Medicaid Recipients Enforce the Medicaid Act

A federal district court in Pennsylvania has reaffirmed the right of Medicaid recipients to enforce the Medicaid Act.

Clark v. Richman, 339 F.Supp. 2d 631 (M.D. Pa. 2004). 

The case revolves around the Pennsylvania Medicaid program’s coverage of dental services. A state has the option to provide dental services to its adult Medicaid population, 42 U.S.C. §1396d(a)(10), which Pennsylvania has exercised (making it, according to the district court, one of eight states to do so). For children under the age of 21 who are covered under the state Medicaid program, dental services are mandatory. Every state must provide early and periodic screening, diagnostic, and treatment (EPSDT) services to its Medicaid-eligible children, 42 U.S.C. §1396d(a)(4)(B), and EPSDT services are defined to include dental services. 42 U.S.C. §1396d(r)(3). Thus, all Pennsylvania residents eligible for Medicaid are eligible for coverage of dental services.

Plaintiffs, two subclasses of Medicaid eligible adults and children, alleged they were not receiving dental services primarily because the state’s outdated and insufficient provider reimbursement rates were not ensuring a sufficient number of dental providers. Plaintiffs claimed that the state’s actions violated 42 U.S.C. §§1396a(a)(8) (the “reasonable promptness” provision); 1396a(a)(10); 1396a(a)(30) (the “equal access” provision); and 1396a(a)(43) (requiring states to inform eligible individuals of EPSDT services and provide or arrange for provision of them).

On the basis of the Third Circuit Court of Appeal’s decision in Sabree ex rel. Sabree v. Richman, 367 F.3d 180 (3rd Cir. May 11, 2004), the district court agreed that 42 U.S.C. §§1396a(a)(8) and (10) do set out enforceable rights. But the court ultimately rejected plaintiffs’ contention that their failure to receive dental services gave rise to claims based on these provisions. The court concluded that 42 U.S.C. §§1396a(a)(8) and (10) do not require states to directly provide services to its Medicaid population. A state could only be in violation of these provisions, according to the court, if the state was denying coverage of medically necessary dental services, which the plaintiffs were not alleging the state agency was doing. “...[T]he statutory sections require the provision of medical assistance, i.e., financial assistance, not direct services.” The court granted partial summary judgment to the state agency on plaintiffs’ claims under these provisions.

The court also found 42 U.S.C. §§1396a(a)(30) and (43) to provide an enforceable rights. “Section 1396a(a)(43) speaks in mandatory terms, as it mandates that a state plan ‘must’ provide for informing eligible individuals of EPSDT services, as well as mandates that a state plan ‘must’ provide or arrange for the provision of EPSDT services.” In regard to the equal access provision, the court stated, “[S]ome circuit courts have either permitted MA recipients to allege claims under the equal access provision, or have only held that MA service providers, as opposed to MA recipients, cannot vindicate any rights under the equal access provision under §1983...[T]he equal access provision is couched in mandatory language which, when combined with the absence of an administrative mechanism to enforce that language, connotes an intent to permit private enforcement of the provision.” The plaintiffs’ equal access and EPSDT claims will proceed to trial.