Opinion ID: 4707402
Heading Depth: 2
Heading Rank: 2

Heading: Bellin’s Due Process Claims

Text: Bellin challenges the district court’s dismissal of her § 1983 claims alleging a due process right to appeal MLTCs’ initial personal care services hours determinations. A plaintiff states a due process claim by plausibly alleging that “(1) state action (2) deprived him or her of liberty or property (3) without due process of law.” Barrows v. Burwell, 777 F.3d 106, 113 (2d Cir. 2015); see also Kapps v. Wing, 404 F.3d 105, 112 (2d Cir. 2005) (“In adjudicating [a procedural due process] claim, we consider two distinct issues: 1) whether plaintiffs possess a liberty or property interest protected by the Due Process Clause; and, if so, 2) whether existing state procedures are constitutionally adequate.”). Bellin alleged in her complaint that “Zucker exercises significant control over the MLTCs” and “the MLTCs are not simply regulated by state and federal law, they are deeply integrated into the regulatory scheme provided for under federal and state law.” Jt. App’x 20. Neither the State nor RiverSpring contests that RiverSpring is a state actor in this context. See, e.g., Catanzano by Catanzano v. Dowling, 60 F.3d 113, 119 16 (2d Cir. 1995) (holding that actions of New York State-certified home health agencies constituted state action in part because those agencies were “the only entities permitted to provide home health care under Medicaid, and are required to evaluate all potential recipients,” and their decisions with respect to beneficiaries were guided by regulation in addition to medical judgment). The district court did not reach the third prong of the due process test because it held that Bellin lacks a property interest “in a particular level of care.” 16 Bellin, 457 F. Supp. 3d at 422. As explained below, the district court’s conclusion may ultimately prove to be correct, but its determination at the motion-todismiss stage was premature. A. Constitutionally Protected Property Interests A constitutionally protected interest exists where “one has a legitimate claim of entitlement to the benefit”; “[a] mere unilateral expectation of receiving a benefit” does not suffice. Kapps, 404 F.3d at 113. To determine whether an applicant for benefits has a constitutionally protected property interest in the receipt of a particular benefit, a court must “look to the statutes and regulations governing the distribution of benefits” and determine whether “those statutes or regulations meaningfully channel official discretion by mandating a defined administrative outcome.” Id.; see Sealed v. Sealed, 332 F.3d 51, 56 (2d Cir. 2003) (“In evaluating whether a state has created a protected interest 16Before reaching this conclusion, the district court expressed skepticism about whether Bellin, as an applicant for benefits, could have a constitutionally protected property interest in receiving benefits at all. See Bellin, 457 F. Supp. 3d at 422-23 (“The Supreme Court has not announced a property interest in cases like Plaintiff’s because ‘[t]he Supreme Court has repeatedly reserved decision on the question of whether applicants for benefits (in contradistinction to current recipients of benefits) possess a property interest protected by the Due Process Clause.’” (quoting Kapps, 404 F.3d at 115)). The district court’s skepticism was misplaced. In Kapps, we acknowledged that the “Supreme Court has repeatedly reserved decision on the question,” but we then observed that “[e]very circuit to address the question . . . has concluded that applicants for benefits, no less than current benefits recipients, may possess a property interest in the receipt of public welfare entitlements.” Kapps, 404 F.3d at 115. 17 in the administrative context, we must determine whether the state statute or regulation at issue meaningfully channels official discretion by mandating a defined administrative outcome.”). In addition to the relevant statutes and regulations, we must consider the regulatory scheme as a whole: just as discretion may be channeled by law, it may also be channeled by informal rules or institutional practices. See Furlong v. Shalala, 156 F.3d 384, 395 (2d Cir. 1998) (“[P]roperty interests may be established through such diverse sources as unwritten common law and informal institutional policies and practices.”); see also Bd. of Regents v. Roth, 408 U.S. 564, 577 (1972) (explaining that “[p]roperty interests . . . are not created by the Constitution,” but rather by “existing rules or understandings that stem from an independent source such as state law—rules or understandings that secure certain benefits and that support claims of entitlement to those benefits”). This inquiry involves two questions, corresponding to two distinct uses of the word “discretion.” First, “discretion” may refer to a decision-maker’s ultimate power to decide—the power to grant or deny a benefit regardless of whether particular criteria are met. When the decision-making authority is accorded such wholesale discretion, a procedural due process claim based on the decision-making process will fail. See Sealed, 332 F.3d at 56 (“Where the administrative scheme does not require a certain outcome, but merely authorizes particular actions and remedies, the scheme does not create ‘entitlements’ that receive constitutional protection under the Fourteenth Amendment.”). Second, “discretion” may refer to the extent to which criteria govern and limit a decision-maker’s power to decide—whether the prescribed criteria are openended and subjective, or determinate and well-defined. When this more restricted type of discretion is at issue, the procedural due process inquiry turns on the question—in an admittedly somewhat circular inquiry—whether the relevant criteria “meaningfully channel official discretion” to an extent sufficient to create a property interest. Kapps, 404 18 F.3d at 113 (emphasis added); see also Bd. of Pardons v. Allen, 482 U.S. 369, 375 (1987) (explaining the “two entirely distinct uses of the term discretion”: (1) where an official “‘is simply not bound by standards set by the authority in question,’” and (2) whether an official “‘must use judgment in applying the standards set . . . by authority’” (quoting RONALD DWORKIN, TAKING RIGHTS SERIOUSLY 31-32 (1977))).
The district court alluded to the presence of both types of discretion in MLTCs’ decision-making authority. It suggested that MLTCs have ultimate discretion to decide whether to offer a particular number of personal care hours. See Bellin, 457 F. Supp. 3d at 423 (“[T]he regulations and agency guidance describe when 24-hour care may be authorized; they do not state that it must be offered.”). It also implied that the relevant regulations do not sufficiently channel MLTCs’ assessments of beneficiaries’ personal care services needs so as to create a constitutionally protected property interest. See id. (explaining that Bellin failed to allege a “scheme to channel discretion in MLTCs’ personal care determinations”). The district court also pointed to two other aspects of the personal care services assessment scheme as relevant to its conclusion: the fact that beneficiaries have the option of seeking and choosing among multiple MLTC offers, and the fact that MLTCs may compete with one another to sign up beneficiaries. See id. (pointing to “choice on the part of the potential Medicaid enrollee, and the possibility of competition among MLTCs as to the quantity and quality of care each proposes to offer” as reasons beneficiaries lack a constitutionally protected due process interest in the initial determination of their care services hours). On appeal, the State and RiverSpring do not substantially defend the district court’s suggestion that MLTCs possess the ultimate discretion to grant or deny care 19 services hours regardless of whether certain criteria are satisfied. 17 They instead argue that MLTCs’ initial determinations of personal care services hours involve the application of fluid, subjective criteria and specialized medical judgment such that their discretion is not “meaningfully channeled.” We consider this argument below, ultimately concluding that Bellin has plausibly alleged that MLTCs lack both this type of unbounded discretion as well as the sort of “ultimate” discretion that the district court suggested they have.
As explained above, determining the extent to which decision-makers’ discretion is channeled demands a careful examination of the required decision-making process. In Barrows v. Burwell, for example, this Court considered whether Medicare beneficiaries have a constitutionally protected property interest in being admitted to hospitals on an inpatient basis as opposed to being placed on observation status, a decision that substantially alters their responsibility under Medicare for the cost of their treatment. 17Both the State and RiverSpring’s briefs could be read to imply that MLTCs are never under an obligation to provide a particular number of personal care services hours—that they possess the sort of “ultimate” discretion that absolutely precludes a constitutionally protected property interest. Upon closer examination, however, both parties’ arguments are simply variations on their claims that the relevant personal care services hours criteria are too fluid and subjective to create a constitutionally protected property interest in any particular number of hours. For example, RiverSpring suggests in passing that under New York regulations “the conferral of the benefit . . . never becomes mandatory.” RiverSpring Br. 32. Yet, in support of this contention, RiverSpring cites the facts that “a nurse conducting a [uniform assessment] considers numerous data points,” that “two individuals with the same [uniform assessment] score may” receive different assessments, and that “different plans may assess the required number of hours differently for [different] individuals.” RiverSpring Br. 32. In much the same way, the State highlights “precatory language throughout the statutory and regulatory framework,” but in the end argues only that this language “reinforces the absence of a predetermined outcome.” State Br. 53. Neither party argues that the MLTC has the option under its contract with the State to deny providing a given level of personal care services altogether to an individual who qualifies for that level of care. 20 777 F.3d 106, 107-09 (2d Cir. 2015). The district court held that because the decision whether to admit a patient was a “complex medical judgment” committed to the discretion of hospital physicians, beneficiaries have no constitutionally protected property interest in being admitted. Id. at 114. In support of this conclusion, it pointed to the Medicare Policy Manual, published by the Centers for Medicare & Medicaid Services (“CMS”), which specifically stated that the decision whether to admit a patient was a “complex medical judgment” based on a physician’s application of various factors. Id. This Court held that the district court’s dismissal of the action for failure to state a claim was premature. The Barrows plaintiff alleged that, despite the CMS guidance, admissions decisions were in fact made “through rote application of ‘commercially available screening tools,’” which, in practice, “substitute[d] for the medical judgment of treating physicians.” Id. In light of this allegation, we explained, the district court could not fairly rely on the Medicare Policy Manual to serve as an accurate representation of the admissions procedures. Otherwise stated, whether the plaintiffs had a constitutionally protected property interest “turn[ed] on facts that [were], at th[at] stage, contested.” Id. at 115. The Barrows Court recognized that a protected property interest can arise in a number of ways and that it is important for district courts to consider the details of the administrative scheme—and the allegations regarding those details— before relying on general discretion-granting regulations to dismiss procedural due process claims. Accordingly, although “[t]he issue of whether an individual has such a property interest is a question of law,” Gagliardi v. Vill. of Pawling, 18 F.3d 188, 192 (2d Cir. 1994), Barrows and other precedents make clear that when a complaint plausibly alleges discretion is meaningfully channeled based on the relevant sources, including 21 informal institutional policies and practices, the case should not be dismissed at the Rule 12(b)(6) stage. 18 In this case, the district court dismissed Bellin’s due process claims after examining the New York regulations that describe—at the highest level of generality— the criteria MLTCs must consider in making initial hours determinations for personal care services. See N.Y. Comp. Codes R. & Regs. tit. 18, § 505.14(a). In the district court’s view, the fact that MLTCs were directed to apply criteria that “require medical judgment and administrative decision making” established that MLTCs’ discretion was not meaningfully channeled. Bellin, 457 F. Supp. 3d at 423. But whether Bellin plausibly alleged that MLTCs’ discretion is meaningfully channeled cannot be answered simply by an examination of the highest-level generally applicable regulations. The relevant regulations, which are incorporated by reference into the complaint, do not establish as a matter of law that the discretion of the MLTCs is not meaningfully channeled. The State and RiverSpring argue that because 18 N.Y.C.R.R. § 505.14(b), which sets forth criteria the MLTCs must consider, contains a physician’s evaluation, a social assessment, and a nursing assessment that each require subjective judgments, the criteria are too open-ended to be meaningfully channeled. For example, the State contends that “[u]nder state law, an MLTC plan may provide personal care services only to the extent those services are ‘determined to meet the patient’s needs for assistance,’ and ‘when’ those services are also ‘cost effective and appropriate.’” State Br. 50 (emphasis omitted). Although the criteria involve professional and subjective 18To be clear, we do not mean to suggest that anytime a plaintiff alleges a due process claim, the case should move on to discovery because there may be sources that could be uncovered during discovery that would help determine whether discretion is meaningfully channeled. The complaint, documents incorporated by reference into the complaint, and matters of which the court may take judicial notice must in totality raise a plausible inference that plaintiffs are entitled to relief and that the case should therefore proceed to discovery. 22 determinations, many of the criteria are also objective and fixed. For instance, the nursing assessment must by regulation include six specific factors, including more objective ones such as “the primary diagnosis code from the ICD-9-CM.” 18 N.Y.C.R.R. § 505.14(b)(3)(iii)(b)(2). Even with the cost-effectiveness criteria, the regulation delineates the considerations and alternatives that should be taken into consideration; it does not just leave the assessment of cost-effectiveness to the MLTCs without providing any substantive guidance. See id. § 505.14(b)(3)(iv); see also Fleury v. Clayton, 847 F.2d 1229, 1232 (7th Cir. 1988) (“[T]he inclusion of elastic items in a list of criteria does not destroy a property interest.”). As a result, this case is different from Yale Auto Parts, Inc. v. Johnson, 758 F.2d 54 (2d Cir. 1985), upon which the State relies in support of the view that “this Court and others [] reject claims of constitutionally protected entitlements” when “the regulatory scheme involves both professional judgment and open-ended criteria.” State Br. 48. In Yale Auto Parts, the Court held that the plaintiff businesspeople had no constitutionally protected property interest in approval by the West Haven Zoning Board of Appeals of the location for an auto junkyard. 758 F.2d at 60. The Court highlighted the appellate zoning board’s statutory duty to take into account highly subjective considerations such as “the health, safety and general welfare of the public,” and, citing this substantial “discretion,” concluded that the plaintiffs lacked the requisite property interest. Id. at 59. 19 19In addition, the Yale Auto Parts court did not affirm dismissal of the complaint simply because the Zoning Board of Appeals applied subjective criteria. The court emphasized that the plaintiff in that case did not allege that “but for the” alleged due process violation, the Zoning Board of Appeals “would have been required to award them the requested” approval. Id. at 60. The presence of highly subjective criteria confirmed that there was no “certainty or a very strong likelihood that,” absent the alleged denial of due process, plaintiff’s “application would have been granted.” Id. at 59. In Bellin’s case, by contrast, the Commissioner’s designee has already 23 In her complaint, Bellin plausibly alleged that “MLTCs’ decisions regarding the appropriateness and amount of personal care services to provide to Medicaid recipients are not independent professional judgments because those decisions are governed by, and must conform with Federal and New York State statutes, regulations, manuals and transmission letters.” Jt. App’x 20. She pointed out that they must by contract provide sufficient services “to reasonably be expected to achieve the purpose for which the services are furnished,” and that they must be furnished at levels “no less . . . than [those] furnished to beneficiaries under fee-for-service Medicaid.” Id. at 17 (quoting 42 C.F.R. § 438.210(a)). She further alleged that, when certain regulatory criteria are satisfied, “MLTC plans are required to provide medically necessary in-home personal care services up to and including 24 hours per day.” Id. (citing 18 N.Y.C.R.R. §§ 505.14(a)(3), (5), 505.28(b)(4), (8)). As explained above, the criteria outlined in 18 N.Y.C.R.R. § 505.14(b) place substantive limitations on the MLTCs’ decision-making. In addition, the complaint identifies the MLTC Policy, which incorporates the Uniform Assessment System, a special tool that all parties discuss in their briefing and as Bellin argues “generates the answers to certain questions about functional impairments.” Bellin Reply Br. 22. Although Bellin’s complaint was not a model of specificity, it included these plausible, relatively specific allegations that MLTCs’ decision-making is determined that RiverSpring’s May 2019 assessment supported her entitlement to 24-hour, livein personal care services. Absent the denial of her right to appeal, then, RiverSpring would almost certainly have been required to offer Bellin that care as part of its initial care services hours determination. We also read the Yale Auto Parts case to be concerned about applying federal due process review to state administrative decision-making. In light of the substantial federal role in overseeing and regulating state Medicaid programs, we see no similar risk here of “open[ing] a Pandora’s Box of unnecessary federal-state conflict.” Yale Auto Parts, 758 F.2d at 59. 24 not unbounded; rather, it is meaningfully channeled, and on this basis she claimed a constitutionally protected property interest in a particular level of care. Other aspects of the record in the district court reinforce the plausibility of Bellin’s due process claim. In opposing the motion to dismiss, Bellin filed with the district court the initial decision and portions of the record in her fair hearing appeal in which she sought reimbursement for the days she went without full-time care before RiverSpring determined she was entitled to care at that level. See Declaration of Aytan Y. Bellin, Exs. A, B, Bellin v. Zucker, 457 F. Supp. 3d 414 (S.D.N.Y. 2020) (No. 19-cv-5694 (AKH)), ECF No. 45. 20 She also included records of another fair hearing decision made publicly available in a redacted format, in light of the privacy interests in the medical information it necessarily contains. 21 Id., Ex. D. In deciding Bellin’s fair hearing appeal (as described above), the Commissioner’s designee reviewed RiverSpring’s evaluations of Bellin’s condition and concluded that they conclusively established her entitlement to 24-hour, live-in care. This fair hearing decision lends plausibility to Bellin’s allegation that the MLTCs are required to provide a particular level of personal care services upon finding that beneficiaries satisfy certain criteria. Contrary to the district court’s suggestion that the regulatory scheme merely authorizes a certain level of care when certain criteria are met, Bellin, 457 F. Supp. 3d at 423, and does not require that care be offered, the fair hearing record plausibly establishes that upon finding certain criteria satisfied, MLTCs must provide 24-hour 20 The record did not include the amended fair hearing decision, which was issued after Bellin filed her opposition to the motion to dismiss. Because it concerned the date on which an entitlement began rather than the entitlement and record itself, it is not relevant to our discussion at this point. 21As discussed in note 10, supra, these fair hearing decisions are matters of public record properly subject to judicial notice. 25 personal care services, see Appellant’s Reply Br. 25 (“The fair hearing decisions indicate unequivocally that upon satisfying the criteria for a particular number of home care hours, the hours must be awarded.”). Critically, Bellin’s fair hearing decision does not appear to be unique in this aspect. She cites several other fair hearing decisions that reflect an apparent practice in the Department of Health of reviewing MLTCs’ assessments and concluding based on the satisfaction of certain criteria that beneficiaries are entitled to a specific number of personal care services hours. See Appellant’s Br. 48-49; Appellant’s Reply Br. 26. For instance, in one case, the Commissioner’s designee ruled that an MLTC had wrongly denied a 99-year-old recipient’s request to increase her personal care services from 12 hours per day to 24-hour, live-in care. The Commissioner’s designee reached this conclusion based on the MLTC’s assessment, which indicated that the recipient could not walk or use a toilet without support. See Decision After Fair Hearing, No. 8110102H (State of N.Y. Dep’t of Health Aug. 12, 2020), https://otda.ny.gov/fair%20hearing%20images/2020-8/Redacted_8110102H.pdf (last visited July 9, 2021); see also Decision After Fair Hearing at 21-22, No. 8171784M (State of N.Y. Dep’t of Health July 13, 2020) (directing MLTC to increase appellant’s personal care services hours from 10 hours per day to 24-hour, live-in care based in part on “skilled services nurse[‘]s notes contained in the Plan’s evidence”), https://otda.ny.gov/fair%20hearing%20images/2020-8/Redacted_8171784M.pdf (last visited July 12, 2021). The fact that administrative review is possible for such similar claims supports Bellin’s claim that beneficiaries have a property interest in the initial determination of their personal care services hours. Our decision in Furlong v. Shalala, 156 F.3d 384 (2d Cir. 1998), is instructive in this regard. In Furlong, plaintiff anesthesiologists challenged the denial of the right of non-assigned physicians to appeal Medicare adverse payment 26 decisions. The anesthesiologists asserted that they were denied a constitutionally protected property interest when they were prevented from appealing insurance carriers’ decisions to deem certain of their services “surgical,” resulting in lower reimbursement rates. Id. at 389, 393. The Court first explained that federal regulations left insurance carriers with considerable discretion in deciding whether a service was “surgical,” and so did not provide a basis for identifying a protected property interest. Id. at 394. But the Court then considered the fact that, when assigned physicians—who had appeal rights—appealed the designation of the same services as the non-assigned plaintiff anesthesiologists performed, ALJs repeatedly reversed the carriers’ decisions. Id. Recognizing that these ALJ decisions were “persuasive authority in interpreting Medicare law,” and ruling that the “constant, consistent pattern of ALJ decisions” was sufficient to create a property interest in the designation of services, the Court held that the plaintiff anesthesiologists had a protected property interest in receiving the higher reimbursement amount. Id. at 395-96. In the same way, the fair hearing appeal decisions Bellin identifies lend support to her assertion of a constitutionally protected property interest. 22 Bellin therefore plausibly alleges a property interest in MLTCs’ initial care services hours determinations. We appreciate the State’s argument that the regulations introduce sufficiently “open-ended considerations” into these determinations that 22The State and RiverSpring are largely silent about the relevance of the State fair hearing decisions to Bellin’s due process claims. RiverSpring argues that “the fact . . . that fair hearing decisions include descriptions of the standards and procedures MLTCs must utilize when making home-care-hour determinations . . . (which are nothing more than recitations of the guidelines) . . . does not demonstrate that a plan is required to authorize a specific level of personal care services upon rote application of such standards and procedures.” RiverSpring Br. 34. However, “rote” application is not required to establish that discretion is meaningfully channeled. 27 Bellin cannot have a constitutionally protected property interest in a particular level of care, even at the full-time, live-in level, where one might imagine few would differ on the level of need. State Br. 51. Yet, to survive the motions to dismiss, it was not Bellin’s burden to make anything more than a plausible allegation that MLTCs’ discretion is channeled so as to create a property interest in initial hours determinations, and the district court was obligated to draw all reasonable inferences from Bellin’s allegations in her favor. Bellin carried this burden. On remand, the parties will likely have the opportunity to develop the record concerning how these personal care services hours determinations are made and what the applicable regulations require of both the MLTC and the State. This includes the various forms of guidance that may be non-public and may limit MLTCs’ discretion to which Bellin alluded in her complaint. See Jt. App’x 20 (“MLTCs’ decisions regarding the appropriateness and amount of personal care services to provide to Medicaid recipients are not independent professional judgments because those decisions are governed by, and must conform with . . . manuals and transmission letters.” (emphasis added)). It also includes the way MLTCs’ discretion is channeled in practice. Given the review of assessment records that occurs in fair hearing appeals, the way the Uniform Assessment System works in practice may be particularly relevant on remand. RiverSpring acknowledges that “the [Uniform Assessment System] assigns a numbered [nursing facility level of care] score based on the various data collected.” RiverSpring Br. 32. Although RiverSpring submits on appeal that this data includes “the subjective observations of the assessor,” and that two beneficiaries may receive the same score and yet receive different levels of care, id., the fair hearing appeal decisions suggest that these assessments at least sometimes support an obvious entitlement to a particular number of personal care services hours. The evaluation of this and other relevant issues will benefit from further factual development on remand. 28
The district court cited “choice on the part of the potential Medicaid enrollee, and the possibility of competition among MLTCs as to the quantity and quality of care each proposes to offer,” as additional reasons for its conclusion that Bellin lacks a constitutionally protected property interest in the initial determination of her care services hours. Bellin, 457 F. Supp. 3d at 423. These aspects of New York’s Medicaid scheme have no legitimate bearing on whether Bellin has a constitutionally protected property interest. The fact that a beneficiary can seek out another MLTC and go through the same evaluation process does not affect whether the regulatory scheme “meaningfully channel[s] official discretion by mandating a defined administrative outcome.” Kapps, 404 F.3d at 113. If we were to hold otherwise, states could dodge the dictates of the Due Process Clause by having multiple firms “compete” to assess beneficiaries’ entitlement to a particular amount of a benefit and to provide that benefit, even if in practice those “competing” assessments yielded the same outcomes and the competition was largely illusory. 23 The fact that beneficiaries can opt to seek initial 23In other words, one cannot infer “choice” and “competition” from the presence of multiple MLTCs to which a beneficiary may apply. The number of available MLTCs varies by region, and federal law requires states to ensure only that two managed care organizations are available to any given enrollee, subject to certain exceptions. See 42 U.S.C. § 1396u-2(a)(3). Meanwhile, the same structure that is designed to generate cost savings in the managed care model may also create incentives for providers not to offer adequate care to high-needs beneficiaries in hopes that those beneficiaries choose the competition. Recall that MLTCs are paid a flat capitation per beneficiary. When considering a high-needs beneficiary such as Bellin, MLTCs may have an incentive not to take her on as a patient—and therefore an incentive not to offer an attractive or even adequate number of personal care hours. See 2003 Interim Report at 20-21 (explaining that MLTCs are “paid a predetermined amount per member per month” and that, although regional rates vary based on broad enrollee demographic and other factors, MLTCs ultimately bear the risks associated with covering the costs of “all needed medical services” for any single enrollee through these payments). The Medicaid and CHIP Payment and Access Commission, a non-partisan federal legislative agency, has observed that 29 offers of personal care service levels from multiple MLTCs, and that these MLTCs may provide different initial determinations, does not preclude finding that Bellin plausibly alleged beneficiaries have a constitutionally protected property interest in the initial determination of the care hours they will receive. B. Constitutionally Adequate Protections The State argues that, even if Bellin has a constitutionally protected interest in the amount of personal care services she receives, New York’s procedures for reviewing MLTCs’ initial offers of such hours “are constitutionally adequate.” State Br. 55; see Furlong, 156 F.3d at 395 (“The issue of what constitutes a substantive property interest is analytically distinct from the issue of what procedures must be followed if such interest is to be taken away.”). In keeping with our general practice, however, we decline to reach this question as it was not addressed by the district court. See Booking v. Gen. Star Mgmt. Co., 254 F.3d 414, 418-19 (2d Cir. 2001) (explaining that, although it has “broad discretion” to address such questions, the Court generally does not reach questions not addressed by district court). The State contends that it raised the constitutional adequacy of process argument in his motion to dismiss to preserve it for our consideration on appeal. We leave it to the district court to decide whether on remand, before discovery proceeds, the State (or RiverSpring) may challenge the adequacy of Bellin’s allegations regarding the inadequacy of current procedural protections. “[c]apitated plans may also seek to enroll as many healthy patients as possible and discourage participation of disabled or high utilizing enrollees.” MEDICAID & CHIP PAYMENT & ACCESS COMM’N, Managed care’s effect on outcomes, https://www.macpac.gov/subtopic/managed-careseffect-on-outcomes/ (last visited July 10, 2021). We do not mean to suggest that this is how RiverSpring or any other MLTC in New York operates in practice—only that one cannot safely infer beneficiary “choice” and “competition” as would be relevant here from the fact that beneficiaries may seek service offers from multiple MLTCs. 30