Opinion ID: 3049436
Heading Depth: 5
Heading Rank: 2

Heading: Given the choice of either institutional

Text: or home and community-based services. (Emphases added.) Section 441.302(d) thus mimics the “rights-creating” language of the statute. See Gonzaga, 536 29 That some of the surrounding provisions are more focused on general policies and practices than individual Medicaid recipients does not detract from the conclusion that Congress intended for other provisions codified under § 1396n to confer individual rights. See Blessing, 520 U.S. at 342 (explaining that the rights “identif[ied] with particularity” can be enforced under § 1983 even if other provisions of the same statute are concerned with aggregate policy and may not be enforced under § 1983). BALL v. RODGERS 8601 U.S. at 287. As explained earlier, although an agency regulation cannot confer an individual right enforceable under § 1983, it may still “be relevant in determining the scope of the right conferred by Congress” and “Congress’s intent.” See Save Our Valley, 335 F.3d at 943 (citing S. Camden Citizens in Action, 274 F.3d at 783); Price, 390 F.3d at 1112-13 (stating that when “[r]ead together” with Section 104(k) of the Housing and Community Development Act, the corresponding agency regulations “confirm Congress’s intent not only to impose a plan certification requirement on grantees, but also to confer upon persons displaced by redevelopment activities an enforceable entitlement to the specific benefits of such plans”). Moreover, that some of the regulations neighboring § 441.302(d) are couched in similar, individual-oriented language underscores the depth of Congress’s intention. See, e.g., § 441.302(c)(1) (explaining that a state agency must guarantee that it will conduct an initial evaluation of individual recipients’ medical needs); id. § 441.302(c)(2) (explaining that a state must guarantee that it will conduct “[p]eriodic reevaluations . . . . at least annually, of each recipient receiving [HCBS] to determine if the recipient continues to need the level of care provided and would, but for the provision of waiver services, otherwise be institutionalized”). Finally, the legislative history of §§ 1396n(c)(2)(C) and (d)(2)(C) highlights the fact that Congress’s main concern when enacting the free choice provisions was the health and welfare of individual Medicaid recipients, not any potential cost-savings that might result from a shift away from institutionalization. This is a critical point. True, at least some of the subsections under §§ 1396n(c)(2) and (d)(2) “were obviously designed to save the government money.” See Wood, 33 F.3d at 607-08 (citing § 1396n(c)(2)(D) as “providing that home care costs may not exceed the cost of institutional care”).30 30 Specifically, under § 1396n(c)(2)(D), a state must guarantee that under such waiver the average per capita expenditure estimated 8602 BALL v. RODGERS There is also a statutory provision mandating fiscal responsibility. See §§ 1396n(c)(2)(A), (d)(2)(A) (requiring that states guarantee that “necessary safeguards . . . have been taken . . . to assure financial accountability for funds expended with respect to [HCBS]”). Yet, although Congress was quite aware that HCBS might “have a long range and significant impact on the size of states’ Medicaid budgets,” legislators were adamant that “[t]he determination of which long-term care options are feasible in a particular instance should be based on an individual’s needs, as determined by an evaluation, and not short-term cost-savings.” H.R. REP. 97-208, at 966 (1981) (Conf. Rep.), as reprinted in 1981 U.S.C.C.A.N. 1010, 1328 (emphasis added); see also id. (explaining that through the adoption of the HCBS waiver program, “the integrity of patient choice should be preserved”); S. REP. 97-139, at 74748 (1981) (acknowledging that “certain cost savings may result,” but stressing that “[a] waiver cannot be granted unless the state provides assurances satisfactory to the Secretary that necessary safeguards have been taken to protect the health and welfare of any of the recipients of such services” (emphasis added)). The result of our examination of the overall context of the HCBS waiver program, including the relevant statutes, implementing regulations, and legislative history, underscores our initial text-based view that Congress consciously used “explicit rights-creating terms” when enacting Medicaid Act’s free choice provisions. See Gonzaga, 536 U.S. at 283-84. In light of this additional, corroborative analysis, we reiterate our earlier holding — namely, that Congress intended §§ 1396n(c)(2)(C) and (d)(2)(C) to “create a federal right,” by the State in any fiscal year for medical assistance provided with respect to such individuals does not exceed 100 percent of the average per capita expenditure that the State reasonably estimates would have been made in that fiscal year for expenditures under the State plan for such individuals if the waiver had not been granted. BALL v. RODGERS 8603 and that the two provisions thus satisfy the first prong of the Blessing framework. Id. at 283 (emphasis omitted).