Public Entities: Managed Care (Medicare & Medicaid)

Case Law:

Davis, et al. v. New York State Dep't of Health, 821 F.3d 231 (2nd Cir. 2016).

• In 2011, New York changed its prescription benefits limiting orthopedic footwear or compression stocking to specific conditions.
• Court ruled that these limitations violated the integration mandate because the plaintiffs would be at serious risk of institutionalization without those services.

Steimel v. Indiana Family and Social Serv. Admin., 823 F.3d 902 (7th Cir. 2016).

• Indiana transferred several people with developmental disabilities from a Medicaid waiver program without an annual cap to a waiver program with an annual cap. They sued alleging that they were not able to spend as much time in the community because of the cap and that the cap led to gaps in care, putting them at risk of institutionalization.
• Indiana argued that the integration mandate did not apply to those residing in the community. Court concluded that the mandate applied whether in an institution or addressing isolation within a person's home.

Taylor v. Colorado Dep't of Health Care Policy and Financing, (10th Cir. 2016).

• Plaintiff sued Colorado agency for not reimbursing for her attendants driving her to her medical appointments. Their Medicaid program reimbursed by mileage but would not pay for the driver's time. She alleged that the mileage reimbursement was discriminatory because it did not sufficiently compensate her for the attendants' driving time.
• Choosing not to pay attendants for their driving time was not discriminatory since the agency provided identical Medicaid benefits to every recipient.

Cohon v. New Mexico Department of Health, 646 F.3d 717 (6th Cir. 2011).

• Plaintiff sued New Mexico agency over her individual budgetary allotment to provide her required residential support services. She alleged that the allotment was discriminatory because it was arbitrarily determined using an undisclosed algorithm.
• States have discretion to determine the mix of programs and services under Medicaid.  She also did not allege supporting facts that the allocation would result in her unjustified isolation or premature institutionalization.

Fisher v. Oklahoma Health Care Authority, 335 F.3d 1175, (10th Cir. 2003).

• State agency's decision to limit prescriptions for Medicaid recipients in the community was discriminatory when limit was not imposed on those in nursing homes. Forced people to go into nursing homes if they need to go over the limit
• Institutionalization is a prerequisite to enforcement of the ADA's integration requirements.

Townsend v. Quasim, 328 F.3d 511 (9th Cir. 2003).

• Refusal to offer community-based in-home nursing services to some disabled persons may violate the ADA unless state agency can demonstrate that extending eligibility to these persons would fundamentally alter its Medicaid programs.
• Plaintiff's income had made him ineligible to receive his Medicaid services in the community. State agency told him to move to a nursing home to continue receiving his benefits.

Bruggeman v. Blagojevich, 324 F.3d 906 (7th Cir. 2003).

• Parents of developmentally disabled adult children in Chicago sued Illinois to provide care facilities in their region. Most facilities are located in southern Illinois and there are low vacancy rates in the Chicago area. Parents did not want to send their children far away from home.
• "The aim is to give the recipient a choice among available facilities, not to require the creation or authorization of new facilities."
• There is a seeming paradox that a residential institution would be the least restrictive environment for the children. However, their parents may not be able to take care of their children making the home environment more restrictive to a child's opportunity to develop.

Rodriguez v. City of New York, 197 F.3d 611 (2nd Cir. 1999).

• It is not the court's role to determine what Medicaid benefits New York must provide. Rather, it determines whether New York discriminates on the basis of a mental disability with regard to the benefits it does provide. Because New York does not "task" safety monitoring as a separate benefit for anyone, it does not violate the ADA by failing to provide this benefit to appellees.

Addis v. Whitburn, 153 F.3d 836 (7th Cir. 1998).

• Wisconsin's policy forbidding disabled parent or caretaker from deducting from his or her income, for purposes of determining parent's eligibility for medicaid benefits, the portion of income allocated to dependent children in determining their own eligibility for benefits does violate the ADA or Rehabilitation Act, in light of Social Security Act's express authorization for state to allocate portion of parent's income to child in assessing child's eligibility for medicaid whether or not parent is disabled and whether or not parent is himself or herself applying for medical assistance.

Vaughn v. Sullivan, 83 F.3d 907 (7th Cir. 1996).

• Distinctions in Indiana's Medicaid plan allowing blind persons, but not other disabilities, to disregard Plan for Achieving SelfSupport (PASS) income when calculating eligibility for Medicaid benefits did not violate the Rehabilitation Act or the ADA.
• Neither the Rehabilitation Act nor ADA requires states to provide identical benefits for people with disabilities. States retain substantial discretion in choosing the proper mix of amount, scope and duration limitations on coverage. Plaintiffs' minimum obligation therefore is to show that the total package of benefits they receive is lower than that of some comparable group.