Opinion ID: 6497990
Heading Depth: 3
Heading Rank: 4

Heading: Alternative Remedial Scheme

Text: Since section 1396u‐2(f) satisfies the three Blessing factors, the right to prompt payment is presumptively enforceable un‐ der section 1983. Talevski, 6 F.4th at 720. HFS can rebut this presumption by “showing that Congress specifically fore‐ closed a remedy under § 1983 … expressly, through specific evidence from the statute itself, or impliedly, by creating a comprehensive enforcement scheme that is incompatible with individual enforcement under § 1983[.]” Id. (alteration and omission in original), quoting Gonzaga, 536 U.S. at 284 n.4. HFS has not identified any express language in the Medicaid Act foreclosing private rights enforcement. HFS relies instead on the implicit approach, which is a “diﬃcult showing.” Bless‐ ing, 520 U.S. at 346. If the MCOs are failing to abide by the contractual terms, says HFS, Saint Anthony should just enforce its own contracts No. 21‐2325 35 with them. And providers like Saint Anthony are “in the best position” to “enforce their right to timely payment directly under their contracts with MCOs.” Appellee’s Br. at 29. As HFS sees the matter, there is no need to permit section 1983 actions to “achieve Congress’s goal of enabling Medicaid pro‐ viders to receive timely payment.” Id. A contractual remedy may oﬀer some prospect of relief to a provider like Saint Anthony. But HFS has not convinced us that “allowing [section 1983] actions to go forward in these circumstances ‘would be inconsistent with’” a “carefully tai‐ lored [Congressional] scheme.’” Blessing, 520 U.S at 346, quot‐ ing Golden State Transit Corp. v. City of Los Angeles, 493 U.S. 103, 107 (1989). Rather, Congress intended the State’s Medi‐ caid plan to ensure timely payment to providers. If, as Saint Anthony alleges, the plan has been failing to meet this re‐ quirement, repeatedly and systematically, we would not be surprised if provider‐MCO arbitrations would do little to cor‐ rect that problem on a systemic basis. There is good reason to doubt that contractual remedies alone can vindicate the provider’s right to prompt payment. Saint Anthony files many thousands of Medicaid claims each year. If most claims are not paid on time, Saint Anthony’s op‐ tion under the contract is to sue the MCO and/or to submit each claim for arbitration. Many other Medicaid providers across Illinois might need to do the same with each of the seven MCOs. That avenue represents a claim‐by‐claim adju‐ dication on the individual provider‐MCO level, across many thousands of claims, all in their own arbitrations. It’s not im‐ mediately obvious that this dispute‐resolution system would even be manageable, let alone superior to a systemic solution implemented by HFS. At the very least, we are not persuaded 36 No. 21‐2325 that Congress, implicitly through the contractual model, cre‐ ated “a comprehensive enforcement scheme that is incompat‐ ible with individual enforcement under [section 1983].” Gon‐ zaga, 536 U.S. at 285 n.4. For these reasons, we conclude that section 1396u‐2(f) sat‐ isfies Blessing and contains a right to timely payment that is enforceable under section 1983. Saint Anthony has plausibly alleged a violation of such a right that would support a claim for relief. We therefore reverse the district court’s dismissal of this claim. We emphasize that this decision is based on the pleadings. This is a hard case with high stakes for the State, Medicaid providers, and Medicaid beneficiaries. We also recognize the potential magnitude of the case and the challenges it may pre‐ sent to the district court. If it turns out that resolving this dis‐ pute would actually require the district court to analyze each late claim, eﬀectively taking on the role of the State’s Medi‐ caid claims processors, or that eﬀective relief could come only by canceling a contract with an MCO, then we may face a dif‐ ferent situation. But we do not know at this point what direc‐ tion the course of this litigation will take. HFS has not con‐ vinced us that we must decide whether Saint Anthony has al‐ leged a viable claim today by assuming only the worst‐case scenarios will emerge down the line. If Saint Anthony can support its factual allegations about systematically late and inadequate payments, we believe the district court could ex‐ ercise its equitable discretion to fashion eﬀective relief. The corrective action plan that HFS demanded from CountyCare may provide a starting point, adaptable to the circumstances of diﬀerent MCOs. No. 21‐2325 37