Docket of Medicaid cases to improve provider participation
National Health Law Program
February 23, 2003

To:     Health Advocates

From: Jane Perkins

Re:     Docket of Medicaid cases to improve provider participation

          This memo provides an annotated listing of Medicaid provider participation cases, by state. Most of these cases involve hospital, pharmacy and/or dental services. Cases have been filed by provider associations and by Medicaid beneficiaries. As noted in the NHeLP's, Update on Sovereign Immunity Defenses and Private Rights of Action in Medicaid Cases (Feb. 2003), providers are increasingly finding it difficult to enforce the Medicaid Act to improve their rates, in light of recent Supreme Court decisions. Medicaid beneficiaries, on the other hand, are for the most part, being allowed to proceed with their cases.

          As noted below, the complaints in these cases cite a number of Medicaid provisions. However, the following provisions are typically relied upon:

          •         42 U.S.C. § 1396a(a)(30)(A) (requiring payments to be consistent with efficiency, economy, quality of care and to assure equal access)

          •         42 U.S.C. §§ 1396a(a)(10)(A), a(a)(43), d(a)(4)(B), d(r) (requiring Early and Periodic Screening, Diagnosis and Treatment (EPSDT) for children under age 21)

          •         42 U.S.C. § 1396a(a)(8) (requiring reasonable promptness of medical assistance)

          NHeLP has various pleadings from these cases and can provide copies upon request. Please help us keep this docket up-to-date.

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Arizona

Ball v. Biedess, No. CIV 00-67 TUC ACM (D. Ariz. filed 2000)

This case concerns the chronic shortage of home health care workers for Medicaid beneficiaries. The claims asserted are § 1396a(a)(8) (reasonable promptness), § 1396a(a)(30)(A) (equal access), and 1396n(c) (free choice of institutional v. community provider). In May 2002, the court denied summary judgement, and the case is now being developed for trial.

Arkansas

Arkansas Medical Society v. Reynolds, 819 F. Supp. 816 (E.D. Ark. 1993), aff'd, 6 F.3d 519 (8^th Cir. 1993), same case, Arkansas Med. Soc'y v. Knickrehm, reprinted in Medicare & Medicaid Guide (CCH) ¶ 300,434 (E.D. Ark., Apr. 11, 2000)

Holding: The Medicaid agency violated 42 U.S.C. § 1396a(a)(30)(A), when it reduced reimbursement rates to providers of outpatient services. The Medicaid agency was ordered to revise its reimbursement plan within 120 days. The 2000 decision enjoined the mental health managed care program as violating § a(a)(30)(A) and the previous case decision.

California

Clark v. Kizer, 758 F. Supp. 572 (E.D. Cal. 1990), aff''d in part & vacated in part sub nom. Clark v. Coye, 967 F.2d 585 (9th Cir. 1992), on remand, No. S-87-1700LKK, 1992 WL 370801, reprinted in Medicare & Medicaid Guide (CCH) ¶ 40,888 (E.D. Cal. 1993), aff''d in part & remanded in part, 8 F.3d 26 (9th Cir. 1993), related references, 66 F.3d 334 (9^th Cir. 1995), vacating, 1994 WL 764117, reprinted in Medicaid & Medicaid Guide (CCH) ¶ 43,026 (E.D.Cal., Dec. 13, 1994) (regarding legislation affecting adult eligibility), 60 F.3d 600 (9^th Cir. 1995), rev'g, 1993 WL 720217, reprinted in Medicare & Medicaid Guide (CCH) ¶ 42,418 (E.D. Cal., Dec. 17, 1993), related reference, 1989 WL 265478, reprinted in Medicare & Medicaid Guide (CCH) ¶ 38, 460 (E.D. Cal., Nov. 3, 1989) (adequate availability of obstetrical care providers), 1988 WL 235548, reprinted in Medicare & Medicaid Guide (CCH) ¶ 37,126 (E.D.Cal., May 9, 1988)

Holdings: The Medicaid agency violated 42 U.S.C. § 1396a(a)(30)(A), when it maintained a dental reimbursement fee schedule that did not ensure that Medicaid beneficiaries have access to dental services at least to the extent that the general population has access to these services. The Clark court was persuaded by the fact that “the present rates are not even adequate to meet overhead, let alone allowing for some marginal profit.” Id. at 577. Other Medicaid provisions were also found to have been violated: § a(a)(1) (statewideness), § a(a)(10) (comparability), and § 1396d(a)(4)(B) (EPSDT). The Medicaid agency was ordered to increase rates to 80% of UCR for 56 commonly performed procedure codes and to provide annual cost of living adjustments.

More recent activity in the case has included an order requiring the Medicaid agency to submit a plan for increasing utilization in under-served counties. On March 24, 1997, the agency's plan was approved to increase utilization to at least 41.7% in 16 underserved counties.

When it was originally filed, the case also concerned obstetrical care access, an issue which settled early on when the state agreed to rate increases, administrative simplification, and beneficiary outreach.

Connecticut

Carr v. Wilson-Coker, Civ. No. CIVA3:00CV01050 (D. Conn.) (Filed, June 8, 2000), class cert. granted at: 203 F.R.D. 66 (D. Conn. 2001).

Connecticut beneficiaries filed this class action lawsuit, which alleges that the Connecticut Department of Social Services has not funded or administered the Medicaid dental program sufficient to attract an adequate number of dentists as required by federal law. EPSDT claims are included in the suit, and the plaintiffs allege that dental screening has shown decreasing utilization. The plaintiffs seek an order requiring the defendant to make needed dental services immediately and locally available to Connecticut Medicaid recipients by taking measures to increase reimbursement rates as necessary to recruit an adequate number and sufficient geographic distribution of qualified dental providers; to improve administration of the Medicaid dental program; to effectively inform children and families of EPSDT dental services and the benefits of preventive dental care; to provide dental screening, diagnostic and treatment to children; to provide services to enable children to access EPSDT dental services; and to otherwise bring the statewide dental program into compliance with applicable law. Class certification has been granted. The parties have engaged in settlement negotiations.

District of Columbia

Salazar v. District of Columbia, No. CA-93-452 (GK), (Jan. 25, 1999) (Consent Judgment; Order Modifying the Amended Remedial Order of May 6, 1997 and vacating the order of March 27, 1997); 1997 WL 306876, reprinted in Medicare & Medicaid Guide ¶ 45,189 (D.D.C., Jan. 17, 1997) (Remedial Order), earlier case history, 938 F. Supp. 926 (D.D.C.), amended and superceded by, 954 F. Supp. 278 (D.D.C. 1996), same case, Wellington v. District of Columbia, 851 F. Supp. 1 (D.D.C. 1994) (EPSDT provisions enforceable through section 1983)

Holding: The District of Columbia violated federal EPSDT laws when it failed to assure that children were receiving screening and treatment services, in either fee-for-service or managed care settings. The District was ordered to engage in extensive outreach and informing of Medicaid families regarding the scope of EPSDT services and to monitor managed care contracts to assure that contracted services actually are being delivered (with corrective action plans for problematic plans). See, e.g., 954 F. Supp. at 328 (to comply with federal periodic screening requirements, the state must “design and employ policies and methods to assure that children receive screening and treatment when due.”) Currently, Plaintiffs' counsel are monitoring enforcement of the order and meeting regularly with the District and the court regarding performance. Pending before the court is a motion to compel the District to improve dental provider participation.

Indiana

Bond v. Stanton, 630 F.2d 1231 (1980), appeal after remand, 655 F.2d 766 (7th Cir.), cert. denied, 454 U.S. 1063 (1981) (EPSDT screening, identification of providers, and follow up), same case, Stanton v. Bond, 372 F. Supp. 872 (N.D. Ind. 1974), aff''d, 504 F.2d 1246 (7th Cir.), cert. denied, 420 U.S. 984 (1975)

Holding: “Indiana's somewhat casual approach to EPSDT hardly conforms to the aggressive search for early detection of child health problems envisaged by congress.... It is utterly beyond belief to expect that children of needy parents will volunteer themselves or that their parents will voluntarily deliver them to the providers of health services for early medical screening and diagnosis.... EPSDT programs must be brought to the recipients; the recipients will not ordinarily go to the programs until it is too late to accomplish the congressional purpose.” 504 F.2d at 1251.

The state was required to provide guidance to providers as to what services are covered under EPSDT, to engage in aggressive outreach to inform beneficiaries of EPSDT, and to document compliance with federal mandates.

Kentucky

Greer. v. Childres, No. 95-CV-11 (E.D. Ky.) (Dismissal, March 1995)

This case was filed by the Kentucky Dental Association (KDA) in 1994, after the state Medicaid agency reduced dental reimbursement rates. The suit was dismissed after the state Medicaid agency raised rates.

Maine

Spencer v. Concannon, Civ. No. 97-197-B-C (D. Me.) (Order of Dismissal, Apr. 27, 1998)

The Medicaid beneficiaries' complaint in this case claimed violations of § 1396a(a)(30) (equal access), § 1396a(a)(1) (statewideness), § a(a)(8) (reasonable promptness in the provision of services), § a(a)(10)(B) (comparability in the provision of services), and §§ a(a)(43), d(a)(4)(B), and d(r) (EPSDT).

The case settled when the state Medicaid agency agreed to increase payment rates, engage in an educational campaign designed to increase dental provider participation, revise the dental claim form, provide toll-free telephone assistance to refer beneficiaries to participating providers, and collect data to monitor provider participation and beneficiary utilization of dental services. The state also agreed promptly to arrange for Medicaid dental services for the named plaintiffs, including entering into private pay arrangements.

Massachusetts

Health Care For All v. Reynolds, Civ. No. 00-CV-10833RWZ (D. Mass.) (Filed, Apr. 28, 2000)

The class action case, filed by Medicaid beneficiaries, alleges that the Division of Medicaid Assistance has failed to provide adequate oral heath services to members of the MassHealth Medicaid program. A number of Medicaid Act violations are alleged: 42 U.S.C. § 1396a(a)(1) (statewideness), § a(a)(8) (reasonable promptness in the provision of services), § a(a)(10)(B) (comparability in the provision of services), § a(a)(30) (payments consistent with efficiency, economy, quality of care, and sufficient to ensure access), § a(a)(43) (EPSDT). The plaintiffs seek an injunction requiring the Division, among other things, to increase reimbursement rates to dental care providers.

Michigan

Westside Mothers v. Haveman, 289 F.3d 852 (6^th Cir. 2002), rev'g in part and aff'g in part, 133 F. Supp. 2d 549 (E.D. Mich. 2001), cert. denied, 123 Sct. 618 (2002)

This case was filed by parents of children who are experiencing difficulties accessing EPSDT services for their children under age 21. The Michigan chapter of the American Academy of Pediatrics is also a plaintiff. The case includes claims based on § 1396a(a)(30)(A) (equal access), § a(a)(8) (reasonable promptness in the delivery of services), and § 1396u-2(b)(5) (adequate number, mix, and geographic distribution of managed care providers), in addition to the federal EPSDT provisions. A novel district court decision dismissing the case on sovereign immunity grounds was reversed by the Sixth Circuit Court of Appeals. The Supreme Court denied review, and the parties are now moving forward with the case.

New Hampshire

Hawkins v. Commissioner, Civ. No. C-99-143-JD (D.N.H.) (Filed 1999).

This class action case has been filed by a parent on behalf of her children, who have difficulty finding a dentist who will accept Medicaid. A number of Medicaid Act violations are alleged in the complaint, including: 42 U.S.C. § 1396a(a)(43) (inform beneficiaries of EPSDT benefits and how to obtain them), 42 C.F.R. § 441.62 (provide transportation and appointment scheduling assistance)), § 1396a(a)(43)(B) and 1396d(r) (provide or arrange for dental screening services and needed treatment, including case management and transportation services), § 1396a(a)(30)(A) (equal access), § 1396a(a)(1) (statewideness), and § 1396a(a)(8) (reasonable promptness in delivery of services). In an August 25, 2000 order, the Court ruled that the provisions listed above can be enforced. The class certification motion was denied without prejudice to refiling. The parties have been discussing settlement.

Swain v. Gregg, Civ. No. 90-91-D (D.N.H.) (Consent Decree, May 5, 1991)

The parties settled this dental access for children case when the state agreed, among other things, to increase dental reimbursement rates, to review the adequacy of rates annually and make needed adjustments, to update its periodicity schedule for dental screening under EPSDT, to use “pay and chase,” rather than “cost avoidance,” third party liability collection practices when dealing with EPSDT claims, and to engage in regular contact and meetings with the New Hampshire Dental Society to resolve problems early and encourage provider participation in Medicaid.

Note: The Hawkins complaint included an allegation that the state has been violating the Swain consent decree. However, this claim was dismissed because the Swain case had been closed by the court after a period of retained jurisdiction and the plaintiffs' state-based breach of contract claim (the consent decree was a contract) was barred by Eleventh Amendment sovereign immunity. (Order, Aug. 25, 2000).

New Jersey

Pelletier v. Waldman, No. ____ (D.N.J.) (Filed June 14, 1993)

The complaint in this case charged that the state was violating mandatory EPSDT provisions by failing to provide preventive dental services to children. Claims for relief included: 42 U.S.C. § 1396a(a)(1) (statewideness), § a(a)(8) (reasonable promptness in the provision of services), § a(a)(10)(B) (comparability in the provision of services), § 1396a(a)(23) (free choice of providers), § a(a)(30) (payments consistent with efficiency, economy, quality of care, and sufficient to ensure access), § a(a)(37) (prompt and efficient claims payment), and §§ a(a)(43), d(a)(4)(B), d(r) (EPSDT). The case was settled.

New York

Dental Society of the State of New York v. Pataki, Civ. No. 99-C-0156 (N.D.N.Y.) (Stipulation, May 24, 2000)

This class action case was filed by the New York State Dental Association, individual dentists, and Medicaid beneficiaries in February 1999. It charged the state Medicaid agency with failure to adhere to 42 U.S.C. § 1396a(a)(1) (statewideness), § a(a)(8) (reasonable promptness in the provision of services), § a(a)(10)(B) (comparability in the provision of services), § a(a)(23) (free choice of providers), § a(a)(30) (quality care and equal access), and § a(a)(37) (prompt and efficient claims payment). Among other things, the complaint pointed out that Medicaid dental payments had not increased appreciably from the inception of the program in 1966.

The parties entered a stipulated settlement on May 24, 2000. This agreement requires dental expenditures to be increased each year for the next four years for selected service fees. In addition, the Governor will establish a Medicaid Dental Advisory Committee (until March 31, 2004) to make recommendations to the Medicaid agency for improving access.

Dental Society of New York v. Carey, 61 N.Y.2d 330, 462 N.E.2d 362, 474 N.Y.S.2d 262 (Ct. App. 1984)

Holding: This case challenged New York's dental reimbursement rates as violating federal comparability and equal access regulations. This decision deals with procedural challenges to the complaint. The court held the Dental Society to have standing to bring the case on behalf of its members and that the claims were justiciable, that is within the court's competence to decide.

North Carolina

Antrican v. Buell,290 F.3d 178 (4^th Cir. 2002), aff'g, 158 F. Supp. 2d 663 (E.D.N.C. 2001), cert. denied, 123 S.Ct. 467 (2002)

This complaint was filed on behalf of Medicaid beneficiaries who allege that dental services are not adequately available and accessible. Plaintiffs allege violations of: 42 U.S.C. §§ 1396a(a)(43) and 1396d(r) (regarding EPSDT benefits and informing), § 1396a(a)(30)(A) (equal access), § 1396a(a)(1) (statewideness), § 1396a(a)(8) (reasonable promptness in delivery of services), § 1396a(a)(23) (freedom of choice of providers), and § 1396a(a)(10) (requirements for comparability of services). The defendants' motion to dismiss, based on sovereign immunity and claims that the Medicaid provisions were unenforceable, was denied, except that the court did not allow the plaintiffs to proceed with the a(a)(23) claim. The Supreme Court denied review, and on remand, the defendants filed another motion to dismiss, based on the recent Gonzaga case. In November 2002, this motion was dismissed, except that the court would no longer allow the plaintiffs to enforce the statewideness provision. The court also certified this case as a class action. The parties have reached a proposal settlement and a fairness hearing is scheduled for early March.

Oklahoma

Oklahoma Chapter of Am. Acad. of Ped. v. Fogarty, No. 01-C-187-EA(J), motion to dismiss denied, 205 F. Supp. 2d 1265 (N.D. Okla. 2002)

In this case, the state chapter of the American Academy of Pediatrics alleges that children have inadequate access to Medicaid services because the state is violating the EPSDT provisions and § 30(A), the equal access requirement. In 2002, the district court denied the state's motion to dismiss the case and expressly rejected the Michigan district court's reasoning in Westside Mothers.

Oregon

Gibson v. Concannon, Civ. No. 94-6306-HO/TC (D. Ore.) (Amended complaint, Sept. 20, 1994)

This complaint was filed on behalf of poor Oregonians who alleged they were unable to obtain timely or adequate dental care. While the state has obtained a federal waiver to operate an experimental Medicaid program, the plaintiffs argued that, except for specifically waived Medicaid laws, the program has to operate within the existing framework of Medicaid laws and regulations. Plaintiffs alleged violations of: § 1396a(a)(1) (statewideness), § a(a)(8) (reasonable promptness in the provision of services), § a(a)(30) (equal access), and § a(a)(37) (prompt and efficient claims payment). The case settled when the state increase payments and established a statewide, toll-free help line.

Pennsylvania

Clark v. Houstoun, No. 4:CV-02-1306 (M.D. Pa.), class certified on Nov. 1, 2002

This case alleges that individuals with disabilities cannot obtain dental services through the Medicaid program, particularly persons who are enrolled in Medicaid -participating HMOs. The plaintiffs allege that they cannot obtain timely dental services because of the unavailability of treating providers. The complaint cites, among other laws, § 1396a(a)(30)(A) (equal access). On November 1, 2002, the court certified this case as a class action.

Scott v. Snider, No. 91-CV-7080 (E.D. Pa. Dec. 2, 1994) (Order and stipulation of settlement), same case, (E.D.Pa. Aug. 11, 1993), reprinted in, Medicare & Medicaid Guide (CCH) ¶ 42,056 (stipulated settlement) (requires EPSDT informing of Medicaid-eligible mothers and infants at the time of the child's birth and before the mother is discharged from care)

The settlement of this broad EPSDT case required the state Medicaid agency to meet, and to include in managed care organizations' contracts, specific performance standards for a variety of EPSDT screening services, including:

          •         80% of enrolled children through age six are to be furnished at least one comprehensive screening examination annually and children age 7-20, at least one comprehensive exam biannually.

          •         By Sept. 30, 1998, 80% of enrolled children will actually receive dental examinations, at least once by age one and semiannually thereafter, and the scope of dental services will be consistent with the EPSDT law (to determine the existence of a suspected illness or condition and which shall at a minimum include relief of pain and infection, restoration of teeth, and maintenance of dental health).

          •         By ages 8 and 14, 50% of children will have received protective sealants on the chewing surfaces of their molar teeth.

The settlement also required the state to execute a range of cooperation agreements to assure the availability of EPSDT; to implement specific protections for children in out-of-home placement and children with mental retardation; and to correct problems with the prior authorization process.

Tennessee

John B. v Menke, No. 3-98-0168 (M.D. Tenn.) (Order, Aug. 28, 1998)

This case involved a broad challenge to the failure of children to receive Medicaid EPSDT services in managed care organizations. Allegations regarding inadequate dental services were included in the complaint. The case was settled in an agreement whereby the state would implement an EPSDT plan that calls for, among other things, improving outreach and informing of beneficiaries about EPSDT, updating and implementing statewide periodicity schedules, and realizing enhanced measures of performance (including more accurate reporting on the EPSDT reporting forms).

Brittney W. v. Preferred Health Partnership of Tennessee and Commissioner Tennessee Department of Health, No. 3-98-0759 (M.D. Tenn.) (Settlement Agreement, November 1999)

This case was filed on behalf of a child who could not find a pediatric dentist to treat her progressing dental care needs. The complaint named a health plan and the Medicaid Commissioner as defendants. The claims included: § 1396a(a)(8) (reasonable promptness), § 1396a(a)(3) (notice and fair hearing rights when claims are not acted on with reasonable promptness), §§ 1396a(a)(43), d(a)(4)(B), and d(r) (EPSDT), and a third party beneficiary contract claim (on the contract between the Medicaid agency and health plan). The case settled when the defendants acknowledged that the child was entitled to dental services and the health plan agreed to pay a named dentist for all the child's pediatric dental care. The health plan also agreed to survey participating dental providers periodically to assure that its dental network is adequate and to send enrollees a notification of the availability of dental services.

Texas

Frew v. Gilbert, 300 F.3d 530 (5^th Cir. 2002), vacating and remanding 109 F. Supp. 2d 579 (E.D. Tex. 2000) (cert. requested sub nom. Frew v. Hawkins).

In a settlement, the state Medicaid agency, among other things, agreed to engage in numerous outreach and informing steps, to work to increase provider participation in the EPSDT program, and to monitor EPSDT performance. On August 14, 2000, the district court held the state Medicaid agency to have fallen short of its settlement promises and ordered the state to comply with the consent decree. The state has appealed this order to the 5^th Circuit Court of Appeals and that court found that the plaintiffs could not enforce the provisions of the settlement. Meanwhile the plaintiffs filed an amended complaint, alleging violations of §1396a(a)(30), caused by the failure of the defendants to assure equal access to necessary dental services. The 5^th circuit returned that part of the case to the district court. An appeal to the US Supreme Court is pending.

Mitchell v. Johnston, 701 F. 2d 337 (5^th Cir. 1983)

Holding: The state's planned cutbacks in EPSDT were enjoined. The state wanted to reduce periodic check ups; limit dental services to emergency, urgent situations; and exclude certain dental services altogether (e.g. topical fluoride, fixed space maintainers, and partial dental appliances).

Note: Congress recognized Mitchell with approval in the legislative history to 1989 amendments to the EPSDT provisions of the Medicaid Act. H. Rep. No. 101-247, 101^st Cong. 1^st Sess. at 399 (1989), reprinted in 1989 U.S.C.C.A.N. 1906, 2125 (1989).

West Virginia

Benjamin H v. Ohl, 1999 U.S. Dist. LEXIS 22454 (S.D.W.Va. 1999) (class certification), same case, 1999 U.S. Dist. LEXIS 22469 (S.D.W.Va. 1999) (preliminary injunction)

Holding: The court issued a preliminary injunction finding that Medicaid beneficiaries were waiting too long for home and community based waiver services. Thereafter, the court entered a consent order requiring the Medicaid agency to provide timely services to individuals with developmental disabilities who were waiting for home and community based care services. The plaintiffs pursued their claim under § 1396a(a)(30)(A), seeking increases in rates paid for residential habilitation and respite care services. The court denied plaintiffs relief, but provided a blue print on proof needed. Thereafter, the state increased the rates at issue.

Randolph v. Miller, Civ. No. 2:91-0212 (S.D.W.Va.) (Order of Dismissal, Aug 7, 1992)

This class action case, filed on behalf of Medicaid beneficiaries needing dental and other Medicaid-covered services, was settled when the state Medicaid agency agreed that it would not reduce reimbursement rates.

Other

There are a number of cases involving health care providers, some of them decided under the now-repealed Boren Amendment. The reasoning of these cases may be helpful. See, e.g.:

Pennsylvania Pharmacists Ass'n v. Houstoun, 283 F.3d 531, 538 (3d Cir. 2002) (stating that § 1396a(a)(30)(A) quality and equal access provisions are “drafted with an unmistakable focus on Medicaid beneficiaries, … phrased in terms benefitting Medicaid recipients … [T]he adequacy of payments is measured in relation to the health needs of recipients. It manifests concern solely for the well-being of recipients. It is therefore apparent from the statutory language that the intended beneficiaries of Section 30(A) are recipients, not providers.)

Evergreen Presbyterian Ministries, Inc. v. Hood, 235 F.3d 908 (5th Cir. 2000), rehearing en banc denied,247 F.3d 243 (2001)

Rite Aid v. Houstoun, 171 F.3d 842 (3d Cir. 1999)

Orthopaedic Hosp. v. Belshe, 103 F.3d 1491, 1496 (9^th Cir. 1997), cert. denied, 522 U.S. 1044 (1998)

Methodist Hosp. v. Sullivan, 91 F.3d 1026 (7^th Cir. 1996) (discussing evidence submitted by parties in (30)(A) case)

Temple University v. White, 941 F.2d 201 (3d Cir. 1991) (invalidating 14% rate reduction based on a “budget neutrality adjustment,” for failure to comply with 42 U.S.C. § 1396a(a)(13)(A))

Nebraska Health Care Ass'n, Inc. v. Dunning, 778 F.2d 1291 (8^th Cir. 1985) (invalidating HCFA's approval of “cap” on reimbursement where sufficient findings were not made, therefore no factual basis for “assurances” made to HCFA), cert. denied, 479 U.S. 1063 (1987)

AMISUB (PSL) v. Colo. Dep't of Social Services, 879 F.2d 789 (10th Cir. 1989) (invalidating Colorado plan cutting provider reimbursement 46% across the board because the State had not made any findings that its rates were “reasonable and adequate” and because the State conceded that the adoption of its “Budget Adjustment Factor” which divided the median cost of care in half had absolutely no relevance to the costs of an efficient hospital)

Missouri Health Care Ass'n v. Stangler, 765 F. Supp. 1413 (W.D. Mo. 1991) (invalidating plan that failed to make findings which identify and determine whether reimbursement rates are reasonable and adequate to meet the reasonable costs that must be incurred by Medicaid facilities)

Multicare Medical Center v. State of Wash., 768 F. Supp. 1349 (W.D. Wash. 1991) (finding Washington Medicaid Plan and its subsequent amendments to be in violation of the procedural provisions of the federal Medicaid laws for failure to make required findings and assurances that the payment rates are reasonable and adequate to meet the costs that must be incurred by economically and efficiently operated providers)

Degregorio v. O'Bannon, 500 F. Supp. 541 (E.D.Pa. 1980) (discussing and dismissing the Medicaid agency's argument that a general shortage of facilities was the cause of low participation)

Ohio Hospital Association v. Ohio Department of Human Services, 62 Ohio St.3d 97, 579 N.E.2d 695 (1991), cert. denied, 112 S.Ct. 1483 (1992) (affirming lower court decision invalidating the State's decision to reduce reimbursement rates for outpatient services because it was implemented without due consideration of its effect on the quality of care, as required by 42 U.S.C. § 1396a(a)(30)(A))

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