Michael T. v. Crouch

344 F. Supp. 3d 856
CourtUnited States District Court
DecidedSeptember 25, 2018
DocketCIVIL ACTION NO. 2:15-cv-09655
StatusPublished

This text of 344 F. Supp. 3d 856 (Michael T. v. Crouch) is published on Counsel Stack Legal Research, covering United States District Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Michael T. v. Crouch, 344 F. Supp. 3d 856 (usdistct 2018).

Opinion

THOMAS E. JOHNSTON, CHIEF JUDGE

Before the Court are Plaintiffs' Motion for Partial Summary Judgment, (ECF No. 182), and Defendant's Motion to Dismiss or, in the Alternative, Motion for Summary Judgment, (ECF No. 179). For the reasons stated herein, the Court DENIES Plaintiffs' motion, (ECF No. 182), and GRANTS IN PART and DENIES IN PART Defendant's motion, (ECF No. 179).

I. BACKGROUND

This case has an intricate history revolving around West Virginia's Intellectual/Developmental Disability Home and Community Based Services waiver program ("I/DD Waiver Program") and benefit reductions suffered by program recipients beginning in 2015. The West Virginia Department of Health and Human Resources' ("DHHR") Bureau for Medical Services ("BMS") administers the State's Medicaid plan, which includes the "intermediate care level services for individuals with intellectual/developmental disabilities" program from the federally recognized optional services. (ECF No. 14 at 36 ¶ 225.) This program provides for individuals with intellectual disabilities institutions that offer residential, health, and rehabilitative services, (id. at 36-37 ¶ 226; ECF No. 54 at 9), known as Intermediate Care Facilities for Individuals with Intellectual Disabilities ("ICF/IIDs"). (ECF No. 179-2 (Nisbet Third Dec.) at 2.) See also 42 U.S.C. § 1396d(d). West Virginia implements an alternative option for individuals otherwise eligible for an ICF/IID to receive home- and community-based services instead because, in part, the State has capped the number of ICF/IID beds. The cap is currently set at 533, "and there are no large or state-run ICF/IIDs in West Virginia." (ECF No. 180 at 7; ECF No. 179-2 (Nisbet Third Dec.) at 3 (noting that "[a]n ICF/IID is the least common service setting for individuals with intellectual disabilities").) This alternative program-the I/DD Waiver Program-is the subject of the current litigation.

*858As detailed in this Court's previous memorandum opinion and orders, the I/DD Waiver Program provides "an array of ... services that an individual needs to avoid institutionalization." 42 C.F.R. § 441.300. (See also ECF No. 122 at 1-10; ECF No. 170 at 1-5.) Many individuals enrolled in the program live with family members in their homes while others live in an "[i]ntensively [s]upported [s]etting," where one to four program members live together in a residential or group home. (See ECF No. 54 at 11; ECF No. 115 at 76.) West Virginia's I/DD Waiver Program currently provides services to 4,684 individuals while over 1,300 individuals remain on the program's waiting list. (ECF No. 179-2 (Nisbet Third Dec.) at 1 (noting that "DHHR added 50 additional slots to the program in July 2018").) BMS contracts with Kepro f/k/a APS Healthcare Inc. ("APS") to assist in the I/DD Waiver Program's administration, such as "monitoring the member's health and safety," (ECF No. 54 at 10-11), "[e]nsuring each [I/DD Waiver Program] participant's medical eligibility is initially established and reestablished on an annual basis," and conducting an "annual assessment of each program participant's abilities and needs," (ECF No. 28-3 at 7). Local service provider agencies ultimately receive contracts to provide individual recipients with their waiver services. (ECF No. 14 at 41 ¶ 252.)

At the time Plaintiffs filed this lawsuit, an I/DD Waiver Program recipient's annual service authorization began with a calculation of their individual "budget" by APS. (ECF No. 54 at 14.) This involved the completion of an "annual assessment," which included, in part, an interview with program members, their legal representatives, their case managers, and other interested parties, (see ECF No. 38-3 at 73), and a compilation of data regarding each participant's "abilities, strengths, and support needs," (id. at 7; see also ECF No. 54 at 14-15). Importantly, APS applied a proprietary algorithm to the assessment's results, producing an individual budget from a multi-variable statistical analysis. (ECF No. 54 at 15; see also ECF No. 14 at 43 ¶ 265.) The algorithm was secret in that "the exact factors it consider[ed], the weight it accord[ed] to each factor, and its overall methodology in determining each member's budget [were] not publicly available information." (ECF No. 122 at 5 (citing ECF No. 115 at 145-50).)

After APS notified individuals-without explanation-of their budget amount, the member's "interdisciplinary team" ("IDT"), consisting of the member, a representative from the provider agency, and possibly "the member's guardian(s) and health care professionals," met to create an "Individualized Program Plan" ("IPP"). (ECF No. 51-1 at 8 ¶ 19; ECF No. 54 at 15.) The IPP detailed "each type of service needed to meet that recipient's individually-assessed safety, health, and care needs." (ECF No. 14 at 42 ¶ 257; see also ECF No. 54 at 15.) If the costs of the requested services fell within the APS-calculated budget and complied with BMS policies, then "APS [would] approve service authorization requests consistent with the [IPP]." (ECF No. 54 at 16.)

Nevertheless, if a recipient's IPP resulted in the need for services costing more than the APS-determined budget, then "the service coordinator submit[ted] requests for authorization of services to APS...." (ECF No. 51-1 at 9 ¶ 21.) Prior to September 2014, "APS made independent determinations to grant or deny these requests for funds in excess of the budget and 'routinely approved' such 'service authorization requests.' " (ECF No. 122 at 6 (citing ECF No. 51-1 at 9-10 ¶ 22; ECF No. 14 at 44 ¶ 272).) After BMS discovered that the I/DD Waiver Program was exceeding its budget and that APS was "approving" IPPs "with services costs in excess of the budgets," (ECF No. 115 at 94-96;

*859ECF No. 51-1 at 9 ¶ 22), BMS instructed APS in September 2014 to "cease unilaterally approving" IPPs that included service costs in excess of the APS-calculated budget. (See ECF No. 51-1 at 9 ¶ 22.) Thereafter, requests for funding in excess of the APS-calculated budget required BMS approval through a "second[-]level negotiation," (id. ¶ 21), which involved BMS review of the recipient's file, attached materials, and an APS recommendation, as well as, if requested, a meeting with the recipient and interested parties prior to deciding whether to grant the funding request. (ECF No. 115 at 88-89.)

After denying a second-level negotiation request for funding in excess of the APS-calculated budget, BMS sent the member a notice containing appeal rights. (ECF No. 54 at 16.) To exercise the right to appeal the second-level denial, the member could request a fair hearing before the State's Board of Review. (ECF No. 115 at 91-92; see also ECF No. 54 at 16.) The BMS and I/DD Waiver Program member could present arguments as well as any supporting documentation at the hearing. (See ECF No. 115 at 92-94.) The Board of Review then issued its decision affirming or reversing the second-level determination by BMS. (Id.

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Bluebook (online)
344 F. Supp. 3d 856, Counsel Stack Legal Research, https://law.counselstack.com/opinion/michael-t-v-crouch-usdistct-2018.