Opinion ID: 200155
Heading Depth: 2
Heading Rank: 1

Heading: Reasonable Promptness

Text: The statute, 42 U.S.C. § 1396a(a)(8), requires that medical assistance . . . shall be furnished with reasonable promptness to all eligible individuals. The plaintiffs contend that New Hampshire's operation of the ABD waiver program violates § 1396a(a)(8) by failing to furnish the waiver services with reasonable promptness. They seek to enforce this provision through 42 U.S.C. § 1983. The plaintiffs make alternative arguments for why they believe that New Hampshire has failed to meet its duties under § 1396a(a)(8).
Plaintiffs first argue that New Hampshire is required by statute to request a waiver to accommodate at least 200 individuals. They rely on statutory language governing waiver programs, which states: (c) Waiver respecting medical assistance requirement in State plan: scope, etc.; habilitation services defined; imposition of certain regulatory limits prohibited; computation of expenditures for certain disabled patients; coordinated services; substitution of participants . . . (10) The Secretary shall not limit to fewer than 200 the number of individuals in the State who may receive home and community-based services under a waiver under this subsection. -10- § 1396n(c)(10). Plaintiffs interpret this statute to require that states requesting waivers design plans that accommodate at least 200 individuals, arguing that is the plain meaning of the statute itself and the thrust of the surrounding legislative history. The core statutory argument is that because the waiver programs must receive the Secretary's approval, this 200-person minimum should be read as a limit on both the state applying for the waiver as well as on the Secretary. Plaintiffs argue that the states are restricted from offering less than 200 slots and the Secretary is restricted from approving less than 200 slots.
We turn first to the language of the statute itself. If a statute is unambiguous, we use neither legislative history,4 Dep't 4 At times, though, we use legislative history as a check to confirm the correctness of our interpretation in very complex areas of regulation. Cablevision of Boston, Inc. v. Pub. Improvement Comm'n, 184 F.3d 88, 101 (1st Cir. 1999) ([A] court should go beyond the literal language of a statute if reliance on that language would defeat the plain purpose of the statute . . . .). Even were we to rely on the legislative history of § 1396n(c)(10), as plaintiffs request, it would not require the conclusion that § 1396n(c)(10) was meant to mandate that waiver plans serve at least 200 individuals. Paragraph 1396n(c)(10), as originally written, stated that [n]o waiver under this subsection shall limit by an amount less than 200 the number of individuals who may receive home and community-based services. Omnibus Budget Reconciliation Act of 1987, Pub. L. No. 100-203, § 4118(b), 101 Stat. 1330-1, 1330-155. The paragraph was amended to the current language the next year. See Medicare Catastrophic Coverage Act of 1988, Pub. L. No. 100360, § 411(k)(10)(A), 102 Stat. 683, 794. The plaintiffs have submitted no legislative history with regard to this change, and there appears to be little discussion in the relevant committee reports. See H.R. Rep. No. 100-105(I) (1987), reprinted in 1988 -11- of Hous. & Urban Dev. v. Rucker, 122 S. Ct. 1230, 1234 (2002), nor administrative agency interpretation, Chevron, 467 U.S. at 842-43. Neither the language nor the structure of § 1396n(c)(10) supports plaintiffs' reading; the statute does not require applications for state waiver programs to serve at least 200 individuals. The language of the paragraph, by its very terms, governs only the Secretary's ability to deny approval of waiver plans. See § 1396n(c)(10) (The Secretary shall not limit . . . .). The statute does not purport to govern the behavior of the states or the contents of the waiver plans themselves. Moreover, the paragraph does not, by its terms, prevent the Secretary from approving plans unless there are a certain number of slots. It only governs the Secretary's actions when she or he is acting to limit the content of waiver plans as to the number of individuals to be served. Comparing the language of § 1396n(c)(10) to the remainder of § 1396n(c), which governs waiver services, makes this reading U.S.C.C.A.N. 803; H.R. Rep. No. 100-105(II) (1987), reprinted in 1988 U.S.C.C.A.N. 857; H.R. Conf. Rep. No. 100-661, at 269 (1988), reprinted in 1988 U.S.C.C.A.N. 923, 1047. The only legislative history the plaintiffs cite, that of the 1987 statute, see H.R. Conf. Rep. No. 100-495, at 760 (1987), reprinted in 1987 U.S.C.C.A.N. 2313-1245, 2313-1506, is inapposite. All we are left with is the simple fact that Congress altered the language of paragraph 10 by striking language that supported the plaintiffs' contentions. Even were we to construe the legislative history, then, we would find that if it has any effect at all, it is to bolster the interpretation that the statute in its current form governs only the actions of the Secretary. -12- even more compelling. Some provisions of subsection (c) directly govern the content of the waiver plans; these clearly state their purpose in limiting the content of the plans directly. See id. § 1396n(c)(2) (A waiver may not be granted under this subsection unless . . . .). By contrast, § 1396n(c)(10) does not contain such language limiting the content of the plans themselves. Other provisions of subsection (c), like (c)(10), operate to prevent the Secretary from unduly restraining the state plans.5 For instance, the Secretary may not restrict the number of hours or days of respite care provided under a waiver plan, id. § 1396n(c)(4), nor may he require that the waiver plan spend no more money than the approved estimates as a condition of waiver approval, id. § 1396n(c)(6). These provisions merely prevent the Secretary from imposing conditions onto the waiver plans. Similarly, § 1396n(c)(10) restricts the Secretary's ability to limit the size and funding of waiver plans. Read together, these provisions, like paragraph 10, ensure that the states will be able to receive funding for waiver plans up to a certain size and free from restrictions on how much care is provided to each individual. They do not dictate to the states the content of their waiver applications. 5 This is also consistent with the language of § 1396n(c), the title of which includes such subjects as imposition of certain regulatory limits prohibited, obviously a reference to paragraph 10. -13- Finally, it is evident that § 1396n(c) contemplates state waiver plans with definite limits on the number of individuals served. Paragraph 9 permits state plans to replace individuals who die or become ineligible with other individuals [i]n the case of any waiver under this subsection which contains a limit on the number of individuals who shall receive home or community-based services. Id. § 1396n(c)(9). State plans, then, certainly have the right to include a limit on the number of waiver slots they request.6 This statute, § 1396n(c)(10), is most plausibly read as limiting only the ability of the Secretary to impose such restrictions, and not the ability of the states to propose or the Secretary to approve waiver plans serving fewer than 200 individuals.
Even if there were doubt as to the plain meaning of § 1396n(c)(10) on its face, the administrative interpretation of HHS does not support the plaintiffs' position. If Congress has not spoken on the precise question at issue, we respect the statutory 6 Our reading is also most consistent with another paragraph of subsection (c), which plainly permits states to set limits on the number of individuals served. Section 1396n(c)(4)(A) permits waiver plans to limit the individuals served to those for whom the state has determined that the amount of medical assistance under the waiver will not exceed the amount that would be provided if the waiver did not apply. This paragraph does not reference § 1396n(c)(10), nor does it restrict a state's ability to limit the number of individuals served by waiver plans. -14- interpretation of the federal administrative agency given that interpretative task, unless the interpretation is unreasonable. Chevron, 467 U.S. at 842-44. Congress has authorized HHS to interpret the statutes in question and implement regulations in this area. 42 U.S.C. § 1302. HHS has interpreted § 1396n(c)(10) through a regulation governing model waivers, which decrees that the number of individuals served under a model waiver program may not exceed 200 recipients. 42 C.F.R. § 441.305(b). It is possible to read the regulation, which permits no more than 200 recipients under a model waiver program, and § 1396n(c)(10), which plaintiffs urge permits no fewer than 200 under any waiver program, to result in a scheme in which all model programs must serve exactly 200 individuals. Nonetheless, that is not the most likely reading. The regulation's use of the term exceed indicates that HHS contemplates model waiver programs that serve fewer than 200 individuals. This conclusion is bolstered by the comments accompanying the announcement of the final rule. HHS concluded that while § 1396n(c)(10) could, arguably, be read to limit the actual number of individuals who may receive model waiver services to no less than 200, . . . we believe that this reading is unsupportable. Medicaid Program; Home and Community-Based Services and Respiratory Care for Ventilator-Dependant Individuals, 59 Fed. Reg. 37,702, 37,711 (July 25, 1994). -15- HHS's interpretation of this statute is certainly not unreasonable. HHS reads § 1396n(c)(10) as allowing states to choose the size of their waiver programs, rather than requiring that the waiver programs be at least a certain size. This interpretation is consistent with the agency's longstanding interpretation of the waiver program. See Medicaid Program; Home and Community-Based Services, 50 Fed. Reg. 10,013, 10,021 (Mar. 13, 1985) (stating that HHS believes that Congress intended to give the States maximum flexibility in operating their waiver programs). The policy reasons are obvious: states, and particularly small states, may be discouraged from applying for model waiver programs at all if the choices are a program serving 200 individuals at the partial expense of the state, or not creating a model program at all and providing only the standard Medicaid services. Rather, Congress wished to encourage the states to pursue waiver programs, so that the states would create the types of model programs contemplated. Sympathetic as these plaintiffs are, the long-term logic of their argument may lead to the constriction, not the expansion, of these types of alternative programs. In sum, even were we to find this statute ambiguous, the interpretation offered by HHS is reasonable, given the structure and language of the statute. The Secretary has also interpreted this statute in a different context. He has approved waiver plans that anticipate -16- serving fewer than 200 individuals, such as the plan at issue here. Because the approval process did not utilize formal procedures, it may not be entitled to Chevron deference, see Christensen v. Harris County, 529 U.S. 576, 587 (2000), but there remains the deference owed agencies due to their specialized experience. Skidmore v. Swift & Co., 323 U.S. 134, 139 (1944); see United States v. Mead Corp., 533 U.S. 218, 234-39 (2001) (applying Skidmore deference). The Secretary has interpreted the statute to permit waiver plans with fewer than 200 slots, and we defer to his expertise in the construction and purpose of the statute.
The district court rested its finding for the plaintiffs on the ground we have rejected: that the state waiver plan must serve at least 200 individuals. Bryson, No. 99-558-M, at 4. Plaintiffs have, however, asserted a separate and distinct argument alleging a violation of the reasonable promptness provision of § 1396a(a)(8). They argue that New Hampshire has failed to fill even the number of individual waiver slots it has requested, and so the plaintiff class members have not been furnished medical assistance with reasonable promptness. We first consider whether there is an actionable claim.
There is liability against persons who act under color of law to deprive individuals of any rights, privileges, or immunities -17- secured by the Constitution and laws of the United States under 42 U.S.C. § 1983. This provision creates a cause of action for federal statutory as well as constitutional rights, Maine v. Thiboutot, 448 U.S. 1, 4-8 (1980), including, in some circumstances, violations of the Medicaid Act, Wilder, 496 U.S. at 524. Not all violations of federal law result in a cause of action under § 1983. A plaintiff must assert the violation of a federal right, not merely the violation of federal law. Blessing v. Freestone, 520 U.S. 329, 340 (1997) (emphasis in original). Moreover, a federal right must be unambiguously conferred in order to support a cause of action under § 1983. Gonzaga Univ. v. Doe, 122 S. Ct. 2268, 2275 (2002). Blessing set out a three-part test for guidance in determining whether a statutory provision confers an enforceable federal right. First, Congress must have intended that the provision benefit the plaintiff. Second, the right must not be vague and amorphous. Third, the statute must unambiguously impose a binding obligation on the states. Blessing, 520 U.S. at 340-41. Ultimately, of course, this is an issue of congressional intent, and the three tests are just a guide. Gonzaga, 122 S. Ct. at 2279 (Breyer, J., concurring). The statute satisfies the three tests as to claims about unfilled waiver slots that are part of an approved state Medicaid plan. -18- First, the statute, on its face, does intend to benefit the plaintiffs. Section 1396a(a)(8) requires that state Medicaid plans provide that medical assistance shall be furnished with reasonable promptness to all eligible individuals. This paragraph is a part of the litany of procedural and substantive protections which state Medicaid plans must provide, such as the opportunity for a hearing, see § 1396a(a)(3), and safeguards against the disclosure of private information, see id. § 1396a(a)(7). By its terms, it benefits eligible individuals. Id. § 1396a(a)(8). Those patients who are on the waiting list and for whom slots are available7 are, we think, eligible under the statute such that they are entitled to reasonable promptness. See Boulet v. Celluci, 107 F. Supp. 2d 61, 77 (D. Mass. 2000) (The cap on waiver services is simply a constraint on eligibility.). The first prong of Blessing has been met. Second, the right conferred is not vague or amorphous. A statute is not impermissibly vague simply because it requires judicial inquiry into 'reasonableness.' Albiston v. Maine Comm'r of Human Servs., 7 F.3d 258, 267 (1st Cir. 1993) (construing the reasonable promptness provision of 42 U.S.C. § 602(a)(10)). 7 The parties advise us that it is not an easy matter to determine the patients on the waiting list for whom slots are available. It is not a matter, necessarily, of who is next on the list. The slots opening up may be in one geographic location; a particular patient may be in another. These are issues that can be considered on remand. -19- Common law courts have reviewed actions for reasonableness since time immemorial. See, e.g., 1 W. Blackstone, Commentaries  (analyzing the reasonableness of customs). Finally, § 1396a(a)(8) does unambiguously bind the states. The subsection mandates that state plans must provide that medical assistance shall be provided with reasonable promptness. These are not mere guidelines, but rather requirements which states must meet under the Medicaid system. One other circuit court has found that the reasonable promptness provision of § 1396a(a)(8) provides a cause of action under § 1983. See Doe v. Chiles, 136 F.3d 709, 719 (11th Cir. 1998); cf. Cospito v. Heckler, 742 F.2d 72, 81 n.14 (3rd Cir. 1984) (interpreting § 1396a(a)(8) in a procedural due process context and finding that eligible patients have a legitimate claim of entitlement to be able to avail themselves of Medicaid benefits). While this Court has never before addressed this precise question, we did uphold a § 1983 cause of action under the reasonable promptness provision of the Social Security Act. Albiston, 7 F.3d at 264 (finding that 42 U.S.C. § 602(a)(10) provides reasonably clear, judicially enforceable obligations directly on the participating States). The strictures of § 1396a(a)(8) should apply with no less force to opt-in plans such as the waiver program. Once the waiver plan is created and approved, it becomes part of the state plan and -20- therefore subject to federal law; the waiver plans must meet all requirements not expressly waived. See Doe, 136 F.3d at 714-15 (upholding a § 1983 cause of action under § 1396a(a)(8) as applied to an optional program). In sum, we find that there is a § 1983 cause of action arising from the reasonable promptness provision of 42 U.S.C. § 1396a(a)(8) under the state model waiver plan as approved.
It is not clear to us, though, whether there is a live controversy on this issue or, if so, what the dimensions of it are. No facts have been developed on this point. New Hampshire claims that there are no longer any unfilled waiver slots, while the plaintiffs believe that the issue may continue to be a live one. Even if there are currently unfilled waiver slots, we know nothing about the history of each waiver slot and the process and procedure of replacing individuals who held those slots. When an individual ceases to use the waiver plan services, there is necessarily a time gap while an individual on the waiting list is chosen to take the unfilled slot and while services are made available. Because of that lag in time, the fact that some slots are unfilled may be consistent with New Hampshire diligently filling the empty slots with reasonable promptness. It may also indicate that New Hampshire is not being reasonably prompt in its provision of medical assistance. -21- The parties have stipulated that absent extraordinary circumstances, ABD waiver services can be implemented within one year from the time that an individual is found to be eligible. More information is necessary in order to ascertain whether or not the guarantee of reasonable promptness has been satisfied. We remand this aspect of plaintiff's claim to the district court.