United States District Court, District of Columbia
GLADYS KESSLER, District Judge.
On September 2, 2014, Plaintiffs filed a Motion to Reverse the Ruling in the Fair Hearing of Class Member Stevenson Denying Reimbursement of Personal Care Aide Services [Dkt. No. 2007]; the District of Columbia ("the District, " "the Government" or "Defendant") filed its Opposition on October 20, 2014 [Dkt. No. 2019]; and Plaintiffs filed their Reply on November 14, 2014 [Dkt. No. 2023]. Plaintiffs seek reversal of a decision ("OAH Opinion") by an Administrative Law Judge ("ALJ") of the District of Columbia Office of Administrative Hearings ("OAH") granting in part and denying in part Magnolia Stevenson's request for reimbursement of certain medical expenses. Final Order on Cross-Motions for Summary Adjudication ("OAH Opinion"), Pis.' Ex. A [Dkt. No. 2007-1]. For the reasons that follow, Plaintiffs' Motion shall be denied.
A. Historical Background
1. The Salazar Class
On March 3, 1993, Plaintiffs filed their class-action Complaint [Dkt. No. 1] on behalf of several named plaintiffs and other similarly situated individuals alleging violations of federal law in the course of the District's administration of its Medicaid program. On June 18, 1993, Plaintiffs filed their Amended Complaint [Dkt. No. 27].
Over the long life of this case, the Plaintiff class has always been described as a collection of several sub-classes, with each sub-class consisting of Medicaid applicants and recipients with a particular set of claims. Plaintiff's Amended Complaint; Amended Memorandum-Order of October 6, 1994 [Dkt. No. 92]; Order of November 3, 1994 [Dkt. No. 100]. Plaintiffs' Amended Complaint stated that "Plaintiffs' class consists of:
All persons who, now or in the future will reside in the District of Columbia who have applied for or who have attempted to apply for Medicaid and who have experienced one or more of the following conditions: (a) a delay in excess of 45 days in processing their initial Medicaid application or application to recertify Medicaid coverage; (b) as newborns of mothers eligible for Medicaid at the time of their birth, the lack of immediate Medicaid coverage using their mothers' Medicaid number; (c) the inability to apply for Medicaid at disproportionate share hospitals and federally-qualified health centers; (d) the inability to submit their completed Medicaid applications to the District of Columbia Department of Human Services; (e) after being found eligible, the lack of advance notice of the discontinuance, suspension or obligation to recertify their Medicaid benefits; (f) after being found eligible, the lack of effective notice of the availability of early and periodic screening, diagnostic and treatment services for children under 21 years of age; (g) after being found eligible, the lack of EPSDT services for children under 21 years of age.
Amended Complaint at ¶ 76.
In the Amended Memorandum-Order of October 6, 1994, which granted Plaintiff's Motion for Class Certification, the Court noted that "for analytical clarity the class should be certified as five separate sub-classes rather than as one comprehensive class [.]" Amended Memorandum-Order at 6. All class members must fit into one or more of the five sub-classes, which "correspond to the causes of action in Plaintiffs' Complaint." Id. at 6 n.2.
On November 1, 1994, the Parties filed a Joint Motion to Amend the Class Definition [Dkt. No. 98]. On November 3, 1994, the Court issued an Order [Dkt. No. 100] granting the Parties' Joint Motion. This Order did not substantively alter the types of claims that would suffice for inclusion in the Plaintiff class. Rather, the Order served to clarify the previous definition and to reemphasize the relationship between individuals' claims and class membership. The Order defined the class as follows:
All persons who have applied, have attempted to apply, or will apply in the future during the pendency of this litigation, for medical assistance pursuant to Title 19 of the Social Security Act ("Medicaid"), and all persons who have received, are receiving, or will receive in the future during the pendency of this litigation, Medicaid in the District of Columbia with respect to the following claims:
Any claims for declaratory, injunctive, or other relief premised on the alleged lack of immediate Medicaid coverage for newborns using the Medicaid number of their mothers, who are eligible for Medicaid at the time of the babies' birth [Sub-Class I]
Any claims for declaratory, injunctive, or other relief premised on an alleged inability to apply for Medicaid at disproportionate share hospitals and federally-qualified health centers [Sub-class II]
Any claims for declaratory, injunctive, or other relief premised on an alleged delay in excess of 45 days in the processing of Medicaid applications [Sub-class III]
Any claims for declaratory, injunctive, or other relief premised on an alleged lack of advance notice of the discontinuance, suspension or obligation to recertify Medicaid benefits, after being found eligible [Sub-class IV]
Any claims for declaratory, injunctive, or other relief premised on an alleged lack of effective notice of the availability of early and periodic screening, diagnostic and treatment ("EPSDT") services for children under 21 years of age, and/or an alleged lack of EPSDT services for eligible children under 21 years of age [Sub-class V].
Id. at 1-2. Thus, in order to be a member of the Plaintiff class an individual must meet the criteria of the preamble paragraph above (i.e., be a present, past, or future, Medicaid applicant or recipient) and have claims that fall into one of the five sub class categories.
2. Injunctive Relief
After years of litigation and some successful negotiation by the Parties, on October 16, 1996, this Court issued an Opinion setting forth extensive findings of fact and conclusions of law. See Salazar v. Dist. of Columbia, 954 F.Supp. 278 (D.D.C. 1996). "In particular, the Court ruled that Defendants had failed to process Medicaid applications for non-disabled, non-foster care [non-public assistance] applicants within 45 days, had terminated or suspended eligible persons' benefits without adequate notice, had failed to provide EPSDT services to eligible families, and had failed to notify those eligible families about the availability of such services." Memorandum Opinion of December 28, 1998 at 2 [Dkt. No. 653] (summarizing findings detailed in Salazar, 954 F.Supp. 278).
Of particular relevance here, the Court found that the District's failure "to process large numbers of Medicaid applications within 45 days of receipt" and inaccurate eligibility determinations caused many Medicaid applicants and beneficiaries to incur out-of-pocket costs for services that should have been covered by Medicaid. Salazar, 954 F.Supp. at 289-302. The Court also found that the District maintained an "unofficial, unwritten practice" of reimbursing Medicaid beneficiaries by "advising the participating provider [e.g., hospital, doctor, or other medical service provider] to reimburse the recipient for any out-of-pocket medical expenditures and thereafter to submit a routine claim for the same expenditures to [the District]." Id. at 323. "Medicaid recipients [were] not notified about the unofficial policy[.]" Id.
In order to redress the harm caused by the District's practices, on September 15, 1997, the Court issued a Reimbursement Procedures Order that established "reimbursement procedures for class members who incurred out-of-pocket expenses because of untimely or inaccurate eligibility determinations made by Defendants." Reimbursement Procedures Order of Sept. 15, 1997 at 1 [Dkt. No. 550]. The Order incorporated a document titled "Summary Notice of Reimbursement Procedures for Class Members' Out-of-Pocket Expenses [, ]" which contained the detailed procedures for obtaining reimbursement of out-of-pocket expenses. Id. Att. A.
Pursuant to the Reimbursement Procedures, "[a]ll class members have the right to be repaid any money they spent from March 2, 1990, to the present, on drug prescriptions, doctor visits, or hospitalizations at a time that they were eligible for Medicaid and the three (3) months prior to their Medicaid application." Id. Att. A at 2. In order to begin the reimbursement process, "[c]lass members are to submit the Medicaid Reimbursement Form' with supporting documents to" the District. Id. The Procedures give class members notice of their "right to a fair hearing" in the event they are unsatisfied with the District's resolution of their claims. Id. at 3. Finally, the Procedures state that if ...