## F I LED Unite d St at e s C ourt o f Appe als Te nt h Ci r c uit 

### Jan u ar y 3, 2007 Elisab eth A. Shumaker C l erk of C ourt PU BL I SH UNI TED S TATES CO URT O F AP PEALS

T E N T H C IR C U IT OKL AHOMA CHAP T E R O F T HE AM E RI CA N AC ADE M Y OF PEDI ATR I CS ( OK AA P) ; CO M M UN I TY A CT I O N PRO J EC T O F TU LSA C O U N T Y , O K L A H O M A (C A P T C ); T R A C Y T . , as m otherand nextfr i end of K at el yn M . W i l banks ; L I SA P. , as m other a n d n e x t f

rie n d o f Jo sh u a L e e O ’N e a l, E r i c H arm an C amm i s o, M el i s s a A nn Padel for d and M athew ScottPadel for d; R O W E N A T . , as par entand nextfr i end of C hr i s tyA . T ow l er , K ather i ne P. T ow l er and J acob W . T ow l er ; K E V I N T . , as p a r e n ta n d n e x tf

r i e n d o f Ch r i s tyA. T ow l er , K ather i ne P. T ow l erand J acob W . T ow l er ; J A N I C E G . , as par entand nextfr i end of Char l es A . Scanl an and R obertM . G arvi n; T H E O D O R E G . , as p a r e n ta n d n e x tf

r i e n d o f Ch a r l e s A. S c a n l a n a n d Ro b e r tM . Ga rv i n ; RE GI NA H . , a s p a r e n ta n d n e x tf r i e n d o f J a c o b W. He r c u l e s a n d E v e r e ttL . He r c u l e s ; GUS H . , a s p a r e n ta n d n e x tf r i e n d o f J a c o b W. H ercul es and E verettL . H ercul es; H E A T H E R R . , as par entand nextfr i end of St ephani e M oncr i ef, P l ai nti ffs-A pp el l ants / C ross A pp el l ees, v. N os . 05- 5100 & 05- 5107-2-

M I C H A E L FO G A R T Y , C hi ef Execut i ve O ff icer o f th e O k laho m a H ea lth C are Auth o r i ty( OH CA ) ; LYN N M I TCH ELL, St a t e M e d i c a i d Di r e c t o r ; CH AR LES E D M cF A L L , C h airm an o f th e O H C A B o ard of D i r ect or s ; T . J . B R I C K N E R , J R . , V i ceC hairof the O H C A B oard of D i rect ors; W AY NE H OFFM AN , J ERRY HEN LEE, RO NAL D R OUNDS , O. D. , GE OR GE M I LL ER, LYL E ROGGOW a n d J ERR Y H U M B L E , M em b ers o f th e O C H A B o ard o f Di r e c t o r s ; OK LAH OM A H EALTH CA RE AUT HOR I T Y, D efen dan t s- A pp el l ees/ C ross A pp el l ants .

__________________________________ AM E RI CA N AC ADE M Y OF P E DI AT RI CS ; AM E RI CA N M E DI CA L A S S O C I A T I O N , a n d O K L A H O MA S T AT E M E DI CA L AS S OC I AT I ON, A m i ci C ur i ae.

AP P EA L F ROM THE UNI TE D S TA TE S DI S TR I CT COURT

F OR THE DI S TR I CT OF OKLAHOM A ( D. C. No . 0 1 - CV- 0 1 8 7 - CVE - S AJ ) L o u is W . B u llo c k , M ill e r, K e f f e r & B u llo c k , L L C , T u lsa , O k lah o m a (R o b e rt M . B l akemor e, M i l l er , K eff er& B ul l ock, L L C , T ul s a, O kl ahoma; T hom as K . G i l hool and J ames Ei s eman, J r . , Publ i c I nt er es tL aw C ent er , Phi l adel phi a, Penns y l vani a, w i th hi m on the b ri efs) , for Plai nti ffs-A pp el l ants / C ross -A pp el l ees. H o w ard J. P all o tt a, (L yn n R am b o -Jon es w ith h im o n the b ri ef s) O k laho m a H ea lth C are A uthori ty , L egal D i vis i on , O klahom a C i ty , O klahom a, for D efen dan t s- A pp el l ees/ C ross A pp el l ants . J onathan S. Fr ankl i n and J es s i ca L. E l l s w orth, H ogan & H art s on, L . L . P. , W as hi ngt on,-3-

D . C . , fi l ed an a m i cus cur i ae br i ef f orthe A m er i can A cade m yof Pedi atr i cs , the A m er i can M edi cat i on A s s oci at i on, and the O kl ahoma St at e M edi cal A s s oci at i on. B ef o re T A C H A , B R I S C O E , and HA RTZ , C i rcui tJudg es. B RI S CO E , C i r cui tJ udge. Pl ai nt i ffs , tw o or gani zat i ons and thi r t een c hi l dr en and thei rpar ent s r epr es ent i ng a c las s o f in d iv id u a ls, f

iled su it u n d e r 4 2 U .S .C . § 1 9 8 3 c laim in g th a t d e f e n d a n ts, o f

f icia ls of the St at e of O kl ahoma and the O kl ahoma H eal th C ar e A uthor i ty , vi ol at ed var i ous pr ovi s i ons of the M edi cai d A ctbyfai l i ng t o pr ovi de M edi cai d- el i gi bl e chi l dr en i n the S tate o f O k lah o m a w ith n e c e ss a ryh e a lth c a re se rv ice s, in c lu d in g e a rlya n d p e rio d ic s cr eeni ng, di agnos i s , and tr eatm ents ervi ces . A ft erconduct i ng a benc h tr i al , the di s tr i ct courtfound i n favorof pl ai nt i ffs on s om e, butnotal l , of thei rcl ai m s , and i s s ued a p e rm a n e n t in

ju n c tio n re q u irin g d e f

e n d a n ts to , in p e rtin e n t p a rt, co n d u c t a s tu d yto determ i ne the providerrei m bu rs em ent r at es necessaryt o en sure r easona blyprom pt access to h e a lth c a re f

o r M e d ica id -e lig ib le c h ild re n , an d to re v ise th e ir f e e sc h e d u le in a c c o rd a n c e w ith th a t stu d y . B o th sid e s h a v e n o w a p p e a led , ch a llen g in g v a rio u s a sp e c ts o f th e d is tr ic t c o u rt ’s d e c is io n . W e exe r ci s e j ur i s di ct i on pur s uantt o 28 U . S. C . § 1291, r ever s e the j udgm entof the d istri ct co u rt , an d rem an d w ith d ir ec ti o n s to e n ter j u d g m en t i n fa v o r of d ef en d an ts. In doi ng s o, w e conc l ude, contr aryt o the di s tr i ctcourt , thatthe def endant s di d notvi ol at e 42 U . S. C . § 1396a( a) ( 8) ’ s “r eas onabl e pr om ptnes s ” r equi r ementbyal l ow i ng s y s t em-w i de-4-

del ay s i n tr eatm entof M edi cai d benef i ci ar i es orbypay i ng pr ovi der s i ns uffi ci entr at es for s e rv ic e s re n d e re d to M e d ic a id b e n e f ic ia ri e s . W e f

u rt h e r c o n c lu d e th a t 4 2 U .S .C . § 1396a( a) ( 10) r equi r es a s t at e M edi cai d pl an t o payfor , butnott o di r ect l ypr ovi de, the sp e c if ic m e d ica l se rv ice s liste d in th e M e d ica id A c t. W e a lso c o n c lu d e , co n sis ten t w ith o u r re c e n t d e c isio n in M a n d yR . ex re l. M r. an d M rs. R . v . O w e n s, 4 6 4 F .3 d 1 1 3 9 (1 0 th C i r . 2006) , that42 U . S. C . § 1396a( a) ( 30) does notcr eat e a pr i vat e r i ghtof ac t i on e n f o rc e a b le b yp lain tiff

s. F in a lly , w e d e c lin e to c o n sid e r p lain tiff s’ a ss e rtio n o f

a p riv a te r i ghtof ac t i on pur s uantt o 42 U . S. C . § 1396a( a) ( 43) beca us e the ar gum ent s now m ade on a p p e a l b yp l a i n t i f

f s we r e n e i th e ra s s e r t e d n o ra d d r e s s e d b e l o w. I . P l ai nti ff O klahom a C hap t er of the A m eri can A cadem yof P ediatri cs ( O K A A P ) i s a non- pr ofi tpr ofes s i onal or gani zat i on of pedi atr i ci ans and pedi atr i c s peci al i s t s . Pl ai nt i ff C om m uni tyA ct i on Pr oj ectof Tul s a C ounty , I nc. ( C A PT C ) i s a non- pr ofi tor gani zat i on l ocat ed i n T ul s a, O kl ahoma. T he i ndi vi dual l y - named pl ai nt i ffs ar e thi r t een c hi l dr en and thei rpar ent s , al l of w hom have be en des i gnat ed as r epr es ent at i ves of the cl as s cert i fi ed by th e d i s tr i c tc o u r t . De f

e n d a n t s a r e o f

f i c i a l s o f th e S t a t e o f

Ok l a h o ma a n d th e Ok l a h o ma H eal th C ar e A uthor i ty( O H C A ) , the des i gnat ed age ncyr es pons i bl e fori m pl ement i ng and a d mi n i s t e r i n g Ok l a h o ma ’ s M e d i c a i d p r o g r a m. Pl ai nt i ffs fi l ed thi s act i on i n M ar ch 2001, al l egi ng thatdefe ndant s ’ pol i ci es and pr ocedur es deni ed ordepr i ved el i gi bl e chi l dr en i n the St at e of O kl ahoma of the hea l th and m edi cal car e t o w hi ch theyw er e ent i t l ed underfede r al l aw . I n part i cul ar , pl ai nt i ffs-5-

as s ert ed cl ai m s under42 U . S. C . § 1983 t o enfor ce ( a) thei ral l eged r i ghtpur s uantt o 42 U .S .C . § § 1 3 9 6 a (a )(8 ), 1 3 9 6 a (1 0 )(A ), 1 3 9 6 d (a )(4 )(B )(2 ), an d 1 3 3 6 d (r) to re c e iv e e a rly and per i odi c s cr eeni ng, di agnos t i c, and tr eatm ents ervi ces ( E PSD T ) , ( b) thei ral l eged r i ght p u rsu a n t to 4 2 U .S .C . § 1 3 9 6 a (a )(8 ) to re c e iv e n e c e ss a ryc a re a n d se rv ice s w ith re a s o n a b le p ro m p tn e s s , a n d (c ) t h e ira lle g e d ri g h t p u rs u a n t to 4 2 U .S .C . § 1 3 9 6 a(a )(30 )(A ) t o h av e p rov ider reim b u rsem en t r ates se t ata su ff ici en t l ev el t o assu re M edi cai d r eci pi ent s of equa l acc es s t o qual i tyheal th car e. T he di s tr i ctcourt , atpl ai nt i ffs ’ r eques t , defi ned and c ert i fi ed a pl ai nt i ff c l as s of chil dren on M ay30 , 20 03 . T he d i stri ctcou rtthen con du ct ed a b ench tri al on plai nti ffs’ cl ai m s i n A pr i l and M ay2004. O n M ar ch 22, 2005, the di s tr i ctcourti s s ued l engthy fi ndi ngs of fa ctand conc l us i ons of l aw . I n i t s or der , the di s tr i ctcourtdi s m i s s ed pl ai nt i ff O K A A P f

o r la c k o f

sta n d in g . T h e d istric t co u rt a lso c o n c lu d e d , in p e rtin e n t p a rt, th a t:

• defe ndant s vi ol at ed 42 U . S. C . § 1396a( a) ( 30) ( A ) byfai l i ng t o as s ur e that paym ent s w er e s uffi ci entt o enl i s tenough pr ovi der s s o thatcar e and s ervi ces w er e ava i l abl e t o M edi cai d- el i gi bl e chi l dr en t o the ext entthats uch c a re a n d se rv ice s w e re a v a ilab le to th e g e n e ra l p o p u latio n in th e g e o g ra p h ic ar eas s erved bythe O H C A ; and

• defe ndant s vi ol at ed 42 U . S. C . § 1396a( a) ( 8) byfai l i ng t o furni s h m edi cal assi st ance w i th reasonab l e prom ptness t o all M edicai d-el i gibl e i nd i vidual s. A tthe conc l us i on of i t s or der , the di s tr i ctcourtdi r ect ed the part i es t o m eetand conf er w i th the magi s tr at e j udge “i n or dert o r eac h an agr eed pr opos ed i nj unct i ve or dert o be s ubm i tt ed” t o the court“cons i s t entw i th [i t s ] Fi ndi ngs of Factand C oncl us i ons of Law . ” A p lt. A p p . a t 3 9 6 .-6-

O n M ay1 9 , 2 0 0 5 , af

ter th e p arti es su b m itted th e a g ree d p rop o sed injun cti v e o rde r, the di s tr i ctcourti s s ued a Fi nal J udgm entand Perm anentI nj unct i on. T her ei n, the di s tr i ct courtr ei t er at ed i t s l egal concl us i ons and, bas ed upon the tw o al l eged vi ol at i ons out l i ned above, di r ect ed def

endant s t o:

• “i ns t i tut e a f

ee s chedul e forfee - for - s ervi ce phy s i ci an . . . r ei m bur s ement forcover ed, m edi cal l ynece s s aryphy s i ci an s ervi ces pr ovi ded t o m i nor chi l dr en” unde rthe M edi cai d pr ogr am “atthe r at e foreac h C urr ent P r o c e d u r a l T e rm i n o l o g y. . . C o d e th a te q u a l s o n e h u n d r e d p e r c e n t( 1 0 0 %) o f th e ra te p a id b yM e d ica re f o r p h y sic ian se rv ice s a s s o o n a s p o ss ib le w ith in th e stric tu re s o f

” sta te a n d f

e d e ra l law ;

• “author i ze O H C A admi ni s tr at i ve s t aff t o negot i at e a c ontr act. . . w i th a n a tio n a llyre c o g n ize d e c o n o m ic c o n su lti n g f irm to c o n d u c t a s tu d yto d eterm ine th e f

ee -fo r-service reim b u rsem en t r ate n ec essa ryto as su re r e a s o n a b l yp r o mp ta c c e s s t o h e a l th c a r e f o rmi n o rc h i l d r e n i n th e Ok l a h o ma M edi cai d Pr ogr am w hi l e al s o compl y i ng w i th the ut i l i zat i on and ef fi ci ency r equi r ement s of 42 U . S. C . § 1396a( a) ( 30) ( a) ”;

• “i ns t i tut e a f

ee- for - s ervi ce s chedul e det erm i ned bythe cons ul t i ng fi rm as nece s s aryt o as s ur e r eas onabl ypr om ptacc es s t o heal th car e form i nor c h ild re n in th e O k lah o m a M e d ica id p ro g ra m ” ;

• “[i ] n the eve ntthatO H C A i s unabl e i n good fai th t o negot i at e the contr act con t em plat ed b ythe F i nal Jud gm ent and P erm anen tInj un ct i on byA ug ust 15, 2005, ori f the s tudycont empl at ed by[the di s tr i ctcourt ] i s not compl et ed w i thi n s i x m onths of the dat e the contr acti s exec ut ed bythe part i es , the O H C A s hal l adj us tal l M edi cai d r at es pai d t o pr ovi der s s o that th e ra tes f

o r c o v e re d , m e d ica llyn e c e ss a ryp h y sic ian se rv ice s p ro v id e d to m in o r c h ild re n u n d e r th e O k lah o m a M e d ica id P ro g ra m a re su f f icie n t to ens ur e equa l and r eas onabl ypr om ptacc es s t o heal th car e fors uch mi nor chi l dr en”;

• “us e [thei r ] bes teff

ort s t o att emptt o obt ai n i ncr eas ed fundi ng fr om the O kl ahoma L egi s l atur e forthe r ei m bur s ementchange s m ent i oned her ei n; h o w e v e r, a la c k o f

su c h f u n d in g sh a ll n o t ex c u se c o m p lian c e w ith th is Perm anentI nj unct i on”; and“W e . . . as s um e w i thoutdeci di ng that§ 1983 gi ves the pl ai nt i ffs a r i ghtof ac t i on 1 t o enfor ce” thes e pr ovi s i ons . M andyR . , 464 F. 3d at1143. -7- • “a ss u re th a t O H C A im m e d iate lya d o p ts a n d im p lem e n ts n e w p e rio d icity schedu l es ( for peri od i c com prehen si ve m edical scr eening ex am i nati on s, dent al s cr eeni ng exami nat i ons and vi s i on s cr eeni ng exami nat i ons ) aft er c o n su lti n g w ith re c o g n ize d m e d ica l an d d e n tal o rg a n iza tio n s in v o lv e d in chi l d heal th car e, i ncl udi ng O K A A P, O kl ahoma St at e M edi cal A s s oci at i on, and the O kl ahoma D ent al A s s oci at i on. I n thi s r egar d, the O H C A B oar d of D i r ect or s s hal l i nvi t e O K A A P, the O kl ahoma St at e M edi cal A s s oci at i on, the O kl ahoma D ent al A s s oci at i on and/ orotherr ecogni zed medi cal and dent al or gani zat i ons i nvol ved i n chi l d heal th car e t o appoi ntm ember s t o an a d v iso ryc o m m itt e e th a t w ill m e e t w ith th e O H C A E P S D T U n it (re c e n tly re n a m e d C h ildH e a lth ) sta f f a t lea st a n n u a llyto c o n su lt o n a p e rio d icity s chedul e forE PSD T s ervi ces . T hi s advi s orycomm i t t ee s hal l m eetno l at er th a n f o rt y -f iv e d a y s a f

te r t h e d a te o f

th is P e rm a n e n t I n

ju n c tio n .” A p lt. A p p . a t 4 2 2 -4 2 5 . O n J une 14, 2005, pl ai nt i ffs fi l ed a not i ce of appea l fr om the di s tr i ctcourt ’ s Fi nal J udgm entand Perm anentI nj unct i on, and fr om the di s tr i ctcourt ’ s A pr i l 20, 2005 O r der d e n y in g p lain tiff

s’ m o tio n to a lter o r a m e n d ju d g m e n t. O n Ju n e 2 7 , 2 0 0 5 , d e f e n d a n ts fi l ed a not i ce of

cr os s appea l fr om the di s tr i ctcourt ’ s Fi nal J udgm entand Perm anent In ju n c tio n , a s w e ll a s th e d is tr ic t c o u rt ’s F in d in g s o f F a c t a n d C o n c lu s io n s o f L a w . II. A . Plainti

f f s ’claim s under 42 U

. S. C . § 1983 1) 42 U. S. C . §§ 13 96 a(

a) ( 8) an d ( a) ( 10 ) ( A) , 13 96 d(

a) ( 4) ( B ) an d ( r) P lai n ti ff s ch all en g e the d istri ct co u rt ’s ruli n g o n the m erit s o f th eir clai m s u n d er § 1 9 8 3 fo r all eg ed v iolati o n s o f 4 2 U . S . C . § § 1 3 9 6 a(a )(8), 1 3 9 6 a(a )(10 )(A ), 1 3 9 6 d (a )(4 )(B ), an d 1 3 9 6 d (r). In p a rticu lar , p lain tiff s c o n ten d th e d istric t co u rt e rre d in 1-8-

appl y i ng a “s ubs t ant i al compl i ance ” s t andar d i n det erm i ni ng w hetherdefe ndant s m et w hatpl ai nt i ffs al l ege, and the di s tr i ctcourtagr eed, w er e def endant s ’ obl i gat i ons under thes e s t atut es t o furni s h compre hens i ve medi cal s cr eeni ng exami nat i ons , pr event i ve dent al s ervi ces and nec es s arym edi cal tr eatm entt o m ember s of the cl as s of i ndi vi dual p l a i n t i f f s . Be c a u s e th i s i s s u e h i n g e s o n th e i n t e rp r e t a t i o n o f th e s e f e d e r a l s t a tu t e s , we appl ya de novo s t andar d of r evi ew . Shi vw i t s B and of Pai ut e I ndi ans v. U t ah, 428 F. 3d 9 6 6 , 9 7 8 (10 th C ir . 2 0 0 5 ). Sect i ons 1396a( a) ( 8) and ( a) ( 10) ( A ) of Ti t l e 42 pr ovi de, i n pert i nentpart , as foll ow s: (a ) A S tate p lan f

o r m e d ica l as sis tan c e m u st – * * * (8 ) p ro v id e . . . tha t su c h [ m e d ica l] a ss ista n c e sh a ll b e f u rn ish e d w ith reas on able pr om ptness t o all el i gibl e i nd i vidual s; * * * ( 10) pr ovi de – (A ) form aking m edical assi st ance a vail able, i ncludi ng atl east the ca r e and s ervi ces l i s t ed i n par agr aphs ( 1) thr ough ( 5) , ( 17) a n d (2 1 ) o f

se c tio n 1 3 9 6 d (a ) o f

th is titl e , to . . . all in d iv id u a ls

. . . w ho ar e r ece i vi ng ai d oras s i s t ance underany[appr oved S ta te M e d ic a id ] p la n . . . . 4 2 U . S . C . § 1 3 9 6 a(a )(8), (10 )(A ). In turn, sect i on s 139 6d (a) (4) (B ) and (r ) pr ov i de as fo l l ow s: F o r pu rpo ses o f th is sub ch ap ter -- (a) M edi calas s i s t ance T he term “m edical assi st ance” m eans pa ym ent of partor al l of the cost o f th e f o llo w in g c a re a n d s e rv ic e s . . . f o r i n d iv id u a ls . . . ( 4) . . . ( B ) ear l yand per i odi c s cr eeni ng, di agnos t i c, and tr eatm ent se rv ice s (a s d e f

in e d in su b se c tio n (r) o f th is s e c tio n ) f

o r in d iv id u a ls-9- w h o a re e lig ib le u n d e r t h e p la n a n d a re u n d e r t h e a g e o f 2 1 . . . . * * * (r) E arly a n d p eri od i c screen i n g, d i ag n osti c, an d treat m en t s ervices T he t erm “ea r l yand per i odi c s cr eeni ng, di agnos t i c, and tr eatm ent services ” m eans the fo l l ow i ng i t em s and servi ces: (1) S creeni ng services

– ( A ) ar e pr ovi ded– ( i ) ati nt erval s w hi ch meetr eas onabl e s t andar ds of m e d ica l an d d e n tal p ra c tice , as d e ter m in e d b yth e S tate aft ercons ul t at i on w i th r ecogni zed medi cal and dent al o rg a n iza tio n s in v o lv e d in c h ildh e a lth c a re a n d , w ith resp ec t t o im m u n izati o n s u n d er su b p ara g rap h (B )(i ii ), i n acc or dance w i th the s chedul e r efe rr ed t o i n s ect i on 13 96 s( c)( 2)( B )( i ) of this t i t l e for ped i atri c vacc i nes, and (ii) a t su c h o th e r in ter v a ls, in d ica ted a s m e d ica lly n e c e ss a ry , to d e ter m in e th e e x iste n c e o f c e rta in phy s i cal orm ent al i l l nes s es orcondi t i ons ; and ( B ) w hi ch s hal l ata mi ni m um i ncl ude– (i ) a c o m p reh en sive h ea lth an d d ev elop m en tal h ist o ry ( i ncl udi ng as s es s m entof both phy s i cal and ment al h ea lth d ev elop m en t) , ( i i ) a c o mp r e h e n s i v e u n c l o th e d p h y s i c a l e x a m, ( i i i ) appr opr i at e i m m uni zat i ons ( acc or di ng t o the sc h e d u le r e f

e rre d to in se c tio n 1 3 9 6 s(c )(2 )(B )(i) o f th is tit le f o r p e d iatric v a c c in e s) a c c o rd in g to a g e a n d h e a lth h i s t o ry, ( i v) l abor at oryt es t s ( i ncl udi ng l ead bl ood l evel as s es s m entappr opr i at e forage a nd r i s k fac t or s ) , and (v) h ea lth ed u ca ti o n (i n clud ing an ti cipa toryg u idan ce ). (2) V i si on services

– ( A ) w hi ch ar e pr ovi ded– ( i ) ati nt erval s w hi ch meetr eas onabl e s t andar ds of m edi cal pr act i ce, as det erm i ned bythe St at e af t er cons ul t at i on w i th r ecogni zed medi cal or gani zat i ons i nvol ved i n chi l d heal th car e, and (ii) a t su c h o th e r in ter v a ls, in d ica ted a s m e d ica lly nece s s ary , t o det erm i ne the exi s t ence of a s us pect ed i l l nes s orcondi t i on; and ( B ) w hi ch s hal l ata mi ni m um i ncl ude di agnos i s and tr eatm ent-10- for defec t s i n v i si on , i ncludi ng ey eglas ses. (3) D ental services

– ( A ) w hi ch ar e pr ovi ded– ( i ) ati nt erval s w hi ch meetr eas onabl e s t andar ds of dent al pr act i ce, as det erm i ned bythe St at e af t er cons ul t at i on w i th r ecogni zed de nt al or gani zat i ons i nvol ved i n chi l d heal th car e, and (ii) a t su c h o th e r in ter v a ls, in d ica ted a s m e d ica lly nece s s ary , t o det erm i ne the exi s t ence of a s us pect ed i l l nes s orcondi t i on; and ( B ) w hi ch s hal l ata mi ni m um i ncl ude r el i ef of pai n and i nfec t i ons , r es t or at i on of t eeth, and mai nt enanc e of de nt al heal th. (4) H eari ng services

– ( A ) w hi ch ar e pr ovi ded– ( i ) ati nt erval s w hi ch meetr eas onabl e s t andar ds of m edi cal pr act i ce, as det erm i ned bythe St at e af t er cons ul t at i on w i th r ecogni zed medi cal or gani zat i ons i nvol ved i n chi l d heal th car e, and (ii) a t su c h o th e r in ter v a ls, in d ica ted a s m e d ica lly nece s s ary , t o det erm i ne the exi s t ence of a s us pect ed i l l nes s orcondi t i on; and ( B ) w hi ch s hal l ata mi ni m um i ncl ude di agnos i s and tr eatm ent for defec t s i n h eari ng , i ncludi ng heari ng ai ds. (5 ) S u c h o th e r n e c e ss a ryh e a lth c a re , d iag n o stic se rv ice s, tre a tm e n t, a n d o th e r m e a su re s d e sc rib e d in su b se c tio n (a ) o f th is s e c tio n to corr ectoramel i or at e def ect s and phy s i cal and ment al i l l nes s es and condi t i ons di s cover ed bythe s cr eeni ng s ervi ces , w hetherornots uch s ervi ces ar e cove r ed underthe St at e pl an. N o th in g in th is s u b c h a p tersh a ll b e c o n stru e d a s lim iti n g p ro v id e rs o f e a rly and per i odi c s cr eeni ng, di agnos t i c, and tr eatm ents ervi ces t o pr ovi der s w ho ar e qual i fi ed t o pr ovi de al l of the i t ems and s ervi ces des cr i bed i n the pr evi ous s ent ence oras pr event i ng a pr ovi derthati s qual i fi ed underthe pl an t o furni s h one orm or e ( butnotal l ) of s uch i t ems ors ervi ces fr om bei ng qual i fi ed t o pr ovi de s uch i t ems and s ervi ces as partof ea r l yand p e rio d ic s c re e n in g , d iag n o stic , an d tre a tm e n t se rv ice s. T h e S e c re tar ysh a ll, notl at erthan J ul y1, 1990, and eve ry12 m onths ther eaf t er , devel op and s et annual part i ci pat i on goal s foreac h St at e forpart i ci pat i on of i ndi vi dual s w ho a re c o v e re d u n d e r th e S tate p lan u n d e r th is s u b c h a p terin e a rlya n d p e rio d ic scr eening, diagnost i c, and treatm ent s ervi ces.-11-

4 2 U . S . C . § 1 3 9 6 d (a)(4)(B ), (r) . Purport i ng t o appl y§ 1396a( a) ( 8) ’ s “r eas onabl e pr om ptnes s ” r equi r ement , the dis tri ctcou rtheld as fol l ow s: 3 2 . P lain tiff

s h a v e o f f e re d su b sta n tial e v id e n c e th a t th e d e lays in tr e a tm e n t f

o r c h ild re n w ith s p e c if

ic c o n d itio n s a re m e d ic a lly in a p p ro p ri a te . I m port ant l y , pl ai nt i ffs have s how n thats y s t em-w i de del ay s i n tr eatm ent exi s tand have pr es ent ed convi nci ng evi dence thatthos e del ay s ar e not r eas onabl e. I n vi ol at i on of 42 U . S. C . § 1396a( a) ( 8) , defe ndant s ar e not e n su rin g th a t m e d ica l as sis tan c e is f u rn ish e d w ith re a so n a b le p ro m p tn e ss to al l el i gibl e i nd i vidual s. 33. T he C ourti s aw ar e of Brugge m an v. B l agoj evi ch, 324 F. 3d 906, 910 (7 th C ir. 2 0 0 3 ), in w h ich th e c o u rt h e ld th a t Illi n o is o f f icia ls’ f a ilu re to adopta pl an forexpandi ng the numberof i nt erm edi at e ca r e fa ci l i t i es forthe devel opm ent al l ydi s abl ed i n anotherpartof the s t at e di d notvi ol at e 42 U . S. C . § 1396a( a) ( 8) . I n s o hol di ng, the courtr emar ked: th e sta tu to ryre f

e re n c e to “ a ss ista n c e ” a p p e a rs to h a v e re f e re n c e to f i nanci alas s i s t ance r atherthan t o actual m edi cal s ervi ces , though the dis t i ncti on w as m i ssed i n B ry son v . S hu m w ay , 30 8 F . 3d 79 , 81 (1st C ir . 2 0 0 2 ), an d D o e v . C h il es, 13 6 F . 3 d 7 0 9 , 7 1 4 , 7 1 7 (11 th C ir . 1998) . M edi cai d i s a paym ents cheme, nota s cheme fors t at epr ovi ded medi cal as s i s t ance , as thr ough s t at e- ow ned hos pi t al s . T he re g u latio n s th a t im p lem e n t th e p ro v isio n in d ica te th a t w h a t is r equi r ed i s a pr om ptdet erm i nat i on of el i gi bi l i tyand pr om pt pr ovi s i on of funds t o el i gi bl e i ndi vi dual s t o enabl e them t o obt ai n the co v ere d m ed ical serv ices tha t th eyn ee d , see 4 2 C . F . R . § § 4 3 5 . 9 1 (a),

. 930( a) - ( b) ; a r equi r ementof pr om pttr eatm entw oul d amountt o a dir ectregul at i on of m edical services . I d. at910. T he C ourtfi nds thatthi s di s t i nct i on, w hi l e ac cur at e, does not p re c lu d e a f

in d in g in th is c a s e th a t d e f e n d a n ts h a v e v io la te d § 1 3 9 6 a (a )( 8 ). W i thoutfi nanci al as s i s t ance ( pr ovi derr ei m bur s ement ) s uffi ci entt o attr act a n a d e q u a te n u m b e r o f

p ro v id e rs, re a so n a b lyp ro m p t as sis tan c e is eff ect i vel ydeni ed. A pl t . A pp. at378.-12-

We r e j e c tth e d i s tr i c tc o u r t ’ s c o n c l u s i o n s . I n o u rr e c e n td e c i s i o n i n M a n d yR. , we agr eed w i th the Seventh C i r cui t ’ s deci s i on i n B ruggeman thatthe t erm “medi cal a ss ista n c e ,” a s e m p lo y e d in § 1 3 9 6 a (a )(8 ), re f e rs “ ‘to f in a n c ial a ss ista n c e ra th e r th a n to ac tual m ed ical serv ices.’” 46 4 F . 3 d at 11 4 3 (qu o ti n g B rug g em an , 3 2 4 F . 3 d at 91 0 ). In tu rn , w e in terp re ted § 1 3 9 6 a (a )(8 ) a s “ re q u ir[ in g ] a n ysta te p a rticip a tin g in M e d ica id to p a yp r o mp t l y. . . f

o rme d i c a l s e rv i c e s wh e n th e s t a t e i s p r e s e n t e d wi th th e b i l l . ” I d . As not ed bydefe ndant s , thi s i nt erpr et at i on i s cl ear l ycontr aryt o the pl ai nt i ffs ’ as s ert i on, and th e d istric t co u rt’s a p p a re n t co n c lu sio n , tha t § 1 3 9 6 a (a )(8 ) m a k e s a sta te M e d ica id pr ogr am di r ect l yr es pons i bl e forens ur i ng thatthe medi cal s ervi ces enumer at ed i n the M e d ica id A c t (i. e ., th o se th a t ar e re im b u rsa b le) a re a c tu a llyp ro v id e d to M e d ica id b e n e f ic ia ri e s in a re a s o n a b ly p ro m p t m a n n e r. T he di s tr i ctcourtal s o err ed, gi ven ourhol di ng i n M andyR . , i n concl udi ng that defe ndant s vi ol at ed § 1396a( a) ( 8) ’ s “r eas onabl e pr om ptnes s ” r equi r ementbypay i ng pr ovi der s i ns uffi ci entr at es fors ervi ces r ender ed t o M edi cai d benef i ci ar i es . A l though the di s tr i ctcourtappar ent l yconcl uded, and perhaps corr ect l ys o, thatl ow r at es of re im b u rse m e n t re d u c e th e n u m b e r o f p ro v id e rs a v a ilab le to M e d ica id b e n e f icia rie s, a n d in turn i ncr eas e the t i m e M edi cai d benef i ci ar i es m us tw ai tt o r ece i ve medi cal s ervi ces fr om a v a ilab le p ro v id e rs, th is c o n c lu sio n d o e s n o t m e a n th a t d e f e n d a n ts f a iled (o r w ill f

a il i n th e f u tu re ) to b e re a so n a b lyp ro m p t in p a y in g f o r se rv ice s a c tu a llyre n d e re d b ya v a ilab le p ro v id e rs, a s re q u ire d b y§ 1 3 9 6 a (a )(8 ). In d e e d , if th e d istric t co u rt’s th e o ryw e re c o rre c t, i tw oul d br oaden § 1396a ( a) ( 8) farbey ond i t s i nt ended s cope, and w oul d r equi r e fe der al-13-

court s t o engage i n w hatthe Thi r d C i r cui thas des cr i bed as the “one r ous ” t as k of “eva l uat i ng w hethera s t at e’ s M edi cai d r ei m bur s ementr at es ar e ‘ r eas onabl e and adequa t e. ’ ” C hi l es , 136 F. 3d at717. T hus , w e agr ee w i th defe ndant s thatthe di s tr i ct courterr ed w hen i tdi r ect ed def endant s t o conducta s tudyof r at es , cos t s and s ervi ces , and then t o us e the s tudyt o corr ectw hatthe di s tr i ctcourtconcl uded w er e t oo- l ow r at es of re im b u rse m e n t. L ik e w ise , w e a g re e w ith d e f e n d a n ts th a t th e d istric t co u rt e rre d in r equi r i ng r at es t o be s etata l evel thatw oul d ens ur e a tw o- thi r ds “l evel of part i ci pat i on” among phy s i ci ans i n the St at e of O kl ahoma. T o b e su re , p lain tiff

s’ c laim s in th is c a se d if f e r slig h tlyf

ro m th o se in M a n d yR . in th a t, in a d d itio n to § 1 3 9 6 a (a )( 8 ), t h e ya ls o re ly o n th e p ro v is io n s o f § 1 3 9 6 a (a )( 1 0 )( A ). A l though M andyR . di d notaddr es s the meani ng of § 1396a( a) ( 10) ( A ) , the fa ctthat pl ai nt i ffs have i ncl uded thatas a bas i s forthei rcl ai m s does nothi ng t o change the o u tco m e . A s n o ted a b o v e , su b se c tio n (a )(1 0 )(A ) sim p lyre q u ire s a sta te M e d ica id p lan to pr ovi de “medi cal as s i s t ance , ” as thatphr as e i s uni quel ydefi ned i n the M edi cai d A ct , for s peci fi c medi cal s ervi ces l i s t ed i n the M edi cai d A ct , i ncl udi ng E PSD T s ervi ces . I n other w or ds , s ubs ect i on ( a) ( 10) ( A ) r equi r es a s t at e M edi cai d pl an t o payforal l s uch medi cal s e rv i c e s , n o t , a s p l a i n t i f f s s u g g e s t , t o d i r e c t l yp r o v i d e th e m. F i nall y , plai nti ffs’ “s ub st anti al com pli ance” argum ents are cl earl yw rong b ecause theyhi nge on the mi s t aken vi ew thatthe above - quot ed pr ovi s i ons of the M edi cai d A ct

“ c lea rlya n d u n a m b ig u o u slyre q u ire sta tes to f u rn ish E P S D T se rv ice s to a ll elig ib le ind ividu als u n d er the ag e o f 2 1 . ” A p lt . B r. at 31 . A s w e h av e d iscu ssed , the term-14-

“medi cal as s i s t ance , ” as us ed thr oughoutthe M edi cai d A ct , r efe r s t o the paym entof al l or partof the cos tof the ca r e and s ervi ces s peci fi cal l ydes cr i bed i n the ac t . T hati s , as not ed i n M andyR . , the M edi cai d A ctr equi r es part i ci pat i ng s t at es t o pr ovi de bene fi ci ar i es fi nanci al as s i s t ance r atherthan ac tual m edi cal s ervi ces . T hus , notonl ydo the s t atut es c i t e d b y p l a i n t i f

f s n o to b l i g a t e d e f

e n d a n t s t o e n s u r e th a tE P S D T s e rv i c e s a r e “ f u l l y” del i ver ed t o the pl ai nt i ff c l as s , thos e s t atut es i m pos e no obl i gat i on w hat s oeveron d e f e n d a n ts to d e liv e r a n ym e d ic a l s e rv ic e s . R a th e r, a s w e c o n c lu d e d in M a n d yR ., defe ndant s ’ obl i gat i on underthes e s t atut es i s t o paypr om pt l yforthe medi cal s ervi ces ou t l i ned i n the M edicai d A ct , i ncludi ng E P S D T services . 2 ) 4 2 U. S . C. §1 3 9 6 a (

a ) ( 3 0 ) ( A) B oth pl ai nt i ffs and def

endant s as s ertchal l enges t o the di s tr i ctcourt ’ s fi nal j u d g me n tg r a n t i n g i n

j u n c t i v e r e l i e f

b a s e d u p o n d e f

e n d a n t s ’ a l l e g e d v i o l a t i o n o f 4 2 U. S . C. § 1 3 9 6 a (a )(3 0 )(A ). W e f in d it u n n e c e ss a ryto a d d re ss a n yo f th e se a rg u m e n ts in d e tail, ho w ever, becau se w e recent l yheld i n M and yR . that § 139 6a(a) (30)( A ) does no tgive r i se t o an enf or ceabl e pr i vat e r i ghton behal f of M edi cai d benef i ci ar i es and pr ovi der s thatcan be pur s ued under§ 1983. 464 F. 3d at1148. T hus , w e s i m pl yconcl ude thatthe di s tr i ct courterr ed i n hol di ng thatdefe ndant s vi ol at ed § 1396a( a) ( 30) ( A ) , and i n turn gr ant i ng i nj unct i ve r el i ef i n favorof pl ai nt i ffs bas ed upon thatpurport ed vi ol at i on. 3) 42 U. S. C . § 1396a(

a) ( 43) I n a s uppl ement al br i ef f i l ed af t erthe i s s uance of M andyR . , pl ai nt i ffs ar gue forthe fi r s tt i m e on appe al that42 U . S. C . § 1396a( a) ( 43) “cr eat e[s ] enfor ceabl e r i ght s ” i n favor-15-

o f M e d ica id re c ip ien ts, “ in c lu d in g th e rig h t to re c e iv e a c tu a l [ E P S D T ] se rv ice s.” A p lt. S u p p . B r. at 6. P lai n ti ff s fu rth er a rgu e tha t “[i]f, as th e tri al co u rtfo u n d h ere , ch il d ren are n o t r ece i vi ngth e c a re a n d se rv ice s th e ya re e n tit led to , the n th e S tate h a s f a iled to c o m p ly w ith ” § 1 3 9 6 a(a )(43 ). Id. at 8 (it ali cs in o ri g inal). W e conc l ude thes e ar gum ent s ar e notpr oper l ybefor e us . “A bs entauthor i zat i on fr om thi s court , a partyi s gener al l ypr ecl uded fr om r ai s i ng i s s ues i n a s uppl ement al br i ef thatw er e notaddr es s ed i n the openi ng br i ef. ” U ni t ed St at es v. L aw r ence , 405 F. 3d 888, 908 n. 15 ( 10th C i r . 2005) . M or eover , w e ar e notper s uaded, aft err evi ew i ng the r ecor d on appea l , thatthe new ar gum ent s as s ert ed bypl ai nt i ffs w er e ade quat el yr ai s ed ordeci ded bel ow . See U ni t ed St eel w orker s of A m . v. O r . St eel M i l l s , I nc. , 322 F. 3d 1222, 1228 ( 10th C i r . 2003) ( not i ng thatar gum ent s notr ai s ed bel ow w i l l notbe cons i der ed forthe f irst tim e o n a p p e a l u n les s th e ya re p u re lym a tters o f law w h o se p ro p e r re so lu tio n is c e rta in ); U n ited S tate s v . E a ste r, 9 8 1 F .2 d 1 5 4 9 , 1 5 5 6 n .5 (1 0 th C ir. 1 9 9 2 ) (re f u sin g to ad d ress issu e n o t dec ided b elow b ec au se itw as “ a f ac t- d ep en d an t cha ll en g e a n d [th ere w as] an insuffi ci ent r ecord” o n ap peal) . W hil e § 1 39 6a(a) (43) w as ci t ed in the fir st amended compl ai ntand al s o r efe r ence d i n the pr etr i al or der , ther e i s no i ndi cat i on i n the r ecor d on appea l thatthe di s tr i ctcourtw as as ked t o det erm i ne, ori n fac tdi d det erm i ne, (a ) w h e th e r § 1 3 9 6 a (a )(4 3 ) c re a tes a n e n f o rc e a b le p riv a te r ig h t o n b e h a lf o f M e d ica id benef i ci ar i es thatcan be pur s ued under§ 1983, and ( b) w hetherdefe ndant s vi ol at ed the s peci fi c pr ovi s i ons of § 1396a( a) ( 43) thatpl ai nt i ffs now as s ertr equi r e the pr ovi s i on of a c tu a l h e a lth c a re s e rv ic e s .-16-

B. D is m is s al

of pl ainti f f O KA APf

orlac k o f s tanding Pl ai nt i ff O K A A P, a non- pr ofi tpr ofes s i onal or gani zat i on of pedi atr i ci ans and pedi atr i c s ub- s peci al i s t s , cont ends the di s tr i ctcourterr ed i n di s m i s s i ng i tfr om the s ui tfor l ack of s t andi ng. O urconclus i ons on the part i es ’ otheri s s ues , w hi ch nec es s i t at e r ever s al o f th e d is tr ic t c o u rt ’s ju d g m e n t, h a v e re n d e re d th is is s u e m o o t. T h e ju d g m e n t o f

th e d istric t co u rt is R E V E R S E D , an d th e c a se R E M A N D E D to the d i stri ctcou rtw i th d i rect i on s t o en t er j ud gm ent i n fav or of d efen dan t s on all cl ai m s.