In the

United States Court of Appeals

For the Seventh Circuit

No. 08-3592

LAMONT G. BAILEY, et al.,

Plaintiff-Appellants,

v.

E. MITCHELL ROOB, JR., et al.,

Defendants-Appellees.

Appeal from the United States District Court

for the Southern District of Indiana, Indianapolis Division.

No. 1:94-cv-00089-SEB-JMS—Sarah Evans Barker, Judge.

ARGUED MARCH 31, 2009—DECIDED JUNE 8, 2009

Before FLAUM, MANION, and ROVNER, Circuit Judges.

FLAUM, Circuit Judge. Years ago, a group of plaintiffs

and the Indiana Medicaid program’s administrators

agreed to certain terms for the handling of applications to

the disability program in Indiana: most relevant for

present purposes was a concession that the program

would compile a complete twelve-month medical

history before reaching a decision on the application. Now,

several members of the affected class want to hold the
2 No. 08-3592

program administrators in civil contempt for violating

that portion of the consent decree. They claim that in too

many cases the program is relying on summary forms

rather than compiling an applicant’s complete medical

history.

The district court rejected the motion because the plaintiffs had not demonstrated by clear and convincing evidence that the defendants were in violation of the terms

of the consent decree. Appellants now challenge that

ruling, citing three errors. First, they claim the district

court improperly tasked them with demonstrating that

the plaintiffs had not been reasonably diligent in

following the demands of the consent decree. Second, they

argue that the district court should have held that the

evidence proffered below was a clear and convincing

demonstration that the program administrators were

violating the decree. Third, they argue that the district

court erred as a matter of law by holding that 20 C.F.R.

§ 416.912(d), a provision of the regulations for the Supplemental Security Income disability program

incorporated by reference into the consent decree, did not

require a full collection of medical records.

For the following reasons, we affirm the district court’s

ruling.

I. Background

The Medicaid for the Disabled program in Indiana

provides medical coverage and benefits to individuals

who suffer from a qualifying disability. The present case
No. 08-3592 3

grew out of a class action lawsuit filed against the Indiana

Medicaid disability plan in the 1990s. That lawsuit was

settled by a consent decree requiring the administrators

of the plan to collect certain evidence before making a

decision on an application for disability benefits. The

consent decree required the Indiana plan to obtain and

evaluate evidence used for Medicaid eligibility in the

same way that the Code of Federal Regulations requires

the Supplemental Security Income administrators to

obtain and evaluate evidence. Specifically, the decree

provided that, “the State of Indiana must obtain and

evaluate evidence in determining Medicaid eligibility

in the same way that Supplemental Security Income

disability determinations are made under 20 C.F.R. 416.901

through 416.988.”

In fact, the consent decree simply incorporated 20 C.F.R.

§ 416.901-416.988 as regulations for how the Indiana

Medicaid program should go about collecting and evaluating applications. As the district court summarized it, the

consent decree required the Indiana Medicaid program

to do three things: First, obtain complete histories from a

Medicaid applicant’s treatment providers, covering at

least the twelve months prior to the application, before

making any determination about Medicaid eligibility;

second, obtain additional medical information from an

applicant’s treating physician or other medical source

when necessary; third, ensure that medical records are

complete and detailed enough to allow for a proper

determination regarding eligibility.

The Indiana Medicaid for the Disabled program is

supposed to follow a defined set of procedures when
4 No. 08-3592

making eligibility determinations. Applicants for

Medicaid for the Disabled first meet with an assigned

caseworker. The caseworker helps an applicant fill out

Form 251B, in which an applicant lists her medical conditions and any information about treatments she’s received in the last twelve months, including her treating

physicians. The caseworker is responsible for collecting

an applicant’s medical history based on the information

provided in Form 251B. If the caseworker is unable to

collect this information, he is supposed to note that in the

applicant’s file. After the caseworker has processed them,

applications are forwarded to the Medicaid Medical

Review Team (MMRT). The MMRT is responsible for

gathering any information that the caseworker has not

tracked down.

The Indiana Medicaid plan uses a Form 251A to collect

information from a physician about an applicant’s

medical history. The Form 251A includes a section asking

for information about the patient’s treatments, diagnostic

tests, and medications going back for at least twelve

months, a “Medical Evidence” section asking for information on the patient’s physical systems, and a “Diagnosis/Prognosis” section asking for the doctor’s opinion

regarding the applicant’s reported impairment.

On April 13, 1999, plaintiffs filed a petition to hold the

defendants in civil contempt for violating the terms of the

consent decree. The parties settled by entering into a

second consent decree that included the same terms as the

original and allowed anyone who had been denied

Medicaid benefits in the preceding three years to

reapply for benefits.
No. 08-3592 5

This procedure raises some obvious concerns about sample 1

size and concentration, but appellants contend that appellees

stipulated that they would not raise those issues in defense

of the action, and they have not.

Seven years later, on September 26, 2006, plaintiffs

filed a second petition to hold defendants in civil contempt, alleging that the Indiana Medicaid program was

again in violation of the consent decree. In response to a

discovery request, the Medicaid administrators agreed

to produce a representative sample of disability benefit

applications. That sample consisted of twenty-six files

in all, representing every application from Marion

County, Indiana with an applicant whose last name

began with “C” and whose application was denied between September 1, 2006 and October 1, 2006. The 1

parties judged twelve of these applications to be complete under any standard, but appellants contend that

the remaining fourteen are incomplete and demonstrate

the Indiana Medicaid program’s violation of the consent

decree.

Appellants contend that in some cases Indiana is improperly using this form as a proxy for the “complete

medical history” required in 20 C.F.R. § 416.912. Appellees

contend that the consent decree does not always

require them to obtain copies of a physician’s medical

records and that Form 251A is a “complete” medical

history within the meaning of the decree.

The district court conducted its own review of the files.

It concluded that five of the fourteen allegedly incomplete
6 No. 08-3592

files were complete under any standard. With respect to

the remaining nine, the district court found that “[f]our of

these nine applications are clearly less complete than

the other five,” and that the other five files contained only

the summary Form 251A, but did not find the administrators of Indiana Medicaid in contempt for violating

the consent decree. The crux of the district court opinion

is that the appellants had not met the burden for a civil

contempt petition: Neither side presented adequate

evidence on what constituted a “complete” medical

history, and thus neither the four arguably incomplete

applications nor the five applications containing only

the Form 251A was clear and convincing evidence that

the appellees violated the consent decree. The district

court invited the appellants to re-file their motion, asking

them to produce “[e]xpert testimony, or information on

how the agency charged with responsibility for compliance with the Decree interprets the definition

Plaintiffs offer” and “factual explication of what precisely

the Medicaid system instructs physicians to do and take

account of in completing Form 251A.” The appellants

instead appealed the district court’s denial of their

motion to this court.

II. Discussion

We review the district court’s decision not to hold the

state in civil contempt deferentially. “It is well established

that the decision by a district court to enter a finding of

civil contempt is discretionary and we review it only to

determine if there was an abuse of discretion or its entry
No. 08-3592 7

was clearly erroneous.” Feltner v. Title Search Co., 283 F.3d

838, 841 (7th Cir. 2002). The case law on contempt

sanctions divides them into two categories: coercive and

remedial. See Jones v. Lincoln Elec. Co., 188 F.3d 709, 738

(7th Cir. 1999). Coercive sanctions induce a party’s compliance with a court order in the future, while remedial

sanctions compensate an injured party for an opponent’s

past non-compliance. Id. The contempt petition here is

coercive; the appellants were seeking to enjoin the

Indiana Medicaid program to contract with an outside

auditor to review its decisions every three months, and

to record each and every instance in which a caseworker requests medical information from an applicant’s

medical care provider.

Appellants argue that the district court made three

errors. First, it improperly placed upon them the burden

of demonstrating that Indiana had not been reasonably

diligent in carrying out the consent decree’s requirements.

They contend that reasonable diligence is an affirmative

defense on which Indiana bears the burden of proof.

Second, they argue that the district court abused its

discretion by not imposing civil contempt sanctions

because of the four applications that the district court

characterized as less than complete. Third, they argue

that the district court improperly declined to hold that

the consent decree requires that Indiana obtain actual

copies of a treating physician’s medical records and thus

that the five applications with only a Form 251A are

evidence of Indiana’s violation of a court order. We

take each claim in turn.
8 No. 08-3592

A. Whether the district court improperly allocated the

burden of proof

The appellants first contend that the district court abused

its discretion because it improperly placed on them the

burden of proving that the appellees were not “reasonably

diligent” in executing the consent decree. The district

court characterized the burden of proof as, “whether

Plaintiffs have shown, by clear and convincing evidence,

that Defendants have not been ‘reasonably diligent and

energetic in attempting to accomplish what was ordered’

in the Consent Decree.” They contend that this was an

error of law and necessarily an abuse of the district court’s

discretion. See United States v. Jaderany, 221 F.3d 989, 994

(7th Cir. 2000). Appellants contend that they need only

show a violation of the terms of the consent decree;

“reasonable diligence,” they contend, is an affirmative

defense on which the appellees’ bear the burden of production.

Appellants cite United States v. Rylander, 460 U.S. 752

(1983), which they argue squarely places the burden of

demonstrating reasonable diligence on the party

defending against the contempt petition. Rylander does

hold that a defendant in a contempt proceeding bears the

burden of producing evidence if he is asserting a present

inability to comply with the terms of a court order. Id. at

757. The defense that the Supreme Court discussed in

Rylander is different from any defense that the state would

present in the present case, however. In Rylander, the

respondent was subject to an IRS summons ordering him

to turn over certain corporate books and records to the
No. 08-3592 9

agency. Id. at 753. A prima facie case for contempt sanctions in that case consisted of a showing that Rylander

had not satisfied the terms of the summons—that is, that

he had not turned over the books and records. The Court

held that Rylander could defend against a finding of civil

contempt by demonstrating “that compliance is now

factually impossible.” Id. at 757. Rylander thus places a

burden of proof on the defendant, but it does so when

the defendant is alleging that “compliance is impossible.”

Id.

Rylander addressed a case where a party defending

against a civil contempt petition for violating a court

order requiring a one-time-only action on his part, but in

doing so it did not address what evidence a party seeking

sanctions must produce in the first instance. The parties

agree that this circuit’s case law requires the party

seeking sanctions to demonstrate that the opposing party

is in violation of a court order by clear and convincing

evidence. See, e.g., SEC v. Homa, 514 F.3d 661, 676 (7th Cir.

2008). They disagree over what evidence a party has to

produce to demonstrate an opponent’s violation of a

court order.

In Goluba v. School Dist. of Ripon, 45 F.3d 1035 (7th Cir.

1995), we noted when discussing civil contempt

sanctions that, “[t]he district court does not, however,

‘ordinarily have to find that the violation was “willful” ‘

and may find a party in civil contempt if that party ‘has not

been reasonably diligent and energetic in attempting to

accomplish what was ordered.’ ” Id. at 1037 (citing Stotler

and Co. v. Able, 870 F.2d 1158, 1163 (7th Cir. 1989)). Appel-
10 No. 08-3592

lees contend that this passage places the burden of

proof on this issue on the party seeking the contempt

sanction; the appellants contend that their burden of

proof is actually spelled out earlier in the same opinion,

where the court noted that in order to prevail, “a party

must prove ‘by clear and convincing evidence’ that the

opposing party violated a court order.” Id. (citing Stotler,

870 F.2d at 1163).

Goluba does not explicitly say which party bears the

burden of demonstrating “reasonable diligence” or the

absence thereof. Our discussion of “reasonable diligence”

in that case refers to what a court must find rather than

to what a party to the action must prove. However,

Goluba spelled out what evidence must be before the

court before it can impose sanctions: evidence that a party

has willfully refused to comply with a court order, or

evidence that a party was not “reasonably diligent”

in carrying out the terms of the court order. We have

subsequently used a test for civil contempt petitions that

explicitly requires a petitioner to demonstrate that the

alleged contemnor was not reasonably diligent. See

Prima Tek II, LLC v. Klerk’s Plastic Industries, B.V., 525

F.3d 533, 542 (7th Cir. 2008) (“To sustain its contempt

claim, PTII has the burden of proving all of the following

elements by clear and convincing evidence: (1) the Order

sets forth an unambiguous command; (2) Klerks violated

that command; (3) Klerks’s violation was significant,

meaning it did not substantially comply with the Order;

and (4) Klerks failed to take steps to reasonabl[y] and

diligently comply with the Order.”) (citing Goluba and

Stotler). Likewise, the Supreme Court has discussed the
No. 08-3592 11

prima facie case in a civil contempt proceeding as the

burden of showing a willful failure. See McPhaul v.

United States, 364 U.S. 372, 379 (1960) (“The Government’s

proof at the trial thus established a prima facie case of

willful failure to comply with the subpoena.”) (emphasis

added). At least one other circuit has used a similar

phrase in elaborating the contempt standard, requiring

that the evidence be sufficient to foreclose a finding of

reasonable diligence. See United States v. Local 1804-1, Int’l

Longshoreman’s Ass’n, AFL-CIO, 44 F.3d 1091, 1096 (2d Cir.

1995) (“In a civil contempt proceeding, like the present

case, a contempt holding will fall unless the order

violated by the contemnor is ‘clear and unambiguous,’ the

proof is ‘clear and convincing,’ and the contemnor was

not reasonably diligent in attempting to comply.”). Thus,

the district court did not commit a clear legal error by

requiring appellants to demonstrate Indiana’s lack of

reasonable diligence.

Furthermore, we could reject the contention that the

district court erred in stating the burden of proof because

it is not clear from reading the opinion that the district

court actually placed the burden of demonstrating the

lack of reasonable diligence on appellants. The statement

quoted above certainly suggests that the court required

as part of the prima facie case evidence that the appellants

had not been reasonably diligent. However, the district

court ultimately rejected the civil contempt petition

because one set of allegedly incomplete applications was

in fact complete, and “their completeness shows ‘reasonable diligence’ on the part of Defendants to follow the

Court’s order and the regulations that support it.” With
12 No. 08-3592

respect to the other allegedly incomplete applications, the

court declined to impose civil contempt sanctions not

because appellants had not demonstrated an absence of

reasonable diligence but because “it remains unclear

what constitutes a ‘complete’ medical history” and consequently appellants had “failed to meet their burden on

the remaining applications, because the standard for

contempt requires clear and convincing evidence that

Defendants violated the decree.” Appellants did not

prevail because they simply failed to produce clear and

convincing evidence that Indiana had violated the

consent decree. They have now latched onto a single

phrase from the opinion and insist that it mandates

reversal, but we think this is an uncharitable characterization of the district court’s opinion and, at any rate, is

neither an error nor grounds for reversal.

B. Whether appellants produced sufficient evidence of

non-compliance

The burden of proof aside, appellants also contend

that the evidence they presented to the district court

adequately demonstrated Indiana Medicaid’s non-compliance with the consent decree and justified civil contempt

sanctions. As the district court summarized it, appellants

made the following factual allegations in the contempt

proceeding, based on their random sampling of applications:

(1) In nine, or 35%, of the applications, Defendants

failed to request twelve-month medical histories;

(2) in seven, or 25%, of the applications, Defendants
No. 08-3592 13

failed to collect information that was “complete and

detailed enough” to make a disability determination;

(3) in three, or 12%, of the applications, Defendants

failed to collect a list of any medical facilities that

treated the applicant; (4) in eight, or 53%, of fifteen

applications, the county office forwarded the application to the MMRT without any medical records; (5) in

four, or 27%, of fifteen applications, the Medicaid

application was denied on the same day that the

Medicaid Medical Review Team requested additional

information about the applicant; (6) in one of fifteen

applications, the only medical information included

in the application was gathered by a registered

nurse, rather than a doctor; (7) in none of the applications did the packet contain Form 2032, which is

supposed to be present any time an applicant was

asked to receive a physical examination; (8) in none

of the applications did the county caseworker make

a record of requests for medical information; and (9) in

neither of the two applications in which a physician

requested that the applicant receive further testing

was the testing actually performed before the application was denied.

The district court conducted its own review of the files

and concluded that at least five of the allegedly incomplete

applications in fact contained detailed records. The

court did note that of the remaining nine applications,

“[f]our of these nine applications are clearly less complete than the other five,” either because those files were

missing Form 251A altogether or because Form 251A was

missing pages or was otherwise incomplete. Appellants
14 No. 08-3592

claim that this statement regarding the four case files is

evidence of Indiana’s non-compliance with the consent

decree and a sufficient basis for holding the program’s

administrators in civil contempt.

Appellants cite case law from this and other circuits

establishing that Medicaid programs are subject to a

strict compliance standard with respect to regulatory

procedures and deadlines for reaching decisions on

individual applications. They rely heavily on Smith v.

Miller, 665 F.2d 172 (7th Cir. 1981), a case involving a

suit for injunctive relief against the Illinois Medicaid

program. Smith contained broad language that seems to

support appellants’ position: “It is uncontested that the

district court possessed the equitable power to enjoin the

Department’s violation of federal laws and regulations.

While a state’s participation in the Medicaid program

is purely voluntary and its acceptance of substantial

federal funds uncoerced, once electing to participate,

it must fully comply with federal statutes and regulations in its administration of the program.” Id. at 175.

Appellants also cite case law from other circuits to

support a full compliance standard. See Withrow v.

Concannon, 942 F.2d 1385, 1387 (9th Cir. 1991) (finding that

“[t]he language of the federal regulations is

unequivocal . . .”); Alexander v. Hill, 707 F.2d 780, 784 (4th

Cir. 1983) (“[t]he law itself compels 100% compliance . . .”).

Indeed, appellants argue that even if this circuit

accepted some kind of de minimis amount of deviation

from regulatory or statutory requirements, the rates of noncompliance in their sample would be sufficient to

require some kind of remedial action.
No. 08-3592 15

We are presented, then, with the question of how much

non-compliance is needed before a district court can

impose civil contempt sanctions. A few preliminary

points will sharpen our analysis on this issue. Other

courts have observed that in civil contempt proceedings,

“context is extremely important to appellate oversight . . .”

Langton v. Johnston, 928 F.2d 1206, 1220 (1st Cir. 1991). In

contempt proceedings between private parties, the

consent decree operates like a contract between the two

and a reviewing court has comparatively greater freedom

to revisit the district court’s interpretation of the decree.

Id. at 1220-21. When the consent decree involves a public

agency, however, “the district court’s construction of a

consent decree should be accorded considerable

deference, because broad leeway is often necessary to

secure complicated, sometimes conflicting, policy objectives.” Id. at 1221.

The Supreme Court has also cautioned district courts

that in using their contempt powers against a public

agency they should select a remedy carefully tailored to the

proposed end. Spallone v. United States, 493 U.S. 265, 276

(1990); see also Missouri v. Jenkins, 495 U.S. 33, 51 (1990)

(“[O]ne of the most important considerations governing

the exercise of equitable power is a proper respect for

the integrity and function of local government institutions.”). This warning recognizes that when a district

court uses its remedial powers (including the power to

enforce a consent decree) in the public law context, district

courts “typically play a proactive role—a role which can

have nearly endless permutations.” Langton, 928 F.2d at

1221. A district court in such circumstances can find
16 No. 08-3592

itself deeply entangled with the development and management of a city or state agency. This circuit’s experience

with the remedial decree in the long-running case of

Gautreaux v. Chicago Housing Authority (of which 491

F.3d 649 (7th Cir. 2007) is only the most recent iteration

in a forty-year lawsuit) illustrates the many ways in

which such a decree can deepen a district court’s involvement with a case and require it to resolve many subsequent disputes between the parties, rather than terminating it through the sort of one-shot transfer that a

consent decree between private parties often involves.

The present case is another example; it has twice been

settled through consent decrees and has been on the

docket of the Southern District of Indiana intermittently

since 1994. We can state the point of these observations

simply: We are sensitive to the district court’s need not

to extend its equitable powers too far and to require a

persuasive showing of contempt before taking such

serious action against a state administrative agency.

We conclude that the district court did not abuse its

discretion by ruling that appellants had not produced

clear and convincing evidence of Indiana’s violation of

the court order. The first problem for appellants is that

the district court did not make a factual finding that any

of the applications are incomplete and in violation of the

consent decree. The district court did note something

that appellants stress in their brief, which is that four of

the files are less complete than the others. However, due

to the inconclusive nature of the parties’ arguments

about what constitutes a “complete” medical history, the

district court was unable to make any factual findings
No. 08-3592 17

One problem complicating this categorization is that those 2

four files are all at various stages of incompleteness. One file,

designated File M, contains no medical history outside of a

copy of a prescription refill; File E contains a Form 251A that is

missing pages; File L contains only one incomplete Form 251A

and nothing from other medical providers; and File H was

denied on the same day that the MMRT requested additional

records which they apparently never received.

Withrow is a particularly problematic citation for appellants, 3

as the Ninth Circuit specifically distinguished between the

initial remedy and enforcement of that remedy in contempt

proceedings. Withrow, 942 F.2d at 1388 (“As with any program

of this size, a few inadvertent errors are inevitable, and we

(continued...)

about whether the files were or were not in compliance

with the regulatory standard incorporated into the

consent decree. (The district court’s uncertainty about the

applicable regulatory standard is covered in the next

section.) Appellants urge us to read the district court’s

identification of four less-than-complete applications as

an implicit finding that Indiana Medicaid is not

collecting complete medical histories and is in violation

of the consent decree. We will not base a civil contempt 2

order on an implicit finding when the district court declined to make that finding on the record or base a contempt order upon it, however.

Second, with respect to the legal standard, the case law

that appellants cited occurred outside the civil contempt

context; those cases sought injunctive or equitable relief

for unsettled cases. They are thus swapping the 3
18 No. 08-3592

(...continued) 3

are confident that the district court will not exercise its

equitable powers to hold the state in contempt for every

minor, inadvertent infraction of the Act if the court is satisfied

that the officials are complying with the Act as strictly as is

humanly possible.”).

standard for civil contempt with the standard for initial

injunctive relief. Appellants anticipate this objection, and

argue in a footnote in their brief that this court cannot

fairly subject motions seeking to enforce the consent

decree to a higher burden of proof than the lawsuit seeking

relief in the first instance. That argument conflates a

standard used to determine an injury with a standard

used to measure the efficacy of a remedy, however. The

appellants’ position is that the failure to follow

regulatory procedures inflicts an injury on them; to the

extent that their allegations are true, their injury does

entitle them to equitable relief. The existence of the

consent decree in this case, however, means that they

already have that relief. The issue at this stage is whether

we can hold the Indiana program in civil contempt for

not taking adequate steps to implement that remedy

and, for the reasons discussed above, a district court is

entitled to require clearer and more convincing evidence

of non-compliance before imposing coercive sanctions.

Thus, even if we did what appellants ask us to do and

took the four “less than complete” applications as an

implicit finding that Indiana fell short of the terms of the

consent decree in some cases, that finding would not

necessarily justify the civil contempt sanctions that ap-
No. 08-3592 19

pellants seek. We agree with the district court that, given

the present context, those sanctions are not warranted

based on the evidence presented.

C. Whether the district court erred by not interpreting

“complete medical history” as always requiring

copies of a treating physician’s records

Appellants’ final issue in this appeal is whether the

district court made an error of law by interpreting the

phrase “complete medical history” in the consent decree

to mean something less than copies of the medical

records of each treatment source of a given applicant. This

issue pertains to the five application files that contain

completed copies of Form 251A but do not contain copies

of the treating physician’s medical record. Appellants

argue now that the district court erred by not concluding

that those files do not contain the complete medical

history required by the regulations.

Once again, the consent decree requires that the administrators of Indiana Medicaid develop records used in

eligibility decisions in the same way that the SSI program

develops records for eligibility decisions. The Code of

Federal Regulations provisions for that program

promises applicants that, “we will develop your complete

medical history for at least the 12 months preceding the

month in which you file your application unless there is

a reason to believe that development of an earlier period

is necessary or unless you say that your disability began

less than 12 months before you filed your application.”

20 C.F.R. § 416.912(d). With respect to the phrase “com-
20 No. 08-3592

plete medical history,” the regulations define that as

follows:

By complete medical history, we mean the records of

your medical source(s) covering at least the 12 months

preceding the month in which you file your application. If you say that your disability began less than

12 months before you filed your application, we will

develop your complete medical history beginning

with the month you say your disability began unless

we have reason to believe that your disability began

earlier.

20 C.F.R. § 416.912(d)(2). Appellants clearly believe that

the phrase “complete medical history” means physical

copies of the physician’s own records, going back at least

twelve months before the date of the application. Indiana

clearly operates under the incompatible belief that

Form 251A suffices as a complete medical history, since

it gathers information from each of the applicants’ treatment providers for at least the previous twelve months.

The district court was unable to sort out this disagreement based on the parties’ presentations. It invited appellants to re-file their contempt petition along with evidence

elaborating on the meaning of “complete medical history.”

Specifically, the district court was interested in receiving

expert or other testimony on “whether the applications

that included only Form 251A, or the other applications

that were otherwise less comprehensive, are ‘complete’

enough to conform to the consent decree. Furthermore,

we require a factual explication of what precisely the

Medicaid system instructs physicians to do and take

account of in completing Form 251A.”
No. 08-3592 21

The appellants urge us to reverse this part of the decision, claiming that this interpretation of the consent decree

violates the plain meaning of the terms as well as the

decisions of courts that have reviewed the meaning of the

relevant C.F.R. provisions. They cite, among other things,

the dictionary definition of complete (meaning “having

all parts or elements; lacking nothing”), and two opinions

from the Second Circuit reversing an agency’s eligibility

determination because some medical records were missing. See Rosa v. Callahan, 168 F.3d 72 (2d Cir. 1999); Pratts v.

Chater, 94 F.3d 34 (2d Cir. 1996).

A court interprets the meaning of a consent decree in the

same way it interprets the meaning of a contract, and a

reviewing court examines that interpretation de novo.

Goluba, 45 F.3d at 1037-38. Of course, because these regulations were only grafted onto the Indiana Medicaid

program as part of a consent decree, no court has previously interpreted what “complete” means in this exact

context, and the district court obviously felt unable to

reach a conclusive interpretation based on the evidence

presented in the contempt petition. This circuit has not

read “complete” in the strict terms that the appellants do,

however. In past cases, where SSI applicants whose

application was denied by an ALJ claimed a violation of

the duty to develop a complete record, we have said that

our court “generally upholds the reasoned judgment of the

Commissioner on how much evidence to gather, even

when the claimant lacks representation.” Nelms v. Astrue,

553 F.3d 1093, 1098 (7th Cir. 2009); see also Luna v. Shalala,

22 F.3d 687, 692 (7th Cir. 1994) (“This court has commented on the difficulty of having a ‘complete’ record as
22 No. 08-3592

‘one may always obtain another medical examination, seek

the views of one more consultant, wait six months to see

whether the claimant’s condition changes, and so on.’ ”).

The regulations also place at least part of the burden for

gathering the relevant medical records on the applicant

rather than on the agency. “In general, you have to prove

to us that you are blind or disabled. This means that you

must furnish medical and other evidence that we can use

to reach conclusions about your medical impairment(s).”

20 C.F.R. § 416.912(a). While the regulations task the

agency with the responsibility to develop an applicant’s

medical history, they discuss this in terms of a duty to

make a “reasonable effort” to do this. “We will make every

reasonable effort to help you get medical reports from your

own medical sources when you give us permission to

request the reports.” 20 C.F.R. § 416.912(d) (emphasis

added). Indiana, in reliance on these portions of the

regulations, interprets the consent decree much more

narrowly, and argues that by training case workers to

interview Medicaid applicants and requesting an applicant’s medical history they fulfill their burden under

the regulations with respect to the collection of a physician’s records.

Appellants’ position that a Form 251A does not suffice as

an applicant’s “complete medical history” within the

meaning of 20 C.F.R. § 416.912(d)(2) is based on an assumption that the document is deficient in some respect,

or that a physician’s records contain material informa-
No. 08-3592 23

Appellants argue that a Form 251A is deficient because it is

4

not a “record” under Indiana law, because the Indiana Code

defines “medical records” as files “possessed” by health

care providers before they are turned over to the state. Ind.

Code. § 1-1-4-5(6). First, appellants do not explain why Indiana

law should inform the meaning of a term used in the federal

regulations. We understand that looking at the Indiana Code

may illuminate how the parties understood the term, but

appellants otherwise urge this court to adopt a strict reading

of the term as it is construed by courts interpreting the federal

regulations themselves. The Indiana Code would be of limited

value in that exercise. Second, appellants do not explain how

the fact of possession makes a substantive difference in the

completeness of an applicant’s file if, for instance, the file

contained a form completed by a health care provider containing all of the relevant information in the provider’s files.

tion not captured in Form 251A. As the district court 4

noted, however, there is not enough information before

the court to reach a determination on that issue. The

regulations require both the applicant and the agency to

develop a record sufficient for the agency to make an

informed determination about the applicant’s disability.

Based on this record we are not prepared to hold categorically that an agency can never use a summary form when

developing that record or that the absence of any document from a physician within the last twelve months,

whatever its relevance, is a violation of the regulations.

While the case is simply underdeveloped on this point,

our ruling does not foreclose all future claims on this

issue from appellants. The district court indicated a

willingness to entertain further petitions and to engage
24 No. 08-3592

in greater fact-finding on the meaning of “complete

medical history” under the terms of the consent decree,

including gathering information about how thorough

health care providers have been when filling out Form

251A. This matter presently comes before us as a contempt petition, however, where the salient issue is

whether appellants have presented sufficient evidence

that the Indiana Medicaid program has violated a court

order. We agree with the district court that they have

not satisfied that burden at this point.

III. Conclusion

For the foregoing reasons, we AFFIRM the decision of

the district court.

6-8-09