under Fourteenth Amendment when state agency terminates Medicaid benefits).
Over the past several years, IMA has repeatedly failed to give non-foster care NPA Medicaid recipients "timely and adequate" notice before terminating or suspending their Medicaid eligibility, and to "furnish Medicaid regularly" to eligible Medicaid recipients. Defendants' own MEO reports again provide the strongest evidence, and reveal that for many months during the period from January 1992 to February 1996, the Multinational Section allowed many Medicaid recipients' benefits to lapse by failing to process recertifications submitted by recipients whose eligibility was due to expire that month. In November 1993, for example, IMA failed to process 69, or 69.7%, of the 99 recertification forms submitted by recipients whose eligibility would expire at the end of that month. During the far more recent 12-month period from March 1995 through February 1996, IMA failed to process an average of 37 per month, or 25%, of the recertification forms pending for recipients whose eligibility would expire at the end of the month. Therefore, substantial numbers of Medicaid recipients in the Multinational Section have suffered, and continue to suffer, lapses or terminations in benefits. These lapses or terminations violate 42 C.F.R. § 435.930(b), which requires Defendants to "continue to furnish Medicaid regularly to all eligible individuals until they are found to be ineligible."
Many of the lapses or terminations also violate 42 C.F.R. § 435.919 and the Due Process Clause of the Fifth Amendment, because they are not preceded by any form of notice whatsoever. When IMA fails to process recipients' recertification forms before the end of their eligibility periods, the only recipients who are notified of an impending lapse or termination of benefits are those recipients who did not submit their recertification forms until 30 or fewer days remained in their eligibility periods. These recipients, as discussed in Findings 36 and 43, receive the ACEDS 30-day termination notice. See, e.g., Pls.' Ex. 113. Neither party produced evidence on the number or percentage of Medicaid recipients who fall into this category; thus, it is difficult to determine what percentage of Medicaid recipients suffered deprivations under § 435.919 and the Due Process Clause. However, recipients in this category still suffer a deprivation of their right, under federal law, to receive Medicaid until they are specifically found ineligible. See 42 C.F.R. § 435.930(b) (1995). Thus, considering the most recent one-year period for which Defendants' MEO reports are available, the monthly average of NPA-Multinational Medicaid recipients who suffered illegal lapses in benefits was still 37, or 25%.
Plaintiffs' statistical sample, again, corroborates Defendants' own MEO reports by demonstrating that IMA frequently terminates Medicaid benefits or allows them to lapse either without providing adequate notice or without specifically finding those recipients ineligible for Medicaid. Defendants concede that in about 34.4% of the non-disability NPA-Nonmultinational cases, 47.2% of the NPA-Multinational cases, and 26.4% of the disability NPA cases, IMA unlawfully terminated or allowed Medicaid eligibility to lapse. Thus, depending on the category of Medicaid recipients, disabled, sick, and poor children and adults are illegally losing their Medicaid benefits 25% to almost 50% of the time.
Individual class members testified to the adverse consequences caused by IMA's unlawful terminations of benefits. For example, in January 1996, two-year old Maria Lopez, who has a heart defect, experienced a delay of approximately one month in receiving a necessary catheter procedure. This was because IMA failed to process Maria's recertification form before December 31, 1995, the end of Maria's Medicaid eligibility period, even though her mother had submitted the recertification form in October 1995.
Defendants have also suspended eligibility for countless Medicaid recipients in all categories, including AFDC, SSI, and NPA, without notice, by failing to correct persistent, longstanding problems with EVS. As discussed extensively in Findings No. 71-94, EVS frequently provides incorrect information about patients' Medicaid eligibility.
Many patients whom EVS incorrectly categorizes as non-eligible are then unable to obtain necessary prescriptions and medical services.
As Findings No. 83-86 clearly show, Defendants have been keenly aware of EVS' unreliability since as early as February 1993. In April 1996, shortly before trial in this case, Defendants hired computer consultants to provide short-term solutions to some of the problems. However, Defendants have yet to take any concrete steps, such as the most basic one of issuing an RFP, toward replacing the EVS system or permanently remedying its persistent defects.
Furthermore, for at least the past several years, Defendants have been well aware of IMA's failures in processing recertifications for all Medicaid recipients whose eligibility was scheduled to expire. Defendants' own MEO reports clearly recorded these failures from as early as 1992 to the current year, 1996.
Based on Findings No. 35-94, the Court concludes that Defendants have been and continue to be depriving non-foster care NPA Medicaid recipients (including NPA-disability recipients) of their rights under the Due Process Clause of the Fifth Amendment, 42 C.F.R. §§ 431.210, 431.211, 435.919, and 435.930(b), in violation of 42 U.S.C. § 1983, and D.C. Code Ann. § 3-205.55(a).
C. Claim 6: Failure to Provide EPSDT Services
As described above, the District must provide or arrange for the following EPSDT services to persons under age 21 who are Medicaid-eligible and who request such services: (1) screening services, including comprehensive health and developmental histories, comprehensive unclothed physical examinations, appropriate immunizations, laboratory tests (including appropriate lead blood level assessments), and health education; (2) vision services, including diagnosis and treatment for vision defects; (3) dental services, including "relief of pain and infections, restoration of teeth, and maintenance of dental health"; (4) hearing services, including diagnosis and treatment for defects in hearing; and (5) "such other necessary health care . . . to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered by the State plan." 42 U.S.C. §§ 1396d(r)(1)(B) and 1396a(43)(B) (1996). These screening services must be provided at "intervals which meet reasonable standards of medical and dental practice." Id. § 1396d(r)(1)(A)(i).
Under § 441.56(b) of Title 42 of the Code of Federal Regulations, the District is also required to provide, to eligible EPSDT recipients who request it, appropriate vision and hearing testing, and "dental screening . . . furnished by a direct referral to a dentist for children beginning at 3 years of age." 42 C.F.R. § 441.56(b)(1)(iii) - (iv) (1996).
The District must provide to eligible EPSDT recipients any diagnostic and treatment services included in its state plan, as well as diagnosis and treatment of vision and hearing defects, dental care, and appropriate immunizations, even if these services are not included in the state plan. Id. § 441.56(c). Furthermore, the District must provide to EPSDT-eligible children any service which states are permitted to cover under Medicaid and which is necessary to treat or ameliorate a defect, physical and mental illness, or a condition identified by a screen, regardless of whether that service is otherwise included in its state plan. HCFA State Medicaid Manual, § 5310 (August 3, 1995), at 6257 (Pls.' Ex. 232).
The HCFA State Medicaid Manual describes the District's "Program Monitoring, Planning and Evaluation" obligations as follows:
Assure that a participating child is periodically screened and treated in conformity with the [state periodicity] schedule and State set timeliness standards. To comply with this requirement, design and employ policies and methods to assure that children receive rescreening and treatment when due. If the family requests assistance with necessary transportation and scheduling to receive Medicaid services, provide it.
Set standards for the timely provision of screening and treatment services which meet reasonable standards of medical and dental practice, as determined after consultation with recognized medical and dental organizations involved in child health care.