FI L ED U.S. COURT OF A P P E A LS E LE V E N T H C IR C U IT APRI L29, 2008 THOMAS K. KAH

N CL ERK [PUBLIS H]

IN THE UN ITED STATES COURT OF APPEALS FO R T HE EL EV EN TH CIRC UI T

____ ____ ____ ____ ____ ____ N o. 05- 1164 5

____ ____ ____ ____ ____ ____ D. C. Docket N o. 89-00984 -CV -KMM FLORIDA ASSOCIATION OF REHABILITATION FACILITIES , INC., UNITED CEREBRAL PALSY ASSOCIATION OF MIAM I, INC., AUGUSTINE CENTE R FOR THE LIVING, INC., ANN STORCK CENTER, INC., SUNRISE COM MUNITY FOR THE RETARDED, INC.,
Pl ai nt iff s- App el la nt s,
ve rs us DE PA RT MEN T O F H EA LT H & RE HA BIL IT AT IV E S ER VI CE S - STATE OF FLORIDA, GREGORY COLER, JOHN C. FARI E, GA RY CL ARKE, Assistant Secr etary for Me dicaid - HRS, KINGSLEY ROSS, PAUL L. FREEDL UND, CHARLES KIMB ER, in hi s o ffi ci al cap aci ty, Defen da nt s- App el le es .Honora ble Eug ene E . Siler, J r., United States Circuit J udg e for the Six th Circuit, sit ting * by desig nation. 2

____ ____ ____ ____ ____ ____ Appeal f rom the United State s District Court fo r the S outhe rnD istri ct

of F lor ida

____ ____ ____ ____ ____ ____ _ (A pr il 29, 200 8) Be fo re T JO FL A T , F A Y , a nd S IL E R , Ci rc uit Jud ge s. * PE R CU RIA M: Pl ai nti ff s are the F lor ida

A sso ci at ionof

Re habil itatio n F ac ili tie s, I nc . a nd several operators of interm ediate car e fa cilities for the developm entally disabled (“ IC F/ D D s” ). N earl y

tw en ty y ears a go the y

f ile d su it ag ai nst

the F lor ida D ep ar tm en t of H ea ltha nd R eh ab ili ta tiv e Se rv ic es ( “ FD H R” ) an d se ve ra l of it s officials for failing adequately to reim burse ICF/D Ds pursuant to the Boren A m en dm en t, f

orm er ly 42 U
. S. C. § 13 96a (a )( 13) (A ), apr ovi sio n of the Me dic ai d A ct that ha s si nc e be enr ep ea le d, se e Ba lanc ed Bu dge t A ct

of 199 7, P ub. L
. 105
- 33, § 47 11( a) (1 ), 111 S ta t. 251 , 507 -0 8 ( 1997 ). O n r em an d f ro m our de ci sio n in Fl a. A ss’ n of

Re hab. F ac ili tie s, I nc . v. F la
. D ep ’ t of H ea ltha nd R eh ab
. S er

vs. , 225 F
. 3 d1 2 0 8 ( 1 1 t h C i r . 2 0 0 0 ) ( F A R F I ) , t h e d i s t r i c tc o u rto r d e r e dp l a i n t i f f s ’ c l a i ms d i s mi s s e da s mo o tb e c au s e , b e f o r e t h e c o u rte n t e r e df

i n a l j u d g me n tt h e f

i r s tt i mePlaintiffs’ complaint states three counts. Count I : defe ndants’ I CF/DD re imbursement 1 plans do not “mee t the require ments” of “ 42 U.S.C. § 1396a as more fully set forth a

bove.” Count I I : defe ndants irrationally use a diff ere nt reimburseme nt formula for skilled nursing fa c ili tie s th an th e y

us e fo r I CF /D Ds , in

vio latio n o f t

he Eq ua l Pr ote c tio n a

nd Du e Pr oc e ss Cla us e s o f t he F ourt e e nth

Am e ndme nt o f t

he Un ite d St ate s Co ns tit

uti on . Co un t I I I : de fe nd ants ’ re imb ur se me nt p lans fo r “ c lus te r f a c ili tie s” – s tate -o wn e d f

a c ili tie s o pe ra

te d b y pr ivate e nti tie s – do no t c omp ly

wi th t he B or e n A me ndme nt. 3 ar ound , F D H R h ad

a m en de d it s r ei m

bur se m en t r at e plan inc om pli an ce w iththe p r o c e du r e r e qu i r e db y B o r e n ’s s u c c e s s o r s t a tu t e . P l a i n t i f

f s ap p e a l , a n dw e a f

f i rm. I.

O ur opi nio n inF A RF I de ta ils the a rd uous his tor

y of thi s c as e. F A RF I , 225 F.3 d a t 1 21 1- 16 . W e n ow s umm ari ze an d u pd at e th athi st ory . Plai nt iff ICF/ DDs pr ov id e 2 4- ho urres id en ti al he al th care an d d ev el op m en ta l s erv ic es forlo winc om e Fl or ida

r es ide nts . I n 19 89, the y

f ile d su it ag ai nst

F D H R and v ar iou s de partm en t of

fi ci al s f or a dopt ing r ei m

bur se m en t r at e plans tha t w er e not

“ re as ona ble a nd a de qua te , ” in v iol at ionof the Bo re n A m en dm en t of the Me dic ai d A ct , f orm er 42 U
. S. C. § 13 96a (a )( 13) (A ). I n 19 91, the dis tr ic t c ourt e nte re d a 1 pr el im inary

inj unc tio n or de ri ng the de fe ndants , in es se nc e, to co m ply w iththe Bo re n A m en dm en t. F A RF I , 225 F
. 3d a t 12 11- 12. E ff ec tiv e O ct obe r 1, 199 7, Co ngr es s r ep ea le d th e Bo re n A m en dm en t and
re pla ce d it

w ithapr ovi sio n th at

r equir es state s to c om

ply w ithanot ic e an dThe c ourt neve r re ache d plaintiffs’ constitutional claims as pre sented in Count I Iof the 2 complaint. Fla. A ss’n of Reha b. Fa cilities, I nc. v. F la. Dep’ t of Hea lth and Rehab. Servs., 225 F.3d 1208, 1211 n.2 ( 11th Cir. 2000) (FA RF I ). 4 co m m en t pr oc ed

ur e w he n th ey

a dopt r at e plans f

or I CF /D D s, in co ntr as t t o Bo re n’ s su

bst an tiv e standard

f or suc h pl an s. F A RF I , 225 F
. 3d a t 12 13. O n Apr il 11, 199 9, a ft er

athr ee -d ay

be nc h tr ia l, the dis tr ic t c ourt e nte re d f ina l j udgm en t i n favor of pla int if fs on the ir

Bo re n c la im

a nd o rd er ed

de fe ndants to m ak e ch an ge s to the ir r at e plan r etro ac tiv e to the da te of the pr el im inary

inj unc tio n. F A RF I , 225

2 F. 3d a t 12 13- 15. O n Apr il 23, 199 8, de fe ndants m ove d f or r ec onsi de ratio n of

that de ci sio n on the gr ound

that pl ai nti ff

s’ Bo re n c la im

w as m oot . D ef

en dants – unbe knownst t o t h e c o u rt –

h ad amen d ed t h ei r r at e p l an i n an at t emp tt o co m p l y wi t h Bo re n ’s
suc ce sso r statut e be fo re the c ourt i ssu ed it s f ina l or de r. T he c ourt de nie d th ei r
m oti on, a nd d ef

en dants appe al ed
. I d. a t 12 15- 16. O n S ep te m

be r 21, 200 0, w e va cate d th e co urt’ s or de r be ca use it e ff ec tiv el y
re qui re d F lor ida

to pay r etro spe ct ive da m ag es , in vio la tio n of the E le ve nth A m en dm en t. I d. a t 12 20- 21; se e E de lm anv. Jor dan, 415 U
. S. 651 , 668 , 94 S
. Ct
. 1347 , 1358, 39 L. Ed. 2d 662 (1974). W e then noted that [i] f indeed the State had properly enacted a new post-Boren r ate plan by the ti m e of

e ntr y of f ina l j udgm en t, the n af

ina l or de r pr ovi din g pr ospe ct ive r el ie f w ithr es pe ct to the S ta te ’ s B or en -e ra

plan w oul dTh e dis tr ic t c ourt de c lin e d to c on sid e r a s b e y on d th e sc op e of our m and ate pla int if

fs ’ 3 alleg ation that FDH R’s new rate plan does not c omply with a diffe rent subsec tion of 42 U.S.C. § 1 3 9 6 a – n am e l y § 1396a(a )(30) (A) – a nd various provisions of the Code of Fe dera l Reg ulations. The c ourt furthe r noted that “ [t ]o t he extent that Plainti ffs have asse rted that De fenda nts have not complied with 42 U.S.C. § 1396a(a )(30) (A) a nd other re g ulatory

require ments . . . any

such c la im w o u ld r e qu ir e th e f

il in go f a s e p ar ate la

w s u it un r e late d to th e un d e r ly

in ga c ti o n . ” We un de rs tand

thi s to me an th at th e c ourt fo un d th at pl a int if

fs fa ile d a de qu ate ly

to p le a d a

c la im under a ny provision of the Medica id Act besides the B oren A mendment, § 1396a(a )(13) (A). Plaintiffs argue on appe al that the district cour t should have consider ed their a lleg ations that FDH R violated § 1396a(a )(30) (A) a nd various re g ulations. W e disag ree . The B oren A mendment is the only provision of the Medica id Act put in issue by the c omp la int , whic h a lle g e s th at “ 42 U. S.C § 1396a(a )(13) (A)” provides the ba sis of fede ral jurisdiction over plaintiffs’ c laims” and zeroe s in on § 13a(a )(13) (A) thr oug hout the statement of the ca se. B esides a g ener al alleg ation that “HRS is required to c omply with the require ments of 42 U.S.C. § 1396a, et se q. and F eder al re g ulations promulgated there under,” the complaint neve r ag ain eve n g ener ally

mentions the Medicaid statute. Pla int if fs no w try to b ro a de n th e sc op e of

the ir atta c k b y arguin gthat th e c omp la int in Count I a lle g e s a g e ne ra l vi olatio n o f e ve ry su bs e c tio n o f § 13 96 a

wi th t his state me nt: De fe nd ants . . . h ave de pr ive d Pl a int if fs of ri g hts c on fe rr e d b y

F e de ra l la

w, to w it: 42 U.S.C. § 1396a as more fully set forth a

bove and a lso including, but not by way of limitation, t he fa ilure to provide r eimbursement r ates a nd/or reimburse ment pay

ments and/or a r eimbursment plan which me et the

5 serve no purpose and th at portion of the case – if not the entire case

– w oul d be m oot . FA RF I , 225 F
. 3d a t 12 18. W e the re fo re r em an de d th e ca se a nd i nstru ct ed the district court to “ determ ine, in the fir st instan ce w hether the newplan com plied
w iththe r equir em en ts o f Bo re n’ s su cc es sor statut e, a nd i f so whe the r the law sui t ha d be co m e m oot

pr ior to the e ntr

y of j udgm en t i n Apr il 1999
. ” I d. A ft er a ddi tio na l br ie fi ng b y

both part ie s, the dis tr ic t c ourt, on D ec em be r 15, 2004 , e nte re d an or de r hol din g th at pla int if fs ’ Bo re n c la im

w as m ad e m oot

by de fe ndants ’ pr ev iou s c om pli an ce w ithBo re n’ s su cc es sor statut e. P la int if

fs f ile d a 3require ments of Fe dera l law for pr oviders oper atingclusters a nd the provider s op e ratin goth e r I CF /MR

fa c ili tie s a

nd pr ov idi ngI CF /MR

se rv ic e s. “[Section] 1396a as more fully set forth a

bove” c an only

rea sonably

ref er to the B oren Amendment, which is the only part of § 1396a “mor e fully set forth a

bove” in the c omplaint. We theref ore a ffirm the district c ourt’s dec ision not t o consider pla intiffs’ Medica id Act argume nts outsi de the ambi t of the B or e n A me ndme nt a nd its su c c e sso r o n th e g ro un d th at th os e a lle g atio ns are no t r oo te d in the c omp la int
. Although pla intiffs labeled the motion as one to alter or amend the c ourt’s judg ment 4 under F eder al Rule of Civil P roce dure 59( e), it appe ars to be a motion for a new

non-jury trial under F ed. R. Civ. P. 59(a)(1)( B) and simultaneously a motion for re lief fr om a final judg ment under F ed. R. Civ. P. 60(b). Th e mot ion

a dd iti on a lly

a lle g e d th at th e c ourt

e rr e d b y no t c on sid e ri ngpla int if

fs ’ 5 constitutional claim. The cour t, in a footnote, dismissed the claim as be y ond the scope of our mandate. A s per supra , note 1, Count I Iof the c omplaint alleg es that def endants g ave be tter treatment to skil led nursingfac iliti es than to I CF/DDs in violation of the Equal Protec tion and Du e Pr oc e ss C la

us e s o f t he F ourt e e nth

Am e ndme nt. On

a pp e a l, p la int if

fs argue tha

t th e ir constitutional claim was unaf fec ted by our mandate bec ause ( 1) we did not address it and (2) the alleg ed constitutional violation is ongoingand ther efor e not susceptible to cha lleng e on the g ro un d o f m oo tne ss. Count I Ialleg es sca

nt fac ts that would provide the basis for a cla im and plaintiffs have not fallen ove r themselves f illing in the blanks on re mand. We issued our mandate in FARF Ion September 1, 2000. The rec ord on appe al re turned to the district cour t on J anuar

y 22, 2001. The next action that appear s on the district court docke t is defenda nts’ motion filed on September 30, 2002 to dismi ss the whole ca se for lack of prosec ution. Pl aintiffs opposed the motion without mentioning their

constitutional claims. After a status confe renc e on Oc tober 16, 2002, the c ourt issued an orde r the ne x t day denying de fenda

nts’ motion to di smiss for lack of pr osecution and order ing the parties to file me moranda addre ssing the issue whether “De fenda

nts’ post-Bor en plan is not in compliance with the B oren A mendment’s succ essor re g ulations.” Plaintiffs filed a me mo o n Jan

ua ry 20 , 2 00 4, in whic h th e y

e xpre ssl y re se rv e d th e ir

c on sti tut ion a l c la im: Th is M e mor and

um o f L aw a dd

re sse s o nly

the iss ue of

the De fe nd ants ’ f

a ilure to comply with the Medica id Act in amendingthe I CF/DD Rate Plan f ollowing repe al of The Bor en Amendme nt and to assist this C ourt in its determination of whether the new Rate Plan complies with the post-Bor en Amendme nt statutory re qu ir e me nts , a s o rd e re d b y the El e ve nth

Cir c uit Court of Ap pe a ls i n it s r e mand

to thi s Co ur t. . . . Ne ith e r t

his c ourt no r t he El e ve nth

Cir c uit Court of Ap pe a ls rea ched the constitutional iss ues ra ised in Plainti ffs’ Complaint on this Court’s 6 tim ely “ Motion for Re hearing and/or Reconsideration,” which the court denied as 4 pr es en ti ng no ne w gro un d fo r rel ie f. Thi s ap pe al fol lo wed
. 5decision, and the ref ore the opinion of the Eleventh Circuit wa s based solely on statut or y (M e dic a id A c t) c la ims . In th e e ve nt t his Court de c ide s th at D e fe nd ants have c omplied with the statutory require ments then Plaintiffs’ constitutional claims still m ust be dec ided. (interna l citations omit ted). On Fe bruar

y 17, 2004, defe ndants filed a r esponsive memora ndum. On Dec ember

15, 2004 – without any

further briefingon plaintiffs’ constitutional claim – the cour t entere d an orde r dis mis sin gthe e nti re a c tio n a s mo ot. Th e n, on De c e mbe r 3 0, pla int if

fs mov e d f

or re c on sid e ratio n o f t

he fi na l ju dg me nt, arguing that the court ig nored the ir constitutional claim. The motion came more than eleve n months after pla intiffs declined to brie f the c laim, more than four y ear s after

our orde r re versing the district court’s judg ment in their favor on their B oren c laim, more than six y ear s after the district court re ceive d scant e vidence on the claim at a bench tr ial and neve r ruled on it, and mor e tha n f if te e n ye ars a ft e r p la int if

fs ini tiate d s uit

a g a ins t de fe nd ants . Inth ei r m o t i o nfo r r ec o n s i d er at i o n , an d i nth ei r b ri ef

o nap p ea l , p l ai n t i ff

s d o n o tal l ege any fa c ts t o s up po rt

the ir c on sti tut ion a l c la im. Th e y me re ly a sse rt tha t th e y have su c h a

c la im and that the c ourt ig nored it. Even supposingplaintiffs’ constitutional claim was pr eser ved for the district court on re mand, we a ffirm the district c ourt’s orde r dismissing the cla im on the g round that plaintiffs aba ndoned it. Alternatively , we a ffirm the dismissal of the c laim on the g round that plaintiffs fa iled in the first place to state a c laim upon which re lief may be g rante d (Count I Iof plaintiffs complaint asse rts littl e more than conc lusory alleg ations of irrational treatment by

defe ndants). We exercise plena

ry revie w of mootness dete rminations. 31 Foster Children v. B ush, 6 329 F.3d 1255, 1263 ( 11th Cir. 2003). 7 II. Our m andate to the district court was to “ determ ine, in the fir st instan ce whether the new plan com plied with the requirem ents of Boren’ s successor statute,
an d if so whe the r the law sui t ha d be co m e m oot pr ior to the e ntr

y of j udgm en t i n Apr il 1999
. ” F A RF I , 225 F
. 3d a t 12 18. 6 I n 1 9 9 7 C o n g r e s s r e p l a c e dt h e B o r e n A me n d me n tw i t h as t a tu t o ry s c h e me
re qui ri ng p ar

tic ipa tin g st at es to “ pr ovi de
. . . apub lic pr oc es s f or de te rm ina tio n of
rate s of paym en t f

or . . . int er m ed ia te c ar e fa ci lit ie s f

or the m en ta lly

r et ar de d. ” 42Pla int if fs make fe w a

rgume nts re g ard ing

the pr oc e dure e mpl oye d b y de fe nd ants in 7 amendingthe rate plan. The arguments they do proff er c onsist almostexclusively of alleg ations that defe ndants did not go into suffic ient detail in the methodolog ies and justifications published a lon g sid e the ir

pr op os e d a

nd fi na l ame nd e d r ate pla

n. Pla int if

fs do no t a lle g e that de fe nd ants skipped a step in the § 1396a(a )(13) (A) pr ocess, nor that they violated a r egulation or offic ial m e m o r an d a

th atf l e s h e s o u tth e d e t a i l s o f

th e n o t i c e an d

c o m m e n tp r o c e s s r e qu i r e d b y § 1396a(a )(13) (A). Arguing that defe ndants’ published methodolog ies and justifications wer e unsatisfac tory

– without alleg ing a

misstep in the procedur al proc ess – amounts to an ar g ument

8 U. S. C. § 139 6a(a)( 13)(A) (em phasis add ed). T he provisio n’ s subs ections require state s to f oll owthe se ste ps: ( i) pub lis h pr opos ed r at es a nd the m ethodo log ie s and j ust if ic at ionf or tho se r at es ; ( ii) giv e re as ona ble opp ortun ity

f or r ev ie wa nd
co m m en t onthe r at es a nd the ir m ethodo log ie s and j ust if ic at ion s to “ pr ovi de rs , be ne fi ci ar ie s and the ir

r ep re se nta tiv es , a nd o the r co nc er ne d S ta te r es ide nts ”; a nd (i ii) pub lis h th e fi na l r at es w iththe ir m ethodo log ie s and j ust if ic at ion s. S ubse ct ion (i v) r equir es that “ in the c as e of hos pit al s, suc h r at es take int o a cc ount . . . the
s i tu a t i o n o f

h o s p i t a l s w h i c hs e rv e ad i s p r o p o rt i o n a t e n u mb e r o f l o w - i n c o me patients with special needs.” 42 U. S. C. § 139 6a(a)( 13)(A) (i)-( iv). Inthe ir br ie f to u s, pla int if

fs a rg ue that “ [t ] he f

ac tua l r ec or d inthi s c as e de m onstrate s th at

D ef en dants did

not sub stanti ve ly

c om ply w ithr el ev an t M ed ic ai d Ac t requirem ents in am ending the Rate P lan following repeal of the Bore n A m en dm en t. ” Appe llants ’ Br ie f at pa ge 11 ( em

pha sis a dde d)
. P la int if

fs poi nt t o no evidence sug gesting that defendants did n ot com ply with the procedural
re qui re m en ts o f § 13 96a (a )( 13) (A ) in d ev el opi ng the a m en de d r at e plan. B ec au se 7about the substance of the rate plan, which Cong ress intende d to forec lose by repe alingthe B oren Amendment. See F ARF I , 225 F.3d at 1213. Pla int if fs atte mpt to d ist inguis h th is c a se fr om o ne in whic h a fe de ra l c ourt

up he ld a rate plan as c omply ing w ith Bore n’s succ essor statute. See Am. Soc’y of Consultant Pharmacists v. Con c ann on , 2 14 F . Su

pp . 2 d 2 3 ( D. Me . 2 00 2) . We are un pe rs ua de d. State s h ave fl e xibil ity in c o mp l yi n gw i thth e p r o c e d ur a l b ar p r e s e n t e d

b y § 1396a(a )(13) (A); without an a lleg ation that defe ndants failed to jump over the bar , it does not avail to alleg e that anothe r state jumped highe r. 9 the ba sis f

or thi s law sui t – the Bo re n A m en dm en t – ha s be enr ep ea le d, a nd defendants com

plied with Boren’ s successor statute before the district court entered final j udgm ent on plain tiffs’ Boren claim , the district court’ s order dis m iss ing the law sui t a s m oot is AFFIRMED.