Medicaid • “Medical Assistance” • Civil Rights • Affordable Care Act

Leonard v. Mackereth, PICS Case No. 14-0295 (E.D. Pa. Feb. 10, 2014) Buckwalter, S.J. (25 pages).

State Medicaid participant must make medical assistance available to eligible beneficiaries not only by paying for assistance, but by providing actual medical services. Motion for summary granted in part and denied in part.

Plaintiffs, all adults with autism and all categorically needy recipients of medical assistance under Pennsylvania’s state plan, requested that they be transferred from home-based care to institutionalized-based care after learning that the Department of Public Welfare was reducing the number of hours for certain services. DPW refused the request as the two facilities operating in Pennsylvania were filled to capacity and there were no plans to build another facility in the near future.

Plaintiffs sued and moved for summary judgment, alleging that DPW violated the Medicaid and Civil Service Acts by failing to make medical assistance available to them. DPW argued that plaintiffs were not entitled to summary judgment because the Medicaid Act did not require DPW to ensure access to or choice of services, but only to provide payment for the same. It, therefore also moved for summary judgment. The U.S. District Court for the Eastern District of Pennsylvania granted the motions in part.

A state plan for medical assistance must make medical assistance available to all individuals who meet certain eligibility requirements, and must provide such assistance with reasonable promptness, and in the same amount, duration or scope as that made available to any other beneficiary under the plan.

As of March 23, 2010, “medical assistance” means not only payment of part or all of the cost of care and services, but also the provision of actual medical services, or both (see 42 U.S.C. §1396d(a)) (clarifying circuit split). To date, DPW had neither provided nor ensured the provision of services to plaintiffs. Other Medicaid beneficiaries were receiving the services needed by plaintiffs in two facilities operating in Pennsylvania, and, therefore, DPW had not provided or ensured the provision of medical assistance to like persons similarly situated. Plaintiffs could no actually choose to switch from home-based services to institutional-based services, and therefore did not have “freedom of choice.” Accordingly, plaintiffs’ motion for summary judgment as to DPW’s liability under the Medicaid and Civil Rights Act for failure to provide or ensure provision of services was granted, and DPW’s motion was denied.

However, plaintiffs were not entitled to declaratory relief as such a declaration would do little to resolve the uncertainty of DPW’s obligation to plaintiffs. Nor was plaintiff entitled to injunctive relief. The full extent of a state’s responsibility under the statute remainedunclear, particularly with respect to how DPW should engage a private party to provide the services owed to plaintiffs or failing that, whether DPW was now a service provider of last resort. Accordingly, plaintiffs’ motion for declaratory and injunctive relief was denied, and DPW’s motion was granted.