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

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In the 

United States Court of Appeals 

For the Seventh Circuit ____________________

No. 18‐3076

BRIA HEALTH SERVICES, LLC, et al., as authorized representa‐

tives of Winnie Boykin, et al.,

Plaintiffs‐Appellants,

v.

THERESA A. EAGLESON, in her official capacity as the Director

of the Illinois Department of Healthcare and Family Services,

et al.,

Defendants‐Appellees.

____________________

Appeal from the United States District Court for the

Northern District of Illinois, Eastern Division.

No. 1:17‐cv‐8920 — Charles R. Norgle, Judge.

____________________

ARGUED SEPTEMBER 19, 2019 — DECIDED FEBRUARY 11, 2020

____________________

Before SYKES, HAMILTON, and BRENNAN, Circuit Judges.

HAMILTON, Circuit Judge. Plaintiffs are consultants who

provide services to nursing homes and long‐term care facili‐

ties. They say they are bringing this suit on behalf of seriously

ill nursing home residents receiving care under Medicaid. The

residents, however, are not parties to this suit, and it seems

Case: 18-3076 Document: 45 Filed: 02/11/2020 Pages: 13
2 No. 18‐3076

unlikely that they would benefit at all if plaintiffs win. By all

appearances, plaintiffs have brought this suit in an effort to

push the State of Illinois and its Medicaid contractors to pay

outstanding bills owed to the consultants’ clients.  

Third parties can bring claims on behalf of others under

some circumstances. Guardians, next friends, and associa‐

tions, for example, can have representative standing. This

case does not involve such established standing doctrines. In‐

stead, plaintiffs rely on a Medicaid regulation. As we read that

regulation, however, it does not permit authorized represent‐

atives to bring civil lawsuits on behalf of Medicaid beneficiar‐

ies. We affirm the district court’s dismissal forlack of standing

and thus lack of subject matter jurisdiction.

I. Facts and Procedural Background

The Medicaid program—established under Title XIX of

the Social Security Act, 42 U.S.C. § 1396 et seq.—is a coopera‐

tive arrangement in which the federal government gives fi‐

nancial assistance to states to provide medical services to poor

residents. See, e.g., National Federation of Independent Business

v. Sebelius, 567 U.S. 519, 541–42 (2012). To participate in the

program, states must comply with detailed statutory and reg‐

ulatory requirements. Among these requirements, states 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 reason‐

able promptness to all eligible individuals.” 42 U.S.C.

§ 1396a(a)(8). States must also ensure that certain medical as‐

sistance is available to all eligible beneficiaries. § 1396a(a)(10).

Illinois administers its Medicaid program through its De‐

partment of Healthcare and Family Services (HFS). At issue

Case: 18-3076 Document: 45 Filed: 02/11/2020 Pages: 13
No. 18‐3076 3

here are the State’s managed care programs, in which HFS

contracts with Medicaid managed care organizations (MCOs)

to deliver Medicaid health benefits to beneficiaries. The State

pays the MCOs a flat fee per patient per month, and the MCOs

pay providers for services rendered to Medicaid beneficiaries.

See generally 305 ILCS 5/5‐30.1.

Plaintiffs in this case are consultants who offer financial

and business services to nursing home and supportive living

facilities in Illinois. They have sued HFS, the HFS director,

and a number of MCOs. Plaintiffs say they are bringing these

claims on behalf of a class of nursing home residents entitled

to Medicaid benefits. They seek various forms of relief for al‐

leged violations of Title XIX of the Social Security Act; Title II

of the Americans with Disabilities Act, 42 U.S.C. § 12132 et

seq.; the Rehabilitation Act of 1973, 29 U.S.C. § 794; and the

Due Process and Equal Protection Clauses of the Fourteenth

Amendment to the United States Constitution.

Plaintiffs allege that the MCOs have failed to process

timely payments for claims submitted by the nursing

homes—the plaintiff‐consultants’ clients—to the MCOs. This,

the consultants argue, constitutes a failure to provide the

medical assistance required by 42 U.S.C. § 1396a(a)(10).1 Be‐

cause the nursing homes have not been paid for services ren‐

dered, the consultants say, the resident‐beneficiaries are at

risk of being discharged from the facilities. This jeopardizes

the resident‐beneficiaries’ health, safety, and well‐being, and

1 The statutory definitions of some Medicaid terms differ from their

everyday meanings. “Medical assistance” is defined by statute as “pay‐

ment of part or all of the cost of [covered] care and services or the care and

services themselves, or both.” 42 U.S.C. § 1396d(a).  

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4 No. 18‐3076

causes mental anguish. The consultants’ claims under the

ADA, the Rehabilitation Act, and the Constitution are all

based on the same alleged denial of benefits.

The plaintiff‐consultants say that they have been author‐

ized to bring these claims by Medicaid beneficiaries residing

in their clients’ nursing homes. Each resident has allegedly

filled out a form designating a consultant as authorized rep‐

resentative, authorizing “action as necessary to establish [] el‐

igibility for Medicaid,” agreeing that legal proceedings

brought in regard to Medicaid eligibility may be brought in

the name of the resident or in that of the facility, and waiving

“potential or actual conflicts of interest.”2

The district court dismissed the case under Federal Rule

of Civil Procedure 12(b)(1) for lack of subject matter jurisdic‐

tion. It determined that the regulation cited by plaintiffs does

not permit authorized representatives to bring civil lawsuits

on behalf of Medicaid beneficiaries so that the consultant‐

plaintiffs lacked standing.

II. Analysis

We review de novo a district court’s dismissal for lack of

standing when standing is not challenged on factual grounds.

Remijas v. Neiman Marcus Group, LLC, 794 F.3d 688, 691 (7th

Cir. 2015). We “accept as true all material allegations of the

complaint, drawing all reasonable inferences therefrom in the

plaintiff’s favor unless standing is challenged as a factual

2 The complaint does not allege that the residents completed authori‐

zation forms, but plaintiffs state in their briefing that all plaintiffs have

signed forms conferring the same authority as the “Designation of Au‐

thorized Representative” form in the plaintiffs’ appendix. We proceed as

if this were alleged in the complaint.  

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No. 18‐3076 5

matter.” Id., quoting Reid L. v. Illinois State Bd. of Education, 358

F.3d 511, 515 (7th Cir. 2004). The plaintiffs bear the burden of

establishing standing. Id.

Article III of the Constitution limits the power of federal

courts to deciding “cases” and “controversies.” To meet this

constitutional requirement, a plaintiff must establish that she

has standing. She must allege and prove (1) a concrete and

particularized injury, (2) caused by the actions of the defend‐

ant, (3) that would likely be redressed by a favorable decision.

Lujan v. Defenders of Wildlife, 504 U.S. 555, 560–61 (1992).  

The consultant‐plaintiffs do not claim to have standing

themselves. Instead, they say they are invoking the rights of

the residents of the facilities whose Medicaid reimbursements

are allegedly being withheld. Plaintiffs argue that because

they have been granted authorization pursuant to regulation

to sue on behalf of the residents—and because the residents

themselves have standing—they may invoke the residents’

standing. This adds a second component to the standing in‐

quiry. In addition to establishing that the residents have

standing under Article III, plaintiffs must also show that they

are entitled to invoke the residents’ standing.  

A. Scope of the Medicaid Regulation

Plaintiffs identify 42 C.F.R. § 435.923, promulgated by the

Secretary of Health and Human Services pursuant to 42

U.S.C. § 1302(a), as the source of their authority to sue on be‐

half of the residents. Here are the key provisions of § 435.923:

(a)(1) The agency must permit applicants and

beneficiaries to designate an individual or or‐

ganization to act responsibly on their behalf in

assisting with the individual’s application and

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renewal of eligibility and other ongoing com‐

munications with the agency. ...  

(b) Applicants and beneficiaries may authorize

their representatives to—

(1) Sign an application on the applicant’s be‐

half;

(2) Complete and submit a renewal form;

(3) Receive copies of the applicant or benefi‐

ciary’s notices and other communications

from the agency;

(4) Act on behalf of the applicant or benefi‐

ciary in all other matters with the agency.

The regulation thus requires state Medicaid agencies to al‐

low Medicaid participants to designate representatives to act

on their behalf and describes the scope of possible represen‐

tation. The regulation describes the scope of representation

using three specific provisions and one general provision. The

general provision in (b)(4) describes the scope of representa‐

tion in superficially broad terms, allowing representatives to

“Act on behalf of the applicant or beneficiary in all other mat‐

ters with the agency.”  

Plaintiffs argue that the general provision allows benefi‐

ciaries to authorize representatives to sue HFS and the MCOs.

The key phrase here is “matters with the agency.” Plaintiffs

say that phrase reaches anything having to do with the agency,

including civil litigation.  

The same basic rules that apply to statutory interpretation

apply to regulatory interpretation. Exelon Generation Co. v. Lo‐

cal 15, International Brotherhood of Electrical Workers, AFL‐CIO,

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No. 18‐3076 7

676 F.3d 566, 570 (7th Cir. 2012); see generally Kisor v. Wilkie,

139 S. Ct. 2400, 2414–18 (2019). We ask first “whether the lan‐

guage at issue has a plain and unambiguous meaning with

regard to the particular dispute in the case.” Exelon Generation,

676 F.3d at 570, quoting Ioffe v. Skokie Motor Sales, Inc., 414 F.3d

708, 710 (7th Cir. 2005). This inquiry looks to the entire text of

the regulation, its purpose and context, and precedents or au‐

thorities that can inform the analysis. See River Road Hotel

Partners, LLC v. Amalgamated Bank, 651 F.3d 642, 649 (7th Cir.

2011). If the language is ambiguous, we may consult the rule‐

making record. Exelon Generation, 676 F.3d at 570.  

In this case, the text of the regulation, the broader regula‐

tory context and purpose, and the comments during rulemak‐

ing all indicate that “matters with the agency” relate only to

communication and document processing in interactions with

the agency and do not reach civil litigation against it.

First, the general provision in (b)(4) should be read in light

of the preceding specific elements in the list to encompass

only those interactions with the agency akin to submitting ap‐

plications, renewing eligibility, and receiving agency commu‐

nications. A general provision following a list of specific pro‐

visions should be interpreted considering those other provi‐

sions. Hall St. Associates, L.L.C. v. Mattel, Inc., 552 U.S. 576, 586

(2008) (canon of ejusdem generis teaches that “when a statute

sets out a series of specific items ending with a general term,

that general term is confined to covering subjects comparable

to the specifics it follows”). Here, “other matters with the

agency” most naturally encompasses only document pro‐

cessing and communication with the agency.  

Second, the agency‐facing character of the regulation sup‐

ports this interpretation. The regulation requires agencies to

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permit Medicaid participants to authorize representatives to

“assist[] with the individual’s application and renewal of eli‐

gibility and other ongoing communications with the agency.”

42 C.F.R. § 435.923(a)(1). This agency requirement and the ap‐

plicant/beneficiary right of authorization are two sides of the

same coin. The agency must allow a certain kind of authori‐

zation, and beneficiaries may exercise the corresponding right

of authorization. The possible scope of authorization that ben‐

eficiaries may give should be read as equivalent to the scope

of representative activities that agencies are required to ac‐

cept, encompassing only “the individual’s application and re‐

newal of eligibility and other ongoing communications.” Id.

(emphasis added).  

Third, the purpose provision for the relevant Part of the

Medicaid regulations and the broader regulatory context con‐

firm that the scope of authorization is limited to agency‐ap‐

plicant communications and does not reach civil lawsuits. See

Schlaf v. Safeguard Property, LLC, 899 F.3d 459, 465 (7th Cir.

2018) (observing that “We must interpret the plain language

of the statute in light of its placement in the overall text of the

statute” and looking to enacted statement of purpose); see

also Jarrod Shobe, Enacted Legislative Findings and Purposes, 86

U. Chi. L. Rev. 669, 712–15 (2019) (describing value of enacted

statements of purpose in determining meaning of other stat‐

utory provisions). The applicable purpose provision, 42

C.F.R. § 435.2, says that the Part sets forth eligibility require‐

ments for state Medicaid programs and establishes “require‐

ments and procedures that the Medicaid agency must use in

determining and redetermining eligibility, and requirements

it may not use.” Id. § 435.2(c). In line with this stated purpose,

the surrounding regulations in the subpart all pertain to

agency policies and procedures. See 42 C.F.R. §§ 435.900–

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No. 18‐3076 9

435.965. The regulation allowing authorized representatives

to deal with the agency is best understood congruent with this

purpose as setting out the procedures that the Medicaid

agency must itself use when determining the eligibility of an

applicant.  

Read in context, the regulation limits the scope of permis‐

sible representation to communication with the agency re‐

garding eligibility and like matters. The responses of the De‐

partment of Health and Human Services to comments in the

rulemaking process further indicate that the regulation is lim‐

ited to communication with the agency, without any indica‐

tion that it would extend to litigation against it. In issuing the

final version of the rule, the Department wrote that it “pro‐

posed to define the term ‘authorized representative’ as an in‐

dividual or organization that acts responsibly on behalf of an

applicant or beneficiary in assisting with the individualʹs ap‐

plication and renewal of eligibility and other ongoing com‐

munications with the Medicaid or CHIP agency.” 78 Fed. Reg.

42174 (July 15, 2013). The Department clarified that the regu‐

lations were “intended to be consistent with current state pol‐

icy and practice, regarding the definition, designation, and re‐

sponsibilities of ‘authorized representatives.’” Id. Plaintiffs do

not suggest that authorized representatives have ever sued on

behalf of Medicaid beneficiaries as plaintiffs seek to do here,

and we have no reason to believe otherwise.

The regulation in question—and even the authorization

agreement presented by the plaintiffs—extends only to eligi‐

bility applications and determinations. These are not at issue

in this case. According to the complaint, the residents have all

been approved to receive Medicaid benefits. So even if the

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authorization were permitted by the regulation, it would not

allow for this suit.

B. Regulations and Representative Standing

We must offer one cautionary clarification to our analysis.

Because the regulation does not authorize plaintiffs to bring

civil claims on behalf of others, we do not need to decide

whether a regulation can ever confer by itself the right to

bring a claim on behalf of another and to invoke that person’s

Article III standing. Ourreliance on interpretation of the Med‐

icaid regulation should not be taken as an implied endorse‐

ment of plaintiffs’ novel standing theory derived solely from

a regulation.

The general rule is that plaintiffs must allege their own in‐

juries to establish standing. See Hollingsworth v. Perry, 570 U.S.

693, 710 (2013) (“mere authorization to represent a third

party’s interests” will not confer standing to a party with no

injuries of her own). Well‐established exceptions to this rule

allow a plaintiff to bring a claim on behalf of another. Guard‐

ians have standing when they sue on behalf of minors. E.g.,

Sherman v. Community Consolidated School District 21 of Wheel‐

ing Township, 980 F.2d 437, 441 (7th Cir. 1992); see also Fed. R.

Civ. P. 17(a) (allowing guardians and similar representatives

to bring claims on behalf of others). A “next friend” may have

standing to bring a habeas corpus petition if she has a “signif‐

icant relationship” with the real party in interest and the real

party in interest is somehow disabled. See Whitmore v. Arkan‐

sas, 495 U.S. 149, 162 (1990). A similar next‐friend doctrine al‐

lows third parties to sue on behalf of minors and incompetent

persons. See Fed. R. Civ. P. 17(c). An association can also have

standing to sue on behalf of its members. United Food & Com‐

mercial Workers Union Local 751 v. Brown Group, Inc., 517 U.S.

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No. 18‐3076 11

544, 546 (1996). And in Hollingsworth v. Perry, the Supreme

Court suggested that an agency relationship combined with

authorization by the principal could establish representative

standing. 570 U.S. at 713–14.3

An uninjured plaintiff suing on behalf of another is nor‐

mally required to identify one of these existing doctrines—

most of which have deep common‐law roots and all of which

are limited in scope to ensure that the dispute is actually an

Article III “case” or “controversy”—to establish representa‐

tive standing. Plaintiffs do not have representative standing

on any of these grounds. Their entire theory of the case as‐

sumes that a regulation can suffice, but they provide no sup‐

port for that position. We need not reach that broader asser‐

tion, however, because even if in theory a regulation could

confer representative standing on the mere basis of authori‐

zation, plaintiffs would not prevail under this regulation.

3 This issue is distinct from that of third‐party standing. The third‐

party standing doctrine applies only when a plaintiff has suffered an in‐

jury in fact. The plaintiff must herself have Article III standing, and must

meet an extra condition to invoke the rights of a non‐party in seeking re‐

dress for that injury. See, e.g., Craig v. Boren, 429 U.S. 190, 194–96 (1976);

see also 13A Charles Alan Wright & Arthur R. Miller, Federal Practice &

Procedure § 3531.9.3 (3d ed. 2019). Cf. Lexmark International, Inc. v. Static

Control Components, Inc., 572 U.S. 118, 127 & n.3 (2014) (reframing “pru‐

dential standing” doctrine as constitutional or statutory but observing that

“limitations on third‐party standing are harder to classify [than zone‐of‐

interests analysis] .... [C]onsideration of that doctrine’s proper place in the

standing firmament can await another day.”). The problem of third‐party

standing is different from the one here. In this case, plaintiffs have not

suffered an injury and cannot themselves establish Article III standing. In‐

stead, they are suing on behalf of others.

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C. Underlying Standing of the Residents

The underlying standing of the residents—which plain‐

tiffs’ standing relies upon—is also disputed. Because plain‐

tiffs’ standing is derivative of the residents’ standing, they

must show that the residents have suffered an injury or that

one is imminent. A plaintiff may establish Article III standing

by showing that harm is “certainly impending,” but it is not

enough to allege “possible future injury.” Remijas v. Neiman

Marcus Group, LLC, 794 F.3d 688, 692 (7th Cir. 2015), quoting

Clapper v. Amnesty International USA, 568 U.S. 398, 409 (2013).

Plaintiffs allege that the residents are at risk of being dis‐

charged from the long‐term care facilities where they are re‐

ceiving nursing services and medical care. But plaintiffs con‐

ceded at oral argument that residents were not threatened

with discharge and are presently receiving medical care. Dis‐

charging residents because of nonpayment to their care‐giv‐

ers would, in fact, violate federal law. See 42 C.F.R.

§ 483.15(c)(1)(E) (permitting discharge of a resident for non‐

payment only where resident has not submitted paperwork

for third‐party payment or where Medicaid denies the claim

and the resident refuses to pay). Suing state officials on the

theory that one’s clients may or will soon violate federal law

is not a promising theory.

We are hesitant to resolve this case based on the residents’

standing because they have not, by all appearances, been in‐

volved in the litigation. We have no reason to believe that their

interests are being represented. Because the regulation does

not give plaintiffs the right to sue on behalf of the residents,

we need not reach this broader issue either.

* * *

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No. 18‐3076 13

None of this means, of course, that third parties may not

bring claims on behalf of Medicaid beneficiaries. If a state

does not comply with its Medicaid obligations and vulnerable

populations do not receive timely notice of eligibility deter‐

minations or do not receive services, they may be entitled to

remedies in court. Given the severe medical conditions that

many of these people face, it may be difficult forthem to assert

their own rights. But there are established processes for bring‐

ing claims on behalf of others that—unlike the system read

into the regulation by the consultants—contain safeguards

and ensure that the interests of vulnerable individuals are

represented. If a beneficiary lacks capacity, a guardian or next

friend may sue on her behalf. These consultant‐plaintiffs,

however, do not have standing.

The judgment of the district court is  

AFFIRMED.

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