salazar v. district of columbia
954 F. Supp. 278 (D.D.C. 1996)
Salazar v. District of Columbia was filed in 1993 by a class of Medicaid beneficiaries against Defendants the District of Columbia, the Mayor, and the Director of the Department of Human Services, to enforce Title XIX of the Social Security Act, 42 U.S.C. 1396, et seq., and accompanying regulations 42 C.F.R. 430, et seq., regarding the District’s Medicaid program. Plaintiffs alleged that the District was depriving them of their statutory and constitutional rights by failing, among other things, to (1) issue decisions and provide Medicaid coverage within 45 days after initial applications were submitted, (2) provide advance notice of termination, discontinuance or suspension of Medicaid benefits and an opportunity for a hearing to contest adverse action at the time of recertification for Medicaid, (3) provide or arrange for the provision of the comprehensive child health benefit known as early and periodic screening, diagnostic, and treatment (EPSDT) services to children who request those services under the Medicaid program and to notify parents about the EPSDT benefit for their children in accordance with federal law.
After a seven-day trial, the Court held that the District had “denied Plaintiffs’ rights under both federal and District of Columbia law, and, in some instances, under the Constitution” regarding these claims. Salazar, et al. v. District of Columbia, 954 F. Supp. 278, 324 (D.D.C. 1996). In 1999, while the District’s appeal was pending, the Court entered an Order based on a settlement between the parties. The Settlement Order has been modified several times between 1999 and 2017 and is still in force.
The Settlement Order contains various sections enjoining the District to take actions to remedy its violations of the Medicaid statute. Over time, some sections of the Settlement Order were terminated by the Court. Section II, related to 45-day application processing, remained in force until February 2009, when the Court granted a consent motion to vacate it based on compliance with the performance standard. The Section III provisions related to recertification processing remained in force until October 17, 2013, when the Court granted Defendants’ motion to terminate the recertification provisions of the Settlement Order based on the passage of the Affordable Care Act.
Today, Sections V and VI of the Settlement Order remain in force and enjoin the District to provide EPSDT services to children up to age 21 on request and to take specific actions to improve the provision of EPSDT services and notice to parents about of the availability of these services. The EPSDT services program is a comprehensive child health benefit for children from birth to age 21. EPSDT services include preventive care such as annual well-child visits, blood lead testing, dental services, hearing and vision screens, as well as necessary corrective treatment such as visits to a specialist, physical therapy, and speech-language therapy. There are several ancillary orders entered by the Court to enforce the EPSDT provisions because the District failed to comply with the Settlement Order. These relate to the provision of blood lead testing and dental services to children.
The substantive actions required of the District include, for example, ensuring that the delivery of medical care to each child enrolled with a managed care plan is tracked, that children receive notice in advance of appointments or if an appointment is missed, that Medicaid providers are trained about the EPSDT benefit, that case management is provided to children whose health condition requires those services, and that parents and custodians receive notice about the EPSDT benefit for their children.
One of the primary obligations under the Settlement Order requires that the District’s managed care plans (MCPs), which provide care to the vast majority of the Plaintiff class, achieve a participant ratio of 80%. The participant ratio is a metric reported by states to the federal government each year that tracks the extent to which Medicaid eligible persons up to age 21 are receiving any initial and periodic screening services during the year. Under the Settlement Order, the District must ensure that the MCPs develop a Corrective Action Plan if they are unable to meet a participant ratio of at least 80% and pay penalties if such a rate falls below 75%, so that the District can meet its District-wide performance standard of a 75% participant ratio. In the last ten years, the District has failed to reach a 75% participant ratio, ranging from 66% in 2017 to a low of 50% in 2020 and 2023. Since 2020, the District’s participant ratio has stayed at around 50%, meaning that approximately half of all Medicaid eligible children are not receiving even a single well-child visit in the fiscal year, as reported by the District to the Centers of Medicare & Medicaid Services (CMS) in it is annual CMS Form 416 report.
Under the Settlement Order, the lawyers for the Salazar Plaintiff class can provide free legal help to people whose Medicaid problems fall within the lawsuit. Some common problems that the Plaintiffs’ lawyers can help with are: recertification problems, getting reimbursed for out-of-pocket expenses that should have been covered by Medicaid, and advocating with the District or a managed care plan (like HSCSN, AmeriHealth, Amerigroup, or Medstar) to provide medical and/or behavioral health services for a child that a doctor or other medical provider has prescribed but that is not being provided or has been reduced, denied or terminated.
For more information, or to obtain free advice and/or free legal help, contact counsel for the Plaintiff class, Terris, Pravlik & Millian, LLP, (202) 682-0578.