EPSDT Case Docket – Behavioral and Mental Health

Executive Summary

This docket summarizes published, reported, and unreported federal and state court cases that discuss the Medicaid EPSDT program as it relates to the behavioral health needs of children.

Reported federal decisions: 
Pediatric Specialty Care, Inc. v. Ark. Dept. of Human Services, 364 F.3d 925 (8th Cir. 2004) (appeal after remand), earlier case, 293 F.3d 472 (8th Cir. 2002) 
On remand, the district court had found that ADHS violated the ?equal access provision? (§ 1396a(a)(30)(A)) of Medicaid Act and enjoined ADHS from changing the program until impact study was completed. The Eighth Circuit affirmed in part, ordering Arkansas to continue Child Health Management Services (CHMS) program until impact study on terminating program was completed. The Court of Appeals reversed the injunction as it extended to CMS, which was not a party to the underlying action and did not actively participate in decision to terminate program. In the earlier 2002 ruling, the Court said that when the state agency planned cutbacks in state Medicaid CHMS services, plaintiffs had standing and state plan was required to reimburse certain physician-approved services, but federal law did not require state to provide for CHMS services. 
Collins v. Hamilton, 349 F.3d 371 (7th Cir. 2003), aff?g, 231 F. Supp. 2d 840 (S.D. Ind. 2002) 
Appellee minor Medicaid recipients brought a class action suit against the state of Indiana, alleging violations of the Medicaid Act based on the state?s failure to provide long-term residential treatment in psychiatric residential treatment facilities for children under age 21. The state?s standing policy of refusing to provide long-term residential treatment for those patients for whom such treatment is found necessary by EPSDT screening violated the federal Medicaid Act. The state was ordered to provide Medicaid-eligible children under the age of 21 with the mental health treatment found to be necessary by EPSDT screening. 
Rosie D. v. Swift, 310 F.3d 230 (1st Cir. 2002), same case, 256 F. Supp. 2d 115 (D. Mass. 2003) (granting motion to compel production of documents having private information regarding class members) 
In case on behalf of children diagnosed with behavioral disorders and needing EPSDT and home-based therapies, 11th Amendment immunity does not protect state officials from federal court suits for prospective injunctive relief under the Medicaid Act; fair hearing requirement set forth in § 1396a(a)(3) falls short of showing that Congress intended to foreclose injunctive relief and Ex parte Young controls.
Westside Mothers v. Haveman, 289 F.3d 852 (6th Cir.), cert denied, 537 U.S. 1045 (2002), rev?g, 133 F. Supp. 2d 549 (E.D. Mich. 2001) 
Westside Mothers was filed by children who are not receiving sufficient and timely medical, dental, and developmental health screening services through Michigan?s Medicaid managed care program. The district court had dismissed the case, finding neither jurisdiction or a cause of action because, among other things, individual could not bring actions under Ex parte Young against state officials to enjoin ongoing violations of spending clause programs such as Medicaid. The Sixth Circuit reversed and remanded district court holding, noting the Medicaid program as supreme federal law and not simply a contract. It also recognized plaintiff?s private right of action under § 1983 and the validity of the suit under Ex parte Young.

Emily Q v. Bonta, 208 F. Supp. 2d 1078 (C.D. Cal. 2001) (permanent injunction) 
This injunction requires the state to take a number of steps to provide home and residential therapies to children who would otherwise be locked in state mental hospitals. Among other things, the state was ordered to: (1) include therapeutic behavioral services (TBS) in the Medi-Cal program; (2) assess institutionalized children to determine if they qualify for TBS; (3) develop and distribute a request and referral form for providers to request TBS services, (4) revise the EPSDT brochure to inform beneficiaries and applicants about TBS and other developmental services; and (5) provide compensatory benefits to class members wrongfully denied TBS services. 
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