S.D. Ex Rel. Dickson v. Hood
391 F.3d 581, 2004 WL 2584704 (2004)
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Rule of Law:
Under the Medicaid Act's Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program, a participating state must provide any federally permissible health care service listed in 42 U.S.C. § 1396d(a) if it is medically necessary to correct or ameliorate a condition in an eligible child, even if the state's plan excludes that service for the general adult Medicaid population. This statutory entitlement creates an individual federal right that is enforceable through a private cause of action under 42 U.S.C. § 1983.
Facts:
- S.D., a sixteen-year-old boy, has spina bifida, a congenital defect which causes total bowel and bladder incontinence and a lack of sensation below his waist.
- S.D. is an eligible recipient of benefits under Louisiana's Medicaid program, specifically through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program for individuals under twenty-one.
- His physician, Dr. Ernest Edward Martin, Jr., prescribed disposable incontinence underwear, deeming it medically necessary to prevent chronic irritation and infection and to allow S.D. to attend school and participate in age-appropriate activities.
- S.D.'s family had previously received coverage for the same item from Virginia's Medicaid program before moving to Louisiana.
- S.D. submitted a claim for the cost of the prescribed underwear to the Louisiana Department of Health and Hospitals (LDHH).
- LDHH denied the claim, stating the item was not medically necessary and was a non-medical supply not covered by Medicaid.
Procedural Posture:
- S.D. administratively appealed LDHH's denial of his claim for medical assistance.
- A state administrative law judge affirmed LDHH's denial.
- S.D. filed an action under 42 U.S.C. § 1983 against LDHH in the U.S. District Court for the Eastern District of Louisiana, seeking injunctive and declaratory relief.
- On cross-motions for summary judgment, the district court granted S.D.'s motion and denied LDHH's motion, ordering LDHH to provide the requested medical assistance.
- LDHH, as appellant, appealed the district court's judgment to the U.S. Court of Appeals for the Fifth Circuit; S.D. is the appellee.
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Issue:
Does a state Medicaid agency's denial of coverage for medically necessary incontinence supplies for a minor with spina bifida violate the federal Medicaid Act's EPSDT provisions, and if so, is this statutory right enforceable through a private cause of action under 42 U.S.C. § 1983?
Opinions:
Majority - Dennis, Circuit Judge
Yes. A state Medicaid agency's denial of medically necessary services to an EPSDT-eligible child violates the Medicaid Act when the service falls within a category of care described in § 1396d(a), and this violation gives rise to an enforceable right of action under § 1983. The court reasoned that the plain language of the Medicaid Act, specifically 42 U.S.C. § 1396d(r)(5), mandates that states provide necessary health care to EPSDT recipients 'whether or not such services are covered under the State plan.' The legislative history of the 1989 amendments confirms Congress's intent to remove state discretion and require coverage for any federally permissible service needed to correct or ameliorate a child's condition. The court found that incontinence supplies are 'described in' § 1396d(a) under the category of 'home health care services,' deferring to CMS regulations and the agency's approval of other state plans that cover these supplies. Finally, applying the Blessing/Gonzaga test, the court held that the EPSDT provisions create an unambiguously conferred individual right enforceable under § 1983 because the statute uses rights-creating language, focuses on individual beneficiaries, and imposes a binding obligation on states.
Analysis:
This decision solidifies the broad and mandatory nature of the Medicaid Act's EPSDT provisions, significantly limiting states' discretion to restrict medical services for children. It establishes that a state's cost-containment measures or service limitations for its general adult Medicaid population cannot override the federal mandate to provide any medically necessary, federally-approved service to an EPSDT-eligible child. The ruling also affirms that this entitlement is not merely a policy goal but a concrete, individual right enforceable in federal court under § 1983, providing a critical legal tool for beneficiaries to challenge wrongful denials of care.
