Salazar v. District of Columbia
954 F. Supp. 278 (D.D.C. 1996)
Overview
Salazar v. District of Columbia is a landmark Medicaid class action filed in 1993. Beginning in 1999, the case was governed by a Consent Order entered by the Court that helped strengthen the District’s Medicaid program and improve access to medically necessary services for Medicaid-enrolled children and young adults.
The Consent Order ended on August 17, 2026. A separate Settlement Agreement governs the resolution of the case and the transition from court supervision through October 31, 2027.
The Litigation
The lawsuit was filed in 1993 on behalf of a class of District of Columbia Medicaid beneficiaries against the District of Columbia, the Mayor, and the Director of the Department of Human Services.
Plaintiffs alleged that the District was violating federal Medicaid law and the Constitution by, among other things:
Failing to process Medicaid applications within 45 days;
Failing to provide adequate notice and hearing rights when Medicaid benefits were reduced, suspended, or terminated; and
Failing to provide or arrange for Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services for eligible children and to provide required notice about those services.
Following a seven-day trial, the Court held that the District had “denied Plaintiffs’ rights under both federal and District of Columbia law, and, in some instances, under the Constitution.” Salazar, et al. v. District of Columbia, 954 F. Supp. 278, 324 (D.D.C. 1996).
In 1999, while the District’s appeal was pending, the Court entered a Consent Order based on a settlement between the parties. The Consent Order, known as the Salazar Settlement Order, was modified several times in response to enforcement motions, and to reflect changing circumstances and legal requirements. It remained in effect until August 2026.
The Salazar Settlement Order
The Settlement Order required the District to take numerous actions to remedy violations of federal Medicaid law. As the District achieved compliance in certain areas, portions of the Settlement Order were terminated, including:
The provisions addressing timely processing of Medicaid applications were terminated in 2009.
The provisions addressing Medicaid recertification were terminated in 2013 following implementation of the Affordable Care Act.
After those provisions were terminated, the remaining sections of the Settlement Order focused primarily on the District’s obligations to provide Medicaid-enrolled children and youth with the full scope of services available through the EPSDT benefit.
EPSDT Requirements Under the Settlement Order
EPSDT is Medicaid’s comprehensive health benefit for children and youth under age 21. It includes preventive services such as well-child visits, hearing and vision screening, dental services, and blood lead screening. It also includes medically necessary treatment services, including specialty medical care, behavioral health services, therapies, nursing, personal care services, medical equipment and supplies, and other treatment needed to correct or improve a physical or behavioral health condition.
To improve access to these services, the Settlement Order required the District to:
Improve outreach to families;
Notify parents and guardians about available benefits;
Track the delivery of services to children enrolled in managed care plans;
Provide appropriate case management to children whose health conditions required those services; and
Train Medicaid providers regarding EPSDT requirements.
The Court subsequently entered additional orders to enforce these obligations, including orders related to blood lead testing and children’s dental services.
Monitoring and Accountability Under the Settlement Order
The Settlement Order not only required the District to provide services. It also established monitoring, reporting, and accountability measures designed to track the District’s performance and promote compliance.
One of the principal performance measures was the Medicaid participant ratio, a metric reported annually to the federal government that measured the percentage of Medicaid-enrolled children who received at least one initial or periodic EPSDT screening during the reporting year.
Under the Settlement Order:
Managed care plans were required to achieve participant ratios of at least 80 percent;
Corrective action plans were required when managed care plans did not achieve the prescribed standard; and
Financial penalties applied when a managed care plan’s participant ratio fell below 75 percent.
During the final decade of court oversight, however, the District did not achieve the 75 percent performance standard. Beginning in 2020, the participant ratio remained at approximately 50 percent. Based on the data reported by the District, this meant that roughly half of Medicaid-eligible children did not receive even one documented well-child visit during the fiscal year. In Fiscal Year 2025, the final full reporting year before the litigation concluded, the District reported an overall participant ratio of 56 percent.
Under the Settlement Order, the District’s managed care plans paid hundreds of thousands of dollars in penalties. The managed care plans remained subject to financial penalties through 2026. For fiscal year 2025 alone, AmeriHealth Caritas District of Columbia paid $312,435, MedStar Family Choice paid $223,380, and Wellpoint (formerly Amerigroup) paid $232,560 in penalties.
Escrow-Funded Projects During the Litigation
The Court created the Salazar Penalty Escrow Account in 2010 with financial penalties imposed on the District for repeatedly missing court-ordered deadlines. The funds were required to benefit the plaintiff class of DC Medicaid-eligible children and young adults under age 21. Projects completed during court supervision included:
In May 2011, the National Academy for State Health Policy produced the report Implications for the District of Columbia of Contemporary Approaches to Measuring Quality of Well-Child Services for Medicaid Enrolled Children, addressing data challenges and recommending improvements in measuring EPSDT services.
In August 2011, two LeadCare II instruments were purchased for blood lead testing in DC children.
In February 2019, the DC Chapter of the American Academy of Pediatrics launched a pediatric practice improvement project to increase EPSDT-compliant blood lead testing.
In January 2020, point-of-care blood lead testing equipment and supplies were purchased for nine Unity Health Care and Mary’s Center clinics serving DC Medicaid-enrolled children.
In February 2020, Children’s National launched an oral health project to improve referrals and care coordination for Medicaid-eligible children in Wards 7 and 8 who lacked a dental home. More information is available in the Children’s National Grant Final Report. As reported in Preventive Oral Health Care Access, a focus group of caregivers and providers conducted in 2023 identified many factors that impact access to preventive dental care by Medicaid eligible children in the District of Columbia.
Assistance Provided to Class Members
During the life of the Settlement Order, counsel for the Salazar plaintiff class provided free legal advice and assistance to hundreds of Medicaid beneficiaries and families. Counsel helped families maintain coverage, obtain reimbursement when they had to pay out-of-pocket for supplies or services that should have been covered by Medicaid, and secure medically necessary services through advocacy, appeals, grievances, and fair hearings, including challenges to unlawful delays, denials, reductions, and terminations.
Conclusion of the Litigation
The Salazar Settlement Order ended on August 17, 2026, after more than three decades of litigation and court oversight. The parties entered into a Settlement Agreement providing for the final resolution of the case, a transition away from court supervision, and the use of the remaining Salazar escrow funds for projects benefiting DC Medicaid-enrolled children and families.
Related Resources
Settlement Agreement and Ongoing Projects
Learn about the Settlement Agreement and projects funded through the remaining Salazar escrow funds.
Court Documents and Resources
Access court orders, administrative agency decisions, and other historical resources from the Salazar litigation.
→ Salazar Documents & Archive Page