Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caDC-11-05161/USCOURTS-caDC-11-05161-0/pdf.json

Parties Involved:
Kathleen Sebelius
Appellee
United States Department of Health and Human Services
Appellee
Virginia Department of Medical Assistance Services
Appellant

Document Text:

United States Court of Appeals

FOR THE DISTRICT OF COLUMBIA CIRCUIT

Argued March 14, 2012 Decided May 8, 2012

No. 11-5161

VIRGINIA DEPARTMENT OF MEDICAL ASSISTANCE SERVICES,

APPELLANT

v.

UNITED STATES DEPARTMENT OF HEALTH AND HUMAN

SERVICES AND KATHLEEN SEBELIUS, SECRETARY OF THE

UNITED STATES DEPARTMENT OF HEALTH AND HUMAN

SERVICES,

APPELLEES

Consolidated with 11-5242

Appeals from the United States District Court

for the District of Columbia

(No. 1:09-cv-00392)

(No. 1:09-cv-01587)

Caroline M. Brown argued the cause for the appellants.

Laura E. Schattschneider was on brief.

Dana Kaersvang, Attorney, United States Department of

Justice, argued the cause for the appellees. Tony West, Assistant

Attorney General, Ronald C. Machen, Jr., United States

Attorney, and Michael S. Raab, Attorney, were on brief. R.

USCA Case #11-5161 Document #1372715 Filed: 05/08/2012 Page 1 of 16
2

Craig Lawrence, Assistant United States Attorney, entered an

appearance. 

Before: HENDERSON, ROGERS and GRIFFITH, Circuit

Judges.

Opinion for the Court filed by Circuit Judge HENDERSON.

KAREN LECRAFT HENDERSON, Circuit Judge: The Virginia

Department of Medical Assistance Services and the Kansas

Health Policy Authority (collectively, States) both appeal the

district court’s grants of summary judgment in favor of the U.S.

Department of Health and Human Services and the Secretary of

Health and Human Services (HHS or Secretary). See Va. Dep’t

of Med. Assistance Servs. v. U.S. Dep’t of Health & Human

Servs., 779 F. Supp. 2d 129 (D.D.C. 2011) (Virginia v. HHS);

Kan. Health Policy Auth. v. U.S. Dep’t of Health & Human

Servs., 798 F. Supp. 2d 162 (D.D.C. 2011) (Kansas v. HHS).

The district court upheld HHS’s disallowance of certain

Medicaid claims for Federal Financial Participation (FFP) as

ineligible for “medical assistance” under the “Institution for

Mental Diseases” (IMD) exclusion set forth in section 1905(a)

of 42 U.S.C. §§ 1396 et seq. (Medicaid Statute).1

 The IMD

exclusion generally carves out from FFP any claims for

1

The Medicaid Statute “defines ‘medical assistance’ as ‘payment

of part or all of the cost’ of medical ‘care and services’ for a defined

set of individuals.” Adena Reg’l Med. Ctr. v. Leavitt, 527 F.3d 176,

180 (D.C. Cir. 2008) (quoting 42 U.S.C. § 1396d(a)). Under the

Medicaid program, each state furnishes medical assistance to its

eligible residents and the federal government covers a portion of the

state’s costs through FFP. Bowen v. Massachusetts, 487 U.S. 879,

883-84 (1988) (noting, although “federal contribution to a State’s

Medicaid program is referred to as a ‘reimbursement,’ the stream of

revenue is actually a series of huge quarterly advance payments that

are based on the State’s estimate of its anticipated future expenditures

. . . . periodically adjusted to reflect actual experience”).

USCA Case #11-5161 Document #1372715 Filed: 05/08/2012 Page 2 of 16
3

“payments with respect to care or services for any individual

who has not attained 65 years of age and who is a patient in an

institution for mental diseases.” 42 U.S.C. § 1396d(a)(B). In

particular, HHS excluded the States’ claims as outside the

narrow statutory exception to the IMD exclusion for “inpatient

psychiatric hospital services for individuals under age 21”

(under-21 exception). Id. § 1396d(a)(B), (16). Because HHS

correctly concluded that the disputed claims are not eligible for

FFP under the plain language of the IMD exclusion and the

under-21 exception, we affirm the court’s grants of summary

judgment in HHS’s favor. 

I.

The Congress enacted the Medicaid Statute in 1965 to

provide federal financial assistance to states that reimburse

certain costs of medical treatment for needy persons pursuant to

an approved state medical assistance plan, which plan identifies

the groups of individuals eligible for assistance as well as the

services that are covered. Pharm. Research & Mfrs. of Am. v.

Walsh, 538 U.S. 644, 650-51 (2003). Section 1905(a) of the

Medicaid Statute, 42 U.S.C. § 1396d(a), sets out which “care

and services” are eligible for “medical assistance” (and

consequently for FFP) under a state plan. Since its enactment in

1965, section 1905(a) has generally excluded from medical

assistance any services provided to individuals in an IMD who

are not age 65 or older. Social Security Amendments of 1965,

Pub. L. No. 89-97, title I, § 121(a)(B), 79 Stat. 286, 351-52

(1965) (codified at 42 U.S.C. § 1396d(a)(B)). 

In 1972, the Congress added an exception to the IMD

exclusion aimed at individuals under age 21. Section

1905(a)(B) now excludes services for individuals under 65

“except as otherwise provided in paragraph (16).” 42 U.S.C.

§ 1396d(a)(B). Paragraph (16) identifies “inpatient psychiatric

hospital services for individuals under age 21, as defined in

subsection (h),” as among the services for which medical

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4

assistance is expressly authorized. Id. § 1396d(a)(16).

Subsection (h), in turn, defines “inpatient psychiatric hospital

services for individuals under age 21” in some detail, to

 include[] only—

(A) inpatient services which are provided

in an institution (or distinct part thereof)

which is a psychiatric hospital as defined in

section 1395x(f) of this title or in another

inpatient setting that the Secretary has

specified in regulations;

(B) inpatient services which, in the case

of any individual (i) involve active treatment

which meets such standards as may be

prescribed in regulations by the Secretary,

and (ii) a team, consisting of physicians and

other personnel qualified to make

determinations with respect to mental health

conditions and the treatment thereof, has

determined are necessary on an inpatient

basis and can reasonably be expected to

improve the condition, by reason of which

such services are necessary, to the extent that

eventually such services will no longer be

necessary; and

(C) inpatient services which, in the case

of any individual, are provided prior to (i) the

date such individual attains age 21, or (ii) in

the case of an individual who was receiving

such services in the period immediately

preceding the date on which he attained age

21, (I) the date such individual no longer

requires such services, or (II) if earlier, the

date such individual attains age 22; . . . . 

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42 U.S.C. § 1396d(h)(1)(A)-(C) (emphasis added). 

In 2001-02, the HHS Inspector General audited Medicaid

claims for IMD residents under age 21 in several

states—including Virginia. As a result of the audit, the Centers

for Medicare and Medicaid Services (CMS)2 disallowed FFP

claims totaling $3,948,532 from Virginia as not authorized by

the under-21 exception because they were not documented to be

for “psychiatric hospital services provided in and by an IMD.”

Letter from Ted Gallagher, Assoc. Rgn’l Adm’r, Div. of

Medicaid & Children’s Health Operations, CMS, to Patrick W.

Finnerty, Dir., Va. Dep’t of Med. Assistance Servs., at 2 (Feb.

29, 2008) (CMS Virginia Letter).3

 Subsequently, following an

audit of Kansas’s 2007-08 claims, CMS similarly disallowed

$3,883,143 of FFP claims because they were for “services other

than inpatient psychiatric services to residents of a [Psychiatric

Residential Treatment Facility (PRTF)].” Letter from James G.

Scott, Assoc. Rgn’l Adm’r, Div. of Medicaid & Children’s

Health Operations, CMS, to Marcia J. Nielsen, Exec. Dir.,

Kansas Health Policy Auth., at 2 (Oct. 20, 2008) (CMS Kansas

Letter).4 Virginia and Kansas both appealed to HHS’s

2

CMS is the agency that administers the Medicaid program on

behalf of the Secretary. Pharm. Research & Mfrs. of Am. v. Walsh,

538 U.S. at 650 n.3.

3

Virginia’s disallowed claims included claims for “physician

services, pharmacy, outpatient hospital clinics, inpatient acute care,

and a miscellaneous category including primarily laboratory, x-ray and

community mental health and mental retardation services.” CMS

Virginia Letter at 2.

4

PRTFs “are non-hospital facilities that, by regulation, may

provide inpatient psychiatric treatment to children in Medicaid.”

Kansas v. HHS, 798 F. Supp. 2d at 164 n.3. All of Kansas’s

disallowed claims were for services provided to residents of PRTFs.

CMS Kansas Letter at 1.

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Departmental Appeals Board (DAB).

The DAB rejected Virginia’s challenge to “CMS’s

determination that the exception applies only to ‘inpatient

psychiatric services.’ ” Va. Dep’t of Med. Assistance, DAB

Dec. No. 2222, at 1 (App. Div. Dec. 31, 2008). In particular, the

DAB declined Virginia’s invitation to reconsider its earlier

decision in New York State Department of Health, DAB Dec.

No. 2066 (App. Div. Feb. 8, 2007). Va. Dep’t of Med.

Assistance, DAB Dec. No. 2222, at 2-3. In New York State,

which arose from the multi-state 2001-02 audit, the DAB upheld

CMS’s interpretation of the IMD exception’s “plain language,”

as applied by the HHS Inspector General, that paragraph (16)

“provides for only one category of Medicaid service—inpatient

psychiatric hospital services for individuals under age 21 as

defined in subsection (h)” and that subsection (h) “in turn

defines those services to mean ‘only’ those inpatient services

that are provided under the direction of a physician in an

institution that qualifies and that meet other specified

requirements.” New York State, Dec. No. 2066, at 9-10.

Accordingly, the DAB rejected New York’s contention that “ ‘if

the eligible individuals happen to be under the age of 21, in

addition to the other benefits set out in the statute, they are also

entitled to receive inpatient psychiatric hospital services.’ ” Id.

at 9 (quoting New York State brief). Consistent with New York

State, the DAB upheld CMS’s disallowance of Virginia’s IMD

claims. Id. at 26. In the Kansas appeal, the DAB likewise

upheld the disallowance explaining that it “ha[d] previously held

that the statutory exception to the IMD exclusion is available

only for services, provided in and by a qualifying facility,

meeting the statutory and regulatory requirements for ‘inpatient

psychiatric facility services’ ” and that CMS had “determined

that the health care services at issue were not part of [such]

inpatient services.” Kan. Health Policy Auth., DAB Decision

No. 2255, at 1-2 (App. Div. June 23, 2009).

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Virginia and Kansas then filed these actions in the district

court, challenging HHS’s interpretation of the IMD exclusion

and its under-21 exception and the disallowance of the States’

claims based thereon. The district court granted summary

judgment in favor of HHS in both cases. In Virginia v. HHS, the

district court agreed with HHS that “the relevant statutory

language is unambiguous.” 779 F. Supp. 2d at 135. The court

specifically found that (1) the IMD exclusion “is clear: except

as provided in paragraph (16), FFP is not available for any

medical care for any individual under age 65 who is a patient in

an IMD” and (2) the “ ‘under–21 exception’ to the IMD

exclusion is equally clear: FFP is only available for inpatient

psychiatric hospital services for individuals under age 21 that

are provided in an IMD.” Id. at 135-36. In Kansas v. HHS, the

court summarily rejected Kansas’s challenge, declining to

“revisit its ruling on this issue” in Virginia v. HHS. 798 F. Supp.

2d at 164. Virginia and Kansas both filed timely notices of

appeal and the two appeals were consolidated. 

II.

“We review the district court’s grant of summary judgment

de novo pursuant to the Administrative Procedure Act and

therefore will uphold the Secretary’s decision unless it is

 ‘arbitrary, capricious, an abuse of discretion, or otherwise not

in accordance with law,’ 5 U.S.C. § 706(2)(A).” Pharm.

Research & Mfrs. of Am. v. Thompson, 362 F.3d 817, 821 (D.C.

Cir. 2004). We review the Secretary’s interpretation of the

Medicaid Statute under the familiar two-step framework set out

in Chevron U.S.A. Inc. v. Natural Resources Defense Council,

Inc., 467 U.S. 837 (1984). Id. at 821-22.

Under Chevron step 1, if the “Congress has directly

spoken to the precise question at issue . . . , that is the

end of the matter; for the court, as well as the agency,

must give effect to the unambiguously expressed intent

of Congress.” Under Chevron step 2, “if the statute is

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silent or ambiguous with respect to the specific issue,

the question for the court is whether the agency’s

answer is based on a permissible construction of the

statute.”

U.S. Postal Serv. v. Postal Regulatory Comm’n, 640 F.3d 1263,

1266 (D.C. Cir. 2011) (quoting Chevron, 467 U.S. at 842-43)

(citation omitted). We stop, as did the district court, at Chevron

step 1 because we conclude the unambiguous statutory language

excepts from the IMD exclusion only “inpatient psychiatric

hospital services” as defined in subsection (h).

As we noted above, section 1905(a) sets out a list of

services eligible for “medical assistance” for which FFP is

available, 42 U.S.C. § 1396d(a)(1)-(29), and expressly excludes

therefrom “any [] payments with respect to care or services for

any individual . . . who is a patient in an institution for mental

diseases,” id. § 1396d(a)(B)—with two specific exceptions: (1)

the broad exception for any individual who “has . . . attained 65

years of age,” id.; and (2) the narrow exception “as otherwise

provided in paragraph (16),” id., that is, “effective January 1,

1973, inpatient psychiatric hospital services for individuals

under age 21, as defined in subsection (h).” Id. § 1396d(a)(16).

Subsection (h), quoted supra p. 4, establishes in its three

separate subsections three discrete criteria that specific services

must meet to qualify as “inpatient psychiatric hospital services”

eligible for medical assistance: they must (1) be “inpatient”

services “provided in . . . a psychiatric hospital” or regulatory

equivalent; (2) “involve active treatment” which is “determined

[to be] necessary on an inpatient basis and can reasonably be

expected to improve the [mental health] condition, by reason of

which such services are necessary, to the extent that eventually

such services will no longer be necessary”; and (3) be performed

before the patient turns 21 or, if performed immediately before

he turns age 21, cease no later than the date he turns 22. 42

U.S.C. § 1396d(h)(1)(A)-(C). Given the unambiguous meaning

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of the first two requirements, HHS correctly disallowed

Virginia’s claims for which Virginia “did not document that the

. . . costs were for ‘inpatient psychiatric hospital services,’ ”

CMS Virginia Letter at 3, and Kansas’s claims that were “for

services other than inpatient psychiatric services to residents of

a PRTF.” CMS Kansas Letter at 2. 

The States assert the IMD exception is indeed ambiguous

“as to whether the phrase ‘except as otherwise provided in

paragraph (16)’ refers to the services described in that paragraph

or to the individuals receiving those services.” Appellants’ Br.

25. If the latter, they contend, the requirement that services be

those defined in subsection (h) may be read simply to establish

a baseline for a patient in an IMD to receive all manner of FFPeligible medical assistance set out in section

1905(a)(1)-(29)—so long as the patient receives any qualifying

“inpatient psychiatric hospital services,” the States maintain, all

of his medical services are then eligible for medical assistance

and FFP. See Appellants’ Br. 32-33 (“In the States’ view,

therefore, far from limiting the scope of the exception to just

that one service, the initial prepositional phrase of the exclusion

ensures that Medicaid would pay for services for children in

IMDs only when the inpatient psychiatric services they received

met the high treatment standard set forth in Section 1396d(h).”).

We disagree. The excepting language refers quite specifically

to an “except[ion] as otherwise provided in paragraph (16)” and

paragraph (16) simply and unambiguously lists among the

services eligible for medical assistance “effective January 1,

1973, inpatient psychiatric hospital services for individuals

under age 21, as defined in subsection (h).” Such services

therefore are the only ones covered by the language of the

under-21 exception—all other services to individuals in IMDs

and under age 65 remain excluded. This is what the Congress

said and this is therefore what we presume the Congress meant.

See Conn. Nat’l Bank v. Germain, 503 U.S. 249, 253-54 (1992)

(“[C]ourts must presume that a legislature says in a statute what

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it means and means in a statute what it says there. When the

words of a statute are unambiguous, then, this first canon [of

construction] is also the last: judicial inquiry is complete.”

(citations and quotation marks omitted)). To overcome this

plain meaning presumption, the States “must ‘show either that,

as a matter of historical fact, Congress did not mean what it

appears to have said, or that, as a matter of logic and statutory

structure, it almost surely could not have meant it.’ ”

Performance Coal Co. v. Fed. Mine & Health Review Comm’n,

642 F.3d 234, 238 (D.C. Cir. 2011) (quoting Engine Mfrs. Ass’n

v. U.S. EPA, 88 F.3d 1075, 1089 (D.C. Cir. 1996)). The States

have not made such a showing.

The States first assert that the structure of the Medicaid

Statute supports their interpretation, pointing to the

“comparability principle” embodied in section 1396a(a)(10),

which, inter alia, requires that the medical assistance to any

individual meeting listed eligibility requirements “shall not be

less in amount, duration, or scope than the medical assistance

made available to any other such individual.” 42 U.S.C.

§ 1396a(a)(10)(B)(i). They contend that if the Congress had

wanted to limit IMD services to inpatient psychiatric hospital

services, it would have done so expressly in the comparability

provision—section 1396a(a)(10)—as it did when establishing

other exceptions thereto. See, e.g., id. § 1396a(a)(10)(G)(VII)

(limiting medical assistance available to certain women during

pregnancy to “medical assistance for services related to

pregnancy (including prenatal, delivery, postpartum, and family

planning services) and to other conditions which may

complicate pregnancy”). Notwithstanding its practice in other

contexts, however, in this instance, logically enough, the

Congress set out the exception in the subsection already

containing the exclusion itself—42 U.S.C. § 1396d(a)—and it

did so in unambiguous terms.

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The States next contend the legislative history supports its

interpretation but we find the cited history at best inconclusive.

The committee report on the 1972 act on which the States rely

expresses an intent to “authorize Federal matching under

medicaid for eligible children, age 21 or under, receiving active

care and treatment for mental diseases in an accredited medical

institution” (with controls “to assure that the new Federal dollars

are utilized to improve and expand treatment of mentally-ill

children”) in an “effort to restore mentally ill children to a point

where they may very well be capable of rejoining and

contributing to society as active and constructive citizens.” S.

Rep. No. 92-1230, at 281 (U.S. Sen. Comm. on Fin.). This

language sheds little light on whether, as the States contend,

matching funds are available for services other than those

expressly cited: “active care and treatment for mental diseases

in an accredited medical institution.” Thus, “[t]his case does not

present the very rare situation where the legislative history of a

statute is more probative of congressional intent than the plain

text.” Consumer Elecs. Ass’n v. FCC, 347 F.3d 291, 298 (D.C.

Cir. 2003); see also Natural Res. Def. Council v. EPA, 489 F.3d

1250, 1259 (D.C. Cir. 2007) (“It is true . . . that we may examine

the statute’s legislative history in order to shed new light on

congressional intent, notwithstanding statutory language that

appears superficially clear. But the bar is high . . . .” (first

ellipsis in original; internal quotation marks and citations

omitted)). 

The States also assert HHS’s own regulations are consistent

with—and therefore support—the States’ interpretation of the

under-21 exception. The recent regulations they cite, however,

are no more compelling than the legislative history as they too

are fully consistent with HHS’s narrow, plain meaning

interpretation of the exception to include only inpatient

psychiatric hospital services. See 42 C.F.R. § 441.13(a)(2)

(“FFP is not available in expenditures for services for . . . [a]ny

individual who is under age 65 and is in an institution for mental

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diseases, except an individual who is under age 22 and receiving

inpatient psychiatric services under Subpart D of this part.”)

(emphasis added); 42 C.F.R. § 435.1009(a)(2) (“FFP is not

available in expenditures for services provided to . . .

[i]ndividuals under age 65 who are patients in an institution for

mental diseases unless they are under age 22 and are receiving

inpatient psychiatric services under § 440.160 of this

subchapter.”) (emphasis added). The regulations are “eligibility

provision[s] which simply recognize[] that the broad ineligibility

that results from the IMD exclusion does not apply to children

receiving inpatient psychiatric services authorized under section

1905(a)(16) of the Act” and are “silent on whether, once a child

is receiving those services, FFP is available for other services as

well.” Va. Dep’t of Med. Assistance, DAB Dec. No. 2222, at

15. As we have explained, this question is answered by the

unambiguous language of paragraph (16) and subsection (h).5

5

Moreover, HHS has plainly expressed its interpretation of the

under-21 exception in rulemakings and in its own manual. See

Medicaid Program; Federal Financial Participation for Inmates in

Public Institutions and Individuals in an Institution for Mental Disease

or Tuberculosis, 48 Fed. Reg. 13,446, 13,446 (Mar. 31, 1983)

(“Section 1905(a) of the Social Security Act prohibits Federal

payments for services provided to inmates of public institutions, or

individuals under age 65 who are patients in an institution for mental

diseases or tuberculosis except for inpatient psychiatric services

received by individuals under age 22.”); Medicaid Program; Inpatient

Psychiatric Services for Individuals Under Age 21, 59 Fed. Reg.

59,624, 59,625 (Nov. 17, 1994) (“Under section 1905(a) of the Act,

Medicaid payment is generally not available for any services provided

to individuals under age 65 who are patients in [IMDs]. . . . The

psychiatric\21 benefit, at section 1905(a)(16) of the Act, is the only

statutory exception to the IMD exclusion.”); State Medicaid Manual

§ 4390.A.2 (1994) (“The IMD exclusion . . . states that FFP is not

available for any medical assistance under title XIX for services

provided to any individual who is under age 65 and who is a patient

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Finally, the States argue that the Secretary’s narrow

interpretation of the under-21 exception is at odds with other

provisions of the Medicaid Statute. We again find their

arguments unpersuasive. None of the statutory provisions they

cite suggests we should ignore the plain meaning of the statutory

IMD exclusion and its under-21 exception. See U.S. ex rel.

Totten v. Bombardier Corp., 380 F.3d 488, 494 (D.C. Cir. 2004)

(“ ‘[W]hen the statute’s language is plain, the sole function of

the courts—at least where the disposition required by the text is

not absurd—is to enforce it according to its terms.’ ” (quoting

Lamie v. United States Tr., 540 U.S. 526, 534 (2004))). 

The States first cite Medicare provisions which authorize

FFP for “early and periodic screening, diagnostic, and treatment

services [EPSDT] . . . for individuals who are eligible under the

plan and are under the age of 21,” 42 U.S.C. § 1396d(a)(4)(B);

see also id. § 1396d(r)(5); and one provision which previously

imposed a financial penalty on any state failing to provide such

services. See Social Security Amendments of 1972, Pub. L. No.

92-603, § 299F, 86 Stat. 1329, 1463 (1972) (formerly codified

at 42 U.S.C. § 403(g)). That the Medicaid Statute generally

encourages or even requires such screening does not negate the

unambiguous exclusion from FFP of all IMD services for

individuals under 65 except “inpatient psychiatric hospital

services for individuals under age 21.” 42 U.S.C.

§ 1396d(a)(16). The statutory language makes no exception for

EPSDT services.6

 

in an IMD unless the payment is for inpatient psychiatric services for

individuals under age 21.”). Based on these documents, we reject the

States’ assertion that HHS failed to provide sufficient notice of its

interpretation. See Appellants’ Br. 52-53. 

6

In fact, when the Congress first enacted EPSDT coverage for

eligible children in 1968 (effective July 1, 1969), it is undisputed that

the IMD exclusion prohibited all medical assistance to IMD residents

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The States also rely on section 1396a(a)(10)(C)(iv), which

provides that if a state plan provides medical assistance for any

of the eligible groups listed in section 1396d(a) that includes

“services in institutions for mental diseases or in an intermediate

care facility for the mentally retarded (or both) for any such

group, it also must include for all groups covered at least the

care and services listed in [paragraphs (1)-(5) and (17) of 42

U.S.C. § 1396d(a)] or the care and services listed in any 7 of

[paragraphs 1-24] of such section.” The States interpret this

language to mean that if they provide any services in an IMD to

a specific covered group, they must also provide the additional

referenced services set out in section 1396d to the same

group—contrary to HHS’s claimed limitation of IMD services

to inpatient psychiatric hospital services. Appellants’ Br. 43-44.

HHS, however, reasonably reads the same provision—consistent

with the IMD exclusion—to require that “[s]tates may only use

federal funding for services in institutions for mental diseases if

they already cover a wide range of services for ‘all groups

covered.’ ” Appellees’ Br. 21. We think HHS’s interpretation,

which maintains the integrity of each provision, is the better

reading. See Ricci v. DeStefano, 129 S.Ct. 2658, 2699 (2009)

(“Our task in interpreting separate provisions of a single Act is

to give the Act the most harmonious, comprehensive meaning

possible in light of the legislative policy and purpose.” (internal

quotation marks and alteration omitted)). In any event, the

language of section 1396a(a)(10)(C)(iv) does not plainly

contravene the unambiguous language of the IMD exclusion and

its exception. 

under age 65—including EPSDT—and that remained the case until

1972 when the Congress added the limited under-21 exception for

“inpatient psychiatric hospital services” only. See Social Security

Amendments of 1967, Pub. L. No. 90-248, § 302(a), 81 Stat. 821, 929

(1968). 

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Finally, the States argue that HHS’s single-service

restriction for IMD funding frustrates the Congress’s intent in

authorizing waivers for individuals with chronic mental illness

to receive care in a home- and community-based treatment

environment in lieu of an IMD—provided the alternative care is

cost-neutral. See 42 U.S.C. § 1396n(c). Because the home- or

community-based care is provided outside an IMD and is

therefore not subject to the IMD exclusion, such alternative care,

the States contend, necessarily provides more services at a

higher cost than the limited services HHS allows pursuant to the

under-21 exception. Thus, they maintain, obtaining a waiver

cannot be cost neutral. HHS responds, however, that the cost of

the additional services available in home- or community-based

care might be offset by the elimination of room-and-board costs

incurred in an IMD. In short, we cannot know from the present

record how often waivers may be cost-neutral and therefore

permissible. What we do know is that the plain language of the

provision that directly addresses services to IMD residents under

age 21—namely, the narrow under-21 exception to the IMD

exclusion which was already well-established when the waiver

provision was extended to cover “chronic mental illness” in

1986—unambiguously limits IMD medical assistance to

inpatient psychiatric hospital services. See Omnibus Budget

Reconciliation Act of 1986, Pub. L. No. 99-509, § 9411(d), 100

Stat. 1874, 2061-62 (1986). There is no indication, that the

Congress intended to alter the exception’s established scope at

that time.

In sum, the longstanding IMD exclusion, as amended by

paragraph (16)’s under-21 exception, plainly and unequivocally

limits Medicaid medical assistance for individuals in IMDs

under age 21 to claims for “inpatient psychiatric hospital

services” as defined in subsection (h) of section 1396d(a). This

restriction may not reflect the most compassionate or even the

most prudent approach to treating young patients in IMDs but it

marks the extent of assistance the Congress unambiguously

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authorized in 1972 when it first decided to fund such services.

Our role is “not to ‘correct’ the text so that it better serves the

statute’s purposes”; nor under Chevron, may we “avoid the

Congressional intent clearly expressed in the text simply by

asserting that [our] preferred approach would be better policy.”

Engine Mfrs. Ass’n v. U.S. EPA, 88 F.3d 1075, 1089 (D.C. Cir.

1996). The Congress has spoken plainly and our function is to

“give effect to the unambiguously expressed intent of

Congress.” Chevron, 467 U.S. at 843. Accordingly, we affirm

the district court’s grants of summary judgment to HHS.

So ordered.

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