Linton ex rel. Arnold v. Commissioner of Health & Environment

65 F.3d 508, 1995 U.S. App. LEXIS 26006
CourtCourt of Appeals for the Sixth Circuit
DecidedSeptember 15, 1995
DocketNos. 93-6142 to 93-6144, 93-6146 and 93-6147
StatusPublished
Cited by5 cases

This text of 65 F.3d 508 (Linton ex rel. Arnold v. Commissioner of Health & Environment) is published on Counsel Stack Legal Research, covering Court of Appeals for the Sixth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Linton ex rel. Arnold v. Commissioner of Health & Environment, 65 F.3d 508, 1995 U.S. App. LEXIS 26006 (6th Cir. 1995).

Opinion

RALPH B. GUY, Jr., Senior Circuit Judge.

This ease involves a class action suit brought in 1987 against the Commissioner of the Tennessee Department of Health and Environment (Tennessee).1 The plaintiffs [511]*511are current or future Medicaid-eligible individuals who seek nursing facility services.2 Plaintiffs contested the validity of Tennessee’s implementation of distinct part certification under Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq. (Medicaid Act).3 Under distinct part certification, a provider of a skilled nursing facility (SNF) could certify a distinct part of a facility (e.g., a wing, one side of a corridor, a floor) for Medicaid participation, for patients requiring a different level of care.4 As part of distinct part certification, Tennessee allowed skilled nursing facilities, at their discretion, to “spot” certify beds for Medicaid participation. This practice allowed fewer than all beds within a particular wing or floor to be available for Medicaid recipients regardless of their required level of care. In addition, Tennessee allowed facilities to certify as Medicaid beds fewer than all beds available for residents residing in intermediate care facilities. These practices shall be referred to as the “limited bed policy.” Twenty-three percent of Tennessee’s Medicaid-participating nursing homes chose to have Tennessee certify beds under the limited bed policy. Under this policy, seven percent of the total beds in Medicaid-participating facilities, which would otherwise have been certified, went uncerti-fied.

Plaintiff, Mildred Linton, receives Medicaid assistance and is severely disabled from rheumatoid arthritis. At the time this lawsuit was commenced, she was receiving an SNF level of care at the Green Valley Health Care Center, a Tennessee nursing facility. In 1986, Medicaid officials, reviewing her medical record, determined that she no longer required such a high level of care and informed her that they were reducing her care eligibility to intermediate. Green Valley, under distinct part certification, had 87 intermediate care facility (ICF) beds. Under Tennessee’s limited bed policy, however, it had apportioned only 40 of those beds as ICF Medicaid beds. Green Valley informed Linton that it intended to decertify her Medicaid bed and, due to a considerable waiting list for ICF Medicaid beds, would not likely have available any ICF Medicaid beds.5 The facility’s action, as condoned under Tennessee’s limited bed policy, would force Linton to leave the nursing home where she had lived for four years and which was located close to her family, with no assurance that a Medicaid bed would be available for her elsewhere.

Plaintiff-intervenor, Belle Carney, age 89 at the time this suit was filed, suffers from Alzheimer’s disease. In 1987, she was hospitalized for two weeks and was to be discharged to a nursing home. Carney, who is eligible for Medicaid and is black, had difficulty finding a Medicaid bed. In the interim, she was shunted among a series of inadequate and unlicensed facilities.

Plaintiffs alleged under 42 U.S.C. § 1983 that Tennessee’s limited bed policy violated [512]*512the Medicaid Act. Plaintiffs raised several challenges under the Medicaid Act, including the claim that Tennessee’s limited bed policy did not meet federal distinct part standards. They also alleged that the policy had a disparate impact on black class members in violation of Title VI of the Civil Rights Act of 1964, 42 U.S.C. § 2000d et seq. (Title VI), and its implementing regulations.

The district court, setting forth findings of fact and conclusions of law, pursuant to Fed. R.Civ.P. 52, found that Tennessee’s limited bed policy violated distinct part certification standards and other provisions of the Medicaid Act. The court indicated that the purpose of distinct part certification was to accommodate the delivery of qualitatively different types of health care within the same facility. Tennessee’s limited bed policy, in contrast, served “the interests of nursing homes who wish to participate in the Medicaid program while also maintaining a separate private pay facility offering the same type of care.” Violations of distinct part certification standards included certification even when a facility did not house all ICF residents in the certified portion of the institution. Moreover, Tennessee certified beds under distinct part standards even when no separately administered unit of a facility existed at all. HCFA in interpreting the distinct part certification provision had expressly advised that spot certification did not satisfy distinct part certification: “ ‘Various beds scattered throughout the institution would not comprise a unit operated distinguishably”’ for certification purposes. The court also found that the limited bed policy violated Title VI.

As a result of its liability determinations, the court instructed Tennessee to submit a remedial plan, including prophylactic measures to prevent or mitigate Medicaid provider attrition. Heightened attrition by Medicaid providers was of acute concern to the district court. Previously, the court had denied plaintiffs’ request to enjoin preliminarily Tennessee’s limited bed policy because the court found that granting relief would cause substantial harm to the plaintiffs: some providers would opt out of the Medicaid program and traumatize their Medicaid patients who, as a result of discontinuation of services, would be transferred away from families or discharged to inadequate alternative care. In response to the district court’s instruction, Tennessee proposed a plan that it had negotiated with plaintiffs. The four-part remedial plan consisted of two introductory parts, followed by two substantive parts addressing the laws found to have been violated, the Medicaid Act and Title VI. The Medicaid Act remedies were included in Part III, entitled “Plan Regarding Distinct Part Certification.” That part required Medicaid providers to certify all available, licensed nursing home beds within their facilities (“full certification”) and to admit residents on a first-come, first-serve basis; prohibited involuntary transfer or discharge based upon source of payment; and adopted procedures for provider withdrawal from the program, including patient protection and disincentives to discourage provider attrition. Providers who chose to withdraw from the system were required to retain current Medicaid patients and comply with Medicaid requirements as to such patients (the so-called “lock-in” requirement). Providers who withdrew would be excluded from Medicaid participation for two years after withdrawal (the so-called “lockout” requirement). Part IV addressed Title VI violations and was entitled “Defendant’s Plan to Redress the Finding of Unintended Disparate Impact on Minorities’ Access to Nursing Homes.” Its remedies included draft rules for Title VI civil rights compliance and enforcement, added staff to Tennessee’s Office of Civil Rights Compliance, and incorporated by reference the measures adopted in Part III of the plan. The district court adopted the plan without amendment.

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Related

Hermiz v. Miller
E.D. Michigan, 2023
John Welch v. Michael Brown
551 F. App'x 804 (Sixth Circuit, 2014)
Washington Health Care Ass'n v. Arnold-Williams
601 F. Supp. 2d 1224 (W.D. Washington, 2009)
Linton v. Commissioner Of Health And Environment
65 F.3d 508 (Sixth Circuit, 1995)

Cite This Page — Counsel Stack

Bluebook (online)
65 F.3d 508, 1995 U.S. App. LEXIS 26006, Counsel Stack Legal Research, https://law.counselstack.com/opinion/linton-ex-rel-arnold-v-commissioner-of-health-environment-ca6-1995.