Source: https://healthlaw.org/resource/complaint-miles-v-leavitt-s-d-n-y/
Timestamp: 2019-04-22 00:16:13+00:00

Document:
whose families cannot otherwise afford all or part of the cost of the coverage.
plaintiffs to obtain necessary health care, including routine check-ups and vaccines, diagnostic tests, prescriptions, and surgical procedures.
continued implementation of the unlawful rule.
5. Venue is proper under 28 U.S.C. § 1391(e).
6. Plaintiff Morganne Miles is a 3-year-old child who lives with her parents in Gorham, New York. She appears in this action through her mother, Krystal Titus.
7. Plaintiff Olivia Miles is a 1-year-old infant who lives with her parents in Gorham, New York. She appears in this action through her mother, Krystal Titus.
8. Plaintiff Pascale Mossin is a 2½-year-old infant who lives with her mother in New York, New York. She appears in this action through her mother, Amy Margaret McCutchin.
10. Plaintiff Leah Chan is a 5-month-old infant who lives with her parents in Brooklyn, New York. She appears in this action through his father, Sunny Chan.
11. Defendant Michael O. Leavitt is the Secretary of the United States Department of Health and Human Services (?Department?) and is responsible for administering the Department?s programs consistent with federal law, including the Social Security Act and the Administrative Procedure Act. The Secretary administers the State Children?s Health Insurance Program (?SCHIP?) through the Centers for Medicare & Medicaid Services (?CMS?). Secretary Leavitt is sued in his official capacity.
requirements set forth in Title XXI of the Social Security Act (the ?SCHIP statute?). See 42 U.S.C. § 1397aa(c).
13. Originally referred to as the Children?s Health Insurance Program, Title XXI was renamed the State Children?s Health Insurance Program, thus emphasizing the States?
broad discretion to establish and operate their programs so long as the programs meet the general requirements of the Act.
an effective and efficient manner that is coordinated with other sources of health benefits coverage for children.? 42 U.S.C. § 1397aa(a).
15. To participate in SCHIP and receive federal funding, the SCHIP statute requires each participating State to submit a State Child Health Plan (a ?State plan?) to the 4 Secretary of the Department. The State plan ?sets forth how the State intends to use the funds provided through Title XXI to provide child health assistance to needy children.?
performance measures and goals. 42 U.S.C. §§ 1397bb-1397gg.
16. Consistent with the SCHIP statute, the regulations promulgated by the Department confirm that ?[w]ithin broad Federal rules, each State decides eligible groups, types and ranges of services, payment levels for benefit coverage, and administrative and operating procedures.? 42 C.F.R. § 457.1.
17. States can participate in SCHIP by expanding their existing Medicaid programs to additional low-income children and/or by creating new, separate programs. 42 U.S.C. § 1397aa(a). The SCHIP statute provides greater flexibility to States choosing to create separate SCHIP programs, allowing these States to fashion their own SCHIP eligibility requirements and benefit packages within the parameters of Title XXI rather than adhering to stricter Medicaid eligibility and coverage rules. Compare 42 U.S.C. §§ 1397aa-1397jj (SCHIP requirements) with 42 U.S.C. § 1396a-1396v (Medicaid requirements). New York participates in SCHIP and has elected to use a separate program.
income. Thus, each State can establish eligibility standards and methodologies for 5 defining income that reflect the cost of living in the state, including health care costs. See 42 U.S.C. § 1397bb.
State child health plan does not substitute for coverage under group health plans?.? 42 U.S.C. § 1397bb(b)(3). The State plan must ?include a description? of the extent to which and manner in which low-income and other classes of children have creditable health insurance coverage, current State efforts to provide or obtain creditable health coverage for uncovered children, and how the State plan is designed to be coordinated with such efforts to increase health coverage. Id. at § 1397bb(a).
The extent to which, and manner in which, children in the State, ? currently have creditable health coverage?; [and] (b) current State efforts to provide or obtain creditable health coverage for uncovered children,?.? 42 C.F.R. § 457.80. In addition, ?The State plan must include a description of reasonable procedures to ensure that health benefits coverage provided under the State plan does not substitute for coverage provided under group health plans?.? 42 C.F.R. § 457.805.
21. Federal regulations address substitution, sometimes referred to as ?crowd out,? in a provision discussing a State?s possible operation of a premium assistance program. 42 C.F.R. § 457.810(a). Under this rule, an enrollee must not have had coverage under a 6 group health plan for a period of at least six months prior to enrollment in a premium assistance program. A State may not require a minimum waiting period that exceeds 12 months. States can permit reasonable exceptions to the minimum waiting period, including for involuntary loss of coverage, economic hardship, and a switch to employment that does not offer dependent coverage. Id.
certain level of private insurance coverage as a condition of establishing or expanding coverage for uninsured children through SCHIP.
Medicaid plan ? are enrolled for such assistance?.? 42 U.S.C. § 1397bb(b)(3)(B); 42 C.F.R. § 457.350.
statute require or authorize the Secretary to require States to enroll a certain percentage of children in Medicaid or SCHIP as a precondition of implementing or expanding SCHIP coverage to children with higher family incomes.
25. The SCHIP statute explicitly gives States that elect to establish separate SCHIPs the discretion whether or not to impose cost sharing. The SCHIP statute provides that a ?State child health plan shall include a description, ?, of the amount (if any) of premiums, deductibles, coinsurance, and other cost sharing imposed.? 42 U.S.C. § 1397cc(e)(1)(A).
26. If a State chooses to implement cost sharing, it cannot impose deductibles, coinsurance, or other cost sharing with respect to well baby and child care and immunizations. 42 U.S.C. § 1397cc(e)(2).
children in a family under this subchapter may not exceed 5 percent of such family?s income for the year involved.? 42 U.S.C. § 1397cc(e)(3)(B).
coverage, or to impose cost sharing on well baby and child care and immunizations through the SCHIP.
Secretary will obtain data and reports from states using ?standardized formats.? 42 C.F.R. § 457.720.
?shall be effective? on the dates specified in the amendment unless the Secretary finds that the amendment does not ?substantially comply? with the requirements of Title XXI. Id. at §§ 1397ff(b)-(e); 42 C.F.R. § 457.65(a)(1) (stating that, in general, ?[a] State plan or plan amendment takes effect on the day specified in the plan or plan amendment?.?).
32. The right to ?alter, amend, or repeal? any provision of Title XXI is reserved to the Congress. 42 U.S.C. § 1304.

References: § 1391
 § 1397
 § 1397
 § 457
 § 1397
 § 1396
 § 1397
 § 1397
 § 1397
 § 457
 § 457
 § 457
 § 1397
 § 457
 § 1397
 § 1397
 § 1397
 § 457
 § 457
 § 1304