WASHINGTON — A federal appeals court on Friday ordered a new hearing for Arizona community health care centers that say the state’s Medicaid system wrongfully denies reimbursement for chiropractic, dental, optometric and podiatric care. .
A three-judge panel of the 9th U.S. Circuit Court of Appeals reversed a lower court decision that dismissed the Arizona Alliance for Community Health Centers’ lawsuit against the Arizona Health Care Cost Containment System, the Medicaid provider of the ‘State.
In his view, Circuit Judge Richard R. Clifton commended the district court judge and attorneys on both sides “for their skillful handling of the unusually complex issues presented by this case.” But he said the decision to dismiss the case was wrong and ordered the case be sent back to the district court for a rehearing.
A lawyer for Health Care Centers declined to comment on the case on Friday until she could speak to her clients. AHCCCS officials said they are still studying the decision and will not be able to comment until next week.
The case was filed in 2019 by Health Care Centers, federally qualified health centers that said they have “an enforceable federal right to reimbursement for FQHC’s services, which include the services of its dentists, podiatrists , optometrists and chiropractors (among others)”.
They said the AHCCCS “categorically excludes” chiropractors from coverage and inappropriately limits reimbursement for adult dental, podiatric and optometric services, which they say are mandatory under Medicaid and the health care plan. State for Medicaid.
But attorneys for AHCCCS said the agency “does not categorically exclude,” as plaintiffs claim, dental, podiatry, optometry or chiropractic services” — it does include those services, the agency said. agency, but it “covers these services only with limitations”.
The district court judge agreed with the health centers that the AHCCCS could not exclude these services, but she said the law did not prohibit her from limiting coverage. And she rejected the claim that chiropractors were excluded, noting that service coverage for patients under 21 is included in the state plan.
She dismissed the case, triggering the call from the health centers.
The appeals panel disagreed with the district court judge, finding that “Arizona’s categorical exclusion from adult chiropractic services violates…Medicaid law.” Clifton’s opinion went on to reject AHCCCS’ interpretation of Medicaid law, which he said “would allow a state to categorically exclude coverage for all FQHC services.”
Finally, the appeals court said the lower court wrongly applied “Chevron deference” to the case, a legal principle that requires courts to generally defer to an administrative agency’s interpretation of regulations. that he applies.
The AHCCCS had argued that its limits had been approved by the regional administrator of the Centers for Medicare and Medicaid Services (CMS), the federal office that oversees state plans for Medicaid and their application of those plans.
But the appeals court said that for Chevron to apply, there must be a clear record of the decision-making that resulted in the approval. Clifton said the filing “has no evidence of CMS’s reasoning” about the Arizona rules.
“We conclude that the record before us does not establish that Chevron’s deference applies to Arizona’s limitations on adult dental, optometry and podiatry services,” Clifton wrote.
While the Supreme Court “has long held that ‘nothing in the (Medicaid) law suggests participating states are required to fund every medical procedure'” included in the mandatory categories, CMS must justify the reason for the decision to exclude the cover. Clifton said no.
The case has been remanded to the District Court to consider, among other things, whether there is sufficient evidence for the Chevron Doctrine to be used in this case.