9th Cir. : Beneficiaries May Enforce Their Medicaid Right To Nursing Care

The U.S. Court of Appeals for the Ninth Circuit has held that individuals who were receiving home-or community-based Medicaid long-term care services and lost those services due to Oregon budget cuts are entitled to challenge the cuts as denying their right to nursing facility services under the Medicaid Act.

The case, Watson v. Weeks, No. 04-35704, — F.3d — (9th Cir. Feb. 8, 2006), was brought to challenge Oregon’s allegedly arbitrary reductions in eligibility for long-term care in the Medicaid program in that state.  The individual plaintiffs, seven seniors and individuals with disabilities, had all been declared eligible for nursing facility services in Oregon’s Medicaid program and until 2003 had been receiving home or community-based long-term care services provided as an alternative to nursing home care under a waiver program approved by the U.S. Centers for Medicare and Medicaid Services (CMS).

In 2003, “purely to cut spending,” according to the plaintiffs, the state eliminated the categories under which these plaintiffs had been certified as medically eligible for Medicaid long term care services. These reductions, the plaintiffs allege, were made without regard to the health needs of the people eliminated from coverage but, instead, were adopted solely to reduce the state’s health care costs. The Court of Appeals’ ruling reversed an earlier decision of the federal district court, which had dismissed plaintiffs’ claim, holding that there is no legally enforceable right to nursing facility services under the Medicaid Act.

The plaintiffs alleged that the cuts violated their right to nursing facility services, which is a mandatory service under 42 U.S.C. §1396a(a)(10), and their right to have eligibility determined using “reasonable standards … consistent with the objectives of [the Medicaid Act],”id. §1396a(a)(17)(a).

The court employed “the current three-prong test” of Blessing v. Freestone, 520 U.S. 329 (1997), as “clarified” by Gonzaga Univ. v. Doe, 536 U.S. 273 (2002), to determine whether those provisions created “rights” enforceable through 42 U.S.C. §1983. 

The court noted that all five federal circuit opinions on the issue had found that §1396a(a)(10) creates enforceable rights. The provision requires the services to be provided “to all individuals,” a phrase that Congress used “as a focal term and established entitlements to specific benefits for individuals.”  The Ninth Circuit also noted – and seemed to endorse – circuit decisions upholding enforcement of other Medicaid provisions “that have wording akin to that in §1396a(a)(10),” including decisions enforcing §1396r-6 (transitional  Medicaid assistance), §1396a(a)(8) (reasonable promptness), and §1396a(a)(3) (fair hearings).

 However, the court found that the “reasonable standards” provision of the Medicaid Act, relied upon by plaintiffs as requiring reasonable, health-related standards in determining eligibility, does not create individual rights and is too vague and amorphous to be enforced by courts at the request of individual beneficiaries.

That “reasonable standards” provision, the court concluded, “is a general discretion-granting requirement” and “fails to even mention individuals or persons.”  Moreover, the court considered the provision too vague and amorphous for judicial enforcement, because it “does not provide meaningful instruction for the interpretation of ‘reasonable standard.’”  Enforcement “would require a court to delve into the medical necessity of particular types of care.  If Congress had intended that result, it would have provided more concrete standards in the statute for determining eligibility based on medical need.”

Although plaintiffs had also challenged the district court’s failure to give leave to amend the complaint to add a preemption cause of action under the Supremacy Clause, the court found it unnecessary to address that argument as the plaintiffs could renew their motion on remand.

In addition to the National Senior Citizens Law Center, counsel for plaintiffs include Lane County Law and Advocacy Center, Legal Aid Services of Oregon, and the Oregon Law Center.