Shin v. Hawaii Medical Service Association

District Court, D. Hawaii·Decided March 9, 2022·No. 1:21-cv-00039·Unknown

Opinion

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF HAWAII

PARK, SOOK JA; PARK, SOON Y.; CIV. NO. 21-00039 JMS-WRP PARK, GRACE; and KIM, JAE SOOK, ORDER (1) GRANTING Plaintiffs, DEFENDANT’S MOTION TO STRIKE, ECF NO. 107; AND vs. (2) GRANTING IN PART AND DENYING IN PART HAWAII MEDICAL SERVICE DEFENDANT’S MOTION FOR ASSOCIATION, SUMMARY JUDGMENT, ECF NO. 68 Defendant.

ORDER (1) GRANTING DEFENDANT’S MOTION TO STRIKE, ECF NO. 107; AND (2) GRANTING IN PART AND DENYING IN PART DEFENDANT’S MOTION FOR SUMMARY JUDGMENT, ECF NO. 68 I. INTRODUCTION Before the court are two motions from Defendant Hawaii Medical Services Association (“HMSA” or “Defendant”). The first is a Motion to Strike, ECF No. 107. In that Motion, HMSA requests that the court strike a report from Plaintiffs’1 expert, Dr. Han-byul Chung, on the basis that Dr. Chung’s report was submitted in a rebuttal posture—i.e., responsive to a report from HMSA’s expert,

1 The Plaintiffs are Sook Ja Park, Soon Y. Park, Grace Park, and Jae Sook Kim. ECF No. 57 at PageID # 503. The First Amended Complaint, ECF No. 57, was originally styled as a class action, but the parties stipulated to the dismissal of the class allegations on February 25, 2022. See ECF No. 120. and past the deadline for opening reports—but contains opinions that go beyond merely rebutting the opinions provided by HMSA’s expert. See ECF No. 107-1.

The Motion to Strike is GRANTED. Dr. Chung’s report is EXCLUDED, and Plaintiffs are precluded from using Dr. Chung as a witness in this case. The second motion is a Motion for Summary Judgment, ECF No. 68,

that seeks judgment against all counts in Plaintiffs’ First Amended Complaint, ECF No. 57 (“FAC”). As the court explained in a prior order,2 all of Plaintiffs’ legal claims in the FAC are based on either or both of two allegations: (1) HMSA improperly denied Plaintiffs medically necessary benefits and services to which

they were entitled (“denial-of-benefits allegations”); and (2) HMSA provided deficient translations of plan documents to Plaintiffs and thus failed to effectively address Plaintiffs’ cultural and language barriers (“deficient-translations

allegations”). In its Motion for Summary Judgment, HMSA argues that both allegations require expert testimony to be proven at trial. See ECF No. 68-1. And because Plaintiffs failed to produce any expert testimony supporting those two allegations, the court should grant summary judgment against all claims in the

FAC. See id. The court agrees as to the deficient-translations allegations— summary judgment is GRANTED against claims involving those allegations. But

2 See ECF No. 99 (available at Park v. Hawaii Med. Serv. Ass’n, 2022 WL 252426, at *1–2 (D. Haw. Jan. 27, 2022) (citing portions of the FAC)). the court disagrees in part as to the denial-of-benefits allegations—summary judgment is GRANTED against claims involving those allegations with respect to

Plaintiff Jae Sook Kim, but summary judgment is DENIED as to claims involving those allegations with respect to Plaintiffs Grace Park, Soon Y. Park, and Sook Ja Park.

II. BACKGROUND A. Factual Background This case concerns the State of Hawaii’s Medicaid program. See ECF No. 57. “Medicaid is a joint state-federal funding program for medical assistance in which the Federal Government approves a state plan for the funding of medical

services for the needy and then subsidizes a significant portion of the financial obligations the State has agreed to assume.” Alexander v. Choate, 469 U.S. 287, 289 n.1 (1985). Hawaii’s Department of Human Services (“DHS”) oversees the

state’s Medicaid plan, i.e., the “Plan for Medicaid, QUEST Integration” or simply the “PLAN.” ECF No. 102 at PageID # 1253, ¶¶ 15, 16. DHS implements the PLAN by contracting with managed care organizations in order to provide medical services to PLAN enrollees. Id., ¶ 16. HMSA is a managed care organization;

Plaintiffs are PLAN enrollees and are beneficiaries to DHS’s contracts with HMSA. See id., ¶¶ 15–20. Plaintiffs were born in Korea, immigrated to the United States, and have limited English proficiency. See ECF No. 57 at PageID ## 541–42, ¶¶ 172–78.

HMSA is contractually obligated to cover “medically necessary” services for enrollees. See ECF No. 102 at PageID # 1253, ¶ 16. 3 That contractual obligation incorporates requirements from various regulations and statutes,

including Hawaii Revised Statutes (“HRS”) § 432E-1.4(a), which requires managed care organizations to cover health services recommended by an enrollee’s treating physician and determined by the managed care organization’s director or physician designee to be “medically necessary,” as defined in HRS § 432E-1.4(b).

See ECF No. 57 at PageID # 511, ¶ 29; see also ECF No. 102 at PageID # 1255, ¶ 32. As one example of medical necessity, HMSA is obligated to provide certain “Long-Term Services and Supports (‘LTSS’)” and “Home and community-based

services (‘HCBS’)” to enrollees that are at risk of deteriorating to the institutional level of care. See ECF No. 102 at PageID # 1253, ¶ 16; ECF No. 57 at PageID # 515, ¶ 46. HMSA completes the “at risk” determinations through quantitative health-and-functional assessments; enrollees scoring above a certain level are

3 The citations in this paragraph and the subsequent two paragraphs are primarily to either the FAC, ECF No. 57, or Plaintiffs’ Concise Statement of Facts, ECF No. 102. Plaintiffs’ Concise Statement of Facts, in turn, cites heavily to the FAC. See ECF No. 102. Although citing to an unverified complaint in opposition to a motion for summary judgment is clearly insufficient to demonstrate disputes of fact, the allegations described in this paragraph are not disputed by HMSA and merely provide context for HMSA’s select challenges to Plaintiffs’ prima facie case. deemed at risk of requiring institutionalization. See ECF No. 102 at PageID ## 1253–55, ¶¶ 16, 18, 29–32; ECF No. 62-2. To illustrate, during the period from

January 27, 2020 through January 26, 2021, enrollees scoring five or more functional points were deemed at risk of institutionalization. ECF No. 57 at PageID ## 547–48, ¶ 209 (referencing “Appendix K”4). At other times, a score of

eleven was the threshold for the at-risk classification. See id. at PageID # 528, ¶ 115. Plaintiffs allege they were improperly denied medically necessary LTSS and/or HCBS benefits when they were at risk of institutionalization. Id. at

PageID ## 511, 535, 544. Plaintiffs cast those denial-of-benefits allegations as various legal claims: In Count I of the FAC, Plaintiffs assert that their denial-of- benefits allegations establish violations of the PLAN contract, Appendix K, and 42

C.F.R. § 438.208. See ECF No. 57 at PageID ## 548–50. In Count II, Plaintiffs request a judgment declaring the meaning and scope of the PLAN’s coverage of HCBS, which will “assist [Plaintiffs] in seeking relief, including specific performance and damages,” to remedy the denial of their benefits. See id. at

4 Appendix K is an emergency amendment issued by DHS and approved by the Centers for Medicare and Medicaid Services during the declared national emergency for the COVID-19 pandemic. See COVID-19: Information for Waiver Providers, State of Haw., Dep’t of Health, https://health.hawaii.gov/ddd/covid-19/waiver-providers/ (last visited Mar. 9, 2022). “Appendix K activates flexibilities available under the Medicaid 1915(c) authority,” “allow[ing] [actions] such as providing services in different settings and in different ways such as telehealth.” Id. PageID ## 550–52.

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