Opinion ID: 2818121
Heading Depth: 3
Heading Rank: 1

Heading: The named plaintiffs in this case are nine D.C.

Text: Medicaid recipients. They contend that the District, the Director of DHCF, and the Mayor of D.C. have systematically failed to provide Medicaid recipients with “adequate and timely notice, the opportunity for a fair hearing, and the opportunity for reinstated coverage pending a hearing decision” when denying prescription drug coverage. Pls.’ Amend. Compl. ¶ 1. Those actions, the plaintiffs allege, violate Title XIX and its implementing regulations, the Due Process Clause of the Fifth Amendment of the Constitution, and D.C. law. The plaintiffs seek no compensation (although they do ask for costs and attorneys’ fees). Id. at 49. Instead, they request declaratory and injunctive relief, and also seek certification of a class. The named plaintiffs allege multiple instances in which their claims for prescription drug coverage have been denied at District pharmacies. The denials, as described in the complaint, appear to have occurred for a variety of reasons. Some plaintiffs were informed that they failed to comply with applicable prior authorization requirements, see, e.g., id. ¶¶ 59, 77; others were advised that they were not covered by Medicaid at all, see, e.g., id. ¶ 50; and still others were given no reason for the coverage denial, see, e.g., id. ¶ 57. The plaintiffs allege that, in all of those circumstances, they did not “receive[] written notice of the fact that coverage of [their] prescriptions was being denied, the reason for the denial[s], the right to appeal, or the circumstances under which Medicaid would continue providing coverage of [their] prescriptions pending the appeal[s].” E.g., id. ¶ 98. 8 2. The plaintiffs filed suit in the U.S. District Court for the District of Columbia, and the district court dismissed the action for lack of Article III standing. NB v. District of Columbia (NB I), 800 F. Supp. 2d 51, 53 (D.D.C. 2011). On appeal, we found that the plaintiffs had established standing, NB II, 682 F.3d at 86-87, and remanded to the district court to proceed to the merits. On remand, the district court dismissed all claims. NB v. District of Columbia (NB III), 34 F. Supp. 3d 146, 152 (D.D.C. 2014). In dismissing the claims under Title XIX, the court initially examined circumstances involving denial of prescription drug coverage for failure to demonstrate Medicaid enrollment or to comply with applicable prior authorization requirements. The court concluded that Medicaid’s procedural protections—including the notice and hearing sought by the plaintiffs—extended only to those who were in fact enrolled in Medicaid and, as applicable, to those who had met required prior authorization and other applicable threshold criteria. Id. at 153-55. As for denials of coverage for other reasons, the court concluded that the plaintiffs had failed to allege that the denials stemmed from government action. In the court’s understanding, the plaintiffs’ inability to procure coverage for their medications was attributable, not to the District, but instead “to a range of acts or omissions by private actors—including errors or oversights by doctors and pharmacists (and perhaps the patients themselves).” Id. The court therefore concluded that the District had no obligation under Title XIX or its regulations to give any written notice of the denials. Id. at 155-56. In dismissing the due process claims, the court again focused initially on denials occasioned by the plaintiffs’ alleged failures to demonstrate Medicaid enrollment status or to comply with prior authorization or other coverage criteria. 9 Those circumstances triggered no protections under the Due Process Clause, the court determined, because the plaintiffs lacked a “legitimate claim of entitlement to the drugs.” Id. at 157-58. As for the denials of prescription drug claims for reasons other than failure to demonstrate Medicaid enrollment status or to comply with threshold coverage criteria, the court again determined that the plaintiffs failed to allege that any “state action” caused the denials. Id. at 158-59. With no federal causes of action remaining in the case, the court then dismissed the D.C.-law claims for lack of pendant jurisdiction. Id.