Opinion ID: 3047906
Heading Depth: 2
Heading Rank: 1

Heading: The Katie A. Class Action

Text: In July 2002, a class of children who were in Los Angeles County foster care or at risk of being placed into foster care (Katie A., et al.) filed a complaint seeking declaratory and injunctive relief against the Director of DHS and the Director of DSS,2 as well as Los Angeles County, the Los Angeles County Department of Children and Family Services (“DCFS”), and the Director of DCFS (“LA County Defendants”). The complaint alleged that the class was entitled to and had not received “medically necessary mental health services in a home-like setting.” Separate claims were alleged under 42 U.S.C. § 1983, based on violations of the children’s rights under the Medicaid Act, 42 U.S.C. § 1396 et seq., and the Due Process Clause of the federal Constitution; under the Americans with Disabilities Act and the Rehabilitation Act; under the Due Process Clause of the California Constitution; and under California statutory law. The complaint was later amended to include a state-wide class of children in foster care or at risk of being placed in foster care. The district court certified the class under Federal Rule of Civil Procedure 23(b)(2),3 and approved a settlement 2 DHS is the State agency responsible for administering Medicaid health services in California. California’s Medicaid program is called “MediCal.” DSS is the State agency responsible for supervising the administration of child welfare services in California. 3 The class was defined as: Children in California who (a) are in foster care or at imminent KATIE A. v. BONTÁ 3393 agreement between the plaintiff class and LA County Defendants. Plaintiffs then moved for a preliminary injunction to require the Director of DHS and the Director of DSS (“defendants”) to provide wraparound services (“wraparound”) and therapeutic foster care (“TFC”) to members of the class. Plaintiffs described wraparound and TFC as highly effective “integrated community-based interventions for children with emotional, behavioral, and mental health disorders.” Plaintiffs argued that the EPSDT provisions obligate the State to provide wraparound and TFC to them. In particular, they alleged that MediCal policies impeding access to wraparound services or TFC violated the Medicaid statute. They alleged that MediCal covered only some components of wraparound and TFC, and that State policies made it difficult to access either type of care. Defendants argued that the Medicaid statute does not require them to provide services in the wraparound or TFC forms demanded by plaintiffs,4 and that MediCal provides all required services. They characterized wraparound and TFC as processes or approaches, rather than services, and argued that risk of foster care placement; and (b) have a mental illness or condition that has been documented or, had an assessment already been conducted, would have been documented; and (c) who need individualized mental health services, including but not limited to professionally acceptable assessments, behavioral support and case management services, family support, crisis support, therapeutic foster care and other necessary services in the home or in a home-like setting, to treat or ameliorate their illness or condition. 4 Both plaintiffs and defendants, as well as the district court, have used the phrase “as such” to modify the phrase “wraparound and TFC” throughout the case, as a shorthand way of expressing the idea of “wraparound and TFC as distinct programs” or as “separately covered packages of services under Medi-Cal.” As discussed below, this modifier was crucial to the district court’s understanding and analysis of the case. 3394 KATIE A. v. BONTÁ the Medicaid Act does not create obligations to provide either. Defendants also disputed plaintiffs’ contention that all of the components of wraparound and TFC are health care services properly covered by Medicaid. On March 14, 2006, the district court entered an order granting a mandatory preliminary injunction against defendants, ordering them to provide medically necessary wraparound services5 and TFC6 to class members on a consistent, statewide basis within 120 days of the order’s entry. Stating that defendants did not dispute that they did not provide wraparound and TFC as such, the court found that “wraparound services and therapeutic foster care fall within the EPSDT obligations of Medicaid-participating states.”7 The court also 5 The court relied on plaintiffs’ description of wraparound services, which was as follows: Providers of wraparound care services: (a) engage in a unique assessment and treatment planning process that is characterized by the formation of a child, family, and multi-agency team, (b) marshal community and natural supports through intensive case management, and (c) make available an array of therapeutic interventions, which may include behavioral support services, crisis planning and intervention, parent coaching and education, mobile therapy, and medication monitoring. 6 The court also incorporated plaintiffs’ description of TFC as programs that: (a) place a child singly, or at most in pairs, with a foster parent who is carefully selected, trained, and supervised and matched with the child’s needs; (b) create, through a team approach, an individualized treatment plan that builds on the child’s strengths; (c) empower the therapeutic foster parent to act as a central agent in implementing the child’s treatment plan; (d) provide intensive oversight of the child’s treatment, often through daily contact with the foster parent; (e) make available an array of therapeutic interventions to the child, the child’s family, and the foster family . . . ; and (f) enable the child to successfully transition from therapeutic foster care to placement with the child’s family or alternative family placement by continuing to provide therapeutic interventions. 7 As a preliminary matter, the court held that plaintiffs properly relied on the private right of action contained in 42 U.S.C. § 1983 to enforce the KATIE A. v. BONTÁ 3395 cited what it described as plaintiffs’ undisputed evidence that wraparound and TFC are medically necessary for children with serious mental health needs. On this basis, the court concluded that plaintiffs had shown a strong likelihood of succeeding on the merits of their Medicaid Act claim. The court also described the potential for irreparable harm to plaintiffs in the form of unnecessary institutionalization and unmet mental health needs, if the injunction were not issued. The court denied defendants’ motions for clarification and reconsideration, but subsequently issued an Addendum to the order, which contained short answers to defendants’ questions from their motion for clarification. The Addendum also contained appendices (“Appendices A and B”) listing the components of wraparound and TFC for purposes of compliance with the order. II. The Medicaid Framework and the EPSDT Obligation Medicaid is a cooperative federal-state program that directs federal funding to states to assist them in providing medical assistance to low-income individuals. 42 U.S.C. § 1396. States choose whether to participate in Medicaid. Once a state enters the program, the state must comply with the Medicaid Act and its implementing regulations. Alexander v. Choate, 469 U.S. 287, 289 n.1 (1985); see generally 42 U.S.C. § 1396 et seq. California has chosen to participate in Medicaid. To participate in Medicaid, a state must submit and have approved by the Secretary of Health and Human Resources a state plan for medical assistance. 42 U.S.C. § 1396. The Medicaid Act requires that each state plan “provide for making medical assistance available, including at least the care and right to EPSDT services created by 42 U.S.C. § 1396a(a)(10), citing Watson v. Weeks, 436 F.3d 1152 (9th Cir.), cert. denied, 127 S.Ct. 598 (2006). Defendants have not disputed that ruling on appeal. 3396 KATIE A. v. BONTÁ services listed in paragraphs (1) through (5), (17) and (21) of section 1396d(a) of this title, to all individuals [listed under certain statutory provisions].” 42 U.S.C. § 1396a(a)(10). “[E]arly and periodic screening, diagnostic, and treatment services . . . for individuals who are eligible under the plan and are under the age of 21” are among the mandatory categories of medical assistance. 42 U.S.C. § 1396d(a)(4)(B).8 Thus, California, like all other states participating in Medicaid, is required to provide EPSDT care to eligible children under the age of 21.9 EPSDT services are defined in § 1396d(r). The EPSDT services at issue in this case, wraparound and TFC, are claimed to fall under subsection (r)(5) as “[s]uch other necessary health care, diagnostic services, treatment, and other measures described in subsection (a) of this section to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the State plan.” 42 U.S.C. § 1396d(r)(5). Under § 1396d(r)(5), states must “cover every type of health care or service necessary for EPSDT corrective or ameliorative purposes that is allowable under § 1396d(a).” S.D. ex rel. Dixon v. Hood, 391 F.3d 581, 590 (5th Cir. 2004) (citing Collins v. Hamilton, 349 F.3d 371 (7th Cir. 2003)); Pediatric Specialty Care, Inc. v. Ark. Dep’t of Human Servs., 293 F.3d 472 (8th Cir. 2002); Pittman v. Sec’y, Fla. Dep’t of Health & Rehab., 998 F.2d 887 (11th Cir. 1993); Pereira v. Kozlowski, 996 F.2d 723 (4th Cir. 1993)).10 Although states have the 8 All subsequent references to statutory sections are to sections of Title 42 of the United States Code, unless otherwise noted. 9 A large subset of the plaintiffs are eligible for Medicaid as foster children receiving federal assistance under Title IV-E of the Social Security Act, and others may be eligible on other grounds. See 42 U.S.C. § 1396a(a)(10)(A)(i)(I). The district court’s order covers only MediCal eligible children. 10 This is subject to certain limits; for example, a state need not pay for experimental medical procedures. See Miller v. Whitburn, 10 F.3d 1315, 1318 (7th Cir. 1993); McLaughlin v. Williams, 801 F. Supp. 633, 637-38 (S.D. Fla. 1992). KATIE A. v. BONTÁ 3397 option of not providing certain “optional” services listed in § 1396d(a) to other populations, they must provide all of the services listed in § 1396d(a) to eligible children when such services are found to be medically necessary. Section 1396d(a) contains a list of 28 categories of care or services; these categories are fairly general, including descriptions such as “inpatient hospital services” and “private duty nursing services.” 42 U.S.C. § 1396d(a)(1)-(8). The EPSDT obligation is thus extremely broad. The federal agency charged with administering the Medicaid Act, the Centers for Medicare and Medicaid Services (“CMS”), has described EPSDT as a “comprehensive child health program of prevention and treatment.” CMS, U.S. Dep’t of Health & Human Servs., Pub. No. 45, State Medicaid Manual § 5010(B) (hereinafter “State Medicaid Manual”).11