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Nature of Suit Code: 446
Nature of Suit: Americans with Disabilities Act - Other
Cause of Action: 

---

In the 

United States Court of Appeals 

For the Seventh Circuit ____________________

No. 15‐2377  

KARLA STEIMEL,

Plaintiff‐Appellant,

and

THOMAS MAERTZ, et al.,

Intervening Plaintiffs‐Appellants,

v.

JOHN J. WERNERT, Secretary of the Indiana Family and Social

Services Administration, et al.,

Defendants‐Appellees.

____________________

No. 15‐2389

MICHAEL BECKEM AND LOIS BECKEM,

Plaintiffs‐Appellants,

v.

INDIANA FAMILY AND SOCIAL SERVICES ADMINISTRATION, and

JOHN J. WERNERT, Secretary of the Indiana Family and Social

Services Administration,

Defendants‐Appellees.

____________________

Case: 15-2389 Document: 43 Filed: 05/10/2016 Pages: 27
2 Nos. 15‐2377 & 15‐2389

Appeals from the United States District Court for the

Southern District of Indiana, Indianapolis Division.

Nos. 13‐cv‐00957, 14‐cv‐00668 — Jane E. Magnus‐Stinson, Judge.

____________________

ARGUED JANUARY 5, 2016 — DECIDED MAY 10, 2016

____________________

Before WOOD, Chief Judge, and KANNE and ROVNER, Circuit

Judges.

WOOD, Chief Judge. No one would accuse the Medicaid

program of simplicity. Our task in this appeal is to consider

whether Indiana has chosen an acceptable way to deliver cer‐

tain home‐ and community‐based services. It does so through

so‐called waiver programs that are operated by state Medi‐

caid agencies. The word “waiver” is used because the default

assumption under Medicaid is that these kinds of services will

be delivered in institutions. Congress has recognized, how‐

ever, that many people are better served by and prefer com‐

munity‐based care. For these people, it uses waiver programs

under which the state (and the federal government) will pick

up the tab.

The Indiana Family and Social Services Administration

(the Agency) runs three waiver programs relevant to this case:

the Aged and Disabled Medicaid Waiver Program (A&D

waiver), the Community Integration and Habilitation Medi‐

caid Waiver Program (CIH waiver), and the Family Supports

Medicaid Waiver Program (FS waiver). Importantly for our

case, the programs vary in how much money each client can

receive, what must be demonstrated to qualify for aid, and

who is entitled to assistance. Because Indiana has closed most

of its institutional facilities, these waiver programs serve the

Case: 15-2389 Document: 43 Filed: 05/10/2016 Pages: 27
Nos. 15‐2377 & 15‐2389 3

vast majority of people with disabilities in Indiana. The state’s

total institutional capacity can accommodate only one quarter

of the number of people on the CIH waiver alone.

Until 2011, the Agency placed many people with develop‐

mental disabilities on the A&D waiver, which has no cap on

services. That changed when the Agency decided that it had

not been adhering to certain A&D rules. In order to fix its mis‐

takes, it enacted a policy change that rendered many develop‐

mentally disabled persons, including the plaintiffs, ineligible

for care under the A&D waiver. These people were moved to

the FS waiver, under which they may receive services worth

no more than $16,545 annually. Developmentally disabled

people who were switched from the A&D waiver to the FS

waiver may apply for the CIH waiver, which is uncapped. But

not everyone qualifies for the CIH waiver, and so this possi‐

bility is an empty one for many.

The plaintiffs in the two cases we have consolidated for

disposition are developmentally disabled persons who were

moved from the A&D waiver to the FS waiver. They argue

that their new assignment violates the integration mandate of

the Americans with Disabilities Act (ADA), 42 U.S.C. §§ 12101

et seq., because it deprives them of community interaction and

puts them at risk of institutionalization. They also seek class

certification.

The district court granted summary judgment to the de‐

fendants on the integration‐mandate claims and denied class

certification. We conclude that there is a genuine dispute of

material fact with respect to the individual claims based on

the integration mandate, and so judgment for the defendants

to that extent was premature. The district court did not abuse

Case: 15-2389 Document: 43 Filed: 05/10/2016 Pages: 27
4 Nos. 15‐2377 & 15‐2389

its discretion, however, in declining to certify the class, be‐

cause the proposed class is too vague.

I

A

In 1981, Congress enacted Section 1915(c) of the Social Se‐

curity Act (SSA), 42 U.S.C. § 1396n, which established the

Home and Community‐Based Care Waiver Program. See An‐

drew I. Batavia, A Right to Personal Assistance Services: “Most

Integrated Setting Appropriateʺ Requirements and the Independent

Living Model of Long‐Term Care, 27 AM. J.L. & MED. 17, 24

(2001). The program allowed states to diverge from the tradi‐

tional Medicaid structure by providing community‐based

services to people who would, under the traditional Medicaid

structure, require institutionalization. Its purpose was to

“provid[e] real choices and opportunities to control their lives

for individuals who wish to live in the community” and allow

deviation from Medicaid’s traditional “institutional bias.” Id.

Participating states have significant discretion in how they

craft their waiver programs. Nonetheless, the programs must

conform to several restrictions: the average annual cost of a

state’s waiver programs cannot exceed that of institutional

services, id.; states must inform eligible persons of their op‐

tions and allow those qualified to take advantage of waiver

slots up to the number available, id.; and states must comply

with the ADA’s integration mandate, which dictates that

states “shall administer services, programs, and activities in

the most integrated setting appropriate to the needs of quali‐

fied individuals with disabilities,” 28 C.F.R. § 35.130(d) (1998).

Case: 15-2389 Document: 43 Filed: 05/10/2016 Pages: 27
Nos. 15‐2377 & 15‐2389 5

B

States submit detailed applications for each waiver pro‐

gram to the Centers for Medicare and Medicaid Services

(CMS). CMS approves waiver programs for an initial term of

three years, after which it may re‐approve them for five‐year

periods. The A&D waiver, the FS waiver, and the CIH waiver

all fall under SSA § 1915(c), 42 U.S.C. § 1396n(c), and have

been approved by CMS. (That approval is not at issue here.)

The Agency oversees all of Indiana’s waiver programs,

through different subdivisions for each one.

Under Indiana law, the A&D waiver is meant “to provide

home‐ and community‐based services to individuals who, but

for the provision of such services, would require nursing fa‐

cility level of care.” The FS waiver provides “waiver services

to participants of any age residing in a range of community

settings as an alternative to care in an intermediate care facil‐

ity for individuals with intellectual disabilities ... or related

conditions.” The CIH waiver provides services to a similar

population that meets additional criteria. While the FS waiver

caps services at $16,545 per year, there is no cap on services

under the A&D or CIH waivers. Different services are availa‐

ble under each waiver, and the rules for reimbursement vary

by program.

Waiver participants may also use services provided

through the state’s traditional Medicaid plan. These include

“prior‐authorization services,” which are services that the

state has pre‐approved as medically necessary. 405 IND.

ADMIN. CODE § 5‐3‐13. There is one type of prior‐authoriza‐

tion service relevant to this case: “home health services.” Id.

§ 5‐3‐13(a)(9). Home‐health services include “[s]killed nurs‐

Case: 15-2389 Document: 43 Filed: 05/10/2016 Pages: 27
6 Nos. 15‐2377 & 15‐2389

ing,” “[h]ome health aid services,” “[p]hysical and occupa‐

tional therapies,” “[s]peech pathology services,” “[r]enal dial‐

ysis,” and “[t]elehealth services.” Id. § 1‐4.2‐3(a). Home‐

health services, as the name suggests, “must be performed in

the home.” Id. § 1‐4.2‐3. If a service is available under both the

relevant waiver and the state Medicaid programs, partici‐

pants must generally use prior‐authorization services before

tapping into their waiver funds.

The Agency assigns a case manager to each waiver partic‐

ipant. The case manager works with the participant and his or

her guardian to determine the appropriate services for that

participant. Certain services are available under some waivers

but not under others. After the case manager, participant, and

guardian create an individualized plan, the case manager

submits it for approval to the appropriate Agency subdivi‐

sion.

C

In 2006, the state opened the A&D waiver to persons with

developmental disabilities, so long as they had either “skilled

medical need” or substantial functional limitations. In 2011, it

reversed this policy, and thereafter allowed only people who

could demonstrate both a skilled medical need and substantial

functional limitations to participate in the A&D waiver. As

space became available on the FS waiver, the state moved

A&D waiver participants to the FS waiver.

The plaintiffs are developmentally disabled people who

rely on Indiana’s home‐  and community‐based Medicaid

waiver programs. Karla Steimel suffers from cerebral palsy,

while Thomas Maertz has been diagnosed with both cerebral

palsy and mental retardation. Colton and Cody Cole are twin

Case: 15-2389 Document: 43 Filed: 05/10/2016 Pages: 27
Nos. 15‐2377 & 15‐2389 7

brothers; they both suffer from cerebral palsy. Timothy Keis‐

ter has been diagnosed with mental retardation. Michael and

Lois Beckem are siblings; Michael has been diagnosed with

mild mental retardation, and Lois has Down’s syndrome.

Before 2013, the plaintiffs were served under Indiana’s

A&D waiver. Under the A&D waiver, they were able to enjoy

community activities such as eating in restaurants, visiting

flea markets, and window‐shopping. Michael and Lois

Beckem attended day services, which allowed them to go into

the community and interact with people without disabilities.

While all of the plaintiffs suffer from severe conditions, none

of them needs the skilled medical services necessary to meet

the prerequisites of the A&D waiver, as it has been structured

since 2011. All were shifted to the FS waiver in 2013. Later,

Karla Steimel and Timothy Keister were moved to the CIH

waiver; they concede that their claims are moot. While Lois

Beckem has since been moved back to the A&D waiver, she

asserts a damages claim. The Coles, Maertz, and Michael

Beckem remain on the FS waiver.

The plaintiffs still before us allege that their forced move

to the FS waiver has dramatically curtailed their ability to par‐

ticipate in community activities. According to their guardi‐

ans’ affidavits, the plaintiffs were able to enjoy roughly 40

hours in the community each week under the A&D waiver.

Since their transition to the FS waiver, their community time

has shrunk to 10 to 12 hours per week. This roughly 30‐hour‐

per‐week reduction is a result of the FS waiver cap, under

which they are allowed to use only $16,545 in waiver services.

(That amount of money works out, plaintiffs say, to roughly

12 hours per week in services that can be used outside the

home.) Although the plaintiffs are also eligible for Medicaid

Case: 15-2389 Document: 43 Filed: 05/10/2016 Pages: 27
8 Nos. 15‐2377 & 15‐2389

prior‐authorization services, those services may not be used

outside the home and so are not relevant to these claims.

The plaintiffs’ guardians also aver that despite the availa‐

bility of prior‐authorization services, restrictions on those ser‐

vices have led to lapses in supervision that have either led to

injury or serious risk of injury to the plaintiffs. The plaintiffs

contend that, given the limitations on prior‐authorization ser‐

vices and the monetary cap on the FS waiver, these gaps in

supervision are unavoidable and have put them at serious

risk of institutionalization. Tamara Awald, the mother of Col‐

ton and Cody Cole, also indicates that she has had to pay out‐

of‐pocket for care when she travels for work.

Karla Steimel filed her initial class‐action complaint and

motion for class certification on June 14, 2013. Before the court

ruled on that motion, Maertz, the Coles, and Keister moved

for leave to intervene as named plaintiffs. The district court

granted the intervention motion, but on March 24, 2014 it de‐

nied class certification. The Beckems commenced their sepa‐

rate case on April 30, 2014.

The parties in both cases filed cross‐motions for summary

judgment. The state argued that it should prevail because the

plaintiffs’ claims did not even implicate the integration man‐

date, while the plaintiffs contended that they were entitled to

judgment because they had shown beyond dispute that the

state was violating the integration mandate. The district court

agreed with the state and granted it summary judgment in

both cases on June 9, 2015. This appeal followed.

Case: 15-2389 Document: 43 Filed: 05/10/2016 Pages: 27
Nos. 15‐2377 & 15‐2389 9

II

Congress intended the ADA “to provide a clear and com‐

prehensive national mandate for the elimination of discrimi‐

nation against individuals with disabilities.” Olmstead v. L.C.

ex rel. Zimring, 527 U.S. 581, 589 (1999) (quoting 42

U.S.C. § 12101(b)(1)). Section 12132 decrees that “no 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.” A “public en‐

tity” includes “any State orlocal government” or “any depart‐

ment [or] agency ... of a State ... or local government.” Id.

§§ 12131(1)(A), (B). A “qualified individual with a disability”

is someone who, “with or without reasonable modifications

to rules, policies, or practices ... meets the essential eligibility

requirements for the receipt of services or the participation in

programs or activities provided by a public entity.” Id.

§ 12131(2).

The ADA directs the Attorney General to “promulgate

regulations ... that implement” the provisions of Title II, in‐

cluding § 12132. Id. § 12134(a). In response to this command,

the Attorney General implemented the regulation known as

the “integration mandate.” The integration mandate states

that “[a] public entity shall administer services, programs,

and activities in the most integrated setting appropriate to the

needs of qualified individuals with disabilities.” 28 C.F.R.

§ 35.130(d) (1998). The regulations’ preamble defines “the

most integrated setting appropriate to the needs of qualified

individuals with disabilities” as “a setting that enables indi‐

viduals with disabilities to interact with non‐disabled persons

to the fullest extent possible.” 28 C.F.R. pt. 35, App. B. Public

Case: 15-2389 Document: 43 Filed: 05/10/2016 Pages: 27
10 Nos. 15‐2377 & 15‐2389

entities are required to “make reasonable modifications” to

avoid “discrimination on the basis of disability” except if do‐

ing so would “fundamentally alter” the nature of the pro‐

grams. 28 C.F.R. § 35.130(b)(7).

Because the relevant provisions of the Rehabilitation Act

and its regulations are “materially identical” to their ADA

counterparts, Bruggeman ex rel. Bruggeman v. Blagojevich, 324

F.3d 906, 912 (7th Cir. 2003), courts “construe and apply them

in a consistent manner.” Radaszewski ex rel. Radaszewski v.

Maram, 383 F.3d 599, 607 (7th Cir. 2004). The state does not

challenge the validity of any of the regulatory provisions at

issue.

We address the parties’ arguments in two stages: first, we

consider whether the plaintiffs’ claims fall within the scope of

the integration mandate; and second, we ask whether the

state’s policy violated the mandate. The plaintiffs offer two

theories for our consideration: (1) that the state’s policies have

impermissibly rendered the plaintiffs institutionalized in

their own homes, and (2) that the state’s policies have put

them at serious risk of institutionalization.

We review de novo the district court’s decision to grant

summary judgment. Advance Cable Co., LLC v. Cincinnati Ins.

Co., 788 F.3d 743, 746 (7th Cir. 2015). When reviewing cross‐

motions for summary judgment, we “take the motions one at

a time and then, as usual, construe all facts and draw all rea‐

sonable inferences in favor of the non‐moving party.” Id. Sum‐

mary judgment is appropriate only “if the movant shows that

there is no genuine dispute as to any material fact and the mo‐

vant is entitled to judgment as a matter of law.” FED. R. CIV. P.

56(a).

Case: 15-2389 Document: 43 Filed: 05/10/2016 Pages: 27
Nos. 15‐2377 & 15‐2389 11

A

In enacting the ADA, Congress prohibited outright dis‐

crimination and “identified unjustified ‘segregation’ of per‐

sons with disabilities as a ‘for[m] of discrimination.’”

Olmstead, 527 U.S. at 600 (quoting § 12101(a)(2)). “Unjustified

isolation” is therefore “properly regarded as discrimination

based on disability.” Id. at 597. The Supreme Court held that

“discrimination” under § 12132 included “not only disparate

treatment of comparably situated persons but also undue in‐

stitutionalization of disabled persons, no matter how anyone

else is treated.” Amundson ex rel. Amundson v. Wisconsin Dep’t of

Health Servs., 721 F.3d 871, 874 (7th Cir. 2013) (citing Olmstead,

527 U.S. at 597–603).

Olmstead dealt only with the problem of unjustified insti‐

tutional segregation. See Olmstead, 527 U.S. at 600. Its ra‐

tionale, however, reaches more broadly. The Court saw “two

evident judgments” in the integration mandate. Id. The first is

that “institutional placement of persons who can handle and

benefit from community settings perpetuates unwarranted

assumptions that persons so isolated are incapable or unwor‐

thy of participating in community life.” Id. The second is that

“confinement in an institution severely diminishes the every‐

day life activities of individuals, including family relations,

social contacts, work options, economic independence, edu‐

cational advancement, and cultural enrichment.” Id. at 601.

The Court had no occasion to consider whether the same

evils it had identified for institutional placements might exist

in some settings outside of an institution. This case presents

that question: whether isolation in the home for a person

“who can handle and benefit from” time out in the general

community is also inconsistent with the integration mandate.

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12 Nos. 15‐2377 & 15‐2389

We see no reason why the same analysis should not apply.

See, e.g., Mark C. Weber, Home and Community‐Based Services,

Olmstead, and Positive Rights: A Preliminary Discussion,

39 WAKE FOREST L. REV. 269, 274 (2004) (“As with race discrim‐

ination, government‐sanctioned separation transmits a strong

message that the out‐group is inferior and that private dis‐

crimination is acceptable.”) (citing Brown v. Bd. of Ed. of Topeka,

347 U.S. 483, 492 n.5 (1954)); Timothy M. Cook, The Americans

with Disabilities Act: The Move to Integration, 64 TEMP. L. REV.

393, 441 (1991) (collecting studies concluding that “[t]he re‐

search data shows, without doubt ... that prejudice is less‐

ened through integration”). Isolation in a home can just as

“severely diminish[] the everyday life activities” of people

with disabilities. Olmstead, 527 U.S. at 601. In fact, although

family relations might be enhanced at home if people are

around, isolation in a home may often be worse than confine‐

ment to an institution on every other measure of “life activi‐

ties” that Olmstead recognized.

In accordance with Olmstead, the Department of Justice

has released guidance directing that the integration mandate

be read broadly. The DOJ’s interpretation of the mandate

“warrant[s] respect” because Congress gave it the task of is‐

suing the relevant regulations. Id. at 597–98. The degree of

deference is another matter: Olmstead said nothing on the sub‐

ject. In general, we defer to an agency’s interpretation of its

own regulation unless the agency’s interpretation is “plainly

erroneous orinconsistent with the regulation” or “there is rea‐

son to suspect that the agency’s interpretation ‘does not reflect

the agency’s fair and considered judgment on the matter in

question.’” Christopher v. SmithKline Beecham Corp., 132 S. Ct.

2156, 2166 (2012) (quoting Auer v. Robbins, 519 U.S. 452, 461–

Case: 15-2389 Document: 43 Filed: 05/10/2016 Pages: 27
Nos. 15‐2377 & 15‐2389 13

62 (1997)). We see no such flaws in the path that DOJ has

taken.

The guidance indicates that the “most integrated setting”

is “a setting that enables individuals with disabilities to inter‐

act with non‐disabled persons to the fullest extent possible.”

U.S. Dep’t of Justice, Statement of the Department of Justice on

the Integration Mandate of Title II of the ADA and Olmstead v. L.C.

(June 22, 2011). It notes that “[i]ntegrated settings are located

in mainstream society.” Id. Such settings “offer access to com‐

munity activities and opportunities at times, frequencies and

with persons of an individual’s choosing; afford individuals

choice in their daily life activities; and, provide individuals

with disabilities the opportunity to interact with non‐disabled

persons to the fullest extent possible.” Id.

Under the Guidance, the state might violate the integra‐

tion mandate if it “operates ... programs that segregate indi‐

viduals with disabilities” or “through its planning, service

system design, funding choices, or service implementation

practices, promotes or relies upon the segregation of individ‐

uals with disabilities in private facilities or programs.” Id. The

mandate “extend[s] to persons at serious risk of institutional‐

ization or segregation and [is] not limited to individuals cur‐

rently in institutional or other segregated settings.” Id. Finally,

so long as any additional services do not cause a fundamental

alteration in the state program, the state may be required to

provide them; budget cuts can violate the integration man‐

date. Id. Given the integration mandate’s maximalist lan‐

guage—it demands “the most integrated setting appropri‐

ate,” 28 C.F.R. § 35.130(d), which it defines as allowing inter‐

action with non‐disabled persons “to the fullest extent possi‐

ble,” 28 C.F.R. pt. 35, App. B—we have no reason not to follow

Case: 15-2389 Document: 43 Filed: 05/10/2016 Pages: 27
14 Nos. 15‐2377 & 15‐2389

the DOJ’s interpretation of the mandate. And the mandate, as

we have noted, logically applies to all settings, not just to in‐

stitutional settings. It bars unjustified segregation of persons

with disabilities, wherever it takes place.

The state responds with a narrow reading of the integra‐

tion mandate and an unwillingness to engage with the DOJ’s

interpretation. It argues that the integration mandate covers

only claims by people who literally have been institutional‐

ized, and that a person with a disability who is housed in the

community is therefore outside its scope. The state insists that

“setting” refers only to two kinds of physical structures: an

institution or a location in the community. But there is no rea‐

son to think that the mandate presents such a crabbed binary.

First, “there is nothing in the plain language of the regulations

that limits protection to persons who are currently institution‐

alized.” Pashby v. Delia, 709 F.3d 307, 322 (4th Cir. 2013) (quot‐

ing Fisher v. Oklahoma Health Care Auth., 335 F.3d 1175, 1181

(10th Cir. 2003)). The mandate’s text uses the general word

“setting” and states that people are entitled to be served “in

the most integrated setting appropriate to the needs of quali‐

fied individuals with disabilities.” 28 C.F.R. § 35.130(d). The

“most integrated setting appropriate” is “a setting that ena‐

bles individuals with disabilities to interact with non‐disabled

persons to the fullest extent possible.” 28 C.F.R. pt. 35, App. B.

Just as importantly, there is plentiful evidence that the

state’s interpretation is incorrect. When interpreting adminis‐

trative rules, a court asks first “whether the language at issue

has a plain and unambiguous meaning with regard to the par‐

ticular dispute in the case.” Exelon Generation Co., LLC v. Local

15, Int’l Bhd. of Elec. Workers, AFL‐CIO, 676 F.3d 566, 570 (7th

Cir. 2012). In doing so, the court “giv[es] the words used their

Case: 15-2389 Document: 43 Filed: 05/10/2016 Pages: 27
Nos. 15‐2377 & 15‐2389 15

ordinary meaning.” Lawson v. FMR LLC, 134 S. Ct. 1158, 1165

(2014) (internal citation omitted). Neither the ADAnor its reg‐

ulations specifically define the word “setting.” Ordinarily,

that word denotes an environment or situation rather than

any particular physical structure. See THE AMERICAN

HERITAGE DICTIONARY OF THE ENGLISH LANGUAGE 1593 (4th

ed. 2000) (“The context and environment in which a situation

is set; the background.”); RANDOM HOUSE WEBSTER’S COLLEGE

DICTIONARY 1200 (2d ed. 1999) (“[T]he surroundings or envi‐

ronment of anything.”); MERRIAM‐WEBSTER’S COLLEGIATE

DICTIONARY 1072 (10th ed. 1994) (“[T]he time, place, and cir‐

cumstances in which something occurs or develops[.]”). The

regulation’s use of the word “most” (integrated) and its refer‐

ence to “a” setting also imply more than two possibilities.

If these facts stick a knife in the state’s argument, the DOJ

guidelines twist it. They specifically include the plaintiffs’two

theories within the integration mandate’s ambit. Moreover,

the ADAand the integration mandate’s “protections would be

meaningless if plaintiffs were required to segregate them‐

selves by entering an institution before they could challenge

an allegedly discriminatory law or policy that threatens to

force them into segregated isolation.” Fisher, 335 F.3d at 1181.

In this case, the plaintiffs’ quandary is Kafkaesque: Indiana’s

institutions can serve only a quarter of the persons with disa‐

bilities currently on the CIH waiver alone. Even if the plain‐

tiffs had to be institutionalized, it is quite possible that they

could not be.

Amundson is not to the contrary. Nowhere did Amundson

indicate that segregation within the community beyond an in‐

stitution’s walls could not implicate the integration mandate.

The Amundson plaintiffs did not present such a claim, and so

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16 Nos. 15‐2377 & 15‐2389

the opinion does not address it. Amundson decided instead

that the plaintiffs’ claims were not ripe because they had not

pleaded sufficient facts to allege that they were at serious risk

of institutionalization. While some of the Amundson plaintiffs

had been required to leave group homes, they did “not allege

inability to find another group home willing to accept the

level of reimbursement” Wisconsin was offering. 721 F.3d at

873–74. Wisconsin had represented that it had “safeguards in

place that [would] prevent any plaintiff from being trans‐

ferred to an institution”; the plaintiffs had not given “suffi‐

cient reason to think that these [would] fail.” Id. at 874.

Amundson did not mention the DOJ Guidance one way or the

other; the state thus overreaches when it contends that

Amundson “presumably” rejected the DOJ Guidance.

The plaintiffs in our case have provided evidence that they

need constant supervision and, despite their best efforts, the

services provided under the FS waiver have proved inade‐

quate to prevent life‐threatening gaps in care. Again turning

to Amundson, the state argues that the hypothetical availabil‐

ity of a CIH waiver is a sufficient safeguard. But the state did

not present this argument to the district court, and it is there‐

fore waived. See Domka v. Portage Cnty., Wis., 523 F.3d 776, 783

(7th Cir. 2008). Even if it were not, the CIH waiver is among

the measures the plaintiffs argue they need to prevent their

institutionalization. The plaintiffs have provided evidence

that they are at serious risk of being institutionalized. At this

point, the state has provided no evidence to the contrary and

has decided that the plaintiffs are currently ineligible for the

CIH waiver. This is enough to raise a genuine question of fact

about the adequacy of the CIH waiver as a safeguard against

a serious risk of institutionalization. The plaintiffs’ claims are

therefore ripe.

Case: 15-2389 Document: 43 Filed: 05/10/2016 Pages: 27
Nos. 15‐2377 & 15‐2389 17

Another argument the state advances to avoid the integra‐

tion mandate rests on language in Amundson and a footnote

in Olmstead, both of which it reads to support the idea that the

integration mandate imposes neither a “standard of care” nor

“a certain level of benefits to individuals with disabilities.”

Olmstead, 527 U.S. at 603 n.14; Amundson, 721 F.3d at 875

(holding that the ADA does not support “a claim of absolute

entitlement” to Medicaid benefits); see also Cohon ex rel. Bass

v. New Mexico Depʹt of Health, 646 F.3d 717, 729 (10th Cir. 2011)

(holding that ADA did not give plaintiff “legal entitlement”

to specific requested services and that she did not state an

Olmstead claim because she failed to allege that the program

would lead to her unjustified isolation or premature institu‐

tionalization); Rodriguez v. City of New York, 197 F.3d 611, 619

(2d Cir. 1999) (noting that “Olmstead reaffirms that the ADA

does not mandate the provision of new benefits” and “ad‐

dressed only [] where Georgia should provide treatment, not

whether it must provide it”).

The problem with that argument is that it misconstrues the

plaintiffs’ theory. They have not argued that they have an ab‐

solute entitlement to any particular services or program. They

instead seek access to existing benefits available under either

the uncapped A&D or CIH waivers—benefits that have been

granted to some persons with disabilities, but not to them.

While “a State is not obligated to create new services,” it “may

violate Title II when it refuses to provide an existing benefit

to a disabled person that would enable that individual to live

in a more community‐integrated setting.” Radaszewski, 383

F.3d at 609 (citing Olmstead, 527 U.S. at 603 n.14 for the princi‐

ple “that States must adhere to the ADA’s nondiscrimination

requirement with regard to the services they in fact provide”).

The plaintiffs seek services that exist and are given to others.

Case: 15-2389 Document: 43 Filed: 05/10/2016 Pages: 27
18 Nos. 15‐2377 & 15‐2389

The state may already be providing at least some of those ser‐

vices through the prior‐authorization program, albeit not out

in the community. That, in fact, is the key difference between

waiver and prior‐authorization services: the former are more

flexible with regard to their timing and may be used outside

the home in the community; the latter must be used in the

home.

The state’s final plea invokes vagueness: If the integration

mandate applies to a multiplicity of “settings” and can re‐

quire the shifting of resources to increase community partici‐

pation, where will it end? The short answer may be that it

ends wherever the state has chosen—this is an anti‐discrimi‐

nation mandate, as we said, not a floor or ceiling. Here, the

state has ways to allow otherwise qualified persons to spend

upwards of 40 hours per week outside their home and in the

community. It thus may not, by invoking the rules of its

waiver program, limit qualified persons to only 12 hours in

the community each week. That fails to “administer services,

programs, and activities in the most integrated setting appro‐

priate to the needs of qualified individuals with disabilities.”

28 C.F.R. § 35.130(d). Based on the purpose and text of the

ADA, the text of the integration mandate, the Supreme

Court’s rationale in Olmstead, and the DOJ Guidance, we hold

that the integration mandate is implicated where the state’s

policies have either (1) segregated persons with disabilities

within their homes, or (2) put them at serious risk of institu‐

tionalization.

B

Because it thought that the integration mandate was not

even implicated here, the district court did not reach the ques‐

tion whether it was violated. We, however, must press on, in

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Nos. 15‐2377 & 15‐2389 19

light of our conclusion that the mandate is in play. On cross‐

motions for summary judgment, plaintiffs presented evi‐

dence that they were segregated from the community and

that the state’s 2011 policy was to blame. Without challenging

the contentions about the degree of community interaction

plaintiffs are receiving, the state presented evidence that

showed, in its view, that the 2011 policy change was not the

cause of whatever segregation is occurring.

1

We turn once again to Olmstead for the proper way to ana‐

lyze these arguments. It set out a test for determining whether

the ADA’s integration mandate is violated:

[U]nder Title II of the ADA, States are required

to provide community‐based treatment for per‐

sons with mental disabilities when [1] the State’s

treatment professionals determine that such

placement is appropriate, [2] the affected per‐

sons do not oppose such treatment, and [3] the

placement can be reasonably accommodated,

taking into account the resources available to

the State and the needs of others with mental

disabilities.

Olmstead, 527 U.S. at 607. We have understood this to be the

Court’s last word on the point. See Omega Healthcare Inv’rs,

Inc. v. Res‐Care, Inc., 475 F.3d 853, 864 (7th Cir. 2007) (noting

that “Olmstead stands for the proposition that in order to

avoid violating the [ADA], the placement of individuals in

community‐based settings is appropriate” when the test is

Case: 15-2389 Document: 43 Filed: 05/10/2016 Pages: 27
20 Nos. 15‐2377 & 15‐2389

met); Radaszewski, 383 F.3d at 608 (noting, without clearly ap‐

plying the test, that “the [Olmstead] Court agreed” with the

plaintiffs’ formulation of it).

The first two elements of the test appear in Section III.A of

the Olmstead decision, which commanded a majority of the

Court and is thus binding on us. The Court noted there that

(1) “the State may generally rely on the reasonable assess‐

ments of its own professionals in determining whether an in‐

dividual ‘meets the essential eligibility requirements’” of the

program, and (2) that there exists no “federal requirement

that community‐based treatment be imposed on patients who

do not desire it.” Olmstead, 527 U.S. at 602.

Olmstead’s articulation of the third element of the test,

however, represents the thinking of only a plurality of the

Court. Those Justices addressed the question of the level at

which the “reasonable modifications” provision should be

evaluated—that is, which matters should be considered in de‐

ciding whether a requirement to provide integrated care

would constitute a fundamental alteration of the state’s pro‐

gram. See 28 C.F.R. § 35.130(b)(7). It is clear that some version

of the “reasonable modifications” provision—and its flip side,

the fundamental‐alteration defense—must be taken into ac‐

count before deciding that the integration mandate was vio‐

lated. Justice Stevens, concurring in the judgment, thought

that the fundamental‐alteration defense rested ultimately on

the facts; he thus saw no need to delve into the limitations on

the state’s duty. See Olmstead, 527 U.S. at 607–08 (Stevens, J.,

concurring in part and concurring in the judgment). Justice

Kennedy, writing for himself and Justice Breyer, focused on

the need for courts to defer to the treatment decisions of the

treating physicians, lest people who need greater care are

Case: 15-2389 Document: 43 Filed: 05/10/2016 Pages: 27
Nos. 15‐2377 & 15‐2389 21

shoved out into the community inappropriately. Id. at 608–615

(Kennedy, J., concurring in the judgment).

As long as we bear in mind the cautionary remarks of the

concurring Justices, we see nothing to prevent our use of Sec‐

tion III.B of the plurality’s opinion as a starting point. Its artic‐

ulation of the “reasonable modifications” element states a

sensible level at which to analyze the question whether re‐

quiring integrated services would “fundamentally alter” the

nature of the programs. 28 C.F.R. § 35.130(b)(7). On the one

hand, a “substantial[] increase” in the cost of a few of plain‐

tiffs’ services should not “defeat [a] Title II claim.”

Radaszewski, 383 F.3d at 614. Such a holding would eviscerate

the integration mandate. See id. (“If every alteration in a pro‐

gram or service that required the outlay of funds were tanta‐

mount to a fundamental alteration, the ADA’s integration

mandate would be hollow indeed.” (quoting Fisher, 335 F.3d

at 1183)). On the other hand, looking only at the cost of chang‐

ing the plaintiffs’ care would be unfair to the state and fail to

give it the leeway for which Justices Kennedy and Breyer

called. “If the expense entailed in placing one or two people

in a community‐based treatment program is properly meas‐

ured for reasonableness against the State’s entire mental

health budget, it is unlikely that a State, relying on the funda‐

mental‐alteration defense, could ever prevail.” Olmstead, 527

U.S. at 603 (plurality opinion).

By specifying that both the “resources available to the

State” and “the needs of others with mental disabilities” must

be taken into account, the plurality’s test allows for a sensitive

balance between the interests of the state and the interests of

the developmentally disabled persons. The test also prevents

a state from describing a program at such a specific level of

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22 Nos. 15‐2377 & 15‐2389

detail that literally any change would result in a “fundamen‐

tal” alteration. In the end, the question under the ADA is a

simple one: what effect will changing the state’s practices have

on the provision of care to the developmentally disabled, tak‐

ing into account the resources available to the state and the

need to avoid discrimination?

The evaluation of whether a change would fundamentally

alterthe nature of a program should be holistic. Here, the state

has produced no evidence that anything approaching a fun‐

damental change would occur if the programs available to

these plaintiffs were handled differently. We thus do not re‐

gard it as a close case.

2

Neither of the first two elements of the Olmstead test is dis‐

puted in our case. By previously allowing the plaintiffs signif‐

icantly more community interaction, the state’s medical pro‐

fessionals have demonstrated that such activity is both appro‐

priate and possible. The plaintiffs’ purpose in this lawsuit is

to have this level of community‐based service restored, under

whatever program umbrella will accomplish that end. The

plaintiffs’ evidence shows that at present, using the FS waiver,

they can arrange for no more than 10 to 12 hours of such ser‐

vices per week. The affidavits maintain that this amount is in‐

sufficient either (1) to allow any significant community inter‐

action or (2) to prevent gaps in supervision that remained un‐

covered by their caretakers or prior‐authorization services.

The state has offered nothing to support its assumption that

the plaintiffs actually spend more time in the community than

their guardians have averred. Plaintiffs have also provided

evidence that a more integrated setting is possible: their affi‐

davits state that they were able both to achieve significantly

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Nos. 15‐2377 & 15‐2389 23

more community interaction and prevent gaps in supervision

under the A&D waiver.

It is the state’s burden to prove that the proposed changes

would fundamentally alter their programs. See Radaszewski,

383 F.3d at 611 (citing 28 C.F.R. § 35.130(b)(7)). It has failed to

carry that burden here. In fact, it did not even argue that the

plaintiffs seek fundamental alteration of their programs. In‐

stead, it contended that “it is not ‘reasonable’ to demand that

the State alter the eligibility requirements for the A&D Waiver

so as to permanently enshrine its error” in placing the plain‐

tiffs on the waiver in the first place.

There are several problems with this argument. The first

is that the plaintiffs are not asking to be put back on the A&D

waiver. While that may be one of the outcomes they will ac‐

cept, it is not the only one. The second is that the state’s logic

is circular. After all, the state creates the waiver programs, and

therefore those programs’ eligibility criteria. If the state’s own

criteria could prevent the enforcement of the integration man‐

date, the mandate would be meaningless. The regulation ad‐

jacent to the “reasonable modifications” provision antici‐

pates—and directly confronts—this problem. See 28 C.F.R.

§ 35.130(b)(8) (“A public entity shall not impose or apply eli‐

gibility criteria that screen out or tend to screen out an indi‐

vidual with a disability or any class of individuals with disa‐

bilities from fully and equally enjoying any service, program,

or activity, unless such criteria can be shown to be necessary

for the provision of the service, program, or activity being of‐

fered.”). The state has made no showing that its criteria are

“necessary for the provision” of the relevant services in this

case. It cannot avoid the integration mandate by binding its

hands in its own red tape.

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24 Nos. 15‐2377 & 15‐2389

The third reason the state’s argument cannot prevail is the

most important: the evidence presented on summary judg‐

ment shows that the plaintiffs’ demands are entirely reasona‐

ble; the state has provided no evidence to the contrary. The

plaintiffs do not demand a significant increase in total ser‐

vices, but rather a different apportionment of the two kinds of

services they already receive. Prior‐authorization services do

not allow the plaintiffs to be taken into the community.

Waiver services do. Allowing the plaintiffs to change their

“mix” of prior‐authorization and waiver services would allow

them to participate more fully in the community. According

to their affidavits, a relatively slight increase in total services

would prevent them from being unsupervised. The state has

provided no evidence that the plaintiffs’ desired distribution

of services would significantly increase their cost, let alone

fundamentally alter any programs.

Finally, the state argues that it should be excused from

changing its waiver system because it has a “comprehensive,

effectively working plan for placing qualified persons with

mental disabilities in less restrictive settings,” and therefore

meets the reasonable‐modification standard. Olmstead, 527

U.S. at 605. The state is referring to the process it is using to

move persons with disabilities from the A&D waiver to the FS

waiver. That is just what plaintiffs are attacking: their evi‐

dence shows that this “plan” is undermining, not furthering,

the integration mandate. Instead of moving people with disa‐

bilities to more integrated settings, the state’s plan is making

their living arrangements less integrated.

3

The plaintiffs have provided evidence that before the pol‐

icy change, they were receiving the kind of services they

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Nos. 15‐2377 & 15‐2389 25

needed to prevent isolation or institutionalization and partic‐

ipate in the community around them. They also have pro‐

vided evidence that the FS waiver services that they currently

receive are insufficient to allow more than limited trips into

the community. They describe current or future gaps in ser‐

vices that plausibly put them at risk of institutionalization.

It also appears, however, that recipients of FS waiver ser‐

vices may choose how to spend their allowance. The state ar‐

gues that the FS waiver actually provides the plaintiffs suffi‐

cient waiver services to participate in the community, but that

these plaintiffs have used the FS resources in a way that has

led to their current isolation. In support of this contention, the

state has offered evidence that the plaintiffs could make dif‐

ferent choices that would allow them more services in the

community. It also offered evidence that the Coles are using a

lower dollar amount of services than they did under the A&D

waiver, and that Maertz’s situation has been influenced by the

fact that his sister is the paid provider of his waiver services.

There is therefore a dispute of material fact as to whether the

state’s 2011 policy change caused the plaintiffs’ isolation, and

summary judgment is inappropriate on that question. See

FED. R. CIV. P. 56(a).

III

The party seeking class certification bears the burden of

showing, by a preponderance of the evidence, that a proposed

class meets the requirements of Federal Rule of Civil Proce‐

dure 23. Messner v. Northshore Univ. HealthSystem, 669 F.3d

802, 811 (7th Cir. 2012). The district court’s decision whether

to certify a class is reviewed for abuse of discretion. Mullins v.

Direct Digital, LLC, 795 F.3d 654, 659 (7th Cir. 2015). The plain‐

tiffs proposed the following class:

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26 Nos. 15‐2377 & 15‐2389

Any and all persons, current and future, termi‐

nated from the [A&D waiver] as a result of the

2011 Policy Change who require more services

each year than are available through the [FS

waiver] and who are not enrolled in the [CIH

waiver].

The district court found that the plaintiffs failed all of Rule

23’s criteria. We have serious reservations about this decision,

which strikes us as too sweeping. Nonetheless, we may affirm

on any basis that fairly appears in the record. Ellis v. CCA of

Tennessee LLC, 650 F.3d 640, 647 (7th Cir. 2011). Because the

class definition was too vague, we find that the district court

did not abuse its discretion in denying class certification.

The vagueness of this definition arises from the word “re‐

quire.” The question is in what ways do the potential class

members “require” more services than available under the FS

waiver? Are they medically required? Required for regular

community interaction? Required so as not to violate the in‐

tegration mandate? (The last of these definitions would risk

making this class an impermissible “fail‐safe” class. See Mul‐

lins, 795 F.3d at 660.) The class definition does not say.

Avoiding vagueness is important “because a court needs

to be able to identify who will receive notice, who will share

in any recovery, and who will be bound by a judgment.” Mul‐

lins, 795 F.3d at 660. “To avoid vagueness, class definitions

generally need to identify a particular group, harmed during

a particular time frame, in a particular location, in a particular

way.” Id. The proposed definition here sufficiently identifies

the time, location, and manner of harm, but we cannot say the

same for the “particular group.” Id. Without knowing how to

Case: 15-2389 Document: 43 Filed: 05/10/2016 Pages: 27
Nos. 15‐2377 & 15‐2389 27

sort between those who were and those who were not de‐

prived of services to which they were entitled, we would not

be able to say who should receive notice, be bound by the

judgment, and, if the class were to prevail on the merits, share

in any recovery. The district court therefore did not abuse its

discretion in denying class certification.

IV

Our decision today does not require the state of Indiana to

adopt any particular solution to make its waiver program

compliant with the integration mandate. If plaintiffs prevail

on the merits, the district court, in conjunction with the par‐

ties, may exercise its equitable powers to craft an appropriate

injunction. But the state cannot avoid the integration mandate

by painting itself into a corner and then lamenting the view.

The state designs, applies for, develops policies regarding,

and executes its waiver programs. If those programs in prac‐

tice allow persons with disabilities to leave their homes only

12 hours each week, cooping them up the rest of the time, or

render them at serious risk of institutionalization, then those

programs violate the integration mandate unless the state can

show that changing them would require a fundamental alter‐

ation of its programs for the disabled.

Because the plaintiffs’ claims both fit within and, if caused

by the state’s policy, represent violations of the integration

mandate, we REVERSE the judgment of the district court and

REMAND for further proceedings consistent with this opinion.

We AFFIRM the district court’s decision not to certify the pro‐

posed class. Costs will be taxed against the state.

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