UNITED STAT ES DIS TRICT COURT F OR THE D ISTRIC T OF CO LU M BIA OSCAR SALAZAR, e t al . , :

: P lai nt iffs, :

: v. : Ci vi l A cti on No. 93 -45 2 (GK) : DISTRICT OF COLUMBIA, e t al . , : : De fend ant s. :

M EM OR

AN DU M OP IN ION Plai n t i ff s h av e m o v edt o C o mp el S p ec i fi c D i s co v ery Concerning

Compli ance with Parag

raph 36 of the Se ttlem ent Ord er as it Pe rt a ins to t he Pr ov isi on

of Ho me He a lthCare , Pr ivate Duty Nursing , and Persona l Care Se rv i ce s . Upon consider ation of the Motion, the Opposition of the District of Columbia a

nd non-par

ties Hea lth Services for

Children with Special Nee ds (“HSCSN”) and McK esson Hea lth Sol utions L L C (“McK esson”) , the Reply , and the e ntire re cord here in, the Court concludes that the Motion should be granted
. On Dec ember 19, 2006, the Court g rante d Plaintiffs’ Motion for L eave to Conduc t L imited Discover y Concern i n g Compli ance with Parag raph 36 of the Settlement Orde r Pertainingto the Pr o v is io n s o f H o me H e a lt h Ca r e , Pr iv a te D u ty

N u r s in g , an d

Pe r s o n a l C ar e Se r

v ic e s [D kt. # 1 2 5 6 ]. Def endants a nd the two non-par

ties, HSCS N and McK esson, who we re g iven per mission t o enter
a sp e c ia l li mit e d a

pp e ara nce f or th e purp os e of

op po sin g the pe nd ingMo tio n, have re fu se d to provide, pursua

nt to a discovery

reque st, the I nterqua l Clini cal Decision Support Criteria (“ I nterqua l Criteria” or “Criter ia”) to Plaintiffs. The Interqua l Criteria ar e evide nce- based tre atment g uidelines that ha ve be e n d e ve lop e d a

nd c op y ri g hte d b y

Mc Ke sso n, wh ic h, in t

ur n, ha s li c e nsed th e ir

us e to HSC SN a nd many oth e r Me dic a id mana g e d c are or g anizatio ns a c ro ss the c ountr y , wh ic h th e n r e lyMcKe sson proposed additional conditions reg arding returning of copies and kee ping 1 the copies se cure . -2- on them to authorize, re- authorize and/or terminate hom e hea lth care (“H HC”), pr ivate duty nursing (“PDN” ), and pe rsonal ca re ( “PC”) ser

vices. HSCS N and Mc Kesson have ref used to provide these Criteria unless Plaintiffs ag ree to a compre hensive c onfidential agree m ent under which the Criteria would be distributed only to (1) phy sicians for the S alazar Pl aintiffs i n case s wher e they have been used to deny , limit , or discontinue service s of a be nefic iary ; (2 ) P l ai n tiffs who ar e member s of the Salazar c lass in case s where they h a v e b e e nu s e d

t o d e n y, l i m i t , o r d i s c o n t i n u e s e r v i c e s ; ( 3 ) T e r

r i s , P r a v l i k & M i l l i an ; an d ( 4 ) a t t o r n e ys wh o a re c o- c ouns e l f

or the Pla int if

f C la ss. 1 Th e re is n o q

ue sti on th at couns e l to the Sa la zar Cla ss a re e nti tle d to dis c los ur e of e lig ibl e
c r i t e r i a f o r H H C , P D N , an d P C s e r v i c e s . A s t h e C o u rt h a s n o t e d i n i t s r u l i n g g r an t i n g Pla int if

fs ’ Motion for limited discovery , Plaintiffs’ counsel have an oblig ation to monitor compliance with the S e t t l e m e n tA g r e e m e n t , i n c l u d i n g p ar a g r a p h 3 6 c o n c e r n i n g t h e p r o v i s i o no f

i n - h o m e s e r

v i c e s . In particula r, Plaintiffs’ counse l need to know what criteria HSCS N is relying up o n i n making decisions, which a

re of g reat significa

nce to their

clients, reg ardingthe authorizat i o n , reauthorization, and/or termination of service s which are often vital to the par ents and c are taker s of children w ith special nee ds. Plaintiffs’ counsel infor

med the Court that t hey rec eive numerous inquiries from member s of the Salazar class about their entit lement t o such services. I n addition, University L eg al Service s -- Protection and Advoc acy (“ UL S - P&A” ) has a lso rece ived inquiries from their clients who ar e members of

the Plaintiff class about the pr ov i s i ons of servic es and ha s conce rns as to whe therT h e e l em en t s co n s i s to f i n fo rm at i o nan d cl i n i ca l d ata distilled from medica l literature; 2 a set of r

ules based upon “ best prac tices” or expert clinical opinion; and a s p ecif ic re view me tho do log y

to b e a pp lie d to ind ivi du a l patie nts ’ c a se s. -3- HSCS N is implementing in-home E PSDT services in a fa shion that comports with Parag raph 36 of the S ettlement Order. I n sum, both sets of counsel need to advise their clients as to what ser vices
are elig ible, whether HSCS N has sufficie nt g rounds to deny claims, and the pr ocedur es HSCSN can
rea sonably

require members to follow whe n authorizing, re -authorizing, or terminating presc ribed
s e r v i c e s . W i t h o u ta c c e s s t o t h e In t e r qu a l C r i t e r i a , an y a d v i c e w o u l d b e o f l i m i t e d r e l i a b i l i t y. McKe sson argues that its Criteria, which c onsist of three e lements to a id in making c linical 2

c are mana g e me nt d e c isi on s, c on sti tut e tr a de se c re ts an d a re the re fo re fu lly

pr ote c te d und e r t

he D. C. Uniform Trade Secre ts A ct, D.C. Code 36-402, et seq ., and the f eder al Copy

rig ht Statutory

Scheme, 17 U.S.C.A. 101, et seq . Even a ssuming that the Criter ia ar e subj ect to such protec tion, McKesson’s argument is not persua sive. Plaintiffs have demonstrated that all Medica id benef iciarie s are entitled to be provided w ith “the amount, duration, and scope of benef its,” as we ll as the “proc edure s for
o b t a i n i n g b e n e f

i t s , i n c l u d i n g a

u t h o r i z a t i o nr e qu i r e m e n t s . ” 4 2 C
. F
. R
. 4 3 8
. 1 0 ( f ) ( 6 ) ( v ) , ( v i )
. In
a dd iti on , 4 2 C. F .R. 43 8. 10 (f )( 6) (v ) s pe c if

ic a lly pr ov ide s th a t su c h in fo rm a tio n mu st be pr ov ide d “ in sufficie nt detail to ensure that enrollee s understand the benef its to which they

are entitled.” Parents and c are taker s of childre n with s p e c ia l n e e ds have a particula rly challeng ing situation to manag e. First, they have to perf orm demanding phy sical t asks which are often re quired for the
car e of c hildren with specia l needs. Sec ond, they have the difficult i ntellectual tasks of understandingwhat ser

vices ar e available to their children, unde r what conditions, and for what duration, so that they

can make re sponsible decisions for their car e. I t is essential that they know the limit s of Medica id cover ag e so that they can attempt to compensate for any g aps in that cove rag e and-4-

make a ppropriate plans to fill suc h g aps. Finally , children with spe cial needs of ten re ceive service s fr om a ra ng e of he a lthc are pr ov ide rs . O nc e a g a in, it is u p to the pa re nts and c are take rs to c oo rd inate those many

service s. I n order to navig ate such a mul ti-lay ere d sy stem for c hildren who themselve s have a set of complex needs, it is essential that those pa rents and c are taker s, as well as the ir lawy ers and hea lth care advoca

tes, be knowledg eable about “the a mount, duration, and scope of bene fits,”
and the “ pr oc e dure s f

or ob ta ini ngbe ne fi ts, inc lud inga uth or iza tio n r e qu ir e me nts
. There is no authority

for the pr oposition whi ch M cKesson puts forwar d that the fe dera l
c op y ri g ht l aws and

loc a l tr a de secret law s tr ump the fe de ra l Me dic a id s ta tut e and re g ulatio ns . I ndeed, a s Plainti ffs point out, a number of fed er al d i s t rict cour

ts have rule d that states ca nnot contra ct awa

y to ma nag ed ca re or g anizations such as HSCSN, or their licensors such a s McKesson, th e ir r e s p o n s ib il it ie s to M e d ic a id b e n e f ic ia r ie s o r th e r ig h ts o f

M e d ic a id b e n e f ic ia r ie s . I ns h o rt, “ [i ]t is patently

irresponsible to pre sume that Congr ess would per mit a sta t e t o disclaim fede ral
res po ns ib il it y

by con tr act in g away

it s o bl igat io n t o a p r i v a t e e n ti ty .” J oh n B. v . M enk e, 1 76 F. S up p. 2d78 6, 80 0-8 01 (M. D. Ten n. 20 07 ) (qu ot in g J .K. By and Th rou gh R. K. v. Di ll enb erg, 83 6 F. Supp. 694, 699 (D. Ariz. 1993). Cf, Cantanzano v. Dowling , 60 F.3d 113, 119- 120 (2d Cir. 1995), wh ic h h e ld s pe c if

ic a lly tha t de c isi on s made by a

ho me he a lthc are a g e nc y , w ithwh ic h th e state
a g e nc y ha d c on tr a c te d to pr ov ide Me dic a id be ne fi ts, c on sti tut e d a c tio n on be ha lf of the g ov e rn me nt. Whil e Plaintiffs are objecting to the very limit ing c onditions of the confidentiality ag ree ment insisted upon by

McKe sson, they

ar e ce rt ai n ly

not reque sting wide sprea d public dissemination of the I nterqua l Criteria. Essentially , t h ey s eek to have those Criteria made available to member s of the Class who might be elig ible for pa rticular be nefits, and ther efor e subjec t to authorization,
re- authorization and/or termination decisions about those benef its, to counsel advising the member s-5-

of the Cl as s ab o ut the availability of such be nefits, and to hea lth care advoca tes who ar e advising
me mbe rs of

the Cla ss w ithre g ard

to t he ir ne e d f or su c h b e ne fi ts. WHEREFORE , for the f oreg oing r easons, the Court c oncludes that Plain t iffs’ Motion should be granted
.

F e br ua ry 6, 20 09 /s/ Glady s Kessler Un i t edS t at es Di s t ri ct J u d ge Copies via ECF t o all couns el of recor d