S.D. Ex Rel. Dickson v. Hood

United States Court of Appeals
Fifth Circuit
F I L E D
UNITED STATES COURT OF APPEALS
For the Fifth Circuit November 15, 2004

Charles R. Fulbruge III
No. 03-30007 Clerk

S.D., by and through his next friend, Richard Dickson,

Plaintiff - Appellee,

VERSUS

DAVID HOOD, in his capacity as Secretary of the Louisiana
Department of Health and Hospitals,

Defendant - Appellant.

Appeal from the United States District Court
For the Eastern District of Louisiana

Before KING, Chief Judge, DENNIS, Circuit Judge, and LYNN*,
District Judge.

DENNIS, Circuit Judge:

This appeal challenges the district court’s judgment

enforcing a Medicaid recipient’s right of action under the Civil

Rights Act, 42 U.S.C. § 1983, based on a state Medicaid agency’s

deprivation of his federal statutory right to medical assistance

under the Medicaid Act, 42 U.S.C. § 1396 et seq. The issues are:

*
District Judge for the Northern District of Texas, sitting
by designation.
1
(1) whether the Louisiana Department of Health and Hospitals

(LDHH), the state Medicaid agency, unlawfully denied the

recipient’s claim under the Medicaid Act’s program for “early and

periodic screening, diagnostic, and treatment services” (EPSDT) by

refusing to pay for his medically prescribed disposable

incontinence underwear that is necessary to ameliorate his physical

and mental conditions caused by spina bifida, which results in his

total bowel and bladder incontinence, loss of sensation, and

continual risk of infection; and, if so, (2) whether LDHH’s

violation of the statute deprived the recipient of a right secured

by federal statute for which he may bring an action for redress

under 42 U.S.C. § 1983.

I.

A.

The plaintiff, S.D., a sixteen-year-old Medicaid recipient,

is afflicted with spina bifida, a congenital defect characterized

by imperfect closure of the spinal column. Because of his birth

defect, S.D. has total bowel and bladder incontinence and does not

have sensation below his waist. Thus, he cannot sense potentially

infectious skin irritations resulting from incontinence. S.D. also

has two club feet and has trouble walking. He requires leg braces,

forearm crutches, and a swing gate to move over short distances.

He requires a wheelchair to move over long distances.

As an infant, S.D. was placed in foster care. He was adopted

by his parents, and he receives Medicaid benefits pursuant to a

2
federal policy to encourage the adoption of special needs children.

He is a qualified recipient of Medicaid’s EPSDT program, under

which states provide, in accordance with federal law, screening,

diagnosis and treatment services to individuals under age twenty-

one. Before S.D. moved to Louisiana with his family, he was

provided with disposable incontinence underwear by the Virginia

Medicaid program.

In 2002, S.D.’s Louisiana physician, Dr. Ernest Edward Martin,

Jr., Chairman of the Department of Family Medicine of the Ochsner

Clinic, prescribed disposable incontinence underwear as health care

that is necessary to ameliorate S.D.’s mental and physical

conditions. Specifically, Dr. Martin concluded that the

prescription of such underwear “was physically necessary because it

draws moisture away from the skin which prevents chronic irritation

and infection from urine wetness.” R. 191. According to Dr.

Martin, “[t]his protection is especially important due to S.D.’s

lack of sensation below the waist. Because of this lack of

sensation, S.D. would not be aware if he developed an infection and

an infection could then progress quickly.” Id. Finally, Dr.

Martin determined that without such a prescription, S.D. would be

home bound, isolated, and unable to attend school or engage in

other age-appropriate activities. Thus, the prescription was

necessary from a mental health standpoint as well. S.D. submitted

a claim for medical assistance for the cost of the prescription to

LDHH under the Louisiana State Medicaid Plan.
3
 LDHH denied S.D.’s claim stating that “the appliance,

equipment, supplies or service is available through another

agency,”1 “the item is not considered medically necessary” and that

it was a “non-medical supply not covered by Medicaid.” S.D.

appealed administratively. The state administrative law judge ruled

in favor of LDHH without referring to the Medicaid EPSDT

provisions. Rather, the administrative law judge concluded that

LDHH properly denied coverage because “diapers” are “specifically

excluded from coverage” under the Louisiana State Medicaid Plan.

S.D. brought this action in the district court against LDHH

under 42 U.S.C. § 1983 seeking injunctive and declaratory relief.

On cross motions for summary judgment, the district court granted

S.D.’s motion and denied that of LDHH. The district court concluded

that under the Medicaid Act’s EPSDT program a qualified recipient

is entitled to the health care, services, treatment and other

measures described in § 1396d(a) of the Act when such care or

services are necessary for corrective or ameliorative purposes; the

EPSDT provisions of the Medicaid Act create rights enforceable by

§ 1983; and LDHH deprived S.D. of his federal right to EPSDT

benefits in violation of the Medicaid Act. Accordingly, the

district court rendered summary judgment declaring that S.D. is

entitled to medical assistance for the prescribed disposable

incontinence underwear under the EPSDT program and ordering LDHH to

1
On appeal, LDHH concedes that this reason for denial
appears to have been in error. LDHH First Br. p. 2.
4
provide medical assistance to S.D. for that purpose. LDHH appealed.

We review the district court’s decision de novo, both because

it is a summary judgment, and because it requires us to answer

issues of statutory interpretation. See Hodges v. Delta Airlines,

Inc., 44 F.3d 334, 335 (5th Cir. 1995) (en banc); Ott v. Johnson,

192 F.3d 510, 513 (5th Cir. 1999). Summary judgment is appropriate

only when the record indicates “no genuine issue as to any material

fact and that the moving party is entitled to judgment as a matter

of law.” Fed. R. Civ. P. 56. Because there is no dispute as to any

material issue of fact in this appeal, our review is limited to

whether the plaintiff is entitled to judgment as a matter of law.

B.

Medicaid is a cooperative federal-state program through which

the federal government provides financial aid to states that

furnish medical assistance to eligible low-income individuals. See

42 U.S.C. § 1396 et seq.; see also Atkins v. Rivera 477 U.S. 154,

156 (1986); Louisiana v. United States Dep’t. of Health and Human

Servs., 905 F.2d 877, 878 (5th Cir. 1990). States electing to

participate in the program must comply with certain requirements

imposed by the Act and regulations of the Secretary of Health and

Human Resources. See Evergreen Presbyterian Ministries, Inc. v.

Hood, 235 F.3d 908, 915 (5th Cir. 2000) (“The [Medicaid] program is

voluntary; however, once a state chooses to join, it must follow

the requirements set forth in the Medicaid Act and in its

5
implementing regulations.”) The Secretary has delegated his federal

administrative authority to the Centers for Medicare and Medicaid

Services (“CMS”), an agency within the Department of Health and

Human Services. See Louisiana v. United States Dep’t of Health and

Human Servs., 905 F.2d at 878.2

To qualify for federal assistance, a state must submit to the

Secretary and have approved a “state plan” for “medical

assistance,” 42 U.S.C. § 1396a(a), that contains a comprehensive

statement describing the nature and scope of the state’s Medicaid

program. 42 CFR § 430.10 (1989). “The state plan is required to

establish, among other things, a scheme for reimbursing health care

providers for the medical assistance provided to eligible

individuals.” Wilder v. Virginia Hosp. Ass’n, 496 U.S. 498, 502

(1990).

The Medicaid Act defines “medical assistance” as “payment of

part or all of the cost of...care and services” included in an

enumerated list of twenty-seven general health care categories

(“medical assistance categories”). 42 U.S.C. § 1396d(a). Some of

the categories must be included within state plans (mandatory

categories) while others may be included at the option of the state

2
Prior to July, 2001, CMS was known as the Health Care and
Financing Administration (“HCFA”). See Department of Health and
Human Services Reorganization Order, 66 Fed. Reg. 35437 (July 5,
2001). For consistency, this opinion will refer to the agency as
CMS, even when referring to the period when it was still
designated as HCFA.

6
(optional categories). 42 U.S.C. § 1396a(a)(10)(A).

The Act requires that each state plan provide EPSDT health

care and services as a mandatory category of medical assistance.

The Act describes EPSDT as “early and periodic screening,

diagnostic, and treatment services (as defined in subsection (r) of

this section) for individuals who are eligible under the plan and

are under the age of twenty-one;”. 42 U.S.C. §§ 1396a(a)10(A),

1396d(4)(B). Subsection (r) further defines EPSDT services as,

inter alia, “[s]uch other necessary health care, diagnostic

services, treatment, and other measures described in [§ 1396d(a)]

to correct or ameliorate defects and physical and mental illnesses

and conditions discovered by the screening services, whether or not

such services are covered under the State plan.” 42 U.S.C. §

1396d(r)(5).

Thus, EPSDT is a comprehensive child health program designed

to assure the availability and accessibility of health care

resources for the treatment, correction and amelioration of the

unhealthful conditions of individual Medicaid recipients under the

age of twenty-one. See CMS State Medicaid Manual § 5010.B

[hereinafter “SMM”]. A principal goal of the program is to

“[a]ssure that health problems found are diagnosed and treated

early, before they become more complex and their treatment more

costly.” Id.

Louisiana’s State Medicaid Plan was approved by CMS. As part

7
of its state plan, Louisiana proposed and CMS approved the

provision of the optional medical assistance category of “home

health care services” to Louisiana’s general adult Medicaid

population. See 42 U.S.C. § 1396d(a)(7). Additionally, Louisiana

proposed and CMS approved a “payment program” which excludes

certain medical supplies from the “home health care services” made

available to the general adult Medicaid population.3 The parties

agree that the “payment program” exclusion implicitly disallows

payment for disposable incontinence underwear for adult recipients

over the age of twenty-one. The Louisiana state plan approved by

CMS does not, however, explicitly or implicitly, exclude the

prescription of incontinence supplies from the EPSDT benefits

which must be provided to EPSDT children, i.e., recipients under

the age of twenty-one qualified for the EPSDT program.4

In its appeal, LDHH does not challenge the district court’s

determinations that (1) S.D. is eligible for coverage by the EPSDT

program, (2) S.D. has physical and mental illnesses and conditions

3
In a section of the state plan describing reimbursement
rates and methods for the home health care services provided
under the plan, the plan states that all covered medical supplies
will be reimbursed through the durable medical equipment program.
The state plan further provides that “[d]iapers and blue pads are
not reimbursable as durable medical equipment items.”
4
The exclusion, described in the preceding footnote, does
not mention the EPSDT program. Payments provided under the EPSDT
program, and the scope of services provided under that program,
are described in other sections of the state Medicaid plan.
Those sections do not contain an exclusion for incontinence
supplies.

8
caused by permanent bowel and bladder incontinence resulting from

an irreparable birth defect of spina bifida, and that, (3) the

medical prescription of disposable incontinence underwear is a

health care, service, treatment, or measure necessary to correct or

ameliorate S.D.’s unhealthful physical and mental conditions

discovered by the screening services. Thus, there is no factual or

legal dispute as to the conclusions that S.D. is eligible to

receive EPSDT services and that the medical assistance for the

prescription of disposable incontinence underwear he seeks is

necessary to ameliorate his unhealthful conditions discovered by

screening within the terms of the EPSDT program.

LDHH contends, however, that, despite the necessity of the

prescription of incontinence underwear to the amelioration of

S.D.’s condition, the denial of S.D.’s claim should be reinstated

because: (1) The district court overstated the scope of the EPSDT

mandate by adopting the “convenient shorthand” or “erroneous

assumption” that a state is required to provide EPSDT children with

any service that could be provided for in a state plan, even if the

service is not one that the state has elected to provide; (2) The

medical prescription of disposable incontinence underwear, although

necessary to ameliorate S.D.’s condition for ESPDT purposes, does

not constitute a health care, service, treatment or measure

“described in Section 1396d(a)” of the Act; (3) Louisiana’s State

Medicaid Plan, as approved by CMS, excludes incontinence supplies

9
from coverage under the EPSDT program; (4) LDHH had the implied

authority or discretion to exclude this type of health care or

service without the approval of CMS; and (5) Section 1983 of Title

42, which affords a cause of action for the “deprivation of any

rights . . . secured by [federal] laws,” does not provide S.D. with

a right of action to sue LDHH because the provisions of the

Medicaid Act upon which S.D. relies does not create an enforceable

“right” within § 1983's meaning.

II.

LDHH sets the stage for all of its arguments by contending

that the district court’s decision was based on the “erroneous

assumption” or “convenient shorthand” that the EPSDT mandate

requires a state to provide eligible children with any health care,

service, treatment or other measure that could be provided for in

its state plan, even if the health care or service is not one that

the state has elected to provide. LDHH conveniently omits a

crucial part of the district court’s holding, however, because that

court said, as does the statute, that states participating in

Medicaid are required to provide medical assistance under the EPSDT

program only for health care, services, treatments and other

measures (1) described in § 1396d(a), that are (2) necessary to

correct or ameliorate defects and physical or mental illnesses and

10
conditions discovered by the screening services.5 Moreover, LDHH

has failed to demonstrate how the statute appropriately may be

construed more narrowly in view of its plain words, legislative

history, authoritative interpretation by CMS, and the consonant

decisions of four other federal Circuits. Nevertheless, in order

to avoid confusion and provide a firm foundation for addressing the

issues, we will set forth our understanding of the nature and scope

of the EPSDT mandate.

In determining the meaning of the Medicaid Act’s EPSDT

provisions, the starting point is the language of the statute

itself. United States v. Ron Pair Enters., Inc., 489 U.S. 235, 241

(1989)( citing Landreth Timber Co. V. Landreth, 471 U.S. 681, 685

(1985)). Section 1396a(a)(10) provides that a state plan for

medical assistance must make available to all qualified individuals

“the care and services listed in” § 1396d(a)(4). Section

1396d(a)(4)(B) provides that “medical assistance” means payment of

5
LDHH’s First Br. P.11-12. LDHH further mischaracterizes
the district court’s decision as holding “that a State must
provide children with any and all services for which it could
receive FFP [, i.e., federal financial participation].” LDHH
First Brief p. 12. LDHH then proceeds to list a variety of
Medicaid services, not described in 42 U.S.C. § 1396d(a), for
which FFP is available. The district court decision does not
address non-§ 1396d(a) FFP, however, but quite correctly decides
the issue raised by this case, viz., whether the prescription of
disposable incontinence underwear necessary for EPSDT corrective
or ameliorative purposes is “described in” 42 U.S.C. § 1396d(a).
See Order and Reasons of district court at 9, 16 (E.D. La #02-
CV-2164) (December 5, 2002). The subject of “FFP” for services
outside the scope of § 1396d(a) is simply irrelevant and LDHH’s
argument regarding it is nothing more than a distraction.

11
part or all of the “cost of the following care and services” for

individuals: “early and periodic screening, diagnostic, and

treatment [EPSDT] services (as defined in subsection (r) of this

section) for individuals who are eligible under the plan and are

under the age of twenty-one[.]” Section 1396d(r), in pertinent

part, provides that “[t]he term ‘early and periodic screening,

diagnostic, and treatment services’ means the following items and

services: ....(5) Such other necessary health care, diagnostic

services, treatment, and other measures described in subsection (a)

of this section to correct or ameliorate defects and physical and

mental illnesses and conditions discovered by the screening

services, whether or not such services are covered under the State

plan.” 42 U.S.C. § 1396d(r)(5).

The crucial phrases of § 1396d(r)(5) provide that EPSDT care

and services include: (1) “health care, diagnostic services,

treatment, and other measures described in [§ 1396d(a)]”

(2)“necessary... to correct or ameliorate...conditions discovered

by the screening services” (3) “whether or not such services are

covered under the State plan.” The natural reading of §

1396d(r)(5)’s phrases is that all of the health care, services,

treatments and other measures described by § 1396d(a) must be

provided by state Medicaid agencies when necessary to correct or

ameliorate unhealthful conditions discovered by screening,

regardless of whether they are covered by the state plan. This

12
reading is also required by the grammatical structure of §

1396d(r)(5). The medical assistance made available to EPSDT

children must be for health care described in the list of twenty-

seven categories set forth in § 1396d(a)-modified by the

requirement that it must be necessary for corrective or

ameliorative EPSDT purposes-further modified by the statutory

mandate that it must be provided whether or not it is covered under

the state plan. The language and structure Congress used cannot be

read in any other way without rendering the crucial phrases

meaningless.

The plain meaning of statutes is conclusive, except in the

“rare cases [in which] the literal application of a statute will

produce a result demonstrably at odds with the intentions of its

drafters.” Griffin v. Oceanic Contractors, Inc., 458 U.S. 564, 571

(1982). This is not one of those rare cases because the Act, as

literally applied, is fully consistent with the intent of its

drafters.

The EPSDT program was added to the Medicaid Act in 1967. Under

the original EPSDT provision, all Medicaid-eligible individuals

under age twenty-one were entitled to “such early and periodic

screening and diagnosis...to ascertain their physical or mental

defects, and such health care, treatment, and other measures to

correct or ameliorate defects and chronic conditions discovered

thereby, as may be provided in regulations of the Secretary.”

13
(emphasis added) Pub.L.90-248, 81 Stat. 929, codified at §

1396d(a)(4)(U.S. Code 1988 edition). Congress thus initially

authorized the Secretary to make regulations providing for

treatment and health care measures to correct or ameliorate defects

and chronic conditions. The Secretary promulgated regulations

which provided for care and treatment that he designated as

“discretionary services” and provided that a state plan “may

provide for any other medical or remedial care” defined as medical

assistance by the Act. See 42 CFR § 441.57.

By 1989 Congress had become concerned that, because the

original EPSDT health care, services and treatment provision was

optional and not described in detail in the statute, many states

had chosen not to provide EPSDT-eligible children all the care and

services allowable under federal law. See Senate Finance Committee

Report, 135 Cong. Rec. 24444 (Oct. 12, 1989) (“The EPSDT benefit

package has never been described in detail in the statute. . . .

Additionally, while states have always had the option to do so,

many still do not provide to children participating in EPSDT all

care and services allowable under federal law, even if not

otherwise included in the state’s plan.”) Congress therefore

amended the Act in 1989 to mandate that a state agency must provide

EPSDT-eligible children “[s]uch other necessary health

care...described in [the Act’s § 1936d(a) definition of “medical

assistance”] to correct or ameliorate defects . . . illnesses and

14
conditions discovered by the screening services, whether or not

such services are covered under the State plan.” 42 U.S.C. §

1396d(r)(5) (emphasis added). Consequently, Congress in the 1989

amendment imposed a mandatory duty upon participating states to

provide EPSDT-eligible children with all the health care, services,

treatments and other measures described in § 1396d(a) of the Act,

when necessary to correct or ameliorate health problems discovered

by screening, regardless of whether the applicable state plan

covers such services.

Furthermore, the Senate Finance Committee noted that the 1989

amendments “require that states provide to children all treatment

items and services that are allowed under federal law and that are

determined to be necessary . . . even if such services are not

otherwise included in the State's plan.” 135 Cong. Rec. S13234

(Oct. 12, 1989) (emphasis added); See also 135 Cong. Rec. S6900

(June 19, 1989)(statement of Sen. Chafee) (Under amendment

“Medicaid would cover any medically necessary service identified as

necessary through the EPSDT program”); H.R. Conf. Rep. 101-386, at

453 (1989) (amendment would require States “to provide any service

that a State is allowed to cover with Federal matching funds under

Medicaid that is required to treat a condition identified during a

screen, whether or not the service is included in the State's

Medicaid plan.”) Thus, the text of the statute and its legislative

history demonstrate that states participating in the Medicaid

15
program must provide all of the health care and services permitted

under § 1396d(a) when necessary to correct or ameliorate a defect

or condition discovered by screening.

Accordingly, every Circuit which has examined the scope of the

EPSDT program has recognized that states must cover every type of

health care or service necessary for EPSDT corrective or

ameliorative purposes that is allowable under § 1396d(a). See

Collins v. Hamilton, 349 F.3d 371, 376, n.8 (7th Cir. 2003) (“a

state’s discretion to exclude services deemed ‘medically necessary’

. . . has been circumscribed by the express mandate of the

statute”); Pittman by Pope v. Sec’y, Fla. Dep’t of Health & Rehab.,

998 F.2d 887, 892 (11th Cir. 1993)(1989 amendment adding §

1396d(r)(5) took away any discretion state might have had to

exclude organ transplants from the treatment available to

individuals under twenty-one); Pediatric Specialty Care, Inc. v.

Ark. Dep’t of Human Services, 293 F.3d 472, 480-81 (8th Cir. 2002)

(state must provide EPSDT coverage for “early intervention day

treatment” as part of § 1396(a)(13)’s “rehabilitative services”

category because program was structured to ameliorate conditions

and strengthen skills children learn in therapy); Pereira v.

Kozlowski, 996 F.2d 723, 725-26 (4th Cir. 1993) (“[i]n section

1396d(r)(5), the Congress imposed upon the states, as a condition

of their participation in the Medicaid program, the obligation to

provide to children under the age of twenty-one all necessary

16
services, including transplants.”)

CMS, the federal agency charged with the responsibility of

administering the Medicaid Act, also recognizes that under the

EPSDT mandate states are required to provide any service which can

be provided under § 1396d(a) if such service is necessary to

correct or ameliorate a defect, illness or condition identified by

screening. In the State Medicaid Manual, the “official medium by

which [CMS] issues mandatory, advisory, and optional Medicaid

policies and procedures to the Medicaid State agencies,”6 CMS

explains:

OBRA 89 amended §§ 1902(a)(43) and 1905(a)(4)(B) and

created §1905(r) of the Social Security Act (the Act)

which set forth the basic requirements of the program.

Under the EPSDT benefit....the Act requires that any

service which you are permitted to cover under Medicaid

that is necessary to treat or ameliorate a defect,

physical and mental illness, or a condition identified by

6
SMM, Foreword. Although not entitled to Chevron deference,
relatively informal CMS interpretations of the Medicaid Act, such
as the State Medicaid Manual, are entitled to respectful
consideration in light of the agency’s significant expertise, the
technical complexity of the Medicaid program, and the
exceptionally broad authority conferred upon the Secretary under
the Act. Wis. Dep't of Health & Family Servs. v. Blumer, 534
U.S. 473, 497 (2002) (citing United States v. Mead Corp., 533
U.S. 218 (2001); Thomas Jefferson Univ. v. Shalala, 512 U.S. 504,
512 (1994); Schweiker v. Gray Panthers, 453 U.S. 34, 43-44
(1981)).

17
 a screen, must be provided to EPSDT participants

regardless of whether the service or item is otherwise

included in your Medicaid plan.

CMS State Medicaid Manual (“SMM”) § 5110 (1990)(emphasis added).

Thus, according to CMS “[t]he law requires the provision of the

services needed by EPSDT clients if the services can be covered

under the Medicaid program.” Id., § 5340 (emphasis added).

Accordingly, CMS interprets the Act to allow a state Medicaid

agency to fix or adjust the amount, duration and scope of services

provided under the EPSDT benefit only if that regulation “comports

with the requirements of the statute that all services included in

[§ 1396d(a)] of the Act that are medically necessary to ameliorate

or correct defects and physical or mental illnesses and conditions

discovered by the screening services are provided.”7 SMM § 5122.

Moreover, the agency construes the statute to require that any

limitation imposed must permit and afford services “sufficient to

achieve their [EPSDT] purpose (within the context of serving the

7
SMM § 5122, in pertinent part, provides: “42 CFR 440.230
allows you to establish the amount, duration and scope of
services provided under the EPSDT benefit. Any limitations
imposed must be reasonable and services must be sufficient to
meet their purpose (within the context of serving the needs of
individuals under twenty-one). You may define the service as
long as the definition comports with the requirements of the
statute in that all services included in [§ 1396d(a)] that are
medically necessary to ameliorate or correct defects and physical
or mental illnesses and conditions discovered by the screening
services are provided.”

18
needs of individuals under the age of twenty-one).” Id.

Consequently, under the CMS interpretation, a state Medicaid agency

may regulate the amount, duration and scope of medical assistance

provided, but its regulation must comply with the statutory

requirement that all health care and services described in §

1396d(a) that are necessary to the corrective and ameliorative

purposes of the EPSDT program must be provided.

On the contrary, appellate counsel for LDHH contend that the

twenty-seven health care and service categories enumerated in §

1396d(a) are only hollow forms that each state may fill with as few

or as many types of health care, treatment, services and measures

as it deems appropriate. Their rationale is that: (1) Section

1396d(a) “is a definitional statute describing the components of

‘medical assistance.’” (2) “By citing to these definitions, the

EPSDT benefit incorporates them as and to the extent they have been

described by Congress in the statute.” (3) “Therefore, EPSDT

entitles Medicaid recipients to what is provided for in section

[1396d(a)], but does not dictate the precise content of

each...category of service.” (4) Thus, “[t]he EPSDT benefit

described in Section [1396d(r)], while broad, does not undermine

the State’s authority and discretion to establish reasonable

standards . . . for determining eligibility for and the extent of

19
medical assistance under the plan.”8

The interpretation proffered by LDHH counsel conflicts

sharply with the Congressional intent of the 1989 EPSDT amendment

as expressed simply and clearly by its plain words, legislative

history, CMS interpretations, and as recognized by the federal

Circuits by which it has been considered. According to its words,

a principal goal of the 1989 amendment is to correct or ameliorate

the defects, illnesses and conditions of EPSDT children discovered

by the screening services. The means to be used for this purpose

are also clear: health care, diagnostic services, treatment, and

other measures described in § 1396d(a). Equally plain is the

criterion for the application of these means: the health care

requested must be necessary to “correct or ameliorate” an eligible

EPSDT child’s defect, illness or condition. 42 U.S.C. §

1396d(r)(5). Furthermore, the legislative history demonstrates

Congress intended the health care and treatment available under

the EPSDT program to be made more accessible and effective by:

removing the Secretary’s express authority to define the means and

the standards for its operation; placing the goal, means and

standards in the statute itself; and by imposing an obligatory,

8
LDHH first brief p.21. Most of LDHH’s brief ostensibly
directed to statutory construction actually presents its
appellate counsel’s post hoc rationalizations of a discretionary
basis for the agency’s action. For the reasons stated in part IV.
of this opinion, we conclude that those reasons cannot provide
justification for LDHH’s denial of S.D.’s statutory right.

20
not discretionary, duty on states to effectuate this aspect of the

EPSDT program “whether or not such services are covered under the

State plan.” 42 U.S.C. § 1396d(r)(5).

Thus the plain words of the statute and the legislative

history make evident that Congress intended that the health care,

services, treatment and other measures that must be provided under

the EPSDT program be determined by reference to federal law, not

state preferences. The 1989 amendment was clearly a response to

the disappointing performance of the EPSDT treatment function as

optional and within each state’s discretion. We reject the notion

of LDHH’s counsel that Congress made the provision of such

treatment mandatory on the states only to cede to the states

complete discretion to decide upon the contents of the twenty-

seven medical assistance categories purportedly made available to

EPSDT eligible children.

All of this is confirmed by the interpretations of CMS. CMS

regulations interpret and implement § 1396d(a) in highly detailed

specific definitions of the supposedly hollow health care

categories. See 42 CFR §§440.1—440.185 (2003). CMS does not

interpret the enumerated health care categories as empty vessels

to be filled according to the states’ discretion. Instead, CMS

construes the twenty-seven categories to have definite substantive

content.

Furthermore, CMS interprets the Act to require that any

21
service a state is permitted to cover under Medicaid that is

necessary to treat or ameliorate a defect, physical and mental

illness, or condition identified by a screen, must be provided to

EPSDT participants regardless of whether the service or item is

otherwise included in the state Medicaid plan. SMM § 5110. Thus,

LDHH counsel’s argument that, for purposes of the EPSDT program,

states are merely required to recognize the twenty-seven medical

assistance categories and fill them with as few or as many types

of health care and services as the states, within their

discretion, see fit is completely inconsistent with CMS’s

interpretation of the EPSDT statutory provisions.

As already related, the federal Circuits that have analyzed

the 1989 ESPDT amendment agree that Congress did not grant or

allow states the discretion to define what types of health care

and services would be provided to ESPDT children, and that

participating states must provide all services within the scope of

§ 1396d(a) which are necessary to correct or ameliorate defects,

illnesses, and conditions in children discovered by the screening

services. Collins v. Hamilton, 349 F.3d 371, 374 (7th Cir. 2003)

(state must provide long term residential treatment to EPSDT

recipients under the “inpatient psychiatric hospital services”

category; state cannot choose to limit category to acute

services); Pittman by Pope v. Sec’y, Fla. Dep’t of Health &

Rehab., 998 F.2d 887, 892 (11th Cir. 1993)(state cannot exclude

22
organ transplants, which are not specifically listed in §

1396d(a), from the health care, services, treatment and other

measures available under the EPSDT program); Pediatric Specialty

Care, Inc. v. Ark. Dep’t of Human Services, 293 F.3d 472, 480-81

(8th Cir. 2002) (state must provide EPSDT medical assistance for

“early intervention day treatment” as part of § 1396(a)(13)’s

“other diagnostic, screening, preventive, and rehabilitative

services” category).

As inspiration for its EPSDT “hollow categories” theory, LDHH

draws only upon the anomalous opinion in Salgado v. Kirschner, 878

P.2d 659, 663 (Ariz. 1994), which devised the theory in dictum in

a non-EPSDT case. Aside from its conflict with all federal

authority, the Salgado court demonstrated a fundamental

misunderstanding of the EPSDT benefit when it stated that “the

special treatment § 1396d(r) accords to persons under twenty-one

are for services directly related to their status as young

persons: basically well-baby and adolescent care.” Id. at 665.

Although the EPSDT program includes youth-related services,

nothing in the statute, its legislative history or CMS

interpretations supports such a restrictive construction of the

EPSDT benefit. In fact, many of the services provided under the

EPSDT program are quite obviously not related to the recipient’s

status as a young person. For example, family planning services,

pre-natal care, and smoking-cessation drug therapy are all

23
provided under the EPSDT program and yet are not applicable only

to youthful recipients. See SMM § 5124(3); CMS Letter to State

Medicaid Directors, Jan. 5, 2001.9 Accordingly, we are not

persuaded by the reasoning of the Salgado Court. See also Leanne

E. Dodds-Eastman, Note, Salgado v. Kirschner: May Arizona Deny

Life-sustaining Organ Transplant Coverage to Adult Medicaid

Recipients under the Federal Medicaid Statute?, 27 Ariz. St. L.J.

251, 263 (1995)(concluding that the Salgado court misinterpreted

the EPSDT statutory mandate.)

For these reasons, we conclude that a state Medicaid agency

must provide, under the EPSDT program, (1) any medical assistance

that a state is permitted to cover under § 1396d(a) of the

Medicaid Act, that is (2) necessary to correct or ameliorate

defects and physical and mental illnesses and conditions

discovered by screening.

III.

Because LDHH does not challenge the district court’s

determination that, for purposes of the EPSDT benefit, the medical

prescription of disposable incontinence underwear is necessary to

ameliorate conditions caused by S.D.’s spina bifida and total

bowel and bladder incontinence, we next address whether this type

9
available at
http://www.cms.hhs.gov/states/letters/smd01051.asp.

24
of medical assistance is “described in” § 1396d(a). As LDHH

acknowledges, this question is “the heart of this case[.]” LDHH

Reply Br., p. 8.

The Medicaid Act does not directly address the question of

whether medically prescribed incontinence supplies are included

within the “home health care services” category of medical

assistance, as argued by the plaintiffs and apparently determined

by the district court. Therefore, we follow the decision of the

Supreme Court in Chevron, U.S.A. v. Natural Resources Defense

Council, Inc., 467 U.S. 837 (1984) by looking first to the

regulations of CMS that interpret the statute. In Chevron, the

Court held that:

“When a court reviews an agency’s construction of the statute

which it administers[, and determines] that Congress has not

directly addressed the precise question at issue, the court does

not simply impose its own construction on the statute, as would be

necessary in the absence of an administrative interpretation.

Rather, if the statute is silent or ambiguous with respect to the

specific issue, the question for the court is whether the agency’s

answer is based on a permissible construction.” Id., 843

(footnotes omitted); See Texas v. United States Dep’t Health &

Human Serv., 61 F.3d 438, 440 (5th Cir. 1995)(following Chevron in

evaluating the agency’s interpretation of the Medicaid statute).

25
 “The power of an administrative agency to administer a

congressionally created...program necessarily requires the

formulation of policy and the making of rules to fill any gap

left, implicitly or explicitly, by Congress.” Chevron, supra, 467

U.S. at 843 (quoting from Morton v. Ruiz, 415 U.S. 199, 231

(1974)). The Supreme Court has long recognized that considerable

weight should be accorded to an executive department’s

construction of a statutory scheme it is entrusted to administer.

Id., 844 (citing eleven of its decisions from Edwards’ Lessee v.

Darby, 12 Wheat. 206, 210, 6 L.Ed. 603 (1827) to Blum v. Bacon,

457 U.S. 132, 141 (1982)); accord White v. United States, 143 F.3d

232, 237 (5th Cir. 1998); Sykes v. Columbus & Greenville Railway,

117 F.3d 287, 295 (5th Cir. 1997).

CMS has promulgated a regulation, codified as 42 CFR §

440.70, which provides, in pertinent parts, that “[h]ome health

services include...[m]edical supplies, equipment, and appliances

suitable for use in the home...[when provided to a recipient at]

his place of residence....” Further, 42 CFR § 441.15, in relevant

part, provides: “With respect to the services defined in §

440.70...a State plan must provide that—(a) Home health services

include, as a minimum....(3) Medical supplies, equipment, and

appliances.” In light of the well settled principles reaffirmed by

Chevron, we conclude that the agency’s interpretation of “home

health care services” as including “medical supplies,” when used

26
under the circumstances specified in its regulation, is clearly a

permissible statutory construction.10

We have consistently held that a regulation should be

construed to give effect to the natural and plain meaning of its

words. Lara v. Cinemark USA, Inc., 207 F.3d 783, 787 (5th Cir.

2000); United States v. Raymer, 876 F.2d 383, 389 (5th Cir. 1989);

Alabama Air Pollution Comm’n v. Republic Steel Corp., 646 F.2d

210, 213 (5th Cir. 1981); Diamond Roofing, Inc. v. Occupational

Safety and Health Review Comm’n, 528 F.2d 645, 649 (5th Cir.

1976). Giving effect to the natural and plain meaning of the

term “medical supplies” in the context of this case, we find that

such medical supplies reasonably include the incontinence supplies

medically prescribed for S.D.11

10
LDHH initially argues that “disposable incontinence
supplies” may not be paid for as part of medical assistance
defined by § 1396d(a) because they are not listed verbatim in
that section; and that the only “supplies” listed in the section
are in § 1396d(a)(12): prescribed drugs, dentures, prosthetic
devices, and eye glasses. LDHH First Brief 13. Two pages later,
however, LDHH acknowledges that the CMS regulation implementing
the Act provides that “home health care services” includes
“medical supplies...suitable for use in the home,” although they
are not listed in the statute. Id., 15
11
“Home health care services” is not strictly limited to
items or services that are used exclusively within the interior
of the recipient’s home. The applicable regulation notes only
that home health care services cannot be provided at “a hospital,
nursing facility, or intermediate care facility for the mentally
retarded.” 42 C.F.R. § 440.70(c). No other restrictions are
placed on the location at which they are provided or used. In
addition, at least one other circuit has noted that limiting the
provision of home health services to services provided inside the

27
 More importantly, CMS has approved state Medicaid plans that

expressly provide incontinence supplies under the home health care

category of medical assistance.12 This demonstrates that CMS

home “ignores the consensus among health care professionals that
community access is not only possible but desirable for disabled
individuals.” Skubel by Skubel v. Fuoroli, 113 F.3d 330, 336 (2d
Cir. 1997). Thus, in Skubel, the court determined that nursing
services provided under the home health care medical assistance
category cannot be limited to services provided inside the
recipient’s home. Id.
12
Because the term “medical supplies” reasonably includes
medically prescribed incontinence supplies, state plans need not
enumerate such items in order to provide them under the home
health care category of medical assistance. Six states, however,
expressly mention the items in their approved state plans either
to note restrictions placed upon the benefit or as part of an
enumerated list of items available under a specific payment
program. Specifically, Montana’s plan notes that it provides
diapers, limiting recipients to the nearest package size over 180
diapers per month; Idaho provides incontinence supplies, noting
that “[i]ncontinent supplies will only be purchased for persons
over the age of four years of age. Disposable diapers are
restricted in number to 240 per month. Disposable underpads are
restricted to 150 per month[;] any request for incontinent
supplies above these amounts must have prior approval by the
Department.” Michigan provides diapers and selected incontinence
supplies under its home health care services program as long as
the supplies are obtained from the state’s contractor; Virginia
provides incontinence supplies, noting only that
“[p]reauthorization is required for incontinence supplies
provided in quantities greater than two cases per month.”
Arkansas provides a more detailed explanation, noting that
“[d]iapers/underpads are limited to $130.00 per month, per
recipient. The $130.00 benefit limit is a combined benefit limit
for diapers/underpads provided through the Prosthetics Program
and Home Health Program. The benefit limit may be extended with
proper documentation. Only patients with a medical diagnosis
other than infancy which results in incontinence of the bladder
and/or bowel may receive diapers. This coverage does not apply
to infants who would otherwise be in diapers regardless of their
medical condition. Providers cannot bill for underpads/diapers
if a recipient is under the age of three years.” Missouri’s plan
states that EPSDT eligible recipients are eligible for certain

28
interprets the § 1396d(a)(7) “home health care services” category

as appropriately covering incontinence supplies under its

construction of the statute. See 42 CFR § 440.70. As the agency

entrusted with the administration of the Medicaid statute, CMS is

required to determine that each state plan is in conformity with

the specific requirements of the Medicaid act. See §1396a(b); 42

CFR 430.10; 430.15; Cmty. Health Ctr. v. Wilson-Coker, 311 F.3d

132, 134 (2d Cir. 2002)(CMS “reviews each plan to assure that it

complies with a long list of federal statutory and regulatory

requirements”); Rite Aid of Penn. v. Houstoun, 171 F.3d 842, 847

(3d Cir. 1999)(“federal statutes and regulations establish the

criteria for [CMS] to make its decision” to approve or disapprove

a state plan). The agency’s review and determination definitively

indicate whether it interprets a state plan or amendment to be in

conformity with the statute. For example, CMS on many occasions

has disapproved proposed state plans or programs because they were

outside the scope of the Act. Texas v. United States Dep’t of

Health and Human Servs., 61 F.3d 438, 441-42 (5th Cir.

1995)(upholding rejection of Texas state plan amendment because it

provided chemical dependency services outside scope of Medicaid

Act); Okla. v. Shalala, 42 F.3d 595, 598 (10th Cir.

durable medical equipment, including diapers. Maryland includes
“incontinency pants and disposable underpads” as part of its
durable medical equipment program. Wisconsin notes that it
provides “disposable diapers” as a disposable medical supply.

29
1994)(discussing the disapproval of Oklahoma’s plan); New Mexico

Dep't of Human Servs. v. Dep’t of Health & Human Servs., 4 F.3d

882, 884 (10th Cir. 1993) (reviewing disapproval of amendment to

New Mexico State Medicaid Plan); New York v. Sullivan, 894 F.2d

20, 24 (2d Cir. 1990) (discussing the disapproval of New York’s

plan); Ohio Dep’t of Human Servs. v. United States Dep’t of Health

& Human Servs., 862 F.2d 1228, 1229 (6th Cir. 1988)(reviewing the

disapproval of Ohio’s plan).

CMS’s approval of state plans affording coverage for the

provision of incontinence supplies as a proper cost of home health

care services demonstrates that the agency construes § 1396d(a)(7)

as encompassing that type of medical care or service.13 See Pharm.

Research and Mfrs. Am. v. Thompmson, 362 F. 3d 817, 821-22 (D.C.

Cir. 2004) (CMS interpretation of relevant statutory provisions,

as embodied in its approval of state Medicaid plans, is entitled

to Chevron deference); Texas v. United States Dep’t of Health &

13
LDHH contends that determining what is “described in” a
medical assistance category by reviewing the services that CMS
has approved as falling within that category permits other states
to dictate the scope of services that must be provided under
Louisiana’s EPSDT program. LDHH Reply Br. 10. This argument
lacks merit. Each state plan must be approved by CMS and CMS
reviews state plans to ensure conformity with the Medicaid Act.
CMS’s approval of a state plan is therefore an implicit
interpretation of the Act. Thus, the Act itself, as interpreted
by CMS (subject to judicial review), dictates the scope of
services that must be provided under the EPSDT program, not mere
proposals of plans or plan amendments by the states. See Pharm.
Research and Mfrs. America v. Thompmson, 362 F. 3d 817, 821-22
(D.C. Cir. 2004).

30
Human Servs, 61 F.3d at 440 (according Chevron deference to CMS

denial of state plan amendment); Indiana Ass’n Homes for Aging

Inc. v. Ind. Office of Med. Policy & Planning, 60 F.3d 262, 266

(7th Cir. 1995)(reviewing approved state plan amendment with

deference); Pinnacle Nursing Home v. Axelrod, 928 F.2d 1306, 1313

(2d Cir. 1991)(same). Accordingly, we conclude that incontinence

supplies are described in the medical assistance category of “home

health care services” and, therefore, must be provided to EPSDT

eligible children if necessary to correct or ameliorate a

condition discovered by screening.

Contrary to LDHH’s contention CMS approval of Louisiana’s

effective exclusion of incontinence supplies from the home health

care services covered for the general Medicaid population, further

corroborates our conclusion that under CMS’s interpretation of the

Act, the prescription of incontinence supplies is a form of

medical assistance that is “described in” the home health care

services medical assistance category. §1396d(a)(7). The natural

and ordinary meaning of “exclusion” in this context is to expel or

bar from a place or position previously occupied.14 Thus, the

submission and approval of the special provisions that effectuate

that exclusion strongly indicates that both Louisiana and CMS

construed the category of “home health care services” to include

14
See Miriam Webster’s Collegiate Dictionary (10th Ed. 1998)
p. 404.

31
incontinence supplies in the absence of the exclusion. The

provision effectuating the exclusion was necessary to expel or bar

incontinence supplies from the place or position they otherwise

occupy as part of the medical supplies covered under the home

health care services medical assistance category. Otherwise, the

provision would have been unnecessary and illogical.

Further, the § 1396d(a)(7) category of home health care

services is an optional, not a mandatory, category of medical

assistance. §1396a(a)(10)(A). Thus, the state was not required to

provide this category of care and services to individuals over the

age of twenty-one at all. Consequently, the fact that CMS

approved a state plan, adopting the optional category of home

health care services, subject to an effective incontinence

supplies exclusion, does not indicate that the agency construed §

1396d(a)(7) itself to exclude incontinence supplies. Instead, it

suggests that both Louisiana and CMS knew that, if the state

adopted that category and did not adopt a provision effectively

excluding incontinence supplies, it would be forced to afford

incontinence supply service to eligible individuals over twenty-

one years old; that the state wished to avoid the cost of this

service for the older class of recipients; and that the CMS

approved the provision effectively excluding the service because

the state was not obligated by the statute to undertake any aspect

of the optional category of coverage in the first place. At most,

32
CMS’s approval of the effective exclusion indicates only that the

exclusion may be an appropriate limitation on the scope of the

home health care benefit as it applies to recipients over twenty-

one years of age. It does not express or imply that CMS has

approved an exclusion applicable to EPSDT benefits.

In sum, the prescription of disposable incontinence underwear

that is necessary to ameliorate S.D.’s birth defect and condition

of incontinence is a form of medical assistance that is described

in § 1396d(a) under the category of “home health care services.”

§ 1396d(a)(7). For all of the foregoing reasons, we conclude

that LDHH violated the Medicaid Act by denying S.D. a service

described in § 1396d(a) that is necessary for ameliorative

purposes under the EPSDT program. See §1396d(r)(5).

IV.

LDHH’s appellate counsel appear to argue, without complete

clarity or consistency, that the EPSDT mandate does not require

LDHH to pay for the prescription of disposable incontinence

underwear for S.D. in this case because (1) CMS approved an

exclusion of those supplies from EPSDT coverage as part of the

Louisiana state plan, or (2) LDHH has implied authority to

establish exclusions from EPSDT coverage without CMS approval, and

LDHH used that authority to exclude medical assistance for

disposable incontinence underwear in this case. These arguments

are without merit.

33
 A.

Before addressing the arguments, in order to avoid confusion,

we need to identify and dispel a number of false issues,

inapposite authorities, and misapplication of statutory elements

that LDHH’s appellate counsel use sophistically in support of

their litigating position: (1) LDHH counsel repeatedly confuse and

blur the important distinction between (a) the Medicaid Act’s

mandatory statutory edict and criterion for the correction or

amelioration of defects, illnesses and conditions of EPSDT

children and (b) the State plans’ bilaterally contracted (state

proposed and CMS approved) definitions and standards for the

medical assistance provided to the general Medicaid population.15

(2) This case does not present an attack upon a state plan’s

federally approved limitation on the basic coverage provided to

15
LDHH First Br. pp. 19, 20 (confusing Medicaid Act’s direct
definition of EPSDT benefit for EPSDT children with Act’s
requirement that participating states propose state plans with
standards for determining the extent of medical assistance under
the plan for the general Medicaid population); 22-24 (confusing
the disputed question of whether states must provide care or
services “medically necessary” for general recipients under its
state plan with the undisputed, more focused EPSTD statutory
requirement that states must provide medical assistance
“necessary...to correct or ameliorate” defects, illnesses and
conditions discovered by screening); 24-25 (misinterpreting CMS’s
approval of Louisiana State plan’s exclusion of incontinence
supplies for general Medicaid population as approving an
exclusion of such medical assistance for EPSDT children); 27
(same as confusion noted on pp. 19, 24-25 of that brief).

34
the general Medicaid population, as in cases relied upon by LDHH.16

(3) The validity of the Louisiana state plan’s exclusion of

incontinence supplies from “home health care services” for the

general Medicaid population is not disputed in this case-it is

LDHH’s attempt to apply that exclusion to coverage under the EPSDT

program that is controversial here.17 (4) Furthermore, because this

case does not call upon us to review CMS’s approval of the

Louisiana state plan, LDHH’s citations and discussion pertaining

to judicial review of such federal agency action are irrelevant

and misleading.18

LDHH’s reliance on other irrelevancies is similarly

misguided. An email from a CMS employee, who did not profess to

speak authoritatively for CMS, does not constitute a thoroughly

16
LDHH First Br. P. 22-24, relying on DeSario v. Thomas, 139
F3d 80, 96 (2d Cir. 1998), vacated by Slekis v. Thomas, 525 U.S.
1098 (1999) (upholding state agency’s decision to deny coverage
of certain medical supplies for the general Medicaid population);
Charleston Mem’l Hosp. v. Conrad, 693 F.2d 324, 329-30 (4th Cir.
1982)(upholding coverage limitations on number of inpatient
hospital days for general Medicaid population); Dougherty v.
Dep’t of Human Services, 449 A.2d 1235, 1238 (N.J. 1982)
(upholding coverage denial for medically necessary environmental
equipment without mentioning EPSDT program.)

17
LDHH First Br. P. 19
18
LDHH First Br. pp. 25-26 (citing cases involving judicial
review of federal agency action: Pinnacle Nursing Home v.
Axelrod, 928 F.2d 1306, 1313 (2d Cir. 1991); Illinois Health Care
Ass’n. v. Bradley, 983 F.2d 1460, 1463 (7th Cir. 1993); Garfield
Medical Ctr. v. Belshe, 80 Cal. Rptr. 2d 527, 532 (Cal.Ct.App.
1998)).

35
considered statutory construction by CMS that is owed any judicial

deference or that is relevant to this case.19 The Medicare manual

relied upon by LDHH is inapposite because the home health benefits

provided under the two programs are not comparable and Medicare,

unlike Medicaid, does not provide for the EPSDT program.20 The

Children’s Choice waiver program that provides, among other

things, diapers to some Medicaid eligible minors does not prove

that incontinence supplies are excluded from coverage under the

EPSDT program.21 CMS approves waiver programs that provide items

and services that are also provided by the EPSDT program if the

nature and amount of services provided under the waiver exceed

19
LDHH First Br. P. 17; Skidmore deference is entirely
inappropriate for the opinion of a single employee who has no
authority to speak on behalf of the agency. See Skidmore v.
Swift, 323 U.S. 134, 139 (1944) (according deference to agency
Administrator’s policies because, inter alia, such ”policies are
made in pursuance of official duty, based upon more specialized
experience and broader investigations and information than is
likely to come to a judge in a particular case.”)
20
LDHH First Br. p. 18. LDHH cites a Home Health Services
Manual issued by CMS and available at
http://cms.hhs.gov/manuals/11_hha/hh205-2.asp#_1_3>. The manual
contains a definition of the medical supplies available under the
Medicare home health benefit that restricts such supplies to
those that are essential to visits by home health aides. In
accordance with that definition, diapers are covered only when
utilized by a home health aide in the normal course of a bathing
visit. There is no similar definition or restriction in the
Medicaid Act. Furthermore, under Medicaid, unlike Medicare,
“home health care services” are not limited to services provided
in the home by a home health aide. See footnote 11. Thus, the
Medicare provision is completely irrelevant to the matter at
hand.
21
LDHH First Br. p. 24.

36
that which is otherwise covered under the state plan. See SMM §

4442.3A.3. LDHH’s arguments based on these immaterial matters

merely obscure and deflect attention from the relevant issues

discussed in previous parts of this opinion.

B.

Contrary to LDHH counsel’s insinuations, the Louisiana state

plan does not contain any provision that expressly or implicitly

excludes the prescription of disposable incontinence underwear

from the coverage provided under the EPSDT program. LDHH’s

creative arguments to that effect are both confusing and

misleading. In short, LDHH contends that, under definitions

contained in its state plan and approved by CMS, incontinence

underwear is not a “medical supply” and, therefore, is not

available under the “home health care services” medical assistance

category.22 Accordingly, although LDHH admits that it is required

to provide “home health care services” including “medical

supplies” to EPSDT recipients, LDHH argues that (1) the Louisiana

state plan defines the “medical supplies” available under the

“home health care services” medical assistance category as

excluding incontinence underwear, (2) CMS has approved Louisiana’s

definition, and (3) because of CMS’s “imprimatur” LDHH’s

definition of “medical supplies” is entitled to deference. This

22
LDHH First Br. 18, 19, 23, 24.

37
argument rests on a fallacy, however, because the state plan does

not contain any definition, applicable to the EPSDT program, that

would exclude incontinence underwear from the medical supplies

available to persons under twenty-one when such supplies are

necessary to correct or ameliorate conditions or defects

discovered by screening.

The incontinence supplies exclusion relied upon by LDHH

appears in Section 4.19-B of the state plan, a section entitled

“Payment for Services.” See LDHH First Br. p. 24-27. (citing

R.135, which refers to Louisiana State Medicaid Plan § 4.19-B,

item 7.) In item 7 of section 4.19-B the plan states that all

medical supplies provided under the optional home health care

services medical assistance category will be reimbursed through

the “durable medical equipment” program. The plan further states

that “diapers and blue pads” are not reimbursable through that

program.23 The section does not purport to define the term

“medical supply” or the medical assistance category of “home

health care services.” Instead, the state plan merely excludes

“diapers and blue pads” from a certain payment program. Although

the parties agree that this section, in effect, excludes

23
The provision counsel relies upon states: “For medically
necessary Medical Supplies, Equipment and Appliances,
reimbursement will be made through the Durable Medical Equipment
Program which requires prior authorization for the item. . . .(a)
Diapers and blue pads are not reimbursable as durable medical
equipment items.” Louisiana State Medicaid Plan § 4.19-B, item 7.

38
incontinence underwear from the medical supplies available to the

general Medicaid population, it is irrelevant to S.D.’s claim

because it does not apply to, refer to, or mention the EPSDT

program. Payments provided under the EPSDT program are described

in an altogether different section of the state plan which does

not contain any exclusion of coverage for incontinence supplies.

Id., item 4.b.

After a careful examination of the Louisiana Medicaid State

Plan,24 including particularly Section 3.1, “Amount, Duration, and

Scope of Services”, and Section 4.19, “Payment for Services”, we

conclude that the plan does not define the term “medical supply”

so as to exclude incontinence underwear nor otherwise implicitly

or explicitly excludes that service from coverage under the EPSDT

program. In addition, we note that LDHH conveniently fails to

cite to the section of the state plan that defines the scope of

services available under Louisiana’s EPSDT program. In that

section, the plan provides that the EPSDT benefit includes “all

other health care described in section [1396d(a)] . . . that is

found to be medically necessary to correct or ameliorate defects

as well as physical and mental illnesses and conditions discovered

by the screening service even when such health care is not

24
See http://www.cms.hhs.gov/medicaid/stateplans/toc.asp?
state=LA; Official plan maintained by the CMS Regional Office;
Copy also maintained by LDHH-BHSF-Policy Section, 1201 Capitol
Access Rd, Fl 6, Baton Rouge, La. 70802.

39
otherwise covered by the State Plan . . . .” Id., § 3.1-A, item

4.b (emphasis added.) Thus, the exclusion of “diapers and blue

pads” that appears in the optional home health care section of the

state plan is specifically not applicable to the EPSDT program.

Therefore, there is no factual or legal basis for LDHH’s argument

that its denial of S.D.’s claim is supported by any definition or

exclusion in the approved state plan.

In this connection, LDHH also argues that, because of CMS’s

“imprimatur” of such a definition or exclusion, its determination

that the state plan bars coverage in this instance should have

been reviewed by the district court under the deferential

standards that courts apply to federal agency actions. The main

flaw in this argument, among others, is, of course, that because

there is no such definition or exclusion in the state plan, CMS

approval of the state plan cannot amount to an imprimatur of such

a provision.

C.

LDHH’s appellate counsel further suggest that LDHH’s denial

of S.D.’s claim should be accorded deference and upheld because

(1) the Medicaid Act grants LDHH the implied authority or

discretion, without CMS review and approval, to make reasonable

exclusions from EPSDT coverage, either by directly excluding

certain types of health care or measures or indirectly by

regulating the amount, duration and scope of the health care

40
provided by the EPSDT program; and that (2) LDHH acted pursuant to

this authority when it denied S.D.’s claim for medical assistance.

Assuming, for the sake or argument only, that the Medicaid Act

delegates such implied authority to LDHH, the short answer to this

attempted justification is that LDHH did not base its action on

such implied authority. Rather, it is clear that LDHH denied

S.D.’s claim on three limited grounds: (1) the disposable

incontinence underwear prescribed by his physician was available

through another agency, (2) was not medically necessary, and (3)

was outside the scope of Medicaid.25 LDHH offered no other reason

for its denial of S.D.’s claim. Specifically, LDHH did not

indicate that S.D.’s claim was within EPSDT coverage but excluded

therefrom by LDHH’s own rule or policy based on its implied

authority or discretion. Nor is there any material in the record

from which we may reasonably discern that this was the basis and

reason for the agency’s decision.

“It is elementary that if an agency’s decision is to be

sustained in the courts on any rationale under which the agency’s

factual or legal determinations are entitled to deference, it must

be upheld on the rationale set forth by the agency itself.” Fort

25
In this appeal, however, LDHH counsel conceded error as to
reason(1). LDHH First Br. 2. Reason (2) is not at issue because
LDHH does not contest the district court’s determination that the
prescription of the incontinence supplies are necessary to the
amelioration of S.D.’s conditions for purposes of the ESPDT
program.

41
Stewart Schools v. FLRA, 495 U.S. 641, 651-652 (1990); SEC v.

Chenery Corp., 318 U.S. 80, 93-95 (1943). “Post-hoc

explanations—especially those offered by appellate counsel—are

simply an inadequate basis for the exercise of substantive review

of an administrative decision.” United States v. Garner, 767 F.2d

104, 117 (5th Cir. 1985)(citing Burlington Truck Lines v. United

States, 371 U.S. 156, 168 (1962)); Baylor Univ. Med. Ctr. v.

Heckler, 758 F.2d 1052, 1060 (5th Cir. 1985); Global Van Lines,

Inc. v. ICC, 714 F.2d 1290, 1299, n.8 (5th Cir. 1983); See also

Bowen v. Georgetown Univ. Hosp., 488 U.S. 204, 212-213 (1988);

Pension Benefit Guaranty Corp. v. Wilson N. Jones Mem’l Hosp., 374

F.3d 362 (5th Cir. 2004); Ass’n of Civilian Technicians, v. FLRA,

269 F.3d 1112, 1117 (D.C. Cir. 2001). Consequently, we must reject

LDHH appellate counsel’s attempts to support the denial of S.D.’s

claim upon a ground not set forth by LDHH itself.

Therefore, we do not reach the hypothetical question which

LDHH appellate counsel’s post hoc rationalizations seek to raise,

viz., whether LDHH has implied authority or discretion to

establish exclusions from EPSDT coverage without CMS approval.26

26
LDHH counsel continually base arguments on their
assumption and assertion that the Medicaid Act grants states
complete or autonomous discretion to adopt or change their state
plans and the coverage provided thereunder without the need for
CMS approval. LDHH First Br. 4, 20, 21. According to LDHH, the
Medicaid Act confers “broad discretion” upon the states. The
statements by courts to that effect, however, appear to stem from
language in cases such as Beal v. Doe, 432 U.S. 438, 444 (1977).

42
We note, however, that, in any event, the cases cited by LDHH

counsel are inapposite to this question.27

V.

Having concluded that the Medicaid Act’s ESPDT mandate

requires LDHH to provide S.D. with medical assistance for the

prescribed disposable incontinence underwear because it is

necessary to ameliorate S.D.’s conditions caused by his total

bowel and bladder incontinence and spina bifida, we now confront

In that case, the Supreme Court quoted 42 U.S.C. § 1396a(a)(17)
(1970 ed., Supp. V), which provided: "A State plan for medical
assistance must . . . include reasonable standards . . . for
determining eligibility for and the extent of medical assistance
under the plan . . . .” (emphasis added.) The Court determined
that “[t]his language confers broad discretion on the States to
adopt standards for determining the extent of medical assistance,
requiring only that such standards be ‘reasonable’ and
‘consistent with the objectives’ of the Act.” Id.(footnote
omitted). When read in context, however, it is evident that the
Court was referring to the Medicaid Act’s conferral of “broad
discretion” upon the states to submit proposed state plan
provisions for review and approval by the Secretary, not to any
authority of the states to autonomously exclude items or services
from the coverage provided under the state plan.
27
See LDHH First Brief pp. 20, 22-24 (citing Alexander v.
Choate, 469 U.S. 287, 303 (1985); Smith v. Rasmussen, 249 F.3d
755, 759(8th Cir. 2001); DeSario v. Thomas, 139 F.3d 80, 88 (2d
Cir. 1998) vacated by Slekis v. Thomas, 525 U.S. 1098 (1999);
Louisiana v. United States Dep’t of Health and Human Servs/, 905
F.2d 877, 878 (5th Cir. 1990); Charleston Mem’l Hosp. v. Conrad,
693 F.2d 324 (4th Cir. 1982); King v. Sullivan, 776 F. Supp. 645
(D.R.I. 1991); Dougherty v. Dep’t of Human Servs., 449 A.2d 1235,
1238 (N.J. 1982)). Most of these cases deal with the general
Medicaid coverage (including adults) provided for under a state
plan; none deal with a state’s attempt adopt an EPSDT coverage
exclusion without CMS approval. Further, none stand for the
proposition that a state plan may be amended to adopt coverage
exclusions without the approval of CMS.

43
LDHH’s assertion that S.D. cannot enforce that requirement under

42 U.S.C. § 1983.

Section 1983 provides a cause of action against state

officials for “the deprivation of any rights, privileges, or

immunities secured by the Constitution and laws” but does not

provide a mechanism through which citizens can enforce federal law

generally. Instead, it provides redress only for a plaintiff who

asserts a “violation of a federal right, not merely a violation

of federal law.” Blessing v. Freestone, 520 U.S. 329, 340 (1997);

see also Wilder v. Virginia Hosp. Ass’n, 496 U.S. 498, 508 (1990).

In Blessing v. Freestone, 520 U.S. at 340, the Supreme Court

reiterated the three factors that it has traditionally considered

when determining whether a particular federal statute gives rise

to a right enforceable by § 1983: (1) whether Congress intended

for the provision to benefit the plaintiff; (2) whether the

plaintiff can show that the right in question is not so “vague and

amorphous” that its enforcement would “strain judicial

competence”; and (3) whether the statute unambiguously imposes a

binding obligation on the states. See Evergreen Presbyterian

Ministries, Inc. v. Hood, 235 F.3d 908, 925 (5th Cir. 2000).

In Gonzaga University v. Doe, 536 U.S. 273, 283 (2002), the

Supreme Court noted that some courts had misinterpreted the first

Blessing factor as permitting a § 1983 action whenever the

44
plaintiff fell within the general zone of interests protected by

the statute at issue. The Court clarified that nothing short of

an unambiguously conferred right can support a cause of action

under § 1983. The appropriate inquiry, therefore, is “whether or

not Congress intended to confer individual rights upon a class of

beneficiaries.” Id., 285. Critical to this inquiry is whether the

pertinent statute contains “rights-creating” language such as that

found in Title VI of the Civil Rights Act of 1964 and Title IX of

the Education Amendments of 1972.28 Id., 284, 287. Accordingly,

we begin our analysis by returning to the text of the Medicaid

Act.

The Medicaid Act provides that “[a] State Plan must provide

for making medical assistance available, including at least the

care and services listed in paragraphs (1) through (5), (17) and

(21) of section 1396d(a) of this title, to all individuals" who

meet certain eligibility criteria. 42 U.S.C. § 1396a(a)(10)(A)(i).

EPSDT care and services are listed in paragraph 4 of § 1396d(a)

and, by reference to § 1396d(r), include all the health care,

treatment, services, and other measures described in § 1396d(a)

28
Title VI provides: "No person in the United States shall
... be subjected to discrimination under any program or activity
receiving Federal financial assistance" on the basis of race,
color, or national origin. 42 U.S.C. § 2000d (emphasis added).
Title IX provides: "No person in the United States shall, on the
basis of sex, ... be subjected to discrimination under any
education program or activity receiving Federal financial
assistance." 20 U.S.C. § 1681(a) (emphasis added).

45
when necessary for corrective or ameliorative purposes. This is

precisely the sort of “rights-creating” language identified in

Gonzaga as critical to demonstrating a congressional intent to

establish a new right. Accordingly, as the Third Circuit

concluded, “it [is] difficult, if not impossible, as a linguistic

matter, to distinguish the import of the relevant [Medicaid Act]

language-‘A State Plan must provide’- from the ‘No person shall’

language of Titles VI and IX” which was held up in Gonzaga as the

prototypical rights-creating language. Sabree v. Richman, 367 F.3d

180, 190 (3d Cir. 2004)(concluding that § 1396a(a)(10)(A) creates

a federal right to medical assistance for intermediate care

facility services); accord Rabin v. Wilson-Coker, 362 F.3d 190,

201-2 (2d Cir. 2004); Bryson v. Shumway, 308 F.3d 79, 89 (1st Cir.

2002).

The only potentially material difference between the rights-

creating language contained in § 1396a(a)(10)(A) and that

contained in Titles VI and IX is that the Medicaid Act requires

state action under a medical assistance plan. The requirement of

action under a plan is not, however, dispositive of the question

of whether the statute confers rights enforceable by § 1983. “In

an action brought to enforce a provision of [the Social Security

chapter of the United States Code], such provision is not to be

deemed unenforceable because of its inclusion in a section of this

chapter requiring a State plan or specifying the required contents

46
of a State plan” 42 U.S.C. § 1320a-2; see also Harris v. James,

127 F.3d 993, 1003 (11th Cir. 1997)(“[I]n light of [§ 1320a-2],

it is clear that the mere fact that an obligation is couched in

a requirement that the State file a plan is not itself sufficient

grounds for finding the obligation unenforceable under § 1983.”)

Thus, for all of the forgoing reasons we conclude that the EPSDT

treatment provisions of the Medicaid Act contains the “rights-

creating language critical to showing the requisite congressional

intent to confer a new right.” Gonzaga, supra, 536 U.S. at 274.

Moreover, the Medicaid Act confers the right to the health

care, treatment, services and other measures described in

§1396d(a) when necessary for EPSDT ameliorative purposes upon an

identified class. The statute requires that participating states

provide such care and services "to all individuals" who meet the

plan eligibility requirements and are under the age of twenty-one.

See 42 U.S.C. §§ 1396a(10)(A), 1396d(a)(4)(B). Thus, rather than

having merely an aggregate focus, the EPSDT provisions are

“concerned with whether the needs of [particular individuals] have

been satisfied.” Gonzaga, supra, 536 U.S. at 275. Furthermore,

the statutory provision at issue in the present case is not

directed to the systemwide administration of the EPSDT program

but, rather, requires that health care and services must be

47
provided to all eligible recipients under the age of twenty-one.29

Thus, because it is undisputed that the plaintiff is an eligible

recipient of EPSDT services, we conclude that the relevant

provisions of the Medicaid Act satisfy the first Blessing factor,

as clarified by Gonzaga, in that the Act evidences a congressional

intent to confer a right to the health care, services, treatments

and other measures described in § 1396d(a), when necessary for

EPSDT ameliorative purposes, upon the plaintiff.

Our conclusion is amply supported by the decisions of this

court and other federal Circuits. Before the Supreme Court’s

decision in Gonzaga, numerous courts, including this court, had

concluded that the Medicaid Act confers, upon eligible children,

a federal right to the health care, treatment and measures

mandated by the EPSDT program. See e.g. Mitchell v. Johnston, 701

F.2d 337, 344 (5th Cir. 1983) (holding that EPSDT children had a

right, enforceable by § 1983, to preventive dental care);

Pediatric Specialty Care, Inc. v. Ark. Dep’t. of Human Servs., 293

29
Accordingly, this case is distinguishable from Frazar v.
Gilbert, 300 F.3d 530 (5th Cir. 2002) rev’d by Frew ex rel. Frew
v. Hawkins, 540 U.S. 431 (2004). In Frazar, the plaintiffs
claims did not concern any individual recipient’s access to
services required by federal law. Rather, the claims concerned
the systemwide standards and measures employed by the state
Medicaid agency in its administration of the EPSDT program. This
court concluded that such generalized standards and procedures do
not create individualized rights actionable under § 1983. In
contrast, this case is solely concerned with the right of an
individual to a particular service to which he is entitled under
federal law.

48
F.3d 472, 479 (8th Cir. 2002) (holding “that the plaintiffs have

a federal right to EPSDT services that is enforceable in a § 1983

action”); Miller by Miller v. Whitburn, 10 F.3d 1315, 1319-1320

(7th Cir. 1993) (EPSDT treatment provisions are enforceable by §

1983). Moreover, the district courts that have considered the

enforceability of the EPSDT provisions after Gonzaga have

concluded that the statute creates rights to treatment that are

enforceable under § 1983. See Memisovski ex rel. Memisovski v.

Maram, 2004 WL 1878332 (N.D. Ill.); Kenny A. ex rel. Winn v.

Perdue, 218 F.R.D. 277, 293-94 (N.D.Ga., 2003); Collins v.

Hamilton, 231 F. Supp. 2d 840, 846-47 (S.D.Ind. 2002).30

Finally, several post-Gonzaga circuit court decisions have

held that provisions of the Medicaid Act containing language

similar to § 1396a(a)(10)(A), i.e. “[a] State Plan must provide for

making medical assistance available, including [EPSDT benefits] to

all individuals", are enforceable by § 1983. Specifically, the

Second Circuit in Rabin v. Wilson-Coker, 362 F.3d 190, 201-2 (2d

Cir. 2004) concluded that Congress intended to create an

enforceable right to a temporary grace period by stating that "each

State plan . . . must provide” the specified grace period for

families meeting certain requirements. See 42 U.S.C. § 1396r-6.

30
The Seventh Circuit affirmed the Collins decision at 349
F.3d 371 (7th Cir. 2003) without specifically addressing the §
1983 issue.

49
The Sixth Circuit has held that the fair hearing provision of the

Medicaid Act, 42 U.S.C. 1369a(3), which states that "[a] State plan

for medical assistance must provide for granting an opportunity for

a fair hearing . . . to any individual whose claim . . . is denied

. . ." unambiguously confers an enforceable federal right. Gean v.

Hattaway 330 F.3d 758, 772-73 (6th Cir. 2003). The First and Third

Circuits concluded that 42 U.S.C. 1396a(8) unambiguously confers a

federal right by requiring that medical assistance under a state

plan "shall be furnished with reasonable promptness to all eligible

individuals." Sabree v. Richman, 367 F.3d 180, 190 (3d Cir. 2004);

Bryson v. Shumway, 308 F.3d 79, 89 (1st Cir. 2002).31

Turning to the second Blessing factor, we conclude that the

right asserted by S.D. is not so “vague and amorphous” that its

31
The First and Seventh Circuits have concluded that certain
provisions of the Medicaid Act are not enforceable by § 1983
after Gonzaga. Those cases are readily distinguishable, however,
in that they concern Medicaid provisions that are insufficiently
definite or that only indirectly benefit a particular plaintiff.
See Long Term Care Pharm. Alliance v. Ferguson, 362 F.3d 50, 57-
58 (1st. Cir. 2004)(section 1396a(a)(30)(A) which provides that
state plans must, inter alia, safeguard against unnecessary
utilization and “assure that payments are consistent with
efficiency, economy and quality of care” so as to enlist
sufficient providers confers only an indirect benefit on
providers and is, therefore, not enforceable by providers);
Bruggeman v. Blagojevich, 324 F.3d 906, 911 (7th Cir.
2003)(section 1396a(a)(19), which requires that state Medicaid
plans "provide such safeguards as may be necessary to assure that
eligibility . . . will be determined, and . . . services
provided, in a manner consistent with . . . the best interests of
the recipients” does not create any specific duty on the part of
the states and does not confer an individual right enforceable by
§ 1983.)
50
enforcement would “strain judicial competence." Blessing v.

Freestone, supra, 520 U.S. at 340. S.D. asks the courts to

interpret the EPSDT statutes to ascertain whether they require

Louisiana to provide him with a specific benefit, namely,

incontinence supplies medically necessary for EPSDT ameliorative

purposes. That level of statutory analysis does not “strain

judicial competence;” it is the sort of work in which courts engage

every day. The EPSDT provisions at issue are no more “vague and

amorphous” than other statutory terms that this court, as well as

other courts, have found capable of judicial enforcement. In

Wilder v. Virginia Hosp. Ass’n, 496 U.S. 498, 519-520 (1990), the

Supreme Court held enforceable under § 1983 the Medicaid Act’s

requirement that states adopt Medicaid reimbursement rates that are

“reasonable and adequate to meet the costs which must be incurred

by efficiently and economically operated facilities.”32 In

Evergreen Presbyterian Ministries, 235 F.3d 908, 925 (5th Cir.

2000), this court followed the lead of “many other courts” and held

that the “equal access” mandate of § 1396(a)(30)(A) is not too

vague to be enforceable. Other Circuits have found that the right

to health care, services, treatment and other measures described in

§ 1396d(a) when necessary for EPSDT ameliorative purposes is not

too vague to be enforceable under § 1983. See Pediatric Speciality

Care, Inc. v. Ark. Dep’t of Human Servs., 293 F.3d 472, 479 (8th

32
42 U.S.C. § 1396a(a)(13)(A)).
51
Cir. 2002); Westside Mothers v. Haveman, 289 F.3d 852, 863 (6th

Cir. 2002); Miller by Miller v. Whitburn, 10 F.3d 1315, 1319-20

(7th Cir. 1993).

Finally, S.D. easily satisfies the third Blessing factor

because the Medicaid statute unambiguously imposes EPSDT

obligations on the participating states. See 42 U.S.C. §

1396a(a)(10)(A) (stating that “[a] State plan for medical

assistance must provide for making medical assistance available,

including [EPSDT benefits]” (emphasis added)); see also Miller by

Miller v. Whitburn, 10 F.3d 1315, 1319 (7th Cir. 1993) (holding

that third Blessing factor is satisfied by EPSDT provisions because

“[s]tates participating in the Medicaid program must provide EPSDT

services to all individuals under age twenty-one") (emphasis

added). Thus the statutory provisions at issue in the present case

satisfy the Blessing test and are enforceable by § 1983.33

LDHH does not dispute that S.D.’s right to receive services

under the EPSDT program is enforceable in an action brought under

§ 1983. Rather, LDHH claims that the right specifically claimed by

S.D., namely, the right to medically necessary incontinence

supplies, is not enforceable because Congress did not specifically

33
Satisfaction of the Blessing factors establishes that a
right is presumptively enforceable by § 1983. See Blessing,
supra, 520 U.S. at 341. Although the State may rebut this
presumption by showing that Congress “specifically foreclosed a
remedy under 1983” it has not done so in this case. Id.
52
list this service in the statute. LDHH claims that even if, as we

have concluded, medically necessary incontinence supplies must be

provided to EPSDT eligible children as a “home health care

service”, this requirement is based upon CMS’s construction of the

statute rather than on the statutory text itself. According to

LDHH, because the specific right at issue is provided by the

agency’s interpretations rather than by Congress, under the Supreme

Court’s decision in Alexander v. Sandoval, 532 U.S. 275, 291

(2001), the right is not enforceable by § 1983. LDHH, however,

misinterprets Sandoval.

In Sandoval, the Supreme Court held that no private right of

action exists to enforce a regulation banning disparate impact

discrimination that was enacted under Title VI of the Civil Rights

Act of 1964 ("Title VI"). Title VI § 601, a rights-creating

provision, states that "No person in the United States shall, on

the ground of race, color, or national origin, be excluded from

participation in, be denied the benefits of, or be subjected to

discrimination under any program or activity" covered. 42 U.S.C. §

2000d. The Supreme Court noted that it was “beyond dispute” that

individuals could sue to enforce § 601's prohibition on

discrimination. Sandoval, supra, 532 U.S. at 280. Furthermore, the

Supreme Court found that it was similarly beyond dispute that § 601

prohibits only intentional discrimination. Id. The plaintiffs in

Sandoval, however, did not allege intentional discrimination but,

53
rather, alleged only disparate impact discrimination.

Section 602 of Title VI states that "each Federal department

and agency which is empowered to extend Federal financial

assistance to any program or activity ... is authorized and

directed to effectuate the provisions of section 2000d of this

title with respect to such program or activity by issuing rules,

regulations, or orders of general applicability...." 42 U.S.C. §

2000d-1. The Department of Justice, pursuant to § 602, had issued

regulations that prohibited disparate impact discrimination.34

The Supreme Court examined the text of § 602, searching for

evidence of congressional intent to create the private right of

action asserted by the plaintiffs. It recognized the absence of any

rights-creating language, such as found in § 601, and concluded

that there was "no evidence anywhere in the text to suggest that

Congress intended to create a private right to enforce regulations

promulgated under § 602." Id., 1522.

Both the government and the plaintiffs argued that the

regulations barring disparate impact discrimination, enacted under

§ 602, were privately enforceable because the regulations

themselves contained rights-creating language. The Supreme Court

rejected this argument stating “[l]anguage in a regulation may

invoke a private right of action that Congress through statutory

34
For the purpose of its decision, the Supreme Court assumed,
without deciding, that the regulation was valid.
54
text has created, but it may not create a right that Congress has

not.” Id., 291. Therefore, “it is most certainly incorrect to say

that language in a regulation can conjure up a private cause of

action that has not been authorized by Congress. Agencies may play

the sorcerer’s apprentice but not the sorcerer himself.” Id.

Important for our purposes, however, the Supreme Court also

stated that it did “not doubt that regulations applying § 601's ban

on intentional discrimination are covered by the cause of action to

enforce that action. Such regulations, if valid and reasonable,

authoritatively construe the statute itself.” Id., 284. Moreover,

“[a] Congress that intends the statute to be enforced through [§

1983] intends the authoritative interpretation of the statute to be

so enforced as well.” Id.

In the present case, the rights-creating language relied upon

by the plaintiff is contained in the statute itself. Furthermore,

the regulations implementing the statute, and defining “home health

care services” to include “medical supplies”, are authoritative

interpretations of the statute and are enforceable by § 1983.

Finally, as discussed in section III, medically necessary

incontinence supplies fall within the natural and plain meaning of

the term “medical supplies” and CMS has interpreted the “home

health care services” category as specifically including such

supplies. Accordingly, the federal statutory right asserted by the

plaintiff is enforceable under § 1983.

55
 For these reasons, the judgment of the district court is

AFFIRMED.

56