Opinion ID: 1033240
Heading Depth: 3
Heading Rank: 1

Heading: Federal Approval Requirement

Text: As noted, the State must amend its plan and submit it for federal approval by the CMS to reflect ―[m]aterial changes 18 in State law, organization, or policy, or in the State‘s operation of the Medicaid program.‖ 42 C.F.R. § 430.12(c)(ii). If the CMS determines that a state plan or plan amendment does not comply with statutory requirements, it may deny the state federal funds. Id. §§ 430.15(c), 430.18. The District Court concluded that New Jersey‘s change in requiring the MCO data and prior MCO payment before processing wraparound payments constituted a de facto amendment to the plan without first securing federal approval in violation of the Medicaid statute. 42 U.S.C. § 1396a; 42 C.F.R. § 430.12(c). Because the FQHCs lack a private right of action to enforce the federal approval requirement—and NJPCA is comprised of New Jersey FQHCs—however, we do not address whether federal approval was required. ―In order to seek redress through § 1983, . . . a plaintiff must assert the violation of a federal right not merely a violation of federal law.‖ Blessing v. Freestone, 520 U.S. 329, 340 (1997). To determine whether a particular statutory provision gives rise to federal right, we look to whether ―Congress [1] must have intended that the provision in question benefit the plaintiff . . . [,] [2] the right assertedly protected by the statute is not so ‗vague and amorphous‘ that its enforcement would strain judicial competence . . . [,] [and] [3] the statute must unambiguously impose a binding obligation on the States.‖ Id. at 340-41. The Court, in Gonzaga University v. Doe, 536 U.S. 273 (2002), emphasized that Congressional authorization of a private right of action must be clear: ―We now reject the notion that our cases permit anything short of an unambiguously conferred right to support a cause of action brought under § 1983.‖ Id. at 283. Even though the FQHCs would benefit from enforcement of the federal approval provision in this case, there is no indication that Congress intended the approval provision to confer a private right of action to health care providers. Pa. Pharmacists Assoc. v. Houstoun, 283 F.3d 531, 536 (3d Cir. 2002) (en banc) (―It is important to keep in mind that the question whether a statute is intended to benefit particular plaintiffs is quite different from the question whether the statute in fact benefits those plaintiffs.‖). 19 Importantly, the provision contains no ―rights-creating language,‖ does not identify any discrete class of beneficiaries, and focuses primarily on the state as a regulated entity rather than any individuals. See Gonzaga, 536 U.S. at 287-90; Long Term Care Pharmacy Alliance v. Ferguson, 362 F.3d 50, 56-57 (1st Cir. 2004). We join several courts in reaching this conclusion. See, e.g., Developmental Servs. Network v. Douglas, 666 F.3d 540, 546-48 (9th Cir. 2011) (holding that even though state plan amendment was required under the Medicaid statute, this provision did not create a private right of action to health care providers because it was not intended to benefit them); Clifton v. Schafer, 969 F.2d 278, 284-85 (7th Cir. 1992) (holding that Medicaid recipients could not challenge a state‘s deviation from a plan which comports with federal law—the only enforceable right is a state plan that comports with federal requirements). Cmty. Health Care Assocs. of New York v. New York State Dep’t of Health, __ F. Supp. 2d __, No. 10–cv–08258 (ALC), 2013 WL 395449, at  (S.D.N.Y. Feb 1, 2013) (finding that ―statutes and regulations requiring prior approval . . . do not indicate Congress‘s unambiguous intention to benefit FQHCs specifically. Thus, there is no basis for relief in a private suit. . . .‖); cf. Pa. Pharmacists Assoc., 283 F.3d at 541-42 (holding that health care providers suing for higher reimbursement rates lacked private right of action to enforce separate Medicaid provision requiring state plans to provide methods and procedures guaranteeing quality of care and adequate access). Because FQHCs lack a private right of action to enforce the requirement of federal approval of state plan amendments, we lack jurisdiction to consider this claim.4 4 In any event, we seriously doubt that the changes implemented by the State materially altered the terms of the federally-approved State plan. New Jersey‘s plan is silent on the methodology for calculating wraparound payments or quarterly reporting requirements, leaving specific implementation to subsequent State regulation and interpretation. See Tinoco v. Belshe, 916 F. Supp. 974, 982 (N.D. Cal. 1995) (―In such a complex area of the law, the 20