S.B. v. Hamos
Filing
13
OPINION: The Court GRANTS Plaintiff's Motion d/e 11 and ORDERS as follows:(1) Defendants are ordered to pay for Plaintiff's placement at Lincoln Prairie Behavioral Health Center in Springfield, Illinois, beginning May 25, 2012 and lasti ng until the restraints of this Order dissolve. (2) A hearing on Plaintiff's Motion for Preliminary Injunction is set for June 7, 2012 at 4:00 p.m. This Order's restraints shall dissolve at the close of that hearing, unless extended before that date and time. If Defendants fail to comply with the terms of this Opinion, Defendants will be in contempt of this Court and subject to sanctions. Entered by Judge Sue E. Myerscough on 5/25/12. (ME, ilcd)
E-FILED
Friday, 25 May, 2012 04:36:50 PM
Clerk, U.S. District Court, ILCD
IN THE UNITED STATES DISTRICT COURT
FOR THE CENTRAL DISTRICT OF ILLINOIS
SPRINGFIELD DIVISION
S.B., by and through her father, W.B., )
)
Plaintiff,
)
)
v.
)
)
JULIE HAMOS, in her official capacity )
as Director of the Illinois Department )
of Healthcare and Family Services,
)
)
Defendant.
)
No. 12-cv-03077
OPINION
SUE E. MYERSCOUGH, U.S. District Judge:
This matter comes before the Court on Plaintiff’s Verified Motion
for Temporary Restraining Order (d/e 11) (“Motion”). For the reasons
that follow, the Motion is GRANTED.
I. BACKGROUND
On March 8, 2012, Plaintiff filed a four-count Complaint (d/e 1)
against Defendant, Julie Hamos, in her official capacity as Director of
the Illinois Department of Healthcare and Family Services. In Count I
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of the Complaint, Plaintiff alleges, pursuant to 42 U.S.C. § 1983, that
Defendant is violating the federal Medicaid Act, 42 U.S.C. § 1396 et
seq., because Defendant has failed and continues to fail to provide
Plaintiff with medically necessary services that Defendant is mandated to
provide under the Early and Periodic Screening, Diagnostic, and
Treatment Services (“EPSDT”) program of the Medicaid Act. Plaintiff
also alleges, pursuant to § 1983, that Defendant is in violation of the
Americans with Disabilities Act (“ADA”) (Count II) and the
Rehabilitation Act (Counts III and IV). Plaintiff seeks declaratory and
injunctive relief in Counts I, II, and III and seeks damages in Count IV.
According to the Complaint, Plaintiff, S.B., is a Medicaid-eligible,
16-year-old girl who suffers from the following conditions: ADHD
(Combined Type), Post-Traumatic Stress Disorder, Oppositional Defiant
Disorder, Depressive Disorder, Sexual Abuse Victim, Sexual Abuse
Perpetrator, and Mild Mental Retardation.
On April 30, 2011, Plaintiff was admitted to Lincoln Prairie
Behavioral Health Center (“Lincoln Prairie”) in Springfield, Illinois.
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After her discharge from Lincoln Prairie, Plaintiff was directly admitted
to Riverside Academy (“Riverside”) in Wichita, Kansas, a psychiatric
residential treatment facility. Blue Cross/ Blue Shield (“Blue Cross”),
Plaintiff’s private health insurance carrier, paid for her treatment at
Riverside through April 2012. While at Riverside, Plaintiff attended
school and participated in recreational activities.
Effective April 2012,1 Blue Cross denied authorization for
Plaintiff’s continued treatment at Riverside. Plaintiff alleges that Blue
Cross also denied authorization for treatment in a step-down residential
treatment facility because Blue Cross alleged that such treatment is not a
covered benefit.
Plaintiff alleges that, in a report dated February 27, 2012,
Plaintiff’s therapist at Riverside advised that Plaintiff should be placed in
a “step-down facility closer to [the] primary care givers upon successful
1
The Motion states that Blue Cross denied authorization for Plaintiff’s
treatment at Riverside effective April 2012, but the Complaint states that Blue Cross
denied that authorization effective March 2, 2012. See Compl. ¶ 80. The Court
notes that, for purposes of deciding this Motion, the Court need not determine which
date is correct.
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discharge from Riverside Academy.” Pl.’s Mem. Ex. E. The Complaint
also states that Mary Dobbins, M.D., recommended that Plaintiff receive
residential treatment.2
Plaintiff alleges that, although Defendant was made aware of
Plaintiff’s need to be placed in a step-down residential treatment facility
on February 28, 2012, Defendant has not attempted to make
arrangements or provide funding for Plaintiff to be placed in such a
facility.
Plaintiff also alleges that she is currently unable to safely reside in
her family’s home. Plaintiff states that she is at risk for further
hospitalization or “institutionalization” if she does not receive treatment
in a step-down residential treatment facility closer to her family.
Plaintiff states that, when in the hospital, she is unable to attend school
or leave the hospital. Plaintiff also alleges that the cost of treatment at a
step-down residential treatment facility is approximately one-third the
2
The Complaint does not indicate the date of Dr. Dobbins’ recommendation.
However, attached to the Motion as Exhibit D is a report stating that Dr. Dobbins
recommended that Plaintiff receive residential treatment. The report reflects that it
was signed by Dr. Dobbins on April 15, 2011.
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cost of treatment as a psychiatric hospital.
Plaintiff asserts that she needs to be placed in a step-down
residential treatment facility “for the maximum reduction of her mental
disability and for the restoration of her to the best possible functional
level.” Pl.’s Mot. 2; Compl. ¶ 88. Plaintiff states that “[u]nless [she]
receives the necessary intensive residential services, she will likely be at
risk for many future hospitalizations.” Compl. ¶ 89. Plaintiff also states
that she requires residential treatment “to correct or ameliorate” her
mental and behavioral conditions.
On May 22, 2012, Plaintiff filed the Motion for Temporary
Restraining Order. Plaintiff seeks a temporary restraining order (“TRO”)
requiring Defendant to provide Plaintiff with Medicaid coverage for
placement in a residential treatment facility found to be medically
necessary, as required under the EPSDT provisions of the Medicaid Act.
On the same day, Plaintiff filed a separate Motion for Preliminary
Injunction (d/e 9), which the Court will consider at a later time.
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On May 24, 2012, the Court held a hearing on the Motion for
TRO. Counsel for Plaintiff and Defendant appeared in person.
Plaintiff’s father also appeared in person. The Court heard argument on
the Motion. Plaintiff’s counsel explained that Plaintiff is currently in
Riverside but is scheduled to be discharged on May 25, 2012. At the
conclusion of arguments, the Court orally granted the Motion. The
Court now sets forth its decision in further detail.
II. JURISDICTION AND VENUE
Federal subject matter jurisdiction over Counts I through IV exists
pursuant to 28 U.S.C. § 1331, as each count asserts a claim that arises
under federal law. Venue is proper because Defendant is located in
Springfield, Illinois, which is in this judicial district, and a substantial
part of the events giving rise to Plaintiff’s claims occurred in this judicial
district. See 28 U.S.C. § 1391.
III. ANALYSIS
Plaintiff requests the Court to enter a TRO ordering Defendant to
provide Medicaid coverage for placement in a residential treatment
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facility found to be “medically necessary” as required under the EPSDT
provisions of the Medicaid Act. See 42. U.S.C. § 1396 et seq.
To obtain a TRO, a movant must show that: (1) she is reasonably
likely to succeed on the merits; (2) no adequate remedy at law exists; (3)
she will suffer irreparable harm that, absent injunctive relief, outweighs
the irreparable harm the respondent will suffer if the injunction is
granted; and (4) the injunction will not harm the public interest. See
Joelner v. Vill. of Washington Park, Illinois, 378 F.3d 613, 619 (7th Cir.
2004) (stating requisite elements for a TRO); Goodman v. Illinois Dep’t
of Fin. and Prof’l Regulation, 430 F.3d 432, 437 (7th Cir. 2005) (stating
that a movant bears the burden of proof). “If the movant can meet this
threshold burden, then the inquiry becomes a ‘sliding scale’ analysis
where these factors are weighed against one another.” Joelner, 378 F.3d
at 619. “The more likely the plaintiff is to win, the less heavily need the
balance of harms weigh in his favor; the less likely he is to win, the more
need it weigh in his favor.” Roland Machinery Co. v. Dresser Industries
Inc. 749 F.2d 380, 387 (7th Cir. 1984).
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Here, all the factors weigh in favor of granting a TRO.
1.
Plaintiff Has Shown a Reasonable Likelihood of Success on the
Merits
In the Motion, Plaintiff requests this Court to enter a TRO
ordering Defendant to provide Plaintiff with Medicaid coverage for
placement in a residential treatment facility found to be medically
necessary as required under the EPSDT provisions of the Medicaid Act.
The Court notes that the injunctive relief that Plaintiff seeks in the
Motion relies predominately on the claim stated in Count I.3 Therefore,
the Court’s analysis of the likelihood of success on the merits for the
purpose of the Motion will be limited to Count I. Specifically, this
Court must determine whether Plaintiff is likely to succeed on the claim
that Illinois is required to provide Plaintiff with coverage for placement
in a residential treatment facility under the EPSDT program of the
Medicaid Act.
3
In Count I, Plaintiff alleges, pursuant to 42 U.S.C. § 1983, that Defendant is
in violation of the EPSDT provision of the federal Medicaid Act because Defendant
refuses to provide funds for medically necessary treatment in a residential treatment
facility.
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“Medicaid is a cooperative federal-state program that provides
federal funding for state medical services to the poor.” Frew v. Hawkins,
124 S. Ct. 899, 901 (2004). State participation is voluntary; however,
once a state has chosen to participate, as Illinois has, it must comply
with all federal requirements. Id. One requirement is that every
participating State must have an “early and periodic screening,
diagnostic, and treatment services” (EPSDT services) for persons under
age 21. See 42 U.S.C. § 1396d(a)(4)(B).
EPSDT services include certain screening, vision, dental and
hearing services (see 42 U.S.C. §§ 1396d(r)(1)-(4)), as well as “[s]uch
other necessary health care, diagnostic services, treatment, and other
measures described in [§ 1396d(a)] to correct or ameliorate defects and
physical and mental illnesses and conditions discovered by the screening
services, whether or not such services are covered under the State plan.”
42 U.S.C. § 1396d(r)(5).
The Seventh Circuit has interpreted the Medicaid Act to find that
placement in a psychiatric residential treatment facility, where such
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placement is determined to be medically necessary through EPSDT
screening, is included “within the ambit of covered EPSDT services.”
Collins v. Hamilton, 349 F.3d 371, 374-75 (7th Cir. 2003). In Collins,
the plaintiffs filed a class action complaint against the State of Indiana
alleging that Indiana had violated the Medicaid Act by failing to provide
medically necessary residential psychiatric treatment for Medicaideligible children under the age of 21. Id. at 372. The district court
entered a permanent injunction requiring Indiana to provide Medicaideligible children under the age of 21 with psychiatric residential
treatment facility placements where the placement was found to be
medically necessary by EPSDT screenings. Id. The Seventh Circuit
affirmed the district court, holding that Indiana’s denial of any funding
for placement in psychiatric residential treatment facilities to children
when deemed medically necessary by EPSDT screening violated the
Medicaid Act. Id. at 376.
In reaching this conclusion, the Seventh Circuit interpreted the
EPSDT provisions of the Medicaid Act. First, the court noted that,
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within the scope of EPSDT services for children, states are required to
furnish “[s]uch other necessary health care, diagnostic services,
treatment, and other measures described in subsection (a) of this section
to correct or ameliorate defects and physical and mental illnesses and
conditions discovered by the screening services, whether or not such
services are covered under the State plan.” Collins, 349 F.3d at 374
(citing 42 U.S.C. § 1396d(r)(5)).
The court next noted that under § 1396d(a)(16), “inpatient
psychiatric hospital services for individuals under age 21” are coverable
Medicaid expenses so long as they abide by the directives of subsection
(h). Collins, 349 F.3d at 374. The court found that the language in §
1396d(h) “broadens the definition of ‘inpatient psychiatric hospitals’ to
include the services rendered in [psychiatric residential treatment
facilities] by expressly incorporating other inpatient settings as specified
by the Secretary in the promulgated regulations.” Collins, 349 F.3d at
374-75 (citing § 1396d(h)(1)(A)). The court then noted that the
Secretary has promulgated regulations “that specifically include
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[psychiatric residential treatment facilities] as possible venues for
patients under the age of 21 to receive psychiatric treatment.” Collins,
349 F.3d at 375 (citing 42 C.F.R. § 441.151(b) (“Inpatient psychiatric
services furnished in a psychiatric residential treatment facility as defined
in § 483.352 of this chapter, must satisfy all requirements in subpart G
of part 483 of this chapter governing the use of restraint and
seclusion.”)). The court then noted that Section 483.352 elaborates on
this requirement by defining a “Psychiatric Residential Treatment
Facility” as “a facility other than a hospital, that provides psychiatric
services [. . .] to individuals under age 21, in an inpatient setting.”
Collins, 349 F.3d at 375 (citing 42 C.F.R. § 483.352). The court
concluded: “Under the language in the Act and the provisions in the
regulations, we find that [psychiatric residential treatment facilities]
qualify as ‘inpatient psychiatric hospitals,’ and therefore placement in a
[psychiatric residential treatment facility] is included within the ambit of
covered EPSDT services.” Collins, 349 F.3d at 375.
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Here, Plaintiff seeks relief very similar to the relief the plaintiffs
sought in Collins. Plaintiff has alleged that she is a Medicaid-eligible
person under the age of 21 and that placement in a residential treatment
facility is medically necessary according to recommendations by her
physician and therapist. Plaintiff has also alleged that Defendant has
refused to arrange for Plaintiff to receive the medically necessary
treatment. Considering these alleged facts and the Seventh Circuit’s
decision in Collins, this Court concludes that Plaintiff has shown a
strong likelihood of success on the merits of Count I.
2.
Plaintiff Has Shown that No Adequate Remedy at Law Exists
Plaintiff has also sufficiently shown that no adequate remedy at
law would suffice. Plaintiff is requesting declaratory and injunctive relief
to require Defendant to provide certain medically necessary services.
Further, at the May 24, 2012 hearing, Plaintiff’s counsel stated that
Plaintiff will be discharged from Riverside on May 25, 2012, at which
point she will have no residential treatment facility alternative if the
Court chooses not to enter a TRO. Under these circumstances, a
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subsequent legal remedy, delivered weeks or months later, will not
adequately address Plaintiff’s claim absent preliminary injunctive relief.
3.
Plaintiff Has Shown that She Will Suffer Irreparable Harm If the
TRO Is Not Granted
Plaintiff has also sufficiently shown that, if Defendant is not
enjoined, Plaintiff will sustain substantial, irreparable harm that
outweighs the harm that Defendant will suffer if the TRO is granted.
See Joelner, 378 F.3d at 619.
At the May 24, 2012 hearing, Plaintiff’s counsel stated that
Plaintiff is scheduled to be discharged from Riverside on May 25, 2012
because neither Blue Cross nor the State of Illinois will pay for her to
remain there. Plaintiff states that she does not have any other source of
funding to pay for her placement at Riverside or at an alternative
residential treatment facility. Plaintiff also states that she cannot safely
reside at her home, where she does not have access to medically
necessary services. Therefore, Plaintiff alleges, if discharged from
Riverside without the requested TRO, Plaintiff would be forced to be
admitted to a hospital to receive services to treat her emotional,
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behavioral, and developmental disorders. Plaintiff states that she would
suffer irreparable harm if forced to stay in a hospital, because treatment
in a psychiatric hospital is far more restrictive than treatment in a
residential treatment facility. Plaintiff cites the Seventh Circuit’s
decision in Collins, 349 F.3d at 376, in which the court stated: “There is
a distinction between the acute care available in a psychiatric hospital
setting and the less restrictive treatment provided by a residential
facility.” Plaintiff explains that psychiatric hospitals are locked facilities
while residential treatment facilities are not. Plaintiff also states that
children cannot attend school or other community events while at a
psychiatric hospital, but they can attend such events while at a
residential treatment center.
Plaintiff also alleges that spending prolonged time in a hospital in
order to receive treatment would lead to unjustified isolation that is
prohibited under the ADA, 42 U.S.C. § 12132. Plaintiff cites to
Olmstead v. L.C. ex rel. Zimring, 527 U.S. 581, 600-01 (1999), in which
the Supreme Court stated that “confinement in an institution severely
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diminishes the everyday activities of individuals including family
relations, social contacts, work options, economic dependence,
educational advancement, and cultural enrichment.”
Based on the facts alleged in the Complaint and the Motion, the
Court finds that Plaintiff has sufficiently shown that placement in
Plaintiff’s home or in a hospital would likely cause irreparable harm to
Plaintiff. The Court also finds that Defendant will not suffer substantial
harm by providing funds for Plaintiff to stay in a residential treatment
facility in Illinois until this Court is able to hold a hearing on Plaintiff’s
pending Motion for Preliminary Injunction. Therefore, this Court finds
that the irreparable harm that Plaintiff would suffer if no TRO is issued
outweighs the harm that Defendant will suffer if the TRO is granted.
4.
The TRO Will Not Harm the Public Interest
The Court further finds that ordering the State of Illinois to fund
Plaintiff’s medical treatment at a residential facility until this Court has
ruled on the Motion for Preliminary Injunction will not harm the public
interest. Therefore, the Court finds that issuing a TRO in this case will
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not harm the public interest.
In sum, this Court finds that a TRO is required to prevent
irreparable harm until a hearing on the motion for preliminary
injunction can be held before this Court.
CONCLUSION
Accordingly, the Court GRANTS Plaintiff’s Motion (d/e 11) and
ORDERS as follows:
1. Defendants are ordered to pay for Plaintiff’s placement at
Lincoln Prairie Behavioral Health Center in Springfield, Illinois,
beginning May 25, 2012 and lasting until the restraints of this
Order dissolve.
2. A hearing on Plaintiff’s Motion for Preliminary Injunction is set
for June 7, 2012 at 4:00 p.m. This Order’s restraints shall dissolve
at the close of that hearing, unless extended before that date and
time.
If Defendants fail to comply with the terms of this Opinion,
Defendants will be in contempt of this Court and subject to sanctions.
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IT IS SO ORDERED.
ENTERED: May 25, 2012
FOR THE COURT:
s/ Sue E. Myerscough
SUE E. MYERSCOUGH
UNITED STATE DISTRICT JUDGE
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