UNITEDSTATESDISTRICTCOURT SOUTHERNDISTRICTOFNEWYORK
------------------------------------- x
ANGIECRUZ,I.H.,AR'ESKPAKA,and .K.L
:CP...C:UKIO:STIB'UHL>ehc.>.1 Lv.L
themselvesandallotherssimilarly situated, Plaintiffs,
-v-HOWARDZUCKER,asCommissionerofthe DepartmentofHealth[oftheStateof
NewYork], Defendant. ------------------------------------- x
JEDS.RAKOFF,U.S.D.J. 14-cv-4456(JSR) OPINION
Theintersectionofourcognitionwithouremotionsisboththe
essenceofourhumanityandthesourceofouranxiety.Accordingto
theplaintiffsinthisclassaction,someonewhoisbornwiththe
physicalequipmentofonesexbutemotionallyidentifiesassomeoneof
theoppositesexsufferssevereanxietyandemotionaldistressthat
may,however,bemateriallyalleviatedbyavailablemedical
procedures.PlaintiffsfurthercontendthatNewYorkwronglydenies
Medicaidcoverageformanysuchprocedures,regardingthemasmerely
"cosmetic"orthelike.TheimmediatequestionbeforetheCourtis
whethertheplaintiffsherecansueforredressofthisallegedwrong.
TheCourtconcludesthattheycan.
PlaintiffAngieCruz,nowfiftyyearsold,allegesthatshewas
assignedmaleatbirthbuthasidentifiedasfemalesinceshewasten
yearsold.SeeAmendedClassActionComplaintdatedMarch27,2015,
ECFNo.27("Am.Compl.") 91,93.Shebegantakinghormonesasa
teenagerinanefforttobringherphysicalappearanceintoalignment Case
1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 1 of
29withhergenderidentityandhasundergonehormonetherapyformuchof
heradultlife,purchasingherhormonessometimesfromdoctorsand
pharmaciesanasome t:..Lmesoncnescrt=t=L.Iu. 34 - ::is..A.1
thou'::::lhLhl;:;
therapyhasgivenherbodyamorefeminineappearance,shestill
experiencesintensedistressandinterferencewithhercapacityfor
normalactivityasaresultofthemismatchbetweenherbodyandher
identity.Id. 96,99,104-05.Cruzisa"categoricallyneedy"
Medicaidrecipient,meaningthatshemeetsoneofnineeligibility
categoriessetforthinthefederalMedicaidAct,42U.S.C.
1396a(a)(10)(A)(i).Id. 29,91. PlaintiffAr'
esKpaka,alsoacategoricallyneedyMedicaid
recipient,allegesthat,althoughbornwithamalebody,shehas
identifiedasfemalesinceshewasthreeyearsold.Id. 136.Asan
adolescent,shehidhergenderidentityfromhermotherandbrothers
until,atagetwenty-one,shewasforcedtomoveoutofhermother's
homeandbecamehomelessforseveralmonths.Id.
137.Nowtwenty-three,sheisundergoinghormonetherapybutstillstruggleswith
depressionrelatingtohergenderidentity.Id. 136,138,140.
PlaintiffRiyaChristieallegesthat,growingupinJamaica,she
facedviolencebecauseofhergenderexpressionandsufferedfrom
severedepressionandsuicidalthoughts.Id. 149-50.Attheageof
twenty-one,shemovedtotheUnitedStatesandwasgrantedasylumon
thegroundthathergenderidentitymadeitunsafeforhertoreturn home.Id.
152.Nowtwenty-three,shecontinuestoexperiencepain
andanxietyasaresultoftheincongruencebetweenherbodyandher 2 Case
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29genderidentity.Id. 159.She,likeCruzandKpaka,isa
categoricallyneedyMedicaidrecipient.Id. 136.
Eachofthethreenamedplaintiffsinthisclassactlonhasbeen
diagnosedwithGenderDysphoria("GD")(formerlyknownasGender
IdentityDisorder).1 Id. 95,138,155.TheyallegethatGDis
recognizedbythemedicalcommunityas"'anidentifiable,severeand
incapacitatingdisease.'"Id. 80(quotingD.Barish&B.Sharma,
MedicalAdvancesinTranssexualismandtheLegalImplications,24Am.
J.ForensicMed.&Pathology100,101(2003)).Itisdefinedinthe
latesteditionoftheAmericanPsychiatricAssociation'sDiagnostic
andStatisticalManualofMentalDisorders("DSM-V")asa"marked
incongruencebetweenone'sexperienced/expressedgenderandassigned
gender,"asmanifestedbyatleasttwoofthefollowing:(i)a"marked
incongruencebetweenone'sexperienced/expressedgenderandprimary
and/orsecondarysexcharacteristics... ";(ii)a"strongdesiretobe
ridofone'sprimaryand/ orsecondarysexcharacteristics ... ";(iii)"a
strongdesirefortheprimaryand/orsecondarysexcharacteristicsof
theothergender";(iv)a"strongdesiretobeoftheothergender... ";
(v)a"strongdesiretobetreatedastheothergender... ";and(vi)a
"strongconvictionthatonehasthetypicalfeelingsandreactionsof
theothergender... "Id. 82(quotingDSM-V302. 06,302. 85).The
DSM-VfurtherspecifiesthatGDis"associatedwithclinically
significantdistressorimpairmentinsocial,occupational,orother
importantareasoffunctioning."Id. 1
Oneoftheoriginalnamedplaintiffs,I.H.,subsequentlywithdrewas 3 Case
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29Plaintiffsallegethat,inordertoalleviatetheprofound
psychologicalsufferingandsocialandoccupationalimpairmentthat
theyexperienceasaresultOLtheirGD,theyneedcertaintreatments
tofacilitatetheirtransitionstothegenderwithwhichthey
identify.Thetreatmentstheyseekincludebreastaugmentation,facial
feminizingsurgery,chondrolarngoplasty(commonlyreferredtoas
"trachealshave"),bodysculptingprocedures,andelectrolysis.Id.
101,141,157.Plaintiffsallegethatthesetreatmentsaresafe,
effective,andmedicallynecessary.Id. 83-88.However,plaintiffs
allege,theyhavebeendeniedaccesstotheneededtreatmentsbecause
suchtreatmentsareexcludedfromcoverageunderNewYorkState's
Medicaidprogram.Id. 103,143,158.
Priorto1998,medicalcoveragewasavailableunderNewYork's
MedicaidprogramforthetreatmentofGD,includinghormonetreatment
andsexreassignmentsurgery.Id. 2.However,in1998,theNewYork
StateDepartmentofHealth("DOH"),whichisresponsiblefor
administeringthestate'sMedicaidprogram,promulgated18N.Y.C.R.R.
505.2(1),whichbarredpaymentforall"care,services,drugsor
suppliesrenderedforthepurposesofgenderreassignment"treatment
orfor"promoting"suchtreatment("Section505.2(1)").Id.
OnJune19,2014,plaintiffsfiledaclassactioncomplainton
behalfofthemselvesandallsimilarlysituatedindividualsagainst
Dr.HowardZucker,actinginhisofficialcapacityasCommissionerof
DOH,allegingthatSection505.2(1)violatesvariousprovisionsof
classrepresentative.ECFNo.28. 4 Case 1:14-cv-04456-JSR Document 52
Filed 07/29/15 Page 4 of
29stateandfederallaw.ECFNo.1.OnAugust21,2014,theparties
agreedtoaProvisionalStipulationandOrderofClassCertification,
pursuanttowhichtheCourt aclass0,
AllNewYorkStateMedicaidrecipientswhohavebeen
diagnosedwithGenderIdentityDisorderorGenderDysphoria,
andwhoseexpensesassociatedwithmedicallynecessary
GenderIdentityDisorder- orGenderDysphoria-related
treatmentarenotreimbursablebyMedicaidpursuantto18
N.Y.C.R.R.505.2(1).
ECFNo.23.Subsequently,onDecember17,2014,DOHpublishedaNotice
ofProposedRuleMakingthatproposedamendmentstoSection505.2(1)
("AmendedSection505. 2( 1) ").
TheproposedAmendedSection505.2(1)liftedtheblanketbanon
coveragefortreatmentofGD,makinghormonetherapyandgender
reassignmentsurgeryavailabletocertainMedicaidrecipients.Am. Compl.
5;DeclarationofJohnGasiordatedApril17,2015,ECFNo.
31("GasiorDeel.")Ex.1.However,itpreservedtwoimportant
coverageexclusions.First,itexcludedcoveragefor"cosmetic
surgery,services,andprocedures,"whichitdefinedas"anything
solelydirectedatimprovinganindividual'sappearance,"including
butnotlimitedtocertainenumeratedproceduressuchasbreast
augmentation,electrolysis,thyroidchondroplasty,andfacialbone
reconstruction,reduction,orsculpturing(the"CosmeticProcedures
Exclusion").GasiorDeel.Ex.1.Second,itdidnotprovidecoverage
forhormonetherapyorgenderreassignmentsurgeryforindividuals
undertheageofeighteen,orforgenderreassignmentsurgeryfor
individualsundertheageoftwenty-onewheresuchsurgerywould 5 Case
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29resultinsterilization(the"YouthExclusion").Id.
TheAmendedSection505.2(1)cameintoeffectonMarch11,2015.
OnMarch27,2015,plaintiffsfiledtheirAmendedcomplalnt.Inlt,
plaintiffsallegethattheAmendedSection505.2(1)violatesvarious
provisionsofTitleXIXoftheSocialSecurityAct(the"Medicaid
Act"),thePatientProtectionandAffordableCareAct("ACA"),andthe
NewYorkStateConstitution.Specifically,plaintiffsassertsix
causesofaction:(I)violationof42U.S.C.1396a(a)(10)(A)andits
implementingregulation,42C.F.R.440.210(the"Availability
Requirement"oftheMedicaidAct);(II)violationof42U.S.C.
1396a(a)(10)(B)anditsimplementingregulation,42C.F.R. 440. 240
(b)(the"ComparabilityRequirement"oftheMedicaidAct);
(III)violationof42U.S.C.1396a(a)(17),1396a(a)(10)(B)(i)and
theirimplementingregulation,42C.F.R.440.230(c)(the"Reasonable
StandardsRequirement"oftheMedicaidAct);(IV)violationofArticle
I,Section11oftheNewYorkStateConstitution,whichguarantees
equalprotectionofthelaws;(V)Section1557oftheACA,42U.S.C.
18116,whichprohibitssexdiscriminationintheprovisionof
healthcare;and(VI)violationof42U.S.C.1396a(a)(43),which
requiresstatestoprovide"earlyandperiodicscreening,diagnostic,
andtreatmentservices"foreligiblepersonsundertheageoftwenty-one(the"EPSDTRequirement"oftheMedicaidAct).2
2 Plaintiffs'sixthcauseofactioncitestheAvailabilityand
ComparabilityRequirements,42U.S.C.1396a(a)(10).SeeAm.Compl.177.However,plaintiffsrepresentedintheiroppositionto
defendant'smotionthattheyintendedtocitetheEPSDTRequirement,
42U.S.C.1396a(a)(43),whichisreferencedinotherparagraphsof 6 Case
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29DefendantmovedtodismisstheAmendedComplaint.By"bottom
line"OrderdatedJune26,2015,theCourtgrantedinpartanddenied
inpartdefendant's ECFNO.46. e=p1al=sthe reasonsforthoserulings.
Asdiscussedabove,intheirAmendedComplaint,plaintiffsallege
violationsofvariousprovisionsofthefederalMedicaidAct.Medicaid
isacooperativestateandfederalbenefitprogramdesignedtoprovide
necessarymedicalservicesto"needypersonsofmodestincome."Cmty.
HealthCtr.v.Wilson-Coker,311F.3d132,134(2dCir.2002).
"'Statesneednotparticipateintheprogram,butiftheychoosetodo
so,theymustimplementandoperateMedicaidprogramsthatcomplywith
detailedfederallymandatedstandards.'"Cmty.HealthCareAss'nof
N.Y.v.Shah,770F.3d129,135(2dCir.2014)(quotingThreeLower
Cnties.Cmty.HealthServs.,Inc.v.Maryland,498F.3d294,297(4th
Cir.2007)(internalquotationmarksomitted)).Statesthatelectto
receivefederalMedicaidfundsmustsubmitaplandetailinghowthey
willspendsuchfundstotheCentersforMedicareandMedicaid
Services,afederalagencywithintheDepartmentofHealthandHuman
Services.Wilson-Coker,311F.3dat134(citing42U.S.C.1396,
1396a).StateMedicaidplansaresubjecttoextensiverequirements,
fourofwhicharerelevanthere.
theAmendedComplaint.ReadingtheAmendedComplaintasawholeand
drawingallinferencesinplaintiffs'favor,itisclearthatthe
citationtoSection1396a(a)(10)wasmerelyascrivener'serror,and
theCourtwilltreatitassuch.Becauseofthiserror,defendantdoes
notmakeanyargumentwithrespecttotheEPSDTRequirement.Defendant
hasnotbeenprejudicedbyplaintiffs'error,however,astheCourt
findsthattheEPSDTRequirementgivesrisetoaprivaterightof 7 Case
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29Availability.TheAvailabilityRequirementprovidesthatastate
planformedicalassistance"mustprovide...formakingmedical s s ~ s t n
c e ava1lable[toallcategorlcallyneedylr1dlvlduals],
includingatleast"certainenumeratedtypesofcareandservices,
includinginpatientandoutpatienthospitalservices,laboratoryand
x-rayservices,nursingfacilityservices,andphysicians'services.
42U.S.C.1396a(a)(10)(A),42U.S.C.1396d(a).Categoricallyneedy
individualsarethosemeetingoneofnineeligibilitycriteria,which
include,forexample,receiptofsupplementalsecurityincomebenefits
andhavinganincomethatdoesnotexceed133percentofthepoverty
line.42U.S.C.1396a(a)(10)(A)(i)(I)- (IX).
Theimplementingregulation,42C.F.R.440.210,requiresthe
Stateplantoprovidecategoricallyneedyindividualswiththe
"servicesdefinedin440.10through440.50[and]440.70."Those
provisions,inturn,furtherdefinethetypesofservicesthatmustbe
provided.Forexample,"inpatienthospitalservices"aredefinedas
servicesthat"(1)areordinarilyfurnishedinahospitalforthecare
andtreatmentofinpatients;(2)arefurnishedunderthedirectionof
aphysicianordentist;and(3)arefurnishedinan[appropriateand
approved]institution... "42C.F.R.440.10 (a).Similarly,"physicians'
services"aredefinedas"servicesfurnishedbyaphysician-[w]ithin
thescopeofpracticeofmedicineorosteopathyasdefinedbyState
law;and...[b] yorunderthepersonalsupervisionofanindividual
action.Seeinfra. 8 Case 1:14-cv-04456-JSR Document 52 Filed
07/29/15 Page 8 of
29licensedunderStatelawtopracticemedicineorosteopathy."42
C.F.R.440.50(a). Theimplementingregulations~ u r t h r
provide,lnre1evantpart:
(b)Eachservicemustbesufficientinamount,duration,and
scopetoreasonablyachieveitspurpose.
(c)TheMedicaidagencymaynotarbitrarilydenyorreduce
theamount,duration,orscopeofarequiredserviceunder
440.210and440.220toanotherwiseeligiblebeneficiary
solelybecauseofthediagnosis,typeofillness,or condition.
(d)Theagencymayplaceappropriate basedonsuchcriteriaasmedical
utilizationcontrolprocedures. 42C.F.R.440.230. limitsona necessity
service oron Comparability.TheMedicaidAct'sComparabilityRequirement
providesthat"themedicalassistancemadeavailabletoany
[categoricallyneedyindividual]...shallnotbelessinamount,
duration,orscopethanthemedicalassistancemadeavailabletoany
othersuchindividual."42U.S.C.1396a(a)(1)(B)(i).Its
implementingregulationprovidesthatthestate's"planmustprovide
thattheservicesavailabletoany[categoricallyneedy]individual...
areequalinamount,duration,andscopeforallbeneficiarieswithin
the[categoricallyneedy]group."42C.F.R.440.240(b).Thepurpose
oftheComparabilityRequirementistomakeclearthat"statesmaynot
providebenefitstosomecategoricallyneedyindividualsbutnotto
others."Rodriguezv.CityofNewYork,197F.3d611,615(2dCir. 1999). 9
Case 1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 9 of
29EPSDT.TheMedicaidActfurtherrequiresastateplanformedical
assistancetoprovide"earlyandperiodicscreening,diagnostic,and
treatmentservices,"includingregularscreeningforphyBlcaland
mentalillnessesandconditions,toeligibleindividualsundertheage
oftwenty-one.42U.S.C.1396a(a)(43),1396d(r).Inaddition,the
stateplanmustprovide"[s]uchothernecessaryhealthcare,
diagnosticservices,treatment,andothermeasures...tocorrector
amelioratedefectsandphysicalandmentalillnessesandconditions
discoveredbythescreeningservices,whetherornotsuchservicesare
coveredundertheStateplan."42U.S.C.1396d(r)(5).
ReasonableStandards.Finally,theMedicaidActrequiresthatthe
stateplanmust"includereasonablestandards...fordetermining
eligibilityforandtheextentofmedicalassistanceundertheplan
which[]areconsistentwiththeobjectivesof[theMedicaidAct]."42
U.S.C.1396a(a)(17).Thissubsectionfurthersetsforthcertain
requirementsforthe"reasonablestandards"thatthestatemustadopt,
suchasthetypesofincomeandresourcesthatthestatemaytakeinto
accountindeterminingeligibility.Id.
Plaintiffs'claimsallegingviolationsoftheAvailability
Requirement(CountI),theComparabilityRequirement(CountII),and
theEPSDTRequirement(CountVI)ofthefederalMedicaidActare
broughtpursuantto42U.S.C.1983("Section1983"),whichprovides:
Everypersonwho,undercolorofanystatute,ordinance,
regulation,custom,orusage,ofanyStateorTerritoryor
theDistrictofColumbia,subjects,orcausestobe
subjected,anycitizenoftheUnitedStatesorotherperson
withinthejurisdictionthereoftothedeprivationofany
rights,privileges,orimmunitiessecuredbythe 10 Case
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29Constitutionandlaws, inanactionatlaw, proceedingforredress ...
shallbeliabletothepartyinjured suitinequity,orotherproper
42U.S.C.1983.Inhismotiontodismiss,defendantarguedthat
Section1983doesnotcreateaprivaterightofactiontoenforce
theseprovisions,andthereforethatplaintiffs'CountsI,II,andVI
mustbedismissedforfailuretostateaclaim.
InMainev.Thiboutot,theSupremeCourtheldthattheSection
1983remedyencompassesrightsconferredbyfederalstatutes.448U.S.
1,4(1980).Nonetheless,"[i]nordertoseekredressthrough1983,
aplaintiffmustasserttheviolationofafederalright,notmerely
aviolationoffederallaw."Blessingv.Freestone,520U.S.329,340
(1997).Indeterminingwhetheraparticularstatutoryprovisiongives
risetoafederalright,courtsapplyathree-prongedtest:(1)
"Congressmusthaveintendedthattheprovisioninquestionbenefit
theplaintiff";(2)"theplaintiffmustdemonstratethattheright
assertedlyprotectedbythestatuteisnotso'vagueandamorphous'
thatitsenforcementwouldstrainjudicialcompetence";and(3)"the
statutemustunambiguouslyimposeabindingobligationontheStates,"
meaningit"mustbecouchedinmandatory,ratherthanprecatory,
terms."Id.at340-41.Iftheplaintiffdemonstratesthatthefederal
statutecreatesanindividualright,thedefendantmanynonetheless
rebutthepresumptionthatsuchrightisenforceableviaaSection
1983actionbyshowingthatCongress"specificallyforeclosedaremedy
under1983,"eitherexpresslyor"impliedly,bycreatinga
comprehensiveenforcementschemethatisincompatiblewithindividual 11
Case 1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 11 of
29enforcementunder1983."Id.at341(internalquotationmarksand
citationsomitted).Thistestisknownasthe"Blessing"test.
InGonzagaUniversityv.Doe,theSupremeCourt
withrespecttothefirstprongoftheBlessingtest,it"reject[ed]
thenotionthatourcasespermitanythingshortofanunambiguously
conferredrighttosupportacauseofactionbroughtunder1983."
536U.S.273,283(2002).Itwasinsufficient,theCourtheld,that
the"plaintifffallswithinthegeneralzoneofinterestthatthe
statuteisintendedtoprotect."Id.at283.TheCourtreaffirmedthat
"unlessCongress'speak[s]withaclearvoice,'andmanifestsan
'unambiguous'intenttoconferindividualrights,federalfunding
provisionsprovidenobasisforprivateenforcementby1983."Id.at
280(quotingPennhurstStateSchoolandHospitalv.Halderman,451
U.S.1,17,28andn.21(1981)).
InarguingthatprovisionsoftheMedicaidActcitedby
plaintiffsdonotcreateprivaterightsofactionunderSection1983,
defendantreliesheavilyonCasillasv.Daines,580F.Supp.2d235,
242(S.D.N.Y.2008).Theplaintiffinthatcase,TerriCasillas,wasa
NewYorkStateMedicaidrecipientwhohadbeendiagnosedwithGD,and
whosephysicianshadrecommendedthatsheundergohormonetherapy,
orchiectomy(removalofthetestes) ,andvaginoplasty(removalofthe
penisandcreationofavagina).Id.at237-38.Shebroughtanaction
underSection1983challengingtheoriginalSection505.2(1)underthe
AvailabilityandComparabilityRequirementsoftheMedicaidAct.3Id. 3
CasillasalsobroughtaSection1983claimallegingthatSection 12 Case
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29at241-44.Thecourtgranteddefendant'smotionforjudgmentonthe
pleadings,holdingthatneitherprovisioncreatedarightenforceable
underSection1983.
WithrespecttotheAvailabilityRequirement,Casillasheldthat
neitherthefirstnorthesecondprongoftheBlessingtestwasmet.
Astothefirstprong,itheldthat,althoughtheAvailability
Requirementmayconfercertainrightsoncertainclassesofpersons,
itdidnotunambiguouslyconfertherightthatplaintiffasserted,
namelytherighttoreceivethespecifictreatmentsforGDthathad
beendeemedmedicallynecessarybyherphysicians.Id.at241-43.The
courtreasonedthattheAvailabilityRequirementrequiresstatesto
providecoverageforcertainbroadcategoriesofmedicalservices,but
doesnot"mandatethataparticularlevelortypeofcaremustbe
provided."Id.at242.Insofinding,itreliedonSupremeCourt's
decisioninBealv.Doe,432U.S.438(1977),forthepropositionthat
"nothinginthestatutesuggeststhatparticipatingstatesare
requiredtofundeverymedicalprocedurethatfallswithinthe
delineatedcategoriesofmedicalcare."Id.(quotingBeal,4 3 2U.S.at
444)(alterationomitted).
TheCasillascourtfurtherreasonedthattherightthatplaintiff
assertedwasinconsistentwiththeAvailabilityRequirement's
implementingregulation,whichallowsstatesto"'placeappropriate
505.2(1)violatedtheReasonableStandardsRequirement.Casillas,580
F.Supp.2dat245-46.Becauseplaintiffsinthiscasebringtheir
claimrelatingtotheReasonableStandardsRequirementunderthe
SupremacyClauseratherthanSection1983,thisportionofthe
Casillasdecisionisnotdirectlyrelevant. 13 Case 1:14-cv-04456-JSR
Document 52 Filed 07/29/15 Page 13 of
29limitsonaservicebasedonsuchcriteriaasmedicalnecessityoron
utilizationcontrolprocedures.'"Id.(quoting42C.F.R.
440.230(d)).Thesecriteria,thecourtheld, the
referenceto"utilizationcontrolprocedures,""capture[]concepts
thatdonotrelatetothecareofanyoneparticularpatientbutlooks
toactualorexpectedutilizationoverabroaderpopulation,"andthus
indicatethattheAvailabilityRequirementisintendedtoprescribe
standardswithwhichthestateplanmustcomplyratherthantocreate
individualrights.Id.
AstothesecondprongoftheBlessingtest,Casillasfurther
heldthatthephrase"utilizationcontrolprocedures"was"so'vague
andamorphous'thatitsenforcementwouldstrainjudicialcompetence."
Id.at243(quotingBlessing,520U.S.at340-41).Thisterm,the
courtnoted,is"susceptibletomultipleplausibleinterpretationsand
lacksafixedmeaning."Id.Moreover,itnoted,theregulationpermits
astatetorelyonotherunspecifiedcriteriaincrafting"appropriate
limits"onmedicalservices,therebycompoundingthevagueness problem.Id.
AlthoughinnowaybindingonthisCourt,Casillasisentitledto
thisCourt'srespectfulattention.Butintheend,theCourtfinds
itselfindisagreementwiththatdecision'sreasoningandconclusions.
Inparticular,theCourtconcludesthattheAvailabilityRequirement
unambiguouslyconfersoncategoricallyneedyindividualsanindividual 14
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29righttothemedicalservicesdescribedinthestatuteandits
implementingregulations.Gonzaga,536U.S.at280.
Asaninitialmatter,Casillas'srelianceonBealismlsp1aced.
ThatcaseconcernedaPennsylvaniaregulationthatlimitedMedicaid
coverageforabortionstothosethathadbeencertifiedbythe
recipient'sphysiciansasmedicallynecessary.Beal,432U.S.at441-42.Inholdingthatthechallengedregulationdidnotviolatethe
MedicaidAct,theSupremeCourtfocusedonthefactthattheexcluded
procedureswerenotmedicallynecessary.Id.at440(describingthe
questionpresentedaswhethertheMedicaidActrequiresstatesto
"fundthecostofnontherapeuticabortions"(emphasisadded)).It
expresslynotedthatdenialofmedicallynecessarytreatmentwould
poseaverydifferentquestion:"Althoughseriousstatutoryquestions
mightbepresentedifastateMedicaidplanexcludednecessarymedical
treatmentfromitscoverage,itishardlyinconsistentwiththe
objectivesoftheActforaStatetorefusetofundunnecessarythough
perhapsdesirablemedicalservices."Id.at444-45(emphasisadded).4
Here,bycontrast,plaintiffsallegethatthetreatmentstheyseekare
medicallynecessary,andonamotiontodismiss,theCourtmustaccept
thatallegationastrue. 4
JusticeBrennan,joinedbyJusticeMarshallandJusticeBlackmunin
dissent,interpretedtheMedicaidActtorequirecoverageevenfor
electiveabortions.Id.at449(Brennan,J.,dissenting).Asrelevant
here,JusticeBrennaninterpretedtheMedicaidActtoleavedecisions
regardingmedicaltreatmenttothedoctorandpatient,notthestate:
"theveryheartofthecongressionalschemeisthatthephysicianand
patientshouldhavecompletefreedomtochoosethosemedical
proceduresforagivenconditionwhicharebestsuitedtotheneedsof
thepatient."Id.at450(Brennan,J.,dissenting). 15 Case
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29RegardingthefirstprongoftheBlessingtest,thelanguageof
theAvailabilityRequirementisexpresslyaddressedtotheneedsof
indJ.Vl.dUa.LMed.1.cal.d.bene.I:l.ciaries:"[ci].SL.aceplan...mu::sLpLuvlcte:tor
makingmedicalassistanceavailable...toallindi victuals"whomeet
certaineligibilityrequirements.42U.S. C.13 96a (a)( 10)(A).Thisis
preciselythe"unmistakablefocusonthebenefitedclass"thatthe
SupremeCourt,inGonzaga,heldwouldevinceCongress'sintentto
createanindividualright.536U.S.at284(citationandinternal
quotationmarksomitted).Indeed,theThirdCircuithasfoundthat
"the'individualfocus'of[theAvailabilityRequirement]is
unmistakable."Sabreeexrel.Sabreev.Richman,367F.3d180,190(3d
Cir.2004). AlthoughtheSecondCircuithasnothadoccasiontoconsiderthis
question,ithasheldthatasimilarlywordedprovisionofthe
MedicaidActcreatedaprivatelyenforceableright.SeeRabinv.
Wilson-Coker,362F.3d190(2004).TheprovisionatissueinRabin
grantedasix-monthextensionofeligibilityformedicalassistance,
providedtherecipientcompliedwithcertainreportingrequirements:
"[E]achStateplanapprovedunderthissubchaptermust
providethateachfamilywhichwasreceivingaidpursuantto
aplanoftheStateinatleast3ofthe6months
immediatelyprecedingthemonthinwhichsuchfamilybecomes
ineligibleforsuchaidshallremaineligiblefor
assistanceundertheplanduringtheimmediately
succeeding6-monthperiod."
Id.at194(quoting42U.S.C.1396r-6(b)).TheSecondCircuitfound
that,byfocusingonindividual(orfamily)entitlementsratherthan
high-levelprogrammaticrequirements,Congressintendedtocreatean 16
Case 1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 16 of
29enforceableright.Id.at201-02.Giventhegrammaticalsimilarity
betweenthisprovisionandtheAvailabilityRequirement,itfollows
thattheAvailabilityRequirementalsoevincescongressiona1lntentto
createanenforceableright.
ContrarytoCasillas,nothingabouttheexistenceofthisright
isinconsistentwiththe"appropriatelimitsnclauseofthe
implementingregulations.42C.F.R.440.230(d).Thatclausesimply
providesthat,likemostrights,therighttothemedicalservices
describedintheAvailabilityRequirementisnotabsolute.Rather,it
issubjecttolimitsthatthestatemayenact,consistentwiththe
discretionvestedinthestatebythestatute.Thatdiscretionisnot
boundless.Thestatemayenactonly"appropriatenlimits,mustprovide
servicesthatare"sufficientinamount,duration,andscopeto
reasonablyachieve[their]purpose,nand"maynotarbitrarilydenyor
reducetheamount,duration,orscopeofarequiredservice...toan
otherwiseeligiblebeneficiarysolelybecauseofthediagnosis,type
ofillness,orcondition.n42C.F.R.440.230(b)-(d).These
provisionsdefinethecontoursoftheright;theydonotnegateits existence.
Noristhisrightso"vagueandamorphousnastobejudicially
unmanageableunderthesecondprongoftheBlessingtest.The
AvailabilityRequirementanditsimplementingregulationssetforthin
detailtheservicesthatstatesmustprovidetotheirneedyresidents,
andstates'compliancewiththeserequirementsisobjectively
measureable.SeeWatsonv.Weeks,436F.3d1152,1161(9thCir.2006) 17 Case
1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 17 of
29("[Sections1396a(a)(10)and1396d(a)supplyconcreteandobjective
standardsforenforcement;theyarehardlyvagueandamorphous.").
CaS1llaSrOUDdthattheterm-utlllzatloncontrol dB
usedintheimplementingregulations,wasnotjudiciallymanageable.
Casillas,580F.Supp.2dat243.Butcourtshavehadnotrouble
adjudicatingwhetheraparticularregulationisavalidutilization
controlprocedure.Forexample,inDeLucav.Hammons,927F.Supp.132
(S.D.N.Y.1996),plaintiffschallengedaregulation,whichthestate
defendedasautilizationcontrolprocedure,thatlimitedhome-care
servicesfornewMedicaidrecipientstotwenty-eighthoursperweek.
Id.at134.Thecourtfoundthatthisarbitrarycapwas"not
appropriateinthatitdiscriminatesamongapplicantsand
intentionallyfailstotakeintoaccounttheamountofservicesthat
havebeendeterminedtobenecessaryforthehealthandsafetyof
thepatient."Id.at136.Seealso,e.g.,Davisv.Shah,No.12-CV-6134CJS,2013WL6451176,at*12(W.D.N.Y.Dec.9,2013)(holding
thatregulationlimitingaccesstomedicallynecessaryorthopedic
shoesandcompressionstockingsbasedondiagnosiswasnotvalid
utilizationcontrolprocedure);Laddv.Thomas,962F.Supp.284,294
(D.Conn.1997)(holdingthatrequirementthatMedicaidrecipients
submitrequestsforpriorauthorizationofdurablemedicalequipment
tovendorwasavalidutilizationcontrolprocedure).
Casillasfurtherexpressedconcernthattheimplementing
regulationpermitsastateagencytoplace"appropriatelimits"on
servicesbasedonunspecifiedothercriteria.Tobesure,this 18 Case
1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 18 of
29provisiongrantsthestateaconsiderablemeasureofdiscretion.It
doesnot,however,rendertheassertedrightentirelystandardless.
Forexample,alimitationbasedongenuinehealthandsafetyconcerns
wouldmostlikelybean"appropriatelimit,"whereasonebasedsolely
onanimustowardsadisfavoredclassmostcertainlywouldnot.Nothing
aboutthisdeterminationstretchestheboundsofjudicialcompetence.
Finally,regardingthethirdprongoftheBlessingtest,the
AvailabilityRequirementisframedinmandatoryterms.Itprovides
thatstateplans"must"makeavailabletheservicesdescribed.
Provisionoftheseservicesisnotoptional.Accordingly,theCourt
findsthatallthreeBlessingfactorsaremetandtheAvailability
RequirementcreatesanindividualrightenforceableunderSection 1983.5 5
Insoholding,theCourtjoinstheoverwhelmingmajorityofcourts,
bothbeforeandafterGonzaga,thathaveconsideredthisquestion.See
Watsonv.Weeks,436F.3d1152,1159-60(9thCir.2006)("Nocircui_t_
courthasheldthatsection1396a(a)(10)doesnotcreateasection
1983right.");Sabreeexrel.Sabreev.Richman,367F.3d180(3dCir.
2004);S.D.exrel.Dicksonv.Hood,391F.3d581,603(5thCir.
2004);PediatricSpecialtyCare,Inc.v.ArkansasDep'tofHuman
Servs.,293F.3d472,478-79(8thCir.2002);WestsideMothersv.
Haveman,289F.3d852,862-63(6thCir.2002);MillerbyMillerv.
Whitburn,10F.3d1315,1319(7thCir.1993);Crawleyv.Ahmed,No.
08-14040,2009WL1384147,at*19(E.D.Mich.May14,2009);Michelle
P.exrel.Deisenrothv.Holsinger,356F.Supp.2d763,767(E.D.Ky.
2005);HealthCareForAll,Inc.v.Romney,No.CIV.A.00-10833-RWZ,
2004WL3088654,at*2(D.Mass.Oct.1,2004);Memisovskiexrel.
Memisovskiv.Maram,No.92C1982,2004WL1878332,at*11(N.D.Ill.
Aug.23,2004);KennyA.exrel.Winnv.Perdue,218F.R.D.277,294
(N.D.Ga.2003);DajourB.v.CityofNewYork,No.00CIV.2044,2001
WL830674,at*8(S.D.N.Y.July23,2001);cf.Brysonv.Shumway,308
F.3d79,88-89(1stCir.2002)(holdingthatsimilarlyworded
provisionofMedicaidActcreatesprivatelyenforceableright);Doe1-13By&ThroughDoe,Sr.1-13v.Chiles,136F.3d709,719(11thCir.
19 9 8)(same). 19 Case 1:14-cv-04456-JSR Document 52 Filed 07/29/15
Page 19 of 29WithrespecttotheComparabilityRequirement,theCourtalso
findsthatallthreeBlessingfactorsaremet.First,thestatutory
languageissquarelydirectedtowardindividualrights:"them e d ~ c
lassistancemadeavailabletoany[categoricallyneedyindividual]
shallnotbelessinamount,duration,orscopethanthemedical
assistancemadeavailabletoanyothersuchindividual."42U.S. C.
1396a(a)(1)(B)(i).Theimplementingregulationsfurtherprovidethata
stateMedicaid"planmustprovidethattheservicesavailabletoany
individualinthefollowinggroupsareequalinamount,duration,and
scopeforallbeneficiarieswithinthegroup:(1)Thecategorically
needy.(2)Acoveredmedicallyneedygroup."42C.F.R.440.240(b).
Theseprovisions,likethoseoftheAvailabilityRequirement,focuson
theparticularservicesthatindividualbeneficiariesareentitledto
receive,notonthebroaderstructureoftheMedicaidprogramasa
whole,andthusevincecongressionalintenttocreateindividual rights.
Inholdingotherwise,theCasillascourtreliedonRodriguezv.
CityofNewYork,197F.3d611(2dCir.1999).InRodriguez,NewYork
hadelectedtoprovidecertaintypesofpersonalcareservicesto
individualswithdisabilities,whichwerenotamongtheservicesit
wasrequiredtoprovideundertheAvailabilityRequirement.Id.at
613.Plaintiffscontendedthat,undertheComparabilityRequirement,
thestatewasrequiredtoprovide"safetymonitoring,"adifferent
servicethatplaintiffsallegedwascomparabletothepersonalcare
servicesthatthestatehadchosentocover.Id.at616.TheSecond 20 Case
1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 20 of
29Circuitrejectedplaintiffs'argument,notingthat"[a]holdingtothe
contrarywouldcreateadisincentiveforstatestoprovideservices
opt1onalunderreaerallawlestacourLdeemother~ e r v l c e
'comparable'tothoseprovided...therebyincreasingthecostsofthe
optionalservices."Id.
TherightassertedinRodriguezisverydifferentfromtheright
assertedhere.TheRodriguezplaintiffssoughtaccesstoaspecific
servicethatthestatewasnotrequiredtoprovideandthatithadnot
chosentoprovidetoanyone.Here,bycontrast,plaintiffsallegethat
thespecifictreatmentstheyseekarealreadyprovidedtoother
Medicaidrecipientsbuthavebeendeniedtothemonthebasisoftheir
GDdiagnosesalone.This,theyallege,demonstratesthattheservices
theyreceiveunderNewYork'sMedicaidprogramarenot"equalin
amount,duration,andscope"tothosereceivedbyothercategorically
needyindividuals.42C.F.R.440.240(b).
InCasillas,thecourtfoundthattherightassertedbyplaintiff
would,asinRodriguez,createadisincentiveforstatestoprovide
specifictreatments:"thestatewouldhavetoconsiderotherpossible
diagnosesforwhichthetreatmentmightbeprescribedbeforedeciding
whethertomakeitavailableforanysinglecondition."Id.at244.
Whilethatmaybethecase,requiringthestatetoundertakesuch
considerationsisentirelyconsistentwiththepurposeofananti-discriminationprovision.InenactingtheComparabilityRequirement,
Congressmadeclearthatthestatesmaynotblithelyprovideservices
tosomeoftheirneedyresidentswhiledenyingthesameservicesto 21 Case
1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 21 of
29otherswhoareequallyneedy.Thus,thisisnotareasontofindthat
theComparabilityRequirementdoesnotgiverisetoanindividual right.
TheComparabilityRequirementalsosatisfiesthesecondandthird
prongsoftheBlessingtest.Thestandardsetforthinthestatute
thatservicesprovidedtosomecategoricallyneedyindividualsmaynot
be"lessinamount,duration,orscope"thanthoseprovidedtoothers
isneithervaguenoramorphous.42U.S.C.1396a(a)(1)(B)(i).And
bydirectingthatservices"shall"becomparable,Congressmadeclear
thatthisrequirementwasmandatoryandbindingonthestates.
Accordingly,theCourtfindsthattheComparabilityRequirement
createsanenforceableindividualright.6
Finally,althoughdefendantmakesnoargumentregardingtheEPSDT
Requirement,seesupranote2,theCourtfindsthattheEPSDT
RequirementisalsoprivatelyenforceableunderSection1983.As
numerouscourtshaveheld,theEPSDTRequirement(1)isunmistakably
focusedontherightsofMedicaid-eligibleyouthtoreceivethe
enumeratedservices,(2)providesdetailed,objective,andmanageable
standards,includingspecificservicesthatmustbeprovided,and(3)
isbindingonstates.See,e.g.,DajourB.v.CityofNewYork,No.00
Civ.2044,2001WL830674,at*8-*10(S.D.N.Y.July23,2001);see 6
Numerousothercourtshavesoheld.See,e.g.,Davisv.Shah,No.
12-CV-6134CJS,2013WL6451176,at*12(W.D.N.Y.Dec.9,2013);
MichelleP.exrel.Deisenrothv.Holsinger,356F.Supp.2d763,767
(E.D.Ky.2005);HealthCareForAll,Inc.v.Romney,No.CIV.A.00-10833-RWZ,2004WL3088654,at*2(D.Mass.Oct.1,2004);Antricanv.
Buell,158F.Supp.2d663,672(E.D.N.C.2001)aff'dsubnom.
Antricanv.Odom,290F.3d178(4thCir.2002). 22 Case 1:14-cv-04456-JSR
Document 52 Filed 07/29/15 Page 22 of
29alsoSalazarv.DistrictofColumbia,729F.Supp.2d257,269(D.D.C. 2010).
BecausethecourtroundthattheAvailab:LLLLy,Comparab:Ll:Lty,and
EPSDTRequirementscreateprivaterightsenforceableviaSection1983,
theCourtdeniedtheportionofdefendant'smotionseekingtodismiss
CountsI,II,andVI.
Withrespecttocertainofplaintiffs'otherclaims,however,the
Courtfoundthatdefendant'smotionhadmerit,atleastinpart.
Regardingplaintiffs'claimthatAmendedSection505.2(1)violatesthe
ReasonableStandardsRequirement(CountIII),thisclaimisbrought
pursuanttotheSupremacyClauseoftheUnitedStatesConstitution.
SeeU.S.Const.art.VI.7 Inhismotion,defendantarguedthatthe
SupremeCourt'srecentopinioninArmstrongv.ExceptionalChild
Center,Inc.,135S.Ct.1378(2015),establishesthatplaintiffshave
nocauseofactionundertheSupremacyClausetoenforcethe
ReasonableStandardsRequirement.
InArmstrong,theCourtheldthattheSupremacyClausedoesnot
conferaprivaterightofaction.Id.at1384.Furthermore,although
federalcourtshaveinherentauthoritytoenjoinunconstitutional
actionsbystateandfederalofficials,thatauthority"issubjectto
expressandimpliedstatutorylimitations."Id.at1385.Specifically, 7
PlaintiffsalsoallegethattheAvailabilityandComparability
Requirements(CountsIandII)arepreemptedbytheSupremacyClause.
BecausetheCourtfindsthatplaintiffshaveaprivaterightofaction
toenforcetheseprovisionsunderSection1983,itdoesnotaddress
whethertheymayalsobringtheirclaimspursuanttotheSupremacy Clause. 23
Case 1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 23 of
29whereastatute"implicitlyprecludesprivateenforcement,"a
plaintiff"cannot,byinvokingourequitablepowers,circumvent
AtissueinthatcasewasSection30(A)oftheMedicaidAct,
whichrequiresstateplansto:
providesuchmethodsandproceduresrelatingtothe
utilizationof,andthepaymentfor,careandservices
availableundertheplan...asmaybenecessarytosafeguard
againstunnecessaryutilizationofsuchcareandservices
andtoassurethatpaymentsareconsistentwithefficiency,
economy,andqualityofcareandaresufficienttoenlist
enoughproviderssothatcareandservicesareavailable
undertheplanatleasttotheextentthatsuchcareand
servicesareavailabletothegeneralpopulationinthe geographicarea...
42U.S. C.13 96a (a)( 3 O)(A).TheCourtheldthatSection3 O (A)isnot
privatelyenforceablebecause,first,thestatuteprovidesanexpress
methodofenforcement,namelywithholdingofMedicaidfundsbythe
SecretaryofHealthandHumanServices.Id.at1385(citing42U.S.C.
1396c).Thecreationofanadministrativeremedy,theCourtheld,
evincedCongress'sintenttoprecludeprivateenforcement.Second,the
CourtfoundthatSection30(A)wasnotamenabletoprivateenforcement
becauseitsmandatewasso"judgment-laden,""broad[],"and
"complex[]"astobe"judiciallyunadministrable."Id.
LikeSection30(A),theReasonableStandardsRequirementis
subjecttoanexpressadministrativeenforcementmechanism,viz.,
defundingbytheSecretaryofHealthandHumanServices.42U.S.C.
1396c.Furthermore,thisprovisionconsistsofabroadgrantof
discretiontothestatestoimplement"reasonablestandards...for 24 Case
1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 24 of
29determiningeligibilityforandtheextentofmedicalassistanceunder
theplan"thatare"consistentwiththeobjectivesof[theMedicaid
Act]."42U.S.C.l396a(a)(l7).er.Watson,436Y.3dat1162
("Section1396a(a)(17)isageneraldiscretion-grantingrequirement
thatastateadoptreasonablestandards.").LikeSection30(A),it
focusesonprogrammaticaspectsofthestateplanasawhole,rather
thanonthespecificbenefitsthatmustbeaccordedtoindividuals.
Therefore,theCourtconcludedthattheReasonableStandards
RequirementisnotprivatelyenforceableunderArmstrong.Accordingly,
theCourtgranteddefendant'smotiontodismissCountIII.
TurningtoCountV,defendantarguedinhismotionthat
plaintiffsfailedtostateaclaimforviolationofSection1557of
theACAwithrespecttotheYouthExclusion.Section1557provides
that"anindividualshallnot...beexcludedfromparticipationin,be
deniedthebenefitsof,orbesubjectedtodiscriminationunder,any
healthprogramoractivity"thatreceivesfederalfundingonthebasis
ofcertaincriteria,includingsex.42U.S.C.18116.Onamotionto
dismissunderRule12(b)(6),acourtmustassesswhetherthecomplaint
"contain[s]sufficientfactualmatter,acceptedastrue,to'statea
claimtoreliefthatisplausibleonitsface.'"Ashcroftv.Iqbal,
556U.S.662,678(2009)(quotingBellAtl.Corp.v.Twombly,550U.S.
544,570(2007)).DefendantarguesthattheYouthExclusiondraws
distinctionsonthebasisofage,notsex,andthereforedoesnot
violatethisprovision. 25 Case 1:14-cv-04456-JSR Document 52 Filed
07/29/15 Page 25 of
29PlaintiffsrespondthattheYouthExclusiondiscriminatesonthe
basisofsexintwoways:"(1)thatcertainservicesareavailableto
non-i::;ransgenaerpeop1-eDuedeniedcut.ra_ns9enderpeuplewhere
medicallynecessary;or(2)thatregardlessoftheavailabilityof
thesetreatmentstopeoplegenerally,thesecoverageexclusionshavea
disparateimpactontransgenderpeopleforwhomtheseservicesare
medicallynecessary."Plaintiffs'OppositiontoDefendant'sMotionto
DismissdatedMay8,2015,ECFNo.34,at19.8
However,plaintiffsfailtoallegeanyfactsinsupportofeither theory.9
Mostnotably,plaintiffsfailtoallegethatthetreatments
barredbytheYouthExclusionareavailabletonon-transgenderyouth.
Intheabsenceofsuchanallegation,defendant'sfailuretomakesuch
servicesavailabletotransgenderyouthcannotconstitutesex
discrimination.Thus,althoughtheCourtiscognizantoftheprinciple
that"[c]omplaintsallegingcivilrightsviolationsmustbeconstrued
especiallyliberally,"UnitedStatesv.CityofNewYork,359F.3d83,
91(2dCir.2004),herethereisnothingtoconstrue.Accordingly,the
Courtgranteddefendant'smotiontodismissClaimVoftheAmended 8
Itisnotsettledwhetheradisparateimpactclaimiscognizable
underSection1557oftheACA.SeeRumblev.FairviewHealthServs.,
No.14-CV-2037SRN/FLN,2015 at*12(D.Minn.Mar.16, 2015) 9
TheonlyfactualallegationintheAmendedComplaintrelatingto
treatmentoftransgenderyouthisthat"numerousrespectedclinics
aroundtheUnitedStatesprovidemedicalservicesforpeoplediagnosed
withGD/GIDwhoareundertheageofeighteen."Am.Compl. 89.This
allegationcannotsupportplaintiffs'claimofdiscrimination. 26 Case
1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 26 of
29complaintwithrespecttotheYouthExclusionforfailuretostatea claim.
Defendantalsoarguedinhismotionthatplaintiffsfalledto
stateaclaimforviolationoftheComparabilityRequirementbecause
theyfailedtopleadsufficientfactualsupportfortheircontention
thattheyhavenotreceivedcomparableservices.However,plaintiffs
clearlyallegethatdefendantprovidesmedicalcoveragetosimilarly
situatedMedicaidrecipientssufferingfromconditionsotherthanGD
forthesurgicalproceduresandothertreatmentsthataredeniedto
themunderAmendedSection505.2(1),andciteaprovisionoftheDOH
regulationssupportingthatcontention.Am.Compl. 107,146,160
(citing18N.Y.C.R.R.533.5).Theseparagraphsadequatelyplead
violationsoftheComparabilityRequirement,astheyallegethat
defendanthasprovidedmedicallynecessaryprocedurestosome
individualsbutnottoothers.SeeProvidencePediatricMed.Daycare,
Inc.v.Alaigh,799F.Supp.2d364,374(D.N.J.2011)(denyingmotion
todismisswhereplaintiffsallegedthatcertain"childrenarenot
receivingthoseservicesthattheirphysicianshavedesignatedas
medicallynecessary").
Defendantfurtherarguedthatplaintiffs'claimswithrespectto
theCosmeticProceduresExclusionarenotyetripeforadjudication
becauseplaintiffsfailedtopleadthattheyhaverequestedandbeen
deniedanyoftheproceduresbarredbyAmendedSection505.2(1)."A
claimisnotripeforadjudicationifitrestsuponcontingentfuture
eventsthatmaynotoccurasanticipated,orindeedmaynotoccurat 27 Case
1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 27 of
29all."Texasv.UnitedStates,523U.S.296,300(1998)(internal
quotationmarksomitted).However,courtswithinthiscircuitdonot
require"afutilegestureasaprerequisiteforadjudicatlonln
federalcourt."Desideriov.Nat'lAss'nofSec.Dealers,Inc.,191
F.3d198,202(2dCir.1999)(quotingWilliamsv.Lambert,46F.3d
1275,1280(2dCir.1995)).AmendedSection505.2(1),byitsplain
terms,excludescoveragefortheproceduresdeemed"cosmetic."See
AmendedSection505.2(1)(4)(statingthat"[p]aymentwillnotbemade"
for"cosmeticsurgery,services,andproceduresincludingbutnot
limitedto"theenumeratedprocedures).Furthermore,theDepartmentof
Health'sMedicaidUpdatemakesclearthat"paymentwillnotbemade
for"theservicesdeemed"cosmetic."DeclarationofArthurBiller
datedMay8,2015,Ex.2,at16.Therefore,theCourtfindsthatany
attempttoseekcoveragefortheso-called"cosmetic"serviceswould
havebeena"futilegesture"andwasnotrequiredtorender
plaintiffs'claimsripeforadjudication.
Accordingly,theCourtdenieddefendant'smotiontodismiss
plaintiffs'claimsregardingtheCosmeticProceduresExclusionas unripe.
Finally,defendantarguedinhismotionthatplaintiffs'Claim
IV,forviolationoftheequalprotectionprovisionsoftheNewYork
StateConstitution,isbarredbytheEleventhAmendmenttotheUnited
StatesConstitutionbecauseitassertsapurelystatelawclaim
againstastateofficial.SeeConcourseRehab.&NursingCtr.,Inc.v.
DeBuono,179F.3d38,44(2dCir.1999);MorningsideSupermarketCorp. 28
Case 1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 28 of
29v.NewYorkStateDep'tofHealth,432F.Supp.2d334,339(S.D.N.Y.
2006)(dismissingstatelawclaimsagainstDOHofficialasbarredby
argument.SeeTranscriptdatedMay22,2015,ECFNo.41,at6:18.
Accordingly,theCourtgranteddefendant'smotiontodismissCountIV
oftheAmendedComplaint.10
Fortheforegoingreasons,theCourt,byOrderdatedJune26,
2015,dismissedClaimsIIIandIV,andalsodismissedClaimVwith
respecttotheYouthExclusion,butotherwisedenieddefendant's
motiontodismisstheAmended Dated:NewYork,NewYork July:tj_,2015
Complaint. ~ - U.S.D.J. 10
Defendantraisedseveralotherargumentsforthefirsttimeinhis
replypapers.Becausetheseargumentswerenotraisedinhisopening
brief,theywerewaived,andtheCourtdoesnotaddressthem.See
Knipev.Skinner,999F.2d708,711(2dCir.1993)("Argumentsmaynot
bemadeforthefirsttimeinareplybrief."). 29 Case 1:14-cv-04456-JSR
Document 52 Filed 07/29/15 Page 29 of 29