Ball et al v. Kasich et al

Filing 486

OPINION AND ORDER granting in part and denying in part 353 Motion to Dismiss; granting in part and denying in part 354 Motion to Dismiss; granting in part and denying in part 355 Motion to Dismiss; granting 373 Motion for Leave to File. Signed by Judge Edmund A. Sargus on 2/17/2021. (cmw)

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UNITED STATES DISTRICT COURT
SOUTHERN DISTRICT
EASTERN DIVISION
PHYLLIS BALL, et al.,
Plaintiffs,
Civil Action 2:16-cv-282
JUDGE EDMUND A. SARGUS, JR.
Magistrate Judge Elizabeth P. Deavers

v.

JOHN KASICH, et al.,
Defendants.

OPINION AND ORDER
This matter is before the Court on three Motions to Dismiss filed by the Ohio County
Boards Serving People with Developmental Disabilities (ECF No. 353), the State of Ohio (ECF
No. 354), and the Governor of Ohio (ECF No. 355). Those motions are ripe for review. (ECF
Nos. 363, 372, 383, 384.) Also, before the Court is the unopposed Motion for Leave to File as
Amicus Curiae filed by VOR, Inc. (ECF Nos. 373.) For the reasons that follow, the Motions to
Dismiss are GRANTED IN PART AND DENIED IN PART (ECF Nos. 353, 354, 355), and
the Motion for Leave to File is GRANTED (ECF No. 373).
I.
This case involves two groups of individuals with developmental disabilities who are not
satisfied with Ohio’s administration of its developmental-disability system. One group,
Plaintiffs and Disability Rights Ohio, filed this case alleging that Ohio’s system violates federal
law because it is allegedly too reliant on Intermediate Care Facilities (“ICFs”) at the expense of
integration into the community for disability services.

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The other group, who intervened as representatives of individuals who prefer institutional
care in ICFs (“Guardians”), allege that Ohio’s system violates the same federal law because it is
fails to inform people of the ICF choice, leaving them only the option of community based care
through waivers or wait lists for those waivers. Defendants frame the general issue before this
Court as follows:
Defendants agree that [the] Guardians should have a voice in this case.
Guardians hold reasonable and firmly-held beliefs that Intermediate Care Facilities
(“ICFs”) are the best places for their loved ones. . . . But that does not mean
Guardians have their own federal claims against State Defendants.
(Ohio Mot. to Dismiss at 1, ECF No. 354.) Defendants have all, therefore, moved for dismissal
of the Guardians’ claims.
A.

Initiation of This Lawsuit
On March 31, 2016, Disability Rights Ohio filed this case on behalf of six individually

named Plaintiffs (“Individual Plaintiffs”) and the Ability Center of Greater Toledo (together
“Plaintiffs”) seeking declarative and injunctive relief against and the Directors of the Ohio
Department of Developmental Disabilities, the Ohio Department of Medicaid, and Opportunities
for Ohioans with Disabilities (together “State of Ohio”) and the Governor of Ohio (together
“Defendants”). Plaintiffs alleged that Ohio’s administration, management, and funding of its
service system for people with intellectual and developmental disabilities such as themselves put
them at serious risk of segregation and institutionalization in violation of Title II of the
Americans with Disabilities Act (“ADA”), 42 U.S.C. § 12132, et seq. and Section 504 of the
Rehabilitation Act, 29 U.S.C. § 794.2 as interpreted by the Supreme Court’s decision in
Olmstead v. L.C., 527 U.S. 581 (1999). Plaintiffs also moved under Title XIX of the Social
Security Act (“Medicaid Act”), 42 U.S.C. 1396, et seq.,

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Defendants filed motions for dismissal of Plaintiffs’ claims for failure to state a claim
upon which relief can be granted. (ECF Nos. 16, 27, 28.) The Court granted in part and denied in
part those motions. (ECF No. 90.)
The Ohio County Boards Serving People with Developmental Disabilities (“County
Boards”) moved to intervene, which was opposed by Plaintiffs. (ECF Nos. 68, 73.) After full
briefing (ECF No. 79), this Court permitted the County Boards to intervene (ECF No. 261),
adding them to the existing Defendants.
The Guardians, representing individuals who prefer institutional care in ICFs also moved
to intervene. (Mot. Intervene 5, ECF No. 107; Individual Guardian Docs., ECF Nos. 123, 125–
29, 138, 139, 141–44, 146–48, 152–53, 155, 160, 161, 166–70, 172–77, 182–86, 192–220, 223–
32, 234–41, 243–45, 247–49, 251–60). Defendants supported the Guardians’ request to
intervene, but only for the purpose of opposing Plaintiffs’ request for class certification. (ECF
No. 130.) Plaintiffs opposed intervention. (ECF No. 131.) The Court granted intervention to
the Guardians in July 2017. (Opinion and Order, ECF No. 261.)
VOR, Inc. moved to intervene to support the Guardians’ opposition to class certification,
(ECF No. 164), which this Court granted (ECF No. 261) after full briefing (ECF Nos. 222, 246).
The Individual Plaintiffs sought to represent a class of similarly situated individuals with
intellectual and developmental disabilities, moving for class certification under Rule 23(b)(2) of
the Federal Rules of Civil Procedure. (ECF No. 42, 53, 276.) Defendants opposed class
certification (ECF Nos. 273, 279, 291), as did the County Boards (ECF Nos. 275, 293), VOR
(ECF No. 294), and the Guardians (ECF No. 296). The Court granted in part Plaintiffs’ Motion
to Certify Class, certifying a narrower class than requested. (Opinion and Order at 1–2, ECF No.
309; Opinion and Order, ECF No. 303.)

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B.

The Guardians’ Crossclaims
The Guardians filed a Third-Party Complaint with Crossclaims against all Defendants

(the State of Ohio, the Governor of Ohio, and the County Boards). (ECF No. 326.) The
Guardians allege that Ohio has systematically denied ICF services, by failing, in their view, to
assure that individuals who qualify for ICF services are informed of that qualification so that
they may be provided that ICF service if they so choose. Guardians aver that the County Boards
routinely fail to provide information about ICFs to eligible individuals so that the individuals
know they have a choice to reside in an ICF, and instead only provide information related to the
individual’s qualification for waiver services, i.e., community based options or wait lists for
community based options.
The State of Ohio, the Governor of Ohio, and the County Boards, all moved for dismissal
of the Guardians’ crossclaims. (ECF No. 353, 354, 355.) VOR has moved for leave to file as
amicus curiae for the purpose of opposing Defendants’ requests for dismissal, which the Court
grants herein. (ECF Nos. 373.) The Guardians and VOR opposed the motions to dismiss (ECF
No. 372, 373-1), and Defendants filed replies (ECF Nos. 383, 384.) At the request of the parties,
the Court stayed decision on the motions to dismiss so that all parties could engage in settlement
negotiations.
C.

Settlement Negotiations
Following extensive settlement negotiations, all parties entered into a settlement as a

complete and final resolution of all matters. The Court granted the unopposed request of the
Plaintiff Class, Defendants, and the County Boards for Preliminary Approval of the Class Action
Settlement Agreement (ECF Nos. 396, 407, 408) on October 18, 2019 (ECF No. 409).
The following month, the Guardians withdrew from their agreement to settle.

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D.

Procedural Posture
On December 17, 2019, the Court held a Fairness Hearing on the Proposed Final

Settlement Agreement. At that Hearing, there were no objections by any class members. The
Guardians had numerous objectors present and each was permitted to speak, giving his or her
reasons for objecting to the Settlement Agreement.
Following the Fairness Hearing, the Court suggested modifications to the Settlement
Agreement to alleviate the concerns of those whose interests are aligned with the Guardians and
offered all parties the opportunity to respond to the proposed modifications, which they all did.
After review of the briefing, the Court approved the Settlement Agreement with the proposed
modifications. (Final Approval Order, ECF No. 473.)
Plaintiffs and Defendants moved for certification of the Final Approval Order under Rule
54(b) of the Federal Rules of Civil Procedure (ECF No. 478), which provides that a district
“court may direct entry of a final judgment as to one or more, but fewer that all, claims or parties
only if the court expressly determines that there is no just reason for delay.” Fed. R. Civ. P.
54(b). The Guardians opposed the request. (ECF No. 481.) The Court granted the request for
Rule 54 certification and entered judgment on the claims brought by Plaintiffs. (ECF No. 482.)
At the parties’ request, the Court vacated the stay on the motions to dismiss of the State
of Ohio, the Governor of Ohio, and the County Boards. The Court also permitted the Guardians
to file a surreply. (ECF No. 476.) The motions are now ripe for review.
II.
In evaluating a complaint to determine whether it states a claim upon which relief can be
granted under Rule 12(b)(6) of the Federal Rules of Civil Procedure, a court must construe it in
favor of the plaintiff, accept the factual allegations contained in the pleading as true, and

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determine whether the factual allegations present any plausible claim. Bell Atlantic Corp. v.
Twombly, 550 U.S. 544, 570 (2007). See also Ashcroft v. Iqbal, 556 U.S. 662 (2009) (clarifying
the plausibility standard articulated in Twombly). “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.” Iqbal, 556 U.S. at 678. Although a plaintiff’s
complaint need not contain “detailed” factual allegations, its “[f]actual allegations must be
enough to raise a right to relief above the speculative level on the assumption that all the
allegations in the complaint are true.” Twombly, 550 U.S. at 555.
III.
The Guardians filed claims under the same three statutes as did Plaintiffs: (A) the ADA
42 U.S.C. § 12132, et seq., the Rehabilitation Act, 29 U.S.C. § 794.2, and (B) the Medicaid Act,
42 U.S.C. 1396, et seq.,
A.

Americans with Disabilities Act and the Rehabilitation Act
The Guardians rely upon anti-discrimination provisions within both the ADA and the

Rehabilitation Act as interpreted by the Supreme Court’s decision in Olmstead v. L.C., 527 U.S.
581 (1999). Defendants argue that the Guardians have failed to state any plausible claim because
Olmstead recognized a claim for community placement, not a claim for ICF services. (Ohio’s
Mot. to Dismiss at 8, ECF No. 354.) This Court agrees.
Title II of the ADA prohibits public entities, when administering services, from denying
services, or discriminating against people, “by reason of [] disability.” 42 U.S.C. § 12132.
Section 504 of the Rehabilitation Act contains an analogous anti-discrimination provision, which
applies to programs receiving federal money. 29 U.S.C. § 794(a). The two provisions “cover
largely the same ground” and should be analyzed together. R.K. v. Bd. of Educ., 637 F. App’x

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922, 924 (6th Cir. 2016); Qiu v. Univ. of Cincinnati, No. 1:18-cv-634, 2018 U.S. Dist. LEXIS
160246, at *12-13 (S.D. Ohio Sept. 19, 2018) (recognizing that claims under the two provisions
“are generally reviewed under the same standards”).
Olmstead outlined a claim under the ADA’s anti-discrimination provision. 527 U.S. at
587. The Court held that the ADA “require[s]” States to place people “in community settings
rather than in institutions.” Id. The requirement, however, exists only when (1) “the State’s
treatment professionals have determined that community placement is appropriate,” (2) “the
transfer from institutional care to a less restrictive setting is not opposed by the affected
individual,” and (3) “the placement can be reasonably accommodated, taking into account the
resources available to the State and the needs of others.” Id. In reaching this holding, the Court
reasoned that “[u]njustified isolation” could be “properly regarded as discrimination” under
federal law. Id. at 597.
Olmstead identified two public policy justifications underlying its decision:
First, institutional placement of persons who can handle and benefit from
community settings perpetuates unwarranted assumptions that persons so isolated
are incapable or unworthy of participating in community life . . . . Second,
confinement in an institution severely diminishes the everyday life activities of
individuals, including family relations, social contacts, work options, economic
independence, educational advancement, and cultural enrichment.
Id. at 600–601 (citations omitted).
Other federal courts have rejected similar arguments to those presented by the Guardians,
in cases where an individual challenges a state decision to close a treatment facility for the
developmentally disabled or relocate such disabled individuals to community settings. These
courts find that failure to provide facility-based services does not constitute discrimination under
the ADA or Rehabilitation Act. See D.T. v. Armstrong, 2017 U.S. Dist. LEXIS 91725, *20-21,
2017 WL 2590137 (D. Idaho 2017) Sciarrillo v. Christie, 2013 U.S. Dist. LEXIS 175178, 2013
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WL 6586569, * 4 (D. N.J. Dec. 13, 2013) (citing Richard S. v. Dep't of Developmental Servs. of
the State of Cal., 2000 U.S. Dist. LEXIS 22750, 2000 WL 35944246, *3 (C.D. Cal. Mar. 27,
2000); Richard C. ex rel. Kathy B. v. Houstoun, 196 F.R.D. 288, 292 (W.D. Pa. 1999); Ill.
League of Advocates for the Developmentally, Disabled v. Quinn, 2013 U.S. Dist. LEXIS 86637,
2013 WL 3168758, *5 (N.D. Ill. June 20, 2013). As one district court explained:
[T]here is no basis for saying a premature discharge into the community is an ADA
discrimination based on disability. There is no ADA provision that providing
community placement is a discrimination. It may be a bad medical decision, or
poor policy, but it is not discrimination based on disability.
Richard S., 2000 U.S. Dist. LEXIS 22750, 2000 WL 35944246, *3.
The analyses in which these courts engaged is just as relevant to the Guardians’ claims
here. Failure to provide institutional settings for individuals cannot constitute discrimination
based on disability. It may be a bad medical decision, or poor policy, but it is not discrimination
based on disability. Accordingly, Defendants are entitled to dismissal of the Guardians’
discrimination claims brought under the ADA and the Rehabilitation Act.
B.

Medicaid Act
“Medicaid, enacted in 1965 as Title XIX of the Social Security Act, 42 U.S.C. § 1396 et

seq., is a cooperative federal-state program that was established to enable the states to provide
medical services to those who cannot afford such services.” Chambers v. Ohio Dep't of Human
Servs., 145 F.3d 793, 797–98 (6th Cir. 1998). “For states that participate in the program, such
as Ohio, the federal government provides partial funding and establishes mandatory and optional
categories of eligibility and services covered.” Id. While participation in the program is
optional, once a state decides to pursue a Medicaid plan, federal law requires that the plan “shall
be in effect in all political subdivisions of the State, and, if administered by them, be mandatory
upon them.” 42 U.S.C.A. § 1396a(a)(1).
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The Guardians allege that Defendants are violating the Medicaid Act by failing to
meaningfully inform people about ICFs, and this failure to inform leads, in turn, to a failure to
provide ICF services with reasonable promptness. Their claims are brought under the “free
choice” provision of the Medicaid Act, located at 42 U.S.C. § 1396n(c)(2)(B) and (C), and the
“reasonable promptness” provision found at 42 U.S.C. § 1396(a)(8). Guardians, as did Plaintiffs,
move under 42 U.S.C. § 1983 to enforce their alleged rights under the Medicaid Act.
Defendants move for dismissal arguing that (1) these provisions do not confer a private
right of action, (2) “[e]ven assuming this language confers a privately-enforceable right, it does
not confer the right Guardians seek to enforce,” and (3) the Guardians’ crossclaims fail because,
“even at this pleading stage, Guardians cannot seriously dispute that Ohio informs people about
ICFs in several ways.” (Ohio’s Mot. to Dismiss at 15, ECF No. 354; Ohio Reply at 14, ECF No.
383.)
1.

Private Right of Action

Defendants move for dismissal of both the Guardians’ claims under the Medicaid Act,
arguing that neither (a) the free choice provision nor (b) the reasonable promptness provision
provide for a private right of action.
a.

Free Choice Provision

Whether the free choice provision of the Medicaid Act confers a private right of action
was an issue first brought before this Court in a motion filed by Defendants, in which they
moved for dismissal of Plaintiffs’ claims under this provision. While Plaintiffs and Defendants
agreed that the Sixth Circuit had previously held that there was such a right, it had not revisited
this conclusion since Blessing v. Freestone, 520 U.S. 329 (1997) and Gonzaga Univ. v. Doe, 536

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U.S. 273, 284 (2002). Defendants maintained that, under the analysis dictated by the later cases
of Blessing and Gonzaga, the free choice provision did not provide a privately enforceable right.
After analysis, the Court disagreed with Defendants’ position. The Court concluded that
Blessing and Gonzaga did not require departure from the previous law of the Sixth Circuit that
held that the free choice provision of the Medicaid Act provides a private right of action. Ball by
Burba v. Kasich, 244 F. Supp. 3d 662, 667 (S.D. Ohio 2017) (denying that portion of
Defendants’ motion to dismiss). Defendants, in their current motions requesting dismissal of the
Guardians’ claim under this same provision, recognize this Court’s previous determination but
note that, while this Court disagreed with their position, it recognized “that federal courts have
split on the issue.” (Mot at 15, n. 2, ECF No. 354.) This argument, however, has since been
made unavailable.
That is, after the briefing on the motions to dismiss the Guardians’ counterclaims was
complete, the Sixth Circuit revisited this exact issue. In October 2020, the Sixth Circuit
concluded that Blessing and Gonzaga did not require departure from the previous law of the
Sixth Circuit, which found that the free choice provision of the Medicaid Act provides a private
right of action enforceable under 42 U.S.C. § 1983. The Sixth Circuit explained:
We have previously found that both §§ 1396n(c)(2)(A) and (C) [the free choice
provisions] are enforceable under § 1983. Wood v. Tompkins, 33 F.3d 600, 611 (6th
Cir. 1994). However, since then, the Supreme Court has issued its decisions in
Blessing and Gonzaga expanding upon when a statute creates rights enforceable
under § 1983, and so that decision no longer binds us.
Nevertheless, upon reconsideration, we adhere to our conclusion that §§
1396n(c)(2)(A) and (C) [the free choice provisions] are enforceable under § 1983.
The analysis that this Court applied in Wood nearly parallels the analysis required
under Blessing and Gonzaga. See id. at 607–11. And the great majority of courts
to consider the question of whether these provisions allow for a private right of
action post-Gonzaga has found that they do.
Waskul v. Washtenaw County Community Mental Health, 979 F.3d 426, 453 (6th Cir. 2020).
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The Sixth Circuit cited numerous cases as support for the observation that the great
majority of courts are in agreement with its holding that the free choice provision of the
Medicaid Act provides for a private right of action, including this Court’s previous decision on
the issue. Id. (citing as Ball v. Rodgers, 492 F.3d 1094, 1117 (9th Cir. 2007) (§ 1396n(c)(2)(C));
Jackson v. Dep't of Human Servs. Div. of Developmental Disabilities, No. 17-118, 2019 WL
669804, at *2–3 (D. N.J. Feb. 19, 2019) (§ 1396n(c)(2)(A)); Ball v. Kasich, 244 F. Supp. 3d
662, 684 (S.D. Ohio 2017) (§ 1396n(c)(2)(C)); Guggenberger v. Minnesota, 198 F. Supp. 3d
973, 1014–15 (D. Minn. 2016) (§ 1396n(c)(2)(C)); Cohen v. Chester Cnty. Dep't of Mental
Health/Intellectual Disabilities Servs., No. 15-2585, 2016 WL 3031719, at *8 (E.D. Pa. May 25,
2016) (§ 1396n(c)(2)(A)); Steward v. Abbott, 189 F. Supp. 3d 620, 635–37 (W.D. Tex. 2016) (§
1396n(c)(2) generally); Ill. League of Advocates for the Developmentally Disabled v. Quinn, No.
13-1300, 2013 WL 5548929, at *9–10 (N.D. Ill. Oct. 8, 2013) (§ 1396n(c)(2)(C)); Zatuchni v.
Richman, No. 07-4600, 2008 WL 3408554, at *8–11 (E.D. Pa. Aug. 12, 2008) (§
1396n(c)(2)(C)); Michelle P. ex el. Deisenroth v. Holsinger, 356 F. Supp. 2d 763, 769 (E.D. Ky.
2005) (§ 1396n(c)(2)(C)); Masterman v. Goodno, No. 03-2939, 2004 WL 51271, at *9–10 (D.
Minn. Jan. 8, 2004) (§§ 1396n(c)(2)(A) and (C)). But see M.A.C. v. Betit, 284 F. Supp. 2d 1298,
1307 (D. Utah 2003) (§ 1396n(c)(2)(C)); Gaines v. Hadi, No. 06-60129, 2006 WL 6035742, at
*23–24 (S.D. Fla. Jan. 30, 2006) (§ 1396n(c)(2)(A)).
b.

Reasonable Promptness Provision

The reasonable promptness provision of the Medicaid Act provides in relevant part that
“[a] State plan for medical assistance must . . . provide that all individuals wishing to make
application for medical assistance under the plan shall have opportunity to do so, and that such
assistance shall be furnished with reasonable promptness to all eligible individuals.” 42 U.S.C.

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1396a(a)(8). Defendants argue that the “Guardians fail to state any independent ‘reasonable
promptness’ claim [because] [m]uch like the free-choice provision, the reasonable-promptness
provision does not confer a personal right to receive information about ICFs.” (Mot. at 20, ECF
No. 354.)
In Waskul, the case just discussed, the Sixth Circuit not only held that a private right of
action is available under the free choice provision, but also held that there is a private right of
action under the reasonable promptness provision. Waskul, 979 F.3d at 448 (stating “we
conclude that Plaintiffs have a private right of action under both §§ 1396a(a)(8) [(reasonable
promptness provision)] and (a)(10)”).
2.

Rights Enforceable Under Free Choice and Reasonable Promptness
Provisions

Defendants argue that, even if there is a private right of action under the free choice
and/or reasonable promptness provisions, the Medicaid Act does not confer the rights the
Guardians seek to enforce.
a.

Rights Enforceable Under the Reasonable Promptness Provision

The Medicaid Act requires that developmentally disabled individuals be provided with
“medical assistance” which, in turn, is expressly defined to include, if necessary, “services in an
intermediate care facility for the mentally retarded.” 42 U.S.C. §§ 1396a(a)(10), 1396d(a)(15).
Further, as cited above, those services must be provided “with reasonable promptness to all
eligible individuals.” 42 U.S.C. § 1396a(a)(8). Defendants contend that the Guardians
“pleadings fall outside any private right the provisions language confers, citing the Guardians’
recognition that thousands of people are in ICFs, including most of the people the Guardians
represent. (Ohio Reply at 15, ECF No. 383.) This argument is not well taken.

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As the Sixth Circuit just highlighted in Waskul, allegations that “Defendants failed to
ensure that the Individual Plaintiffs were able to obtain medically necessary services with
reasonable promptness, in violation of §§ 1396a(a)(8)” sufficiently stated a claim upon which
relief can be granted. Waskul, 979 F.3d at 449. In their crossclaims, the Guardians similarly
allege that Defendants failed to ensure that the individuals under the care of the Guardians were
able to obtain medically necessary services with reasonable promptness, in violation of §§
1396a(a)(8), because they were never provided information about the availability of the
medically necessary services (ICFs). Consequently, the Guardians have alleged rights that are
enforceable under the reasonable promptness provision.
b.

Rights Enforceable Under the Free Choice Provision

The free choice provision of the Medicaid Act provides in relevant part:
(2) A waiver shall not be granted under this subsection unless the State provides
assurances satisfactory to the Secretary that--. . . .
....
(B) the State will provide, with respect to individuals who—
(i) are entitled to medical assistance for inpatient
hospital services, nursing facility services, or
services in an intermediate care facility for the
mentally retarded under the State plan,
(ii) may require such services, and
(iii) may be eligible for such home or communitybased care under such waiver,
for an evaluation of the need for inpatient hospital
services, nursing facility services, or services in an
intermediate care facility for the mentally retarded;
(C) such individuals who are determined to be likely to require the
level of care provided in a hospital, nursing facility, or intermediate
care facility for the mentally retarded are informed of the feasible
alternatives, if available under the waiver, at the choice of such
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individuals, to the provision of inpatient hospital services, nursing
facility services, or services in an intermediate care facility for the
mentally retarded;
42 U.S.C. § 1396n(c)(2)(B) and (C).
Defendants contend that under this free choice provision, “[t]he State must assure the
Secretary that people needing an ICF-level of care will be ‘informed of the feasible
alternatives.’” 42 U.S.C. § 1396n(c)(2).” They conclude that, “[n]othing in the free-choice
provision’s language reflects—much less unambiguously states—that a State has an obverse
duty to provide information about ICFs.” (Ohio’s Mot. to Dismiss at 15–16, ECF No. 354.)
This Court, however, disagrees.
Under Defendants’ interpretation, people who qualify for ICF-level care must be
informed of community-based services but need not be informed of ICF services. This is an
untenable interpretation of the statute.
The plain language of the free choice provision requires the state to ensure that
individuals who are eligible for an institutional level of care “are informed of the feasible
alternatives, if available under the [state’s home and community-based services] waiver, at the
choice of such individuals, to the provision of inpatient hospital services, nursing facility
services, or services in an intermediate care facility.” 42 U.S.C. § 1396n(c)(2)(C). It is
impossible to provide information of the feasible alternatives to the provision of inpatient
hospital services, nursing facility services, or services in an intermediate care facility if the
individual has no knowledge of the option of inpatient hospital services, nursing facility services,
or services in an intermediate care facility.
The Court’s reading of the plain language of the Medicaid Act is confirmed by the
implementing regulations, which in relevant part provide:

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(d) Alternatives—Assurance that when a beneficiary is determined to be likely to
require the level of care provided in a hospital, NF, or ICF/IID, the beneficiary or
his or her legal representative will be—
(1) Informed of any feasible alternatives available under the waiver;
and
(2) Given the choice of either institutional or home and communitybased services.
42 C.F.R. § 441.302(d) (emphasis added). See also Holsinger, 356 F.Supp.2d at 769 (cited with
approval by the Sixth Circuit in Waskul, where the district court explained that the free choice
provision requires a state to provide “assurances that it has informed eligible individuals of their
options, and provided them with ICF/MR services (if the individuals so choose)”). Thus, the
Guardians have alleged rights that are enforceable under the free choice provision.
3.

Pleading Sufficiency

Defendants’ last argument for dismissal of the Guardians’ claims under the Medicaid Act
is that they are already providing all of the services requested by the Guardians. Defendants
assert that, “[r]ather than micromanaging, the provision leaves to the States’ discretion, subject to
the Secretary’s approval, how best to comply” with the requirements under the free choice
provision. (Ohio Mot. to Dismiss at 16, ECF No. 354.) Defendants are adamant in their briefing
that they “absolutely seek to inform people about their service options.” (Ohio Reply at 14–15,
ECF No. 383.) They conclude, however, “[t]he pleadings and judicially-noticeable materials
show that State Defendants provide people with information about available services, including
ICFs.” (Ohio Mot. to Dismiss at 16, ECF No. 354.)
The Guardians, however, do not allege that they are entitled to micromanage Ohio’s
methods on how to inform qualified individuals of their choices. Instead, they contend that in
large measure Ohio completely fails to inform about ICFs, instead hiding that option from

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individuals. The Guardians argue that “Defendants have systematically thwarted and denied the
ICF entitlement to eligible residents. . . . [and] [a]s a result today, thousands of eligible Ohioans
sit on ‘wait lists’ for ‘waiver’ services not knowing they have an immediate entitlement to an
ICF bed.” (Guardians’ Mem. in Opp. at 1, ECF No. 372.) The Guardians continue, maintaining
that “tens of thousands of eligible Ohioans do not know of their ICF entitlement. Likewise
hundreds, if not thousands, of ICF beds have been eliminated in Ohio not because they are
unneeded or unwanted, but instead because they are effectively hidden from the disabled
beneficiaries who are entitled to them.” (Id. at 2, ECF No. 372.)
The Guardians have filed detailed crossclaims supporting these contentions that Ohio and
the County Boards fail to inform qualified individuals about ICFs. For example, the Guardians
allege that “the vast majority of DD Medicaid eligible residents receive information about DD
services only from, or principally from, their [County] Boards, but their [County] Boards do not
provide them information about ICF services.” (Crossclaims ¶ 221, ECF No. 326.) They aver
that “[f]ew, if any, of the 88 [County] Boards provide information about ICF services on their
websites (other than on how to leave an ICF or be diverted from an ICF).” (Id. ¶ 216.) The
Guardians further allege that, Defendants “publish[] a detailed guide called ‘Life Map,’ which is
a guide for DD services from birth through retirement.” http://www.oacbdd.org/clientuploads/
publications/OACBLifeMap-ThirdEdition.pdf (visited Sept. 7, 2018).” (Id. ¶ 217.) They
continue, that although “the Life Map references nursing homes, it makes no reference to ICFs.”
(Id. ¶ 218.) The Guardians also allege that, “[w]hen [County] Boards annually send wait-listed
individuals letters regarding their status on the waiver wait list, they do not mention that the
recipient has the right – the entitlement – to an immediate ICF placement, let alone provide
information on the ICF entitlement.” (Id. ¶ 220.)

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In their crossclaims the Guardians offer information about twenty individuals with
disabilities who qualify for ICF services and who were allegedly not provided information about,
and therefore not given the option to utilize, the ICF option. (Id. ¶¶ 26–108.) The Guardians
also included in their claims the stories of Noah Goldberg, Zoe Edler, and Maya Edler, whom the
Guardians moved to join as parties. (ECF No. 325). Noah, Zoe, and Maya currently do not
receive ICF services, may someday want or need ICF services, but allege that they were never
informed of their ICF entitlement by their respective County Boards. Specifically, with regard to
Noah Goldberg, the pleading provides:
Despite interacting with the DD Board for almost two decades, [his mother] has
never been told about – let alone offered – the ICF option. Whether she would select
it or not, she would like to know of all her (and Noah’s) options.
(Crossclaims ¶ 111, ECF No. 326.) As to Zoe and Maya Edler, their parents report that despite
numerous meetings with their local County Board, the following is there experience:
At no time was an ICF mentioned in the discussion– either as an option or
alternative. Additionally, it was never explained that a waiver meant ‘waiving our
rights’ to an alternative option. Both children have been placed on the DD Board
waiting list for approximately four years running” without ever being informed of
their ICF option.
(Id. at ¶ 112.)
These allegations contain sufficient factual content that allows the Court to draw the
reasonable inference for pleading purposes that the Guardians’ Medicaid Act has facial
plausibility.
The Court notes that it is sensitive to Defendants’ concerns articulated here:
Ohio’s developmental-disability system finds itself between two policy
extremes in this case. On one end, Plaintiffs and Disability Rights Ohio say Ohio’s
system is discriminating under federal law because it is allegedly too reliant on
Intermediate Care Facilities (“ICFs”). On the other end, Guardians now say Ohio’s
system is discriminating under the same federal law because it is allegedly too
reliant on waivers. Both extremes are wrong.
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When serving Ohioans with developmental disabilities, and allocating finite
resources, Ohio can permissibly consider people’s competing interests and
preferences. It can work to promote and expand waivers, but still preserve ICFs as
another option. Considering and balancing everyone’s interests in this complex
field is reasonable, not discriminatory. Nothing in federal law says otherwise.
(Ohio Mot. to Dismiss at 1, ECF No. 354.)
This Court too does not say otherwise. This Court is not suggesting how the state of
Ohio should allocate its finite resources. Here, the Court simply finds that the Medicaid Act
requires Ohio to provide information about all of the services available, allow choice between
waiver services and ICFs, and provide ICF services if that is the choice made by the individual or
his or her guardian. There is no dispute in the record before this Court that there are ICF beds
available. Thus, there is no indication that enforcement of the provision of the Medicaid Act at
issue here will prevent Ohio from balancing all of the different interests in this complex field.
Moreover, the Court does not agree that the law allows for the Guardians to direct how
Ohio transmits the information about the ICF choice. If it is shown that Defendants are
providing the ICF information and that the ICF beds are therefore empty by the choice of those
individuals who qualify for services, then the claims have no merit. If, however, the Guardians
show that Defendants are not providing information about the ICF choice, Defendants will be
ordered to comply with the law.
IV.
Based on the foregoing, the Court GRANTS the unopposed Motion for Leave to File as
Amicus Curiae filed by VOR, Inc. (ECF Nos. 373) and GRANTS IN PART AND DENIES IN
PART the Motions to Dismiss filed by the Ohio County Boards Serving People with
Developmental Disabilities (ECF No. 353), the State of Ohio (ECF No. 354), and the Governor
of Ohio (ECF No. 355). Specifically, the Court GRANTS all Defendants’ requests for dismissal
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of the Guardians claims under the ADA and the Rehabilitation Act and DENIES their request
for dismissal of the Guardians’ claims under the Medicaid Act.
IT IS SO ORDERED.

2/17/2021
DATE

s/Edmund A. Sargus, Jr.
EDMUND A. SARGUS, JR.
UNITED STATES DISTRICT JUDGE

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