United States District Court, D. Arizona
BRIDGET S. BADE, Magistrate Judge.
Defendants Thomas J. Betlach, Director of Arizona Health Care Cost Containment System (AHCCCS), Richard Kenney, Jessica Lopez, Terry Robbins, Ana Fuentavilla, M.D., Janine Roumain, M.D., and the Arizona Long Term Care System (ALTCS) (collectively Defendants), have filed a motion to dismiss the Amended Complaint, pursuant to Rules 8(a), 12(b)(1), and 12(b)(6) of the Federal Rules of Civil Procedure. (Doc. 16.) Plaintiff opposes the motion. (Doc. 20.) For the reasons below, the Court grants Defendants' motion and dismisses this action.
On May 7, 2014, Plaintiff, proceeding pro se, filed her initial complaint. (Doc. 1.) Plaintiff later filed a redacted complaint with several exhibits. (Doc. 8.) Plaintiff requested permission to file the exhibits under seal. (Doc. 10.) The Court granted Plaintiff leave to file exhibits A, B, and C to the redacted complaint under seal and permitted Plaintiff leave to refile redacted copies of those exhibits. (Doc. 11.) Plaintiff did not file redacted copies of those exhibits. Instead, on May 27, 2014, she filed an Amended Complaint. (Doc. 12.) Although Plaintiff did not attach any exhibits to the Amended Complaint, that complaint refers to the exhibits filed with the redacted complaint. ( Id. ) Defendants have not objected to Plaintiff's reliance on her previously submitted exhibits to support her Amended Complaint. Accordingly, the Court may consider Plaintiff's exhibits when considering the motion to dismiss.
A. ALTCS Benefits
AHCCCS is the state agency that receives federal funding to ensure provision of health care services to Arizona's Medicaid clients. Ball v. Biedess, 2004 WL 2566262, at *1 (D. Ariz. Aug. 13, 2004), rev'd in part on other grounds, 492 P.3d 1094 (9th Cir. 2007). AHCCCS provides Medicaid long-term care benefits to elderly or disabled persons through ALTCS. Id. The allegations in the Amended Complaint involve the denial of Plaintiff's application for benefits under ALTCS. (Doc. 12.)
ALTCS provides eligible persons various health care services, including institutional services, home and community based services (HCBS), acute care, and behavioral health services. Id. Individuals are eligible for ALTCS if they pass both a financial and a medical screen. Id. The medical requirement is that the individual be "at risk of institutionalization." Id. The director of AHCCCS must provide an assessment of functional and medical criteria as a prerequisite to eligibility for long-term care. See Ariz. Rev. Stat. §§ 36-2934 and 36-2936, Ariz. Admin. Code R9-28-301. In accordance with these laws, the Director of AHCCCS (the Director) has established the preadmission screening (PAS) program. Ariz. Rev. Stat. § 36-2936. The PAS assessment is designed to determine the skills and needs of the applicant. See Ariz. Rev. Stat. § 36-2936; Ariz. Admin. Code R9-28-303 (setting forth the preadmission screening process).
B. Plaintiff's Applications for ALTCS Benefits
In the Amended Complaint, Plaintiff asserts that she has epilepsy that causes her seizures and "puts her at risk of an assisted living level of care." (Doc. 12 at 8.) On three separate occasions she applied for ALTCS benefits. For each application, a preadmission screening (PAS) of Plaintiff's eligibility for ALTCS was conducted. ( Id. at 4, 5, 7.)
On August 15, 2011, as part of Plaintiff's first application, Richard Kenney gave Plaintiff a functional score of forty and a medical score of zero. (Doc. 12 at 4.) On October 11, 2011, Kenney submitted the PAS assessment for physician review. ( Id. ) Plaintiff asserts that the doctor conducting the review, Ana Fuentavilla, M.D., determined that Plaintiff was "medically complex due to uncontrolled seizure disorder." ( Id. ) Plaintiff alleges that, on October 29, 2011, Kenney and Dr. Fuentavilla denied Plaintiff's application for "ALTCS/HCBS" even though they knew her PAS "omitted a required medical score" and that she was a "qualified individual under Title XIX of" the Social Security Act. ( Id. at 5.)
Plaintiff applied for ALTCS/HCBS benefits a second time. ( Id. ) On March 12, 2012, Jessica Lopez conducted a PAS of Plaintiff's eligibility for ALTCS. ( Id. ) She gave Plaintiff a functional score of fifty-two and a medical score of zero. ( Id. ) On June 12, 2011, Lopez submitted the PAS assessment for physician review. ( Id. at 6.) Plaintiff asserts that Janine Roumain, M.D., conducted the review based solely on "summary notes, " that she requested records from a neurologist that Plaintiff had never seen, that she did not review Plaintiff's "neurological notes and EEG from UCLA, " and she did not discuss Plaintiff's epilepsy. (Doc. 12 at 6, 8.) Plaintiff alleges that on June 12, 2012, Lopez and Dr. Roumain denied Plaintiff's application for "ATLCS/HCBS" even though they knew her PAS "omitted a required medical score" and that she was a "qualified disabled individual under Title XIX of" the Social Security Act. ( Id. at 6.)
Plaintiff applied for ALTCS/HCBS benefits a third time. On January 2, 2013, Terry Robbins conducted a PAS of Plaintiff's eligibility for ALTCS. ( Id. at 7.) Robbins gave Plaintiff a functional score of forty-seven and a medical score of zero. ( Id. ) On March 5, 2013, Robbins submitted the PAS assessment for physician review. ( Id. ) Plaintiff asserts that on review Dr. Roumain found that Plaintiff had a normal neurological examination, but did not physically examine Plaintiff, review her neurological records, or discuss her epilepsy. ( Id. at 7, 8.) Plaintiff alleges that on March 22, 2013, Robbins and Dr. Roumain denied her application for "ALTCS/HCBS" even though they knew her PAS "omitted a medical score required by PAS policy" and that she was a "qualified disabled individual according to Title XIX of" the Social Security Act. ( Id. at 7.)
After AHCCCS denied Plaintiff's application for ALTCS/HCBS benefits in March 2013, Plaintiff requested an administrative hearing to review AHCCCS's decision. AHCCCS forwarded that request to the Office of Administrative Hearings for an evidentiary hearing. (Doc. 8-2 at 7.) On October 8, 2013, after a hearing before an Administrative Law Judge (ALJ), which Plaintiff attended with counsel, the ALJ recommended affirming AHCCCS's denial of Plaintiff's application for ALTCS benefits. (Doc. 8-2 at 7-10.) The Director then reviewed the ALJ's decision and adopted it. (Doc. 8-2 at 1-4.) The Director's decision, which was mailed to Plaintiff on October 31, 2013, advised Plaintiff that she could appeal that decision to the Arizona ...