of the District’s policies are paramount.  The District will comply with its statutory obligations when it actually locates and identifies children to provide them with a FAPE [free appropriate public education], timely evaluates them, timely determines their eligibility, and smoothly and effectively transitions them—not when they establish policies that, if properly implemented, would achieve these goals.  If the defendants fail[] to abide by the order and adopt a more outcome-based approach, the District will earn far more significant court involvement and oversight than is ordered today.”

We are pleased with the injunction and believe that it will have a positive and lasting impact on children with disabilities in the District of Columbia.  We hope that this will draw this case closer to its end and that, rather than appealing, the District will focus its attention and resources on the needed improvements.

For more information with regard to this case, click here.

Following the Court’s May 18, 2015 Ruling in Salazar, Medicaid Implements New Procedures for Reimbursement of Out-of-Pocket Expenses

The District of Columbia has issued a new transmittal informing managed care organizations, providers, and the public about changes affecting reimbursement of out-of-pocket medical expenses for Medicaid beneficiaries as a result of the District Court’s May 18, 2015, Memorandum and Order in Salazar v. District of Columbia.

Prior to the Court’s May 18, 2015, Memorandum and Order, all D.C. Medicaid-eligible individuals who incurred an out-of-pocket expense for drug prescriptions, doctor visits, or hospitalizations when they were eligible for Medicaid could potentially seek and receive free legal assistance from Terris, Pravlik & Millian, LLP to submit a claim for reimbursement.  If the Medicaid recipient was unsatisfied with the District of Columbia’s decision, she could seek a fair hearing before the Office of Administrative Hearings (“OAH”) to contest it.  If the Medicaid recipient was unsatisfied with the OAH decision, she could appeal it to Judge Gladys Kessler of the U.S. District Court for the District of Columbia.  Terris, Pravlik & Millian, LLP would provide free legal assistance throughout this process.

The Court’s May 18, 2015 Memorandum and Order made several changes to these procedures.  First, only Salazar class members may now obtain free legal assistance from Terris, Pravlik & Millian, LLP, concerning claims for reimbursement.  Non-class members may obtain free legal assistance from other legal aid service agencies in the District of Columbia.  

Salazar class members who can receive free legal assistance from Terris, Pravlik & Millian, LLP, are those individuals who were eligible for Medicaid or should have been eligible for Medicaid, but were forced to incur a medical expense for any of the following reasons:

1. There was a delay in excess of 45 days in the processing of the individual’s Medicaid application.
2. The pharmacy, clinic, hospital, or doctor’s office stated that the recipient was not eligible when she was eligible.
3. The District of Columbia improperly terminated, suspended, or discontinued an individual’s Medicaid eligibility at the time of renewal or recertification.
4. In the case of a child under 21 years of age, if the child was denied any Early and Periodic Screening Diagnostic Treatment service, including medical services, dental services, medication, medical equipment, supplies, or transportation services to Medicaid appointments.
5. In the case of newborns, who lack immediate Medicaid coverage using the Medicaid number of their mothers, but are eligible for Medicaid at the time of their birth.

Second, if an individual is not happy with the results of the fair hearing before the OAH, she must now appeal the decision to the District of Columbia Court of Appeals, rather than the U.S. District Court for the District of Columbia.

As a result of the Court’s May 18, 2015 Memorandum  Opinion and Order, individuals who previously received free legal assistance to submit claims for reimbursement , but are not Salazar class members will no longer be able to obtain free legal assistance from Terris, Pravlik & Millian LLP.  These individuals include (a) Qualified Medicare Beneficiaries, who are being billed by medical providers that only accept Medicare and not District of Columbia Medicaid, (b) beneficiaries who failed to present their Medicaid or Managed Care Organization card at the point of service, and (c) beneficiaries who inform their provider of their Medicaid eligibility but are being billed for medical expenses. 

Non-class members may obtain free legal assistance from Bread for the City Legal Clinic, (202) 265-2400, Legal Aid Society, (202) 628-1161, Legal Counsel for the Elderly, (202) 434-2120, Neighborhood Legal Services, (202) 269-5100, and University Legal Services, (202) 547-4747.  

Non-class members may submit a claim for reimbursement on their own and send letters to providers to request that they stop billing them for medical expenses.   If you are a Qualified Medicare Beneficiary, contact us for more information about what you can do to resolve billing issues. 

TPM Files Motion to Prevent the District from Improperly Terminating Medicaid Recipients at Renewal and Making Applicants Wait More than 45 Days for Eligibility Determinations

On December 22, 2015, Terris, Pravlik & Millian, LLP, filed a motion for a preliminary injunction against the District of Columbia in the United States District Court for the District of Columbia on behalf of the Salazar plaintiff class.  The preliminary injunction seeks to ensure that no Medicaid applicant (non-disabled) waits longer than 45 days for a decision on an application for Medicaid benefits and that no Medicaid recipient’s coverage is improperly terminated as a result of the District’s inability to make correct and timely eligibility decisions at the time of renewal or recertification.  The District of Columbia has until January 15, 2016, to respond.

Class counsel filed the preliminary injunction after hearing increasing concerns from class members, medical providers, and Medicaid advocates about the technological and other problems causing excessive delays for Medicaid applicants and improper terminations for Medicaid recipients.  In addition, DC has announced that there will be no passive renewals for Medicaid for a period of time beginning on January 1, 2016. 

Plaintiffs presented documents produced by the District of Columbia in response to Freedom of Information Act (FOIA) requests which show that the District of Columbia is depriving thousands of Medicaid applicants of their right to have their applications processed within 45 days.  As of December 10, 2015, there was a backlog of approximately 4,500 Medicaid applicants who applied in DC Health Link, the District’s health insurance online exchange, who have been waiting more than 45 days for a decision, with an additional backlog of paper applications.  Plaintiffs show in their motion that the District of Columbia routinely loses or fails to process application paperwork, forcing applicants to resubmit paperwork and stand in line at service centers for hours.

At the time of renewal, the District of Columbia is also depriving Medicaid recipients of their right to receive Medicaid benefits until found to be ineligible and to receive advance notice and an opportunity for a hearing prior to termination of their benefits.  Technological problems caused by the District’s poorly functioning computer systems routinely cause improper termination of benefits at the time of renewal or recertification.  In addition, plaintiffs show that despite the District of Columbia’s efforts, ongoing systemic document processing problems cause benefits to lapse, leaving otherwise eligible families and children without access to needed healthcare and medications, with burdensome out-of-pocket expenses, or high medical bills.

The Salazar plaintiff class seeks to have the Court enter an injunction requiring all applicants to be added to the Medicaid rolls within 45 days of their application and requiring that no recipient be terminated at renewal until the District of Columbia can demonstrate to the Court, based on substantial evidence, that their technology and business processing systems for making timely eligibility determinations on applications and renewals, and providing adequate notice to Medicaid recipients and applicants of such decisions, are functioning as required to ensure and protect their rights under the United States Constitution and applicable federal law and regulations.

Plaintiffs’ motion is supported by FOIA documents provided by District of Columbia agencies, the testimony of class members, the Legal Aid Society of the District of Columbia, Whitman-Walker Health, Bread for the City, Legal Counsel for the Elderly, and the DC Fiscal Policy Institute.  The motion and supporting documentation are available through Dropbox at the following link:

https://www.dropbox.com/sh/nuzr290yc5s4weq/AACI339sLZyrUGYUnF6x5vyxa?oref=e&n=363363361

TPM Wins Ruling in Federal Appeals Court that Denial of Plaintiffs’ Prescription Drug Benefits at Pharmacy Is a Deprivation of a Protected Property Interest that Triggers Due Process

On July 17, 2015, the United States Court of Appeals for the District of Columbia Circuit issued a decision in N.B. v. District of Columbia in favor of Plaintiffs represented by Terris, Pravlik & Millian, LLP and the National Health Law Program. Plaintiffs allege that the District of Columbia has systematically failed to provide Medicaid recipients with due process when prescription drug benefits are denied at the point-of-sale. The Court partially reversed and remanded a March 31, 2014, decision from the district court granting defendants’ motion to dismiss.

Amici curiae in support of reversal included the Legal Aid Society of the District of Columbia, New Haven Legal Assistance Association, American Association of Retired Persons (AARP), Bread for the City, Florida Legal Services, Legal Counsel for the Elderly, the National Senior Citizens Law Center, The Public Justice Center, The Tennessee Justice Center, and University Legal Services.

Plaintiffs filed their complaint on September 7, 2010. On August 8, 2011, the district court granted defendants’ first motion to dismiss on the ground that plaintiffs lacked standing. On June 8, 2012, the Court of Appeals for the District of Columbia Circuit reversed the district court’s decision and remanded the case for further proceedings. The Court of Appeal’s July 2015 decision, therefore, is the second reversal of the district court in this case. 

Plaintiffs contend that the existing point-of-sale prescription drug system violates Title XIX of the Social Security Act and its implementing regulations (“Title XIX”), the Due Process Clause of the Fifth Amendment, and D.C. law by failing to provide adequate and timely written notice of the basis for denial, the opportunity for a fair hearing, and the opportunity for reinstated coverage pending a hearing decision. Based on a computerized reply from an electronic claims system, a pharmacist will either fill a prescription or tell an individual that they will have to pay out-of-pocket to receive their prescribed medications. Many individuals, without the ability to pay for their prescription drugs on their own, leave the pharmacy without these medically necessary treatments. 

The district court granted defendants’ second motion to dismiss in March 2014, because, inter alia, it determined that many of the plaintiffs lacked a “legitimate claim of entitlement to the drugs” and had no protections under the Due Process Clause, nor were they “denied” a covered Medicaid benefit under Title XIX. The district court also held that in cases where there was a legitimate claim, plaintiffs failed to allege adequately that any “state action” caused the denials. The D.C.-law claims were dismissed by the district court for lack of pendant jurisdiction as no federal causes of action remained in the case.

The Court of Appeals for the District of Columbia Circuit, in its July 2015 decision, found that, inter alia, plaintiffs and all other D.C. Medicaid recipients have a “legitimate claim of entitlement” to the reimbursement of any prescription drug prescribed for a medical purpose and not completely excluded from coverage under Medicaid. The Court found that the District’s arguments “misapprehend[ ]” the meaning of a “legitimate claim of entitlement” by “incorrectly skip[ping] ahead to the plaintiff’s ultimate eligibility for a government benefit instead of asking whether she would be entitled to the benefit if she were to satisfy the preconditions to obtaining it.” Instead, the Court found a “ ‘legitimate claim of entitlement’ means that a person would be entitled to receive the government benefit assuming she satisfied the preconditions to obtaining it” (emphasis in original). 

The Court explained that plaintiffs and all other D.C. Medicaid recipients are entitled to receive prescription drug benefits upon satisfaction of all preconditions, because the language of the District’s Medicaid regulations (29 D.C.M.R. 2700, et seq.) provides for prescription drug coverage using “mandatory, non-discretionary terms.” The eligibility requirements place “substantive limitations on official discretion” to withhold a benefit upon satisfaction of the eligibility criteria.

In addition, the Court found that plaintiffs adequately alleged that the electronic claims system “determined their eligibility for benefits while acting as an agent of the District” and the Due Process Clause’s state action requirement was satisfied. However, the Court’s decision does affirm the district court’s dismissal of the Title XIX claims.

In conclusion, the Court found that plaintiffs’ constitutionally protected property interest triggers the District’s obligation to provide due process and that the case must be remanded for “further proceedings to determine what process is ‘due’ to the plaintiffs.” The Court also noted that on remand, the district court could reconsider its jurisdiction over the D.C.-law claims in light of its partial reversal.

Click here for the decision.