Holly Hill Nursing LLC et al v. Malhotra et al

Filing 25

MEMORANDUM OPINION. Signed by Judge Paul W. Grimm on 10/16/2018. (jf3s, Deputy Clerk)

IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF MARYLAND
Southern Division
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HOLLY HILL NURSING LLC et al.,
Plaintiffs,

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v.

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Case No.: 8:17-cv-03554-PWG

LOURDES R. PADILLA et al.,
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Defendants.
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MEMORANDUM OPINION
The plaintiffs 1 in this case are Ohio and Maryland companies that provide care for elderly
and infirm patients. Each company purports to be acting in its capacity as the “authorized
representative” of a patient who sought Medicaid benefits from the state of Maryland while in
the company’s care. See 42 C.F.R. § 435.923. The companies have brought this suit against two
Maryland state officials, Department of Human Services Secretary Lourdes Padilla and
Department of Health Secretary Robert Neall, 2 suing each in his official capacity for allegedly
failing to administer the state’s Medicaid program in accordance with federal law. Am. Compl.,
ECF No. 18.

1

The plaintiffs are: Holly Hill Nursing LLC; St. Mary’s Nursing Center, Inc.; and Howard
Leasing Co.
2
Padilla and Neall stepped into the role of Defendants in February 2018 as a result of a
substitution of parties under Federal Rule of Civil Procedure 25(d). ECF No. 17. Plaintiffs’
complaint had initially named Defendants’ predecessors in office, Department of Human
Services Secretary Sam Malhotra and Department of Health Secretary Dennis Shrader. Compl.,
ECF No. 1.
1

In broad strokes, Plaintiffs assert that state officials frustrated three of their patients’
attempts to secure benefits through Maryland’s medical assistance program. They allege, in
particular, that program administrators failed to issue timely eligibility determinations and
unlawfully required the patients to produce financial records that, because of their mental and
physical impairments, they were ill equipped to locate or supply.
The Amended Complaint, ECF No. 18, brings seven claims. To begin, Plaintiffs seek
relief under 42 U.S.C. § 1983 for violations of the federal Medicaid Act, 42 U.S.C.
§§ 1396a(a)(1)(A), (a)(8), 1396d(a)(4)(A) (Counts II and III) and deprivations of due process
and equal protection under the Fourteenth Amendment to the U.S. Constitution (Count VI).
They further allege discrimination under Title II of the Americans with Disabilities Act, 42
U.S.C. § 12132 (Count IV) and under § 504 of the Rehabilitation Act, 29 U.S.C. § 794(a) (Count
V).

Finally, Plaintiffs ask this Court to issue orders for declaratory relief (Count I) and

injunctive relief (Count VII). 3
Defendants have filed a motion to dismiss or, alternatively, for summary judgment,
asserting a host of jurisdictional and merits-based defenses. 4 As this Memorandum Opinion will
explain, I conclude the doctrine of sovereign immunity requires the Court to dismiss several of
Plaintiffs’ claims. I also conclude Plaintiffs have failed to state a claim under the Rehabilitation
Act. Because none of Plaintiffs’ claims survives scrutiny, the Motion to Dismiss will be granted.

3

While Plaintiffs style their request for injunctive relief as an independent cause of action, case
law makes plain that this is in error. Injunctive relief is not a cause of action; it is a remedy. See
Doe v. Salisbury Univ., 107 F. Supp. 3d 481, 493 (D. Md. 2015); Augustson v. Bank of Am.,
N.A., 864 F. Supp. 2d 422, 439 (E.D.N.C. 2012). Accordingly, Count VII fails to state a claim
and is dismissed with prejudice.
4
The parties fully briefed the motion. ECF Nos. 19, 22 & 23. A hearing is not necessary. See
Loc. R. 105.6.
2

I.
Background
Plaintiffs’ Amended Complaint takes aim at the processes the State of Maryland has put
in place to administer Medicaid benefits under Title XIX of the Social Security Act, commonly
known as the Medicaid Act, 42 U.S.C. §§ 1396-1396w-5. The program, which draws funding
from both state and federal sources, offers assistance to individuals who cannot afford to pay for
their medical care. See generally Dep’t of Health & Mental Hygiene v. Campbell, 771 A.2d
1051, 1053-54 (Md. 2001). Federal laws and regulations impose a number of conditions on
states that accept federal funding for Medicaid, a few of which are especially relevant for present
purposes. First, a state must furnish Medicaid benefits to eligible applicants “with reasonable
promptness.” 42 U.S.C. § 1396a(a)(8). Federal regulations go further, requiring states to make
eligibility determinations “promptly and without undue delay.” 42 C.F.R. § 435.912(b); see also
42 C.F.R. § 435.952(a) (requiring states to “promptly” evaluate the information they receive in
the course of making an eligibility determination). The maximum amount of time permitted for
determining an applicant’s eligibility is set at 90 days. 42 C.F.R. § 435.912(c)(3). Maryland
regulations tighten the timeframe, capping the eligibility-determination period at 30 days. Md.
Code Regs. 10.09.24.04(I)(1)(b).
To facilitate the eligibility-determination process, Congress requires states to implement
an “asset verification program,” through which applicants authorize the state to obtain relevant
financial records from financial institutions. 42 U.S.C. § 1396w(a)-(b). A state agency also
must solicit information “from other agencies in the State and other States and Federal programs
to the extent the agency determines such information is useful to verifying the [applicant’s]
financial eligibility.” 42 C.F.R. § 435.948(a). A federal regulation provides: “An individual

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must not be required to provide additional information or documentation unless information
needed by the agency . . . cannot be obtained electronically or the information obtained
electronically is not reasonably compatible.” Id. § 435.952(c).
Here, Plaintiffs brought suit on behalf of three Maryland residents who encountered
challenges in their attempts to secure Medicaid benefits through the state program. I will
summarize their accounts in brief. 5
A.
William H.
Plaintiff Holly Hill Nursing LLC (“Holly Hill”), an Ohio corporation, here seeks to
represent the interests of William H., 6 a resident at the Holly Hill Healthcare Center in Towson,
Maryland, since August 2016. Am. Compl. ¶¶ 1, 4. While at the facility, William H. was
suffering from a range of “severe” illnesses, including pulmonary hypertension, chronic
obstructive pulmonary disease, type 2 diabetes, and acute bronchitis, as well as muscle weakness
and atrophy. Id. ¶¶ 13, 14. Not long after his arrival at Holly Hill, he designated the facility as
his “authorized representative” for purposes of the Medicaid application process and “other
ongoing communications” with Maryland Medicaid program administrators, per 42 C.F.R.
§ 435.923. 7 Id. ¶ 21. Holly Hill submitted an application for long-term care Medicaid benefits
on his behalf on November 22, 2016. Id. ¶ 16. Two and a half weeks later, on December 9,
2016, the State sent Holly Hill “various requests for verifications.” Id. ¶ 5. Holly Hill responded
5

In assessing a motion to dismiss, I accept the facts in the amended complaint as true. Ashcroft
v. Iqbal, 556 U.S. 662, 678 (2009).
6
To protect the privacy of the individual patients, I refer only to their first names and the first
initial of their last names.
7
This regulation provides in part: “The agency must permit applicants and beneficiaries to
designate an individual or organization to act responsibly on their behalf in assisting with the
individual’s application and renewal of eligibility and other ongoing communications with the
agency.” 42 C.F.R. § 435.923(a)(1).
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that an extension might be necessary. Id. On April 18, 2017, William H. personally wrote to the
State to ask for extra time to acquire the requested information. Id. ¶ 17. The State did not
respond. Id.
The State ultimately denied William H.’s application, issuing a notice of denial on May
1, 2017. Id. ¶ 19. However, on March 27, 2018, about four months after Holly Hill initiated this
suit, the State notified William H. that it had deemed him eligible for Medicaid benefits. 8 See
Notice of Eligibility 3, Mot. to Dismiss Ex. 1, ECF No. 19-2. The period of eligibility was to run
from November 2017 to October 2018. Id.
B.
June H.
A second plaintiff, St. Mary’s Nursing Center, Inc. (“St. Mary’s”), is here representing
the interests of June H., who resided at the company’s facility in Leonardtown, Maryland, from
June 4, 2014, until her death on February 16, 2016. Am. Compl. ¶¶ 2, 5.
While at St. Mary’s, June H. suffered from mental illnesses, including dementia, that
impaired her ability to think, communicate, or care for herself. Id. ¶ 23. She also suffered from
epilepsy, major depressive disorder, and type 2 diabetes. Id. ¶ 22. These conditions left her
unable to participate in the Medicaid application process “without assistance.” Id. ¶ 25.
June H.’s application for long-term care medical assistance is dated October 3, 2014. Id.
At the time, it was her son, David, who acted as her attorney-in-fact and authorized

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Naturally, William H.’s receipt of benefits several months after the commencement of this
action is a fact that cannot be found in the amended complaint. Plaintiffs do acknowledge,
though, that he has been receiving benefits through the program. Pls.’ Opp’n 8-9, ECF No. 22.
To the extent the Court relies on this fact in the following analysis, the Court treats Defendants’
motion as a motion for summary judgment. See Loconte v. Montgomery Cty., Md., No. PWG17-2052, 2018 WL 3642586, at *3 (Aug. 1, 2018).
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representative. Id. June H. and David, whose own health was in decline after a cancer diagnosis,
struggled to provide verifications. Id.
June H. submitted a second Medicaid application on October 20, 2015, roughly one year
after the first application had been filed. Id. The government issued a notice of ineligibility the
following month, on November 19, 2015, explaining the decision was based on her failure to
provide required information. Id. ¶ 26. The notice permitted her to reactivate her application by
submitting requested verifications by April 20, 2016. Id. The notice further directed her to
explain certain transfers she had made to her son. Id.
David died on December 2, 2015, leaving his widow to take over as June H.’s secondary
attorney-in-fact. Id. ¶ 27. David’s widow soon named St. Mary’s as June H.’s authorized
representative.

Id.

St. Mary’s submitted “some” verifications to the government in early

February 2016 but, because of June H.’s physical and mental disabilities, the facility was unable
to provide an explanation about the transfers to her son. Id.
June H. died February 16, 2016. Id. ¶ 29. St. Mary’s submitted a request for a good faith
waiver on March 9, 2016. Id. The government did not respond to the request. Id. While a
county case worker initially indicated the application would be approved, the government soon
afterward stated in an email the application was being denied. Id. ¶ 30. On November 15, 2016,
an administrative law judge dismissed an appeal of the denial, holding the appeal was untimely.
Id. ¶ 33.
C.
Christine D.
The third plaintiff, Howard Leasing Co. (“Howard Leasing”), is an Ohio company that
owns and operates the Marley Neck Health & Rehabilitation Center in Glen Burnie, Maryland.

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Am. Compl. ¶ 3. Howard Leasing is here representing Christine D., a patient who, like June H.,
suffered from mental illness, including dementia. Id. ¶ 35. Her illness impaired her ability to
think, communicate, or care for herself. Id.
Christine D.’s application for long-term medical assistance was dated December 10,
2015. Id. ¶ 36. Two days later, the State asked her to provide additional information. Id. She
died on January 18, 2016, without having designated anyone to serve as her authorized
representative for Medicaid benefits. Id. ¶¶ 6, 40. Nevertheless, the State continued to send
requests for verifications. Id. ¶ 38. These requests included a revised request for information on
February 16, 2016, and a “reminder notice” on May 7, 2016. Id. The State finally issued a
notice of denial on June 3, 2016, citing Christine D.’s failure to provide requested verifications.
Id. ¶ 39.
The personal representative of Christine D.’s estate unsuccessfully appealed the denial.
Id. ¶ 42-44. Later, just before this suit was filed, the personal representative designated Marley
Neck as Christine D.’s authorized representative under 42 C.F.R. § 435.923. Id. ¶ 41.
II.
Standard of Review
A district court assesses a motion to dismiss on the pleadings, without need of a hearing.
Smith v. Montgomery Cty. Corr. Facility, No. PWG-13-3177, 2014 WL 4094963, at *1 (D. Md.
Aug. 18, 2014). A complaint that “fails to state a claim upon which relief can be granted”
warrants dismissal under Federal Rule of Civil Procedure 12(b)(6). Pegues v. Wal-Mart Stores,
Inc., 63 F. Supp. 3d 539, 541 (D. Md. 2014). Under Rule 8(a)(2), the complaint must contain “a
short and plain statement of the claim showing that the pleader is entitled to relief.” Fed. R. Civ.
P. 8(a)(2). Beyond that, the Supreme Court has held that claims for relief must be “plausible,”

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specifying that “[t]hreadbare recitals of the elements of a cause of action, supported by mere
conclusory statements, do not suffice.” Ashcroft v. Iqbal, 556 U.S. 662, 678-79 (2009). “A
claim has facial plausibility when the plaintiff pleads factual content that allows the court to
draw the reasonable inference that the defendant is liable for the misconduct alleged.” Id. at 663.
When reviewing a motion to dismiss, “[t]he court may consider documents attached to
the complaint, as well as documents attached to the motion to dismiss, if they are integral to the
complaint and their authenticity is not disputed.” Sposato v. First Mariner Bank, No. CCB–12–
1569, 2013 WL 1308582, at *2 (D. Md. Mar. 28, 2013); see also CACI Int'l v. St. Paul Fire &
Marine Ins. Co., 566 F.3d 150, 154 (4th Cir. 2009). However, if the Court considers matters
outside the pleadings, the Court must treat the motion as a motion for summary judgment. Fed.
R. Civ. P. 12(d); Syncrude Canada Ltd. v. Highland Consulting Grp., Inc., 916 F. Supp. 2d 620,
622–23 (D. Md. 2013).
III.
Discussion
A.
Sovereign Immunity
Defendants first argue the Eleventh Amendment bars Plaintiffs’ § 1983 claims alleging
violations of the Medicaid Act (Counts II and III) and the Due Process and Equal Protection
Clauses of the U.S. Constitution (Count VI). They then argue, separately, that Congress’s
abrogation of sovereign immunity for claims brought under Title II of the ADA does not apply to
Plaintiffs’ ADA discrimination claim (Count IV) because Plaintiffs have not adequately alleged
that Defendants violated a right guaranteed by the Fourteenth Amendment to the U.S.
Constitution. These two arguments are distinct. I will address them separately.

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1.
§ 1983 Claims
The Eleventh Amendment bars citizens from bringing a federal lawsuit against a state
without the state’s consent. See Seminole Tribe of Fla. v. Florida, 517 U.S. 44 (1996); LeeThomas v. Prince George’s Cty. Pub. Schs., 666 F.3d 244, 248 (4th Cir. 2012). This grant of
immunity extends to “state agents and state instrumentalities,” including state officials. Bland v.
Roberts, 730 F.3d 368, 389-90 (4th Cir. 2013) (quoting Regents of the Univ. of Cal. v. Doe, 519
U.S. 425, 429 (1997)). Plaintiffs, who have sued Defendants in their official capacities as the
heads of the Maryland Department of Human Services and Department of Health, do not dispute
that Defendants are state officials for Eleventh Amendment purposes. They maintain, though,
that their suit may proceed under the Ex Parte Young exception.
The Ex Parte Young doctrine makes it possible for plaintiffs to petition the courts to
enjoin state officers from engaging in conduct that violates the U.S. Constitution or federal law.
See Antrican v. Odom, 290 F.3d 178, 184 (4th Cir. 2002). The doctrine does not permit the
recovery of damages for past violations. It concerns itself only with future conduct, asking the
court to “conduct a ‘straightforward inquiry into whether the complaint alleges an ongoing
violation of federal law and seeks relief properly characterized as prospective.’” D.T.M. ex rel.
McCartney v. Cansler, 382 F. App’x 334, 337 (4th Cir. 2010) (per curiam) (quoting Verizon Md.
Inc. v. Pub. Serv. Comm’n, 535 U.S. 635, 645 (2002)).
Throughout the Amended Complaint, Plaintiffs broadly insist that Defendants are
engaging in ongoing violations of the U.S. Constitution and federal law. See, e.g., Am. Compl.
¶ 135. I pause a moment to point out, though, that the strict terms of 42 U.S.C. § 1983 state that
a person acting under color of law “shall be liable to the party injured.” 42 U.S.C. § 1983

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(emphasis added). It should be clear, then, that Plaintiffs’ § 1983 claims (Counts II, III, and VI)
necessarily seek redress for the harm Defendants allegedly inflicted on William H., June H., and
Christine D. in particular – not on similarly situated Medicaid applicants in general. Cf. City of
Los Angeles v. Lyons, 461 U.S. 95, 105 (1983) (concluding that a victim of police violence
lacked standing to seek prospective injunctive relief in a § 1983 suit “absent a [showing of] a
significant likelihood that he will again be wronged in a similar way (emphasis added)).
With that said, the Court must now consider the two distinct arguments Defendants’ raise
in seeking to dismiss the § 1983 claims. First, Defendants argue that because June H. and
Christine D. are deceased, any relief sought on their behalf cannot be considered prospective.
Mot. to Dismiss 14, ECF No. 19-1. Second, they argue Holly Hill’s claims on behalf of William
H. cannot allege an “ongoing violation of federal law” because he is currently receiving longterm Medicaid benefits. Id. at 15. I will address each of these contentions in turn.
i.
June H. and Christine D.
June H. and Christine D. died before this suit commenced. That being the case, there is
simply no way to accord prospective relief for the wrongs their authorized representatives allege.
This Court recently said as much in Wicomico Nursing Home v. Padilla, holding that Eleventh
Amendment immunity shielded Maryland Medicaid administrators in a suit brought by the
assignees of several deceased Medicaid applicants. No. RDB-16-1078, 2017 WL 3383105, at *5
(D. Md. Aug. 7, 2017) (“Notwithstanding the Facilities’ assertion that they are seeking
prospective relief, they are unable to demonstrate how the relief sought in this suit on behalf of
these residents can be characterized as ‘prospective’ so as to fall within the Young exception.
There is, of course, no prospective relief available to the deceased residents.” (emphasis

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omitted)); see also Lorien Life Ctr. Balt. Cty., Inc. v. Malhotra, No. MJG-15-2865, 2016 WL
1696451, at *2 (D. Md. Apr. 28, 2016) (holding that Eleventh Amendment immunity barred a
deceased Medicaid applicant’s claims against Maryland program administrators).
At least one other court has arrived at the same conclusion.

See Future Care

Consultants, LLC v. Connolly, No. 17-2552, 2018 WL 1069414, at *4-5 (D.N.J. Feb. 26, 2018);
see also Carespring Healthcare, 2018 WL 1138428, at *11 (concluding that claims relating to
deceased Medicaid applicants “must be characterized as requests for retroactive relief” under Ex
Parte Young). Plaintiffs, meanwhile, have not identified any cases where a court permitted a
party representing the interests of a deceased welfare program applicant to sue state officials
under the Ex Parte Young doctrine.
On these facts, Plaintiffs cannot establish an ongoing violation of law capable of
prospective relief. See Wicomico Nursing Home, 2017 WL 3383105, at *5. I therefore dismiss
Counts II, III, and VI with prejudice, insofar as they relate to June H. and Christine D. See
Kabando v. Boente, No. 1:17-cv-76, 2017 WL 4507471, at *2 n.7 (E.D. Va. May 31, 2017)
(“[T]he fact that immunity may be waived suggests that it is quasi-jurisdictional, and that judicial
power remains to dismiss the action with prejudice, as the alleged cause of action is not
cognizable.”).
ii.
William H.
Defendants contend the § 1983 claims brought on William H.’s behalf must be scuttled
for similar reasons. Along with their Motion to Dismiss, Defendants submitted documentation
showing that, following the commencement of this suit, the State deemed William H. eligible to
receive benefits under Maryland’s Medicaid program. Notice of Eligibility 3, ECF No. 19-2.

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Plaintiffs do not dispute that he is currently receiving benefits. See Pls.’ Opp’n 8-9, ECF No. 22.
Defendants argue he cannot be suffering an ongoing violation of law now that he is benefitting
from the program.
As before, whether a Plaintiff seeks prospective relief depends, at least in part, on the
particularities of the violations alleged in the complaint. Count II alleges state officials failed to
provide benefits in compliance with 42 U.S.C. § 1396a(a)(10)(A).

That provision of the

Medicaid Act requires states to “mak[e] medical assistance available” to qualifying individuals.
42 U.S.C. § 1396a(a)(10)(A).

As of this moment, though, the State is making assistance

available to William H. 9 Plaintiffs have not explained how this Court might fashion prospective
relief under these circumstances.
Count III alleges the State violated 42 U.S.C. § 1396a(a)(8), which requires states to
“provide that all individuals wishing to make application for medical assistance under the plan
shall have [an] opportunity to do so, and that such assistance shall be furnished with reasonable
promptness to all eligible individuals.” 42 U.S.C. § 1396a(a)(8). Plaintiffs allege, in particular,
that officials were slow in reviewing William H.’s application and failed to issue a timely notice
of denial. Perhaps so, but any tardiness on the part of the State occurred in the past, and
Plaintiffs fail to explain how the Court might accord prospective relief now that William H. is
receiving benefits. Try as I might, I cannot order the State to take action in the future to speed up
an eligibility evaluation that concluded before suit was brought, especially when, as here, it
changed its course and began providing the very benefits originally sought.

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In considering this fact, which postdates the amended complaint but is undisputed, I treat
Plaintiffs’ motion as a motion for summary judgment. See Loconte v. Montgomery Cty., Md.,
No. PWG-17-2052, 2018 WL 3642586, at *3 (Aug. 1, 2018).
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Plaintiffs’ claims under the U.S. Constitution (Count VI) raise similar questions. Were it
not for the Eleventh Amendment, Plaintiffs might seek compensation for these past wrongs.
That is not available here, though, and Plaintiffs have not identified any prospective relief the
Court might order in its place.
Plaintiffs ask this Court to take guidance from the Fourth Circuit’s unpublished opinion
in D.T.M. ex rel. McCartney v. Cansler. There, the Fourth Circuit held the Eleventh Amendment
did not bar a § 1983 suit against a state official responsible for administering Medicaid programs.
382 F. App’x 334, 335 (4th Cir. 2010) (per curiam). That case, though, is inapposite. First,
unlike two of the applicants in this case, the plaintiffs in D.T.M. were alive at the time the court
rendered its judgment. Second, the D.T.M. plaintiffs’ allegation was that state officials had
arbitrarily terminated or reduced their benefits. They sought to enjoin the State to (1) continue
providing services to current beneficiaries while bringing the program in line with federal law
and (2) reinstate services the State had previously provided. See id. at 336. The Fourth Circuit
concluded, first, that “the request for prospective reinstatement of benefits is precisely the type of
relief” the Fourth Circuit has upheld under Ex Parte Young. See id. at 337 (citing Kimble v.
Solomon, 599 F.2d 599, 605 (4th Cir. 1979)). Second, while not deciding whether reinstating
benefits would qualify as prospective relief under Ex Parte Young, the Fourth Circuit concluded
that “injunctive relief from the continuation of [the State’s] illegal practices would.” No such
remedies are available here.
Plaintiffs’ reliance on Doctors Nursing & Rehabilitation Center, LLC v. Norwood, No.
1:16-cv-9837, 2017 WL 2461544 (N.D. Ill. June 7, 2017), is similarly misplaced. The patients in
that case were either still awaiting Medicaid eligibility determinations or had been approved but
were waiting to start receiving benefits. 2017 WL 2461544, at *1. The District Court for the

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Northern District of Illinois concluded the patients could properly seek prospective relief in the
form of an injunction requiring state officials to arrange for medical assistance and nursing
facility services for those patients. Id. at *3. Plaintiffs here, who either are deceased or are
already receiving benefits, cannot seek the same.
For these reasons, I conclude the Eleventh Amendment bars Counts II, III, and VI of the
Amended Complaint. These claims are dismissed with prejudice. See Kabando, 2017 WL
4507471, at *2 n.7.
2.
ADA Claim
Plaintiffs’ discrimination claim under Title II of the ADA also implicates the Eleventh
Amendment, but this claim requires a different analysis.
Congress has expressly abrogated Eleventh Amendment immunity under the ADA. See
42 U.S.C. § 12202. The pertinent statute provides: “A State shall not be immune under the
eleventh amendment to the Constitution of the United States from an action in Federal or State
court of competent jurisdiction for a violation of [42 U.S.C., Ch. 126].” Id. In United States v.
Georgia, the Supreme Court explained that this provision abrogates state sovereign immunity
“insofar as Title II creates a private cause of action for damages against the States for conduct
that actually violates the Fourteenth Amendment.”
omitted).

546 U.S. 151, 159 (2006) (emphasis

Defendants cite Georgia for the proposition that states and state officials retain

immunity for Title II claims that do not properly allege a Fourteenth Amendment violation, but
this is incorrect. The Georgia Court expressly contemplated the possibility that, in exercising its
enforcement power under § 5 of the Fourteenth Amendment, Congress may have abrogated state
immunity for at least some claims alleging conduct that violates Title II but does not in and of

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itself run afoul of the U.S. Constitution. See 546 U.S. at 159; see also Guttman v. Khalsa, 669
F.3d 1101, 1117 (10th Cir. 2012) (explaining that § 5 of the Fourteenth Amendment accords
Congress “broad” enforcement powers, including the power to deter violations of Fourteenth
Amendment rights by “‘prohibiting a somewhat broader swath of conduct’ than that which the
Amendment itself proscribes” (quoting Kimel v. Fla. Bd. of Regents, 528 U.S. 62, 81 (2000)));
Spencer v. Earley, 278 F. App’x 254, 257-58 (4th Cir. 2008). Although the Court declined to
limn the boundaries of Congress’s abrogation of state sovereign immunity under Title II, it did
offer guidance to assist lower courts in their examinations. The three-part Georgia test asks the
district court to determine
on a claim-by-claim basis, (1) which aspects of the State’s alleged
conduct violated Title II; (2) to what extent such misconduct also
violated the Fourteenth Amendment; and (3) insofar as such
misconduct violated Title II but did not violate the Fourteenth
Amendment, whether Congress’s purported abrogation of
sovereign immunity as to that class of conduct is nevertheless
valid.
Georgia, 546 U.S. at 159.
Here, Plaintiffs assert broadly that state officials discriminated against the three patients
by “fail[ing] to provide a system which ensures that medical assistance will be available” and
“fail[ing] to afford the Plaintiffs public benefits and services to which they are entitled under
federal law.” Am. Compl. ¶¶ 95, 96. In support of this assertion, the Amended Complaint
chronicles several bureaucratic obstacles the applicants or their authorized representatives
encountered during the application process. I find it useful to separate the allegations.

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i.
Eligibility Verifications
I first consider Plaintiffs’ allegations that the State placed improper demands on the
Medicaid applicants to produce records demonstrating their eligibility to receive benefits, in spite
of a federal regulation requiring states to seek out available information from third parties. See
42 C.F.R. § 435.952(c). As I will explain, I conclude the facts in the Amended Complaint are
not adequate to state a claim of discrimination under Title II and therefore fail the first prong of
the Georgia test. It is possible, though, that further amendments to the complaint might remedy
this defect. Accordingly, for the reasons that follow, I will dismiss this aspect of Plaintiffs’ Title
II claim without prejudice.
The first step of the Georgia inquiry requires the district court to assess whether
Defendants’ alleged conduct “forms the basis for a Title II claim.” Bowers v. Nat’l Collegiate
Athletic Ass’n, 475 F.3d 524, 553 (3rd Cir. 2007); see Gattuso v. N.J. Dep’t of Human Servs.,
881 F. Supp. 2d 639, 647-48 (D.N.J. 2012).
Plaintiffs accuse state officials of violating 42 U.S.C. § 12132, which provides: “[N]o
qualified individual with a disability shall, by reason of such disability, be excluded from
participation in or be denied the benefits of the services, programs, or activities of a public entity,
or be subjected to discrimination by any such entity.” 42 U.S.C. § 12132. To establish a
violation of this statute, a plaintiff must show that (1) she has a disability, (2) she is otherwise
qualified for the benefit in question, and (3) she was denied the benefit, or was otherwise
discriminated against, on the basis of the disability. See Nat’l Fed’n of the Blind v. Lamone, 813
F.3d 494, 502-03 (4th Cir. 2016). A failure to make reasonable accommodations may constitute
discrimination under Title II. See id. at 503 n.5.

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The Amended Complaint alleges that each of the three patients suffered from “severe”
mental or physical impairments that complicated their efforts to obtain Medicaid benefits.
William H. suffered from pulmonary hypertension, chronic pulmonary disease, type 2 diabetes,
[and] acute bronchitis, among other severe medical illnesses, as well as “muscle weakeness and
muscle wasting atrophy, which substantially impaired his mobility.” Am. Compl. ¶¶ 13, 14.
June H. and Christine D. each suffered from dementia, among other ailments. Id. ¶ 23, 35. The
crux of Plaintiff’s Title II claim is that these impairments left the applicants “physically and
mentally unable to engage and respond to the complicated and multifaceted eligibility process.
Id. ¶ 142.
Plaintiffs observe that federal regulations seek to spare Medicaid applicants the burden of
having to supplement their applications with page after page of supporting financial records. See
42 C.F.R. § 435.952(c) (“An individual must not be required to provide additional information or
documentation unless information needed by the agency in accordance with § 435,948,
§ 435.949 or § 435.956 of this subpart cannot be obtained electronically or the information
obtained electronically is not reasonably compatible . . . .”). Despite this, Plaintiffs allege, “The
Defendants did not seek to obtain any of the Plaintiffs’ information electronically . . . . Nor did
[Defendants] try to obtain Plaintiffs’ information from secondary sources.

Instead, the

Defendants placed the burden of providing information entirely on the Plaintiffs.” Am. Compl.
¶ 61. The Amended Complaint goes on to allege that when one of the applicants, William H.,
personally requested an extension to track down the requested information, the State failed to
respond. Id. ¶ 17.
The problem with the Amended Complaint is that it fails to plead any particulars about
the details of the State’s document requests. Plaintiffs have not asserted that the requested

17

records were indeed available either electronically or from third parties the State was legally
required to consult before placing the burden of production on the applicants themselves. As
filed, the Amended Complaint fails to indicate that proper adherence to the State’s regulatory
obligations would have made it unnecessary to solicit the patients directly.

I conclude,

accordingly, that Count IV of the Amended Complaint fails to state a claim under Title II of the
ADA and that Plaintiffs have not satisfied the first prong of the Georgia test. However, because
it may be possible for Plaintiffs to allege additional facts in support of their claim, I dismiss
Count IV without prejudice.
In taking this step, I note that neither party’s submissions to this Court properly applied
the three-part Georgia framework. Even if, in amending the complaint a second time, Plaintiffs
adequately state a claim under Title II, they will still need to persuade the Court their claim
survives Georgia’s second and third prongs. I reserve the right to request further briefing on the
matter, should the need arise.
ii.
Other Alleged Deficiencies
Plaintiffs also argue the State discriminated against the applicants in other ways. In
particular, they assert that officials failed to respond adequately to a St. Mary’s representative’s
April 2016 request for a notice of the State’s decision to deny benefits for June H. Am. Compl.
¶ 30. Plaintiffs also take issue with the administrative law judges’ dismissals of the appeals of
June H. and Christine D., citing these as further evidence of discrimination. Id. ¶¶ 33, 44. These
allegations, I find, do not support a Title II claim.
Plaintiffs acknowledge the patients were not seeking benefits on their own. Two of them,
William H. and June H., designated a third party to act as his or her authorized representative

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pursuant to 42 C.F.R. § 435.923.

Federal Medicaid regulations state that an authorized

representative is empowered to: “(1) sign an application on the applicant’s behalf, (2) complete
and submit a renewal form, (3) receive copies of the applicant or beneficiary’s notices and other
communications from the agency; [and] (4) act on behalf of the applicant or beneficiary in all
other matters with the agency.” 42 C.F.R. § 435.923(b).
In June H.’s case, the Amended Complaint makes clear that she played no more than a
limited role in the Medicaid application process, on account of her debilitating mental illness.
Am. Compl. ¶¶ 24-27. Her son first acted as her attorney-in-fact and authorized representative.
Id. ¶ 25. Later, the son’s widow provided assistance as secondary attorney-in-fact and named St.
Mary’s as June H.’s authorized representative. Id. ¶¶ 27-28. While Plaintiffs complain the State
failed to respond to St. Mary’s subsequent requests for a waiver or for a notice of denial, there is
simply no way to construe these failures as a form of disability-based discrimination against June
H. herself.
Plaintiffs’ assertions that the administrative law judges “wrongly” denied the appeals of
June H. and Christine D.’s appeals are no more availing. Those appeals were brought by third
parties after the two of them had passed away. Am. Compl. ¶¶ 33, 44. The administrative law
judges’ decisions cannot have denied June H. or Christine D. a reasonable accommodation on the
basis of their disabilities.
I conclude that these allegations do not support a claim of discrimination under 42 U.S.C.
§ 12132 and are not sufficiently well pleaded to overcome Defendants’ Eleventh Amendment
sovereign immunity. I therefore dismiss these aspects of Plaintiffs’ Title II claim with prejudice.

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B.
Failure to State a Claim
Defendants next argue that Plaintiffs’ claim under § 504 of the Rehabilitation Act (Count
V) fails to state a claim for relief under Federal Rule of Civil Procedure 12(b)(6). 10 I need not
expound on this at length here, though, because I have already explained why the amended
complaint, in its present form, fails to state a claim under Title II of the ADA.
The elements of a § 504 claim and a Title II claim are not exactly the same, though they
do overlap. For present purposes, the most relevant distinction is that § 504 claims have a
stricter causation requirement.

To state a claim under § 504, a plaintiff must allege facts

establishing he suffered discrimination “solely by reason of her or his disability.” 29 U.S.C.
§ 794(a).

By contrast, Title II claims merely require a showing that the disability was a

“motivating cause.” Thomas v. Salvation Army S. Territory, 841 F.3d 632, 641 (4th Cir. 2016).
As I detail above, Plaintiffs have not properly alleged that Defendants discriminated
against the three patients on whose behalf this suit was brought. Plaintiffs may be able to repair
this defect by alleging that the information state officials pressed the three patients to provide
was either unnecessary or otherwise available. To the limited extent, then, that Plaintiffs seek to
base Count V on Defendants’ failure to seek records from third-party sources, this claim is
dismissed without prejudice.
10

Defendants did not assert a sovereign immunity defense for this claim, presumably
recognizing that Congress has expressly and unequivocally abrogated Eleventh Amendment
immunity for § 504 claims. See 42 U.S.C. § 2000d-7(a)(1) (“A state shall not be immune under
the Eleventh Amendment of the Constitution of the United States from suit in Federal court for a
violation of section 504 of the Rehabilitation Act of 1973 . . . .”); Levy v. Kan. Dep’t of Soc. &
Rehab. Servs., 789 F.3d 1164, 1170 (10th Cir. 2015) (explaining that Congress’s power to
abrogate state sovereign immunity for Rehabilitation Act claims derives from Congress’s
authority under the Spending Clause, whereas its power to abrogate immunity for ADA claims is
subject to the constitutional limitations on congressional power to enforce the Fourteenth
Amendment).
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C.
Declaratory Relief
Having dismissed Counts II through VI, I am left with Plaintiffs’ request for declaratory
relief under the Declaratory Judgment Act, 28 U.S.C. § 2201 (Count I). I conclude that this
claim cannot proceed at present because there is no longer a “case” or “controversy” this Court
may properly adjudicate under Article III of the U.S. Constitution. See Dyer v. Md. State Bd. of
Educ., 685 F. App’x 261, 262 (4th Cir. 2017) (per curiam).
The Declaratory Judgment Act “is remedial only and neither extends federal courts’
jurisdiction nor creates any substantive rights.” CGM, LLC v. Bell S. Telecomms., Inc., 664 F.3d
46, 55 (4th Cir. 2011). Accordingly, “a request for declaratory relief [under § 2201] is barred to
the same extent that the claim for substantive relief on which it is based would be barred.” Id. at
55-56 (alteration omitted) (quoting Int’l Ass’n of Machinists & Aerospace Workers v. Tenn.
Valley Auth., 108 F.3d 658, 668 (6th Cir. 1997)).
As I have explained, Plaintiffs’ substantive claims in Counts II, III, IV, and VI are barred
by the Eleventh Amendment. The lone remaining substantive claim, brought under § 504 of the
Rehabilitation Act claim (Count V), fails to state a claim under Federal Rule of Civil Procedure
12(b)(6). Plaintiffs’ case, now devoid of all claims for substantive relief, cannot survive on the
sole basis of a request for declaratory relief. Count I is therefore dismissed without prejudice.
IV.
Conclusion
In sum, I conclude that Plaintiffs’ § 1983 claims (Counts II, III, and VI) are barred by
sovereign immunity. I dismiss these claims with prejudice. I also conclude that Plaintiffs have
failed to state a claim for relief under Title II of the ADA (Count IV) or the Rehabilitation Act

21

(Count V). I recognize, though, that Plaintiffs may be able to cure the pleading deficiencies for
those two claims by alleging facts that would support a determination that Defendants’ failure to
solicit financial records from electronic databases or third-party sources discriminated against the
three patients. (Plaintiffs are cautioned, however, that any further amendment of the complaint
that may be permitted will be limited to this narrow ground.) Accordingly, I dismiss Counts IV
and V without prejudice. 11 I do so only, though, to the extent these counts allege Defendants
failed to properly seek financial records from third-party sources. To the extent the counts are
based on other alleged deficiencies, the counts are dismissed with prejudice. Having dismissed
all of Plaintiffs’ claims for substantive relief, I must also dismiss Plaintiffs’ claim for declaratory
relief (Count I). That claim is dismissed without prejudice.
A separate order will follow.

Date: October 16, 2018

_______
/S/
Paul W. Grimm
United States District Judge

11

As explained above, though, it is my view that neither party has adequately briefed the issue of
whether the Eleventh Amendment would bar Plaintiffs’ ADA claim (Count IV) in the event
Plaintiffs do cure the pleading deficiency. If necessary, I will request additional briefing on this
question.
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