Q & A: Emily Q. EPSDT Case

Executive Summary

This Q&A discusses the significance and impact of the decision in Emily Q v. Bonta, regarding failure by the state to cover Therapeutic Behavioral Services (TBS).

Question: What is the significance of the recently issued Emily Q. v. Bonta decision in federal District Court in California?

Answer: Emily Q. v. Bonta1 is significant because it reaffirms that EPSDT provisions confer enforceable rights upon Medicaid beneficiaries after the Supreme Court?s decision in Gonzaga University v. Doe and the Ninth Circuit?s decision in Sanchez v. Johnson and it maintains that courts have inherent authority to establish appropriate injunctive relief for violations of EPSDT provisions.

Background
 
In 1998, children with intensive mental health needs brought a suit alleging that California Medicaid officials failed to cover a full range of mental health services, including Therapeutic Behavioral Services. According to the children?s attorneys, Therapeutic Behavioral Services (TBS) would enable the children to work one-on-one with a trained mental health aide or coach in their homes rather than be housed in one of two state mental hospitals or placed in other locked mental facilities. After the Emily Q. v. Bonta complaint was filed, the State stipulated to the allegations of the First Amended Complaint, to entry of judgment against Diana Bonta, director of the California Department of Health Services (DHS), and to entry of a permanent injunction. Issues related to the extent of the relief were litigated and Plaintiffs filed a motion for a permanent injunction.

Granting in part and denying in part the permanent injunction motion, federal District Judge A. Howard Matz ordered the State to include TBS in its Medi-Cal program.2 Diana Bonta, as director, was required to conduct special assessments of 135 young people in the State?s two mental hospitals to see if they might be discharged.3 Additionally, Judge Matz ordered Bonta and DHS to provide notices explaining the new service to all Medi-Cal families.4 Notices also were required to be mailed to families when a child was hospitalized for psychiatric emergency, entered foster care or was considered for institutional placement.5 The Court ordered DHS to assure that assessment and treatment of children occur and required that it consult with state licensing boards and mental health providers to adopt certification standards for mental health professionals providing TBS.6

In 2005, Sandra Shewry, current director of DHS, moved for relief from the 2001 Judgment and Permanent Injunction, the 2004 Interim Order Clarifying Judgment, the 2004 Amended Judgment and Permanent Injunction and the 2004 Order Regarding Plan to Increase TBS Utilization.7 In her motion, Shewry argued that (1) Plaintiffs have no right to enforce Early and Periodic Screening, Diagnostic and Treatment (EPSDT) provisions underlying their claim, (2) Plaintiffs have no right to impose participation or performance standards or enforce a right of access to TBS, and (3) DHS and Department of Mental Health have complied with the Injunction.8

Emily Q. Opinion
 
On February 28, 2006, Judge Matz issued the order denying the Defendant?s motion for relief. Before delving into the substantive issues, Judge Matz outlined the legal standard for seeking relief of a final judgment or order. The Federal Civil Procedure Rule 60(b)(5) provides that parties in a lawsuit may obtain relief of a final judgment or order if that the judgment has been satisfied, released or discharged, the prior judgment has been reversed or vacated, or applying the judgment is no longer considered equitable.9 According to Judge Matz, ?[t]he party moving to set aside a judgment ?must establish that a significant change in facts or law warrants revision of the decree and that the proposed modification is suitably tailored to the changed circumstance.??10
 
Court Holds That There Is No Change In Law
In seeking relief from the judgment, Defendant Shewry first argued that Plaintiff children no longer had a private right of action under 42 U.S.C. § 1983 following the U.S. Supreme Court decision in Gonzaga University v. Doe,11 and the Ninth Circuit decisions in ASW v. Oregon12 and Sanchez v. Johnson.13 In Gonzaga, Supreme Court held that a violation of the Family Educational Rights and Privacy Act of 1974 was not privately enforceable under 42 U.S.C. § 1983. Following that case, the Ninth Circuit in Sanchez found that § 1396a(a)(30)(A) of the Medicaid Act was similarly unenforceable by private persons under § 1983.14 Defendant asserted that the three cases ?constituted a fundamental and substantial change in federal jurisprudence governing private rights of action under § 1983.?15

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