The Seventh Circuit Weighs in on ADA Fundamental Alteration Defense in Medicaid

On September 8, 2004, the Seventh Circuit reversed a decision to issue a judgment on the pleadings against a Medicaid beneficiary in an Americans with Disabilities Act case. Radaszewski v. Maram, No. 02-3657, 2004 U.S. App. LEXIS 18940 (Sept. 8, 2003 7th Cir. 2004). The plaintiffs argued that Illinois? decision to eliminate private duty nursing from its Medicaid plan violated Title II of the Americans with Disabilities Act, which prohibits discrimination on the basis of disability in federally-funded public programs. Regulations implementing the ADA also require that services be provided in the most integrated setting possible. The plaintiffs also raised a claim under Section 504 of the Rehabilitation Act, which prohibits disability discrimination by federally-funded entities. In essence, the state had argued that neither federal law requires it to offer a service to the plaintiff that it did not offer to others.
The district court initially dismissed the ADA claim on the grounds that Title II claims could only be brought against state agencies and not an individual. The district court also ruled in favor of the state on the Section 504 claim, reasoning that neither Section 504 nor the ADA required that ?the state create and fund a program that does not already exist.? The Seventh Circuit reversed the decision that Title II claims could only be brought against a state agency, based upon subsequent precedent. The court also reversed the decision to issue a judgment on the pleadings, holding that important factual questions remained as to whether providing private duty nursing to the plaintiff constituted a fundamental alteration of the Medicaid program.
For one example, the state claimed that the plaintiff would not receive private duty nursing in any institutional setting, thus, no institutional precedent supported a demand for private duty nursing at home. The court ruled, however, that if the plaintiff needs the equivalent of private duty nursing care in an institution, he may be able to prove that he is entitled to receive private duty nursing care at home. Notably, the court stated that ?[n]othing . . . conditions the viability of a Title II or Section 504 claim on proof that the services a plaintiff wishes to receive in a community-integrated setting already exist in exactly the same form in an institutional setting.
Although a state is not obliged to create entirely new services or to otherwise alter the substance of the care that it provides to Medicaid recipients in order to accommodate an individual?s desire to be cared for at home, the integration mandate may well require the State to make reasonable modifications to the form of existing services in order to adapt them to community-integrated setting.? The case was remanded for further proceedings.

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