United States Court of Appeals For the First Circuit
No. 25-1359
REBECCA HOLLAND, on her own behalf and on behalf of those similarly situated,
Plaintiff, Appellant,
v.
ELEVANCE HEALTH, INC., f/k/a Anthem, Inc.,
Defendant, Appellee.
APPEAL FROM THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF MAINE
[Hon. Lance E. Walker, U.S. District Judge]
Before
Montecalvo, Lynch, and Thompson, Circuit Judges.
Anna P. Prakash, with whom Kiese T. Hansen, Nichols Kaster, PLLP, Eleanor Hamburger, Richard E. Spoonemore, Ari Robbins Greene, Sirianni Youtz Spoonemore Hamburger PLLC, Shelby Leighton, and Public Justice were on brief, for appellant.
Elizabeth Parr Hecker, with whom Raymond A. Cardozo, Carol B. Lewis, Daniel J. Hofmeister, Bryan M. Webster, Alex M. Lucas, and Reed Smith LLP were on brief, for appellee.
March 27, 2026 MONTECALVO, Circuit Judge. Rebecca Holland filed a
putative class action against Elevance Health, Inc. ("Elevance"),
alleging that it designed and administered a health insurance
plan -- through its subsidiary Anthem Health Plans of Maine, Inc.
("Anthem") -- that excluded coverage for weight-loss medication
(the "Exclusion").1 Holland alleged that the Exclusion violated
federal law because it discriminated against plan enrollees
diagnosed with obesity. The district court dismissed the matter,
concluding that Holland's allegations failed to plausibly support
her theories of unlawful disability discrimination. For the
reasons stated below, we affirm.
I. Background
A. Factual Background2
As a Falmouth Public Schools employee, Holland is
enrolled in a health insurance plan (the "Plan") through the Maine
Education Association Benefits Trust. Anthem, a health insurance
company, designed and administers the Plan. The Plan contains an
exclusion in its "What's Covered" section under the heading
"Bariatric Surgery / Morbid Obesity," which states, in relevant
1 Elevance Health, Inc. was formerly known as Anthem, Inc. Elevance's subsidiary, Anthem Health Plans of Maine, Inc., does business as Anthem Blue Cross and Blue Shield. 2 We take the facts from Holland's complaint and draw all reasonable inferences in her favor. Freeman v. Town of Hudson, 714 F.3d 29, 33 (1st Cir. 2013) (citing San Juan Cable, LLC v. P.R. Tel. Co., 612 F.3d 25, 28 (1st Cir. 2010)).
- 2 - part, that "[b]enefits are not provided for weight loss
medications."
In September 2022, Holland visited Dr. Rebecca
Hemphill's office "to discuss anti-obesity treatment." There,
Holland met with a physician assistant who diagnosed Holland with
obesity and indicated that Holland had been unable to sustain
weight loss despite her diet and exercise attempts. Accordingly,
the physician assistant prescribed Holland an FDA-approved
weight-loss medication, Wegovy, to treat her obesity. However,
Anthem denied coverage for Wegovy. When the physician assistant
prescribed Holland another FDA-approved weight-loss medication,
Contrave, Anthem again denied coverage. Eventually, Dr. Hemphill
appealed Anthem's coverage denial for Wegovy, emphasizing
Holland's eligibility for the medication, Holland's medical
history, and supporting medical literature. Despite the appeal,
Anthem did not provide coverage for the weight-loss medication.
In July 2023, Holland's new doctor, Dr. Jared Cassin,
wrote a letter to Anthem to assist Holland with obtaining coverage
for weight-loss medication to treat her obesity.3 In the letter,
Dr. Cassin explained how Holland would benefit from such
medication, noting Holland's obesity and binge eating disorder
3In between her move from Dr. Hemphill to Dr. Cassin, Holland was able to treat her obesity by paying out-of-pocket for semaglutide -- a medication typically sold under the brand names Ozempic and Wegovy -- through a compounding pharmacy.
- 3 - diagnoses. Still, Anthem did not provide coverage. Over a year
later, Dr. Cassin submitted to Anthem a preauthorization request
for Wegovy on Holland's behalf. In denying the request, Anthem
told Dr. Cassin's office that it could not process the request
because Holland's Plan did not cover Wegovy.
B. Procedural Background
On September 20, 2024, Holland -- on behalf of herself
and a proposed class -- sued Anthem's parent company, Elevance,
for disability discrimination under Section 1557 of the Patient
Protection and Affordable Care Act ("ACA"), 42 U.S.C. § 18116.
Holland alleged that Elevance designed and administered health
plans that discriminated "based on the disabling condition of
obesity." Elevance moved to dismiss.
On April 9, 2025, the district court granted Elevance's
motion to dismiss. The district court rejected as "conclusory"
Holland's allegations that she and every Plan participant with an
obesity diagnosis and weight-loss medication prescription were
disabled. Rather, the district court explained that whether a
health condition results in disability under the Americans with
Disabilities Act ("ADA") was "not a formulaic inquiry based on a
mere diagnosis and prescription" but was an "individualized
inquiry." But "for purposes of the [m]otion to [d]ismiss" the
district court assumed that Holland "alleged individual
limitations that ma[de] her allegation of disability plausible."
- 4 - Nonetheless, the district court rejected Holland's
discrimination allegations as conclusory and conjectural. It
reasoned that the Exclusion under the Plan applied even if an
enrollee was overweight rather than obese, and that the Exclusion
operated for both overweight and obese participants regardless of
whether they were disabled. Accordingly, the district court
determined that, "on its face, the [E]xclusion does not turn on
disability status, impacts participants whether they are disabled
or not, and does not isolate disabled participants for
discriminatory treatment." Thus, the district court concluded
that Holland's allegations did not support a plausible finding
that the Exclusion amounted to "intentional, proxy, disparate
impact, or deliberate indifference discrimination against Holland
or the putative class."
Lastly, the district court declined to rule on whether
Elevance or Anthem, as Elevance's subsidiary administering the
Plan at issue, was the appropriate defendant in this Section 1557
action. Rather, it determined that due to "the lack of reliable
guidance on the issue," it would rest its decision to dismiss on
Holland's failure to state a disability discrimination claim.
Holland's timely appeal followed.
II. Standard of Review
"This court reviews de novo a district court's dismissal
of a plaintiff's complaint under Rule 12(b)(6)." Rae v. Woburn
- 5 - Pub. Schs., 113 F.4th 86, 98 (1st Cir. 2024), cert. denied, 145
S. Ct. 1431 (2025). "To assess whether a complaint can withstand
a Rule 12(b)(6) motion, we 'must accept as true all well-pleaded
facts[,] indulging all reasonable inferences in Appellant's
favor.'" Id. (citation modified) (quoting Fantini v. Salem State
Coll., 557 F.3d 22, 26 (1st Cir. 2009)).
III. Discussion
Holland raises three issues on appeal. First, Holland
argues that the district court erred in concluding that she failed
to plausibly state a claim of disability discrimination. Rather,
Holland asserts that she sufficiently stated a claim for
intentional discrimination, proxy discrimination, and disparate
impact discrimination. Second, Holland contends that the district
court erred in its "commentary" regarding whether Elevance is the
proper defendant in this case. Lastly, Holland asserts that the
district court "improperly opined" on whether disability status
can be proven on a class-wide basis. We need not address the
latter two issues because, for the reasons stated below, we hold
that Holland failed to plausibly state a claim for disability
discrimination under Section 1557.
A. Background Law
The ACA proscribes discrimination in the design or
implementation of a health insurance plan adopted by a provider
that receives federal funding. See 42 U.S.C. § 18116(a); id.
- 6 - § 18022(b)(4)(B)-(C); 45 C.F.R. § 156.125(a). Specifically,
Section 1557 provides that "an individual shall not . . . be
excluded from participation in, be denied the benefits of, or be
subjected to discrimination under, any health program or activity,
any part of which is receiving Federal financial assistance" on
the grounds prohibited under four federal nondiscrimination
statutes. 42 U.S.C. § 18116(a). The prohibited ground relevant
here stems from Section 504 of the Rehabilitation Act ("Section
504"), which proscribes discrimination "solely by reason of [an
individual's] disability." 29 U.S.C. § 794(a). Along with the
other nondiscrimination statutes it incorporates, Section 1557
applies the enforcement mechanisms provided under Section 504.
See 42 U.S.C. § 18116(a). Thus, "the case law construing the
Rehabilitation Act" applies to Holland's Section 1557 claim "for
disability discrimination by a health care insurer." See Schmitt
v. Kaiser Found. Health Plan of Wash., 965 F.3d 945, 954 (9th Cir.
2020). Accordingly, pleading a disability discrimination claim
under Section 504, as incorporated by Section 1557, requires
Holland to show: "(1) that she is disabled; (2) that she sought
services from a federally funded entity; (3) that she was
'otherwise qualified' to receive those services; and (4) that she
was denied those services 'solely by reason of her . . .
disability.'" Lesley v. Hee Man Chie, 250 F.3d 47, 53 (1st Cir.
2001) (alteration in original). Elevance disputes the first,
- 7 - third, and fourth elements, each of which must be proven. Like
the district court, we focus on the fourth element -- the "solely
by reason of her disability" prong. Holland's claim fails at this
fourth element.
B. Proxy Discrimination
We first address Holland's allegation that the Exclusion
constitutes proxy discrimination. This Circuit has never
recognized a proxy discrimination theory, whether framed as a
theory of disparate impact or facial discrimination. But, as we
will explain below, Holland's proxy discrimination claim fails
even under the law of those circuits which have posited the
viability of such claims. In courts which do so, proxy
discrimination may be found to exist when "the defendant enacts a
law or policy that treats individuals differently on the basis of
seemingly neutral criteria that are so closely associated with the
disfavored group that discrimination on the basis of such criteria
is, constructively, facial discrimination against the disfavored
group." Pac. Shores Props., LLC v. City of Newport Beach, 730
F.3d 1142, 1160 n.23 (9th Cir. 2013). When those courts analyze
a proxy discrimination claim, the central inquiry is "whether the
proxy's 'fit' is 'sufficiently close' to make a discriminatory
inference plausible." Schmitt, 965 F.3d at 959 (quoting Davis v.
Guam, 932 F.3d 822, 838 (9th Cir. 2019)). For instance,
"discriminating against individuals with gray hair is a proxy for
- 8 - age discrimination because 'the "fit" between age and gray hair is
sufficiently close.'" Pac. Shores Props., 730 F.3d at 1160 n.23
(quoting McWright v. Alexander, 982 F.2d 222, 228 (7th Cir. 1992)).
In her complaint, Holland alleges that "all people
diagnosed with obesity who require prescription medications to
treat" the condition meet the definition of "disability" such that
excluding coverage for weight-loss prescription medication
"discriminates against people with the disability of obesity."
She then alleges that "there is a reasonably strong correlation
between disability and treatment with medically necessary weight
loss drugs, as indicated by Anthem's Prescription Drug List,"4 and
thus, there is a close "fit" between individuals with obesity and
those who require the prescription weight-loss medications for
which the Plan excludes coverage. She relies on these allegations
in her brief to assert that excluding coverage for weight-loss
medications is a proxy for discriminating against enrollees with
"disabling obesity" because such enrollees "overwhelmingly or
entirely" comprise the individuals who seek coverage for weight-
loss medications.
4 Anthem's Prescription Drug List comprises the prescription medications generally covered under the enrollee's health insurance plan, though, such medications are subject to coverage limitations or exclusions enumerated in the enrollee's plan design.
- 9 - Elevance counters that "Anthem administers other [health
insurance] plans that cover weight loss medication" and, thus,
there is no "fit" between the Exclusion and disability because
"coverage depends on the plan, not disability status." Further,
Elevance asserts that Holland's complaint "does not include any
allegations about the population of overweight plan participants
who are eligible for prescription weight loss drug coverage, the
percentage who are prescribed such drugs, the percentage who seek
coverage for such drugs, or how these factors compare to the needs
of the population of individuals diagnosed with obesity." Elevance
argues that the lack of such allegations is fatal to Holland's
proxy discrimination claim because her complaint fails to
demonstrate who would or would not be affected by the Exclusion.
Even were we to assume dubitante the viability of such
a proxy discrimination theory under Section 1557, we hold that
Holland has not adequately pled that the Exclusion is "so closely
associated with" people with disabling obesity as to amount to
proxy discrimination. See id. This is because Anthem's
Prescription Drug List does not provide a basis to reasonably infer
that the weight-loss medications enumerated within it are
medically necessary only when treating obesity such that those
with disabling obesity are the enrollees "overwhelmingly or
entirely" impacted by the Exclusion. Anthem's Prescription Drug
List does not set forth the criteria an enrollee must meet for a
- 10 - provider to prescribe, as medically necessary, any of the listed
drugs. Even the sources Holland cited and linked to in her
complaint5 indicate that the "anti-obesity" medications in Anthem's
Prescription Drug List, such as Wegovy and Zepbound, are FDA-
approved for weight management for individuals with obesity or who
are overweight with a weight-related condition "such as high blood
pressure, type 2 diabetes or high cholesterol."6 These sources
show that individuals without disabling obesity may also require
and be eligible for treatment with the prescription weight-loss
medications included on Anthem's Prescription Drug List. Thus,
5 When reviewing an order of dismissal for failure to state a claim, we may "consider facts from 'documents incorporated by reference into the complaint, matters of public record, and facts susceptible to judicial notice.'" Saccoccia v. United States, 955 F.3d 171, 172 (1st Cir. 2020) (quoting Butler v. Balolia, 736 F.3d 609, 611 (1st Cir. 2013)). 6 See FDA Approves New Drug for Chronic Weight Management, First Since 2014, FDA (Jun. 4, 2021), https://www.fda.gov/news- events/press-announcements/fda-approves-new-drug-treatment- chronic-weight-management-first-2014 [https://web.archive.org/web/20250324145450/https://www.fda.gov/ news-events/press-announcements/fda-approves-new-drug-treatment- chronic-weight-management-first-2014] (announcing the FDA's approval of Wegovy for chronic weight management in adults who are overweight (defined as those with a body mass index of twenty-seven kilograms per square meter or greater) with at least one weight-related ailment or adults with obesity (defined as a body mass index of thirty kilograms per square meter or greater)); FDA Approves New Medication for Chronic Weight Management, FDA (Nov. 8, 2023), https://www.fda.gov/news-events/press- announcements/fda-approves-new-medication-chronic-weight- management [https://perma.cc/RM2S-TF9R] (announcing the FDA's approval of Zepbound for chronic weight management in adults who are overweight with at least one weight-related condition or adults with obesity).
- 11 - despite Holland's assertions, Anthem's Prescription Drug List does
not support a plausible claim that there is a close "fit" or a
sufficiently close association between individuals with obesity
and those who require prescription weight-loss medications.
That said, Holland alleges that just because the
Exclusion may also impact non-disabled people, "a form of 'over-
discrimination,'" does not mean Elevance is relieved from
liability. For support, Holland cites Schmitt, in which the Ninth
Circuit noted that the fact that the policy exclusion at issue in
that case also affected some non-disabled people did not doom the
plaintiffs' proxy discrimination claim because "overdiscrimination
is prohibited." 965 F.3d at 958 (quoting Pac. Shores Props., 730
F.3d at 1160). However, in Schmitt, the plaintiffs' proxy
discrimination allegations still failed because their complaint
did "not make clear to what extent the proxy [was] overinclusive."
Id. at 959. The Ninth Circuit noted that the class of people the
plaintiffs alleged were affected by the challenged policy included
non-disabled individuals, and thus it was "impossible to infer
whether the exclusion primarily affect[ed] disabled persons." Id.
The Ninth Circuit also rejected the plaintiffs' attempt to minimize
the alleged proxy's over-inclusiveness by claiming that "few, if
any, non-disabled insureds had claims denied under the
[exclusion]." Id. The court explained that such allegation needed
"further explanation to be plausible." Id.
- 12 - Like the Schmitt plaintiffs, Holland suggests that the
Exclusion has no significant effect on non-disabled enrollees,
asserting in her complaint that the "weight control" treatments
non-disabled enrollees seek "are not typically medical in nature"
as such treatments are not prescribed by a licensed health provider
and do not treat diagnosed obesity or a co-morbid condition.
Further, Holland alleges that, under the Plan, such individuals
would not be eligible for coverage of these treatments regardless
of the Exclusion. While not as terse as the arguments rejected in
Schmitt, these allegations comprise "unsubstantiated conclusions,"
devoid of any underlying factual support that would permit us to
accept them as true.7 See Waleyko v. Phelan, 146 F.4th 89, 95-96
(1st Cir. 2025).
Holland must offer more than conjecture to plausibly
allege that the Exclusion disproportionately affects people with
disabilities. See Frith v. Whole Foods Mkt., Inc., 38 F.4th 263,
274 (1st Cir. 2022) ("[A] complaint's factual allegations must be
sufficient to take a claim beyond the realm of pure conjecture,
7 In Holland's brief, she argues that, under the Plan, "prescription medications are only covered when medically necessary for a diagnosed 'illness or injury.'" Therefore, she contends that because being overweight is not an illness or injury, even without the Exclusion, no coverage obligation attaches for overweight individuals seeking prescription medication for weight loss. But such an argument was not before the district court, and thus, we consider it waived on appeal. See United States v. Zannino, 895 F.2d 1, 17 (1st Cir. 1990).
- 13 - that is, across the line from conceivable to plausible." (citation
modified)). When stripped of such conjecture and down to its bare
bones, Holland's complaint lacks the facts needed to support a
plausible finding that there is a sufficiently close "fit" between
individuals with obesity and individuals who require prescription
weight-loss medication. This in turn inhibits our ability to infer
that the Exclusion is a proxy for disability discrimination against
individuals with, as Holland asserts, "disabling obesity."
Accordingly, Holland fails to state a claim for proxy
discrimination.
C. Intentional Discrimination
Holland attempts to show intentional discrimination by
alleging that: (1) the Plan constitutes facial discrimination; and
(2) Elevance acted with deliberate indifference. We address each
allegation in turn.
1. Facial Discrimination
Holland alleges that the Plan constitutes facial
discrimination against enrollees with obesity because the Plan
expressly excludes prescription medications to treat obesity,
while enrollees without an obesity diagnosis have access to
prescription medications to treat their medical conditions. To
illustrate the alleged express exclusion, Holland points to the
plain language of the Plan's "Bariatric Surgery / Morbid Obesity"
section. Holland asserts that this section, which she contends is
- 14 - the Exclusion, explicitly targets obesity because it uses the term
"Morbid Obesity" to indicate that "[b]enefits are not provided for
weight loss medications." She further explains that this section
excludes all treatment for obesity, including prescription
medication, except for "extremely limited" bariatric surgery
coverage. Holland asserts that these features of the Plan evince
facial discrimination against enrollees diagnosed with obesity.
Elevance counters that the Exclusion is not
discriminatory because it applies to all enrollees, regardless of
whether they are obese. Elevance also asserts that any health
insurance plan will cover some treatments but not others, and
therefore, the Plan does not establish intentional discrimination
simply because it provides coverage for treatments of only some
medical conditions.
Holland's facial discrimination theory is unavailing.
Under the Plan, the Exclusion does not apply solely because an
enrollee is diagnosed with obesity. Rather, in addition to its
inclusion in the "Bariatric Surgery / Morbid Obesity" section, the
Exclusion is also enumerated under a section titled "What's Not
Covered Under Your Prescription Drug . . . Pharmacy Benefit," where
it indicates that "[a]ny [d]rug mainly used for weight loss" is
not covered. This iteration of the Exclusion is not tethered to
a specific condition. Thus, on its face, the Exclusion is neutral
- 15 - because it applies to all enrollees who seek coverage for weight-
loss medications -- not just enrollees with obesity.
2. Deliberate Indifference
Next, Holland argues that her intentional discrimination
claim can be shown under a deliberate indifference theory. Holland
asserts that Elevance acted with deliberate indifference by
historically excluding anti-obesity medications and designing and
administering a health insurance plan that excludes coverage for
prescription weight-loss medications that treat obesity without:
(1) conducting a cost-benefit analysis; or (2) evaluating whether
the Exclusion complied with the ACA's nondiscrimination
requirements or was based on medical and scientific evidence. She
contends that these allegations clearly demonstrate "thoughtless
indifference or benign neglect."
Elevance counters that other circuits have determined
that "obesity[,] standing alone[,] does not qualify as a recognized
disability under federal law." Thus, Elevance contends that
Holland has not plausibly alleged that Anthem knew or should have
known that obesity is a federally protected disability or that
Anthem was substantially likely to violate Section 1557 when
designing and administering the Exclusion.
This Circuit has never held that a plaintiff alleging
disability discrimination may show intentional discrimination by
showing deliberate indifference. But assuming dubitante that a
- 16 - plaintiff may do so, Holland has not plausibly stated a claim for
deliberate indifference. To state a deliberate indifference
claim, Holland must allege that the defendant (1) had "knowledge
that a harm to a federally protected right is substantially likely"
and (2) "fail[ed] to act upon that likelihood." Lovell v.
Chandler, 303 F.3d 1039, 1056 (9th Cir. 2002).
To begin, alleging "thoughtless indifference or benign
neglect" is not sufficient to state a claim for deliberate
indifference. See Basta v. Novant Health Inc., 56 F.4th 307, 317
(4th Cir. 2022) (noting that a deliberate indifference claim under
Section 504 "requires much more than a showing of pure
negligence"); Updike v. Multnomah Cnty., 870 F.3d 939, 951–52 (9th
Cir. 2017) ("[T]o meet the second element of the deliberate
indifference test, a failure to act must be a result of conduct
that is more than negligence, and involves an element of
deliberateness.") (quoting Duvall v. Cnty. of Kitsap, 260 F.3d
1124, 1139 (9th Cir. 2001), as amended on denial of reh'g (Oct.
11, 2001)).
Holland's pleadings do not raise a plausible inference
that Elevance knowingly and intentionally discriminated by being
deliberately indifferent that individuals diagnosed with obesity
and prescribed weight-loss medications are disabled under the
ADA -- the statute from which Section 504, and Section 1557 by
- 17 - extension, borrow their "disability" definition.8 See 29 U.S.C.
§ 705(9). Holland suggests that our decision in Cook v. State of
R.I., Dep't of Mental Health, Retardation, & Hosps., 10 F.3d 17
(1st Cir. 1993), "established that obesity can be a federally
protected disability." But even if we were to assume that obesity
could be a federally protected disability, that, without more,
does not raise a plausible inference that Elevance knew that those
diagnosed with obesity and prescribed weight-loss medications are
disabled. Without such an inference, it does not then logically
follow that Elevance knew that the Exclusion was substantially
likely to harm the federally protected rights of disabled
individuals under Section 1557. Accordingly, Holland's
allegations are insufficient to state a claim for deliberate
indifference under Section 1557.
D. Disparate Impact
Turning to Holland's disparate impact claim, she alleges
that the Exclusion disparately impacts Plan enrollees diagnosed
with obesity. She argues that such enrollees "do not have
'meaningful access' to the prescription drug benefit" due to the
Under the ADA, "disability" is defined, in part, as "a 8
physical or mental impairment that substantially limits one or more major life activities." 42 U.S.C. § 12102(1)(A).
- 18 - Exclusion, while enrollees without obesity "have access to
medically necessary medications to treat their conditions."
Elevance counters that individuals with or without
obesity have meaningful access to other Anthem-administered plans
that cover weight-loss medications. Further, Elevance explains
that a plan that excludes weight-loss medication coverage for all
enrollees cannot disparately impact an enrollee by denying a
benefit that it never offered. Elevance also contends that
Holland's failure to plead facts that: (1) provide any basis for
the court to assess or estimate what portion of those affected by
the Exclusion are disabled; or (2) illuminate "the percentage of
plan members [who] . . . seek coverage for medical or surgical
treatments as opposed to prescription drugs" is sufficient to merit
dismissal of Holland's disparate impact claim.
We hold that Holland has failed to adequately allege
that enrollees diagnosed with obesity do not have meaningful access
to the prescription drug benefit. In Alexander v. Choate, the
Supreme Court rejected "the boundless notion that all disparate-
impact showings constitute prima facie cases under [Section] 504."
469 U.S. 287, 299 (1985). Instead, the Court determined that a
disparate impact claim might arise under Section 504 when an
otherwise qualified disabled individual is denied "meaningful
access to the benefit that the grantee offers." Id. at 301
(emphasis added). Choate centered on Medicaid recipients'
- 19 - challenge to a proposed reduction in the number of inpatient
hospital days that Tennessee's Medicaid program covered from
twenty days to fourteen days. Id. at 289-90. The plaintiffs
argued that the reduction would disproportionately affect people
with disabilities, who generally required longer care, and thus
constituted unlawful discrimination under Section 504. Id. The
Court assessed Section 504 and the relevant statutes and
regulations to determine the benefit guaranteed under the Medicaid
Act and the scope of that benefit. Id. at 303-06. The Court, in
part, found that Section 504 did not "guarantee [disabled people]
equal results from the provision of state Medicaid . . . ."9 Id.
at 304.
Here, unlike in Choate, Holland's allegation that
enrollees diagnosed with obesity "do not have 'meaningful access'
to the prescription drug benefit" does not set forth a basis to
discern the scope of such benefit under the ACA. For instance,
Holland did allege that the ACA "requires covered health entities
to ensure that their benefit design and administration do not
9 The Court in Choate held that the fourteen-day limitation did not deny the plaintiffs "meaningful access to Tennessee Medicaid services" because: (1) the facially neutral limitation did not "invoke criteria that ha[d] a particularly exclusionary effect" on disabled individuals; (2) there was no evidence that disabled individuals would not "benefit meaningfully from the coverage" received under the fourteen-day rule; and (3) the reduction in coverage would leave both disabled and nondisabled individuals with full access to "identical and effective hospital services." Id. at 302.
- 20 - result in disability discrimination." But the ACA's prohibition
on discrimination in benefit design and implementation does not
give rise to a reasonable inference that health entities must
design benefits in a manner that provides coverage for every form
of medically necessary treatment for a disabled individual's
particular condition. Accordingly, absent sufficient factual
allegations as to the scope of the benefits guaranteed under the
ACA, Holland fails to plausibly allege lack of meaningful access,
and thus her disparate impact claim fails.
IV. Conclusion
For the foregoing reasons, we affirm the district
court's order granting Elevance's motion to dismiss.
- 21 -