Forloine v. Coben

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MARA FORLOINE, Plaintiff, v. JEFFREY H. COBEN, M.D., Interim Cabinet Secretary of the West Virginia Department of Health and Human Services, in his official capacity only, and YNTHIA BEAN, Deputy Commissioner of the Bureau of Medical Services, in her official capacity only, and AETNA BETTER HEALTH OF WEST VIRGINIA, Defendants.

Civil Action No. 3:23-0450

United States District Court, S.D. West Virginia, Huntington Division

August 1, 2023

MEMORANDUM OPINION AND ORDER

ROBERT C. CHAMBERS, UNITED STATES DISTRICT JUDGE

Plaintiff Mara Forloine's Motion for Temporary and Preliminary Injunctive Relief (ECF No. 6) was GRANTED by Court Order on July 26, 2023. ECF No. 29. The following Memorandum Opinion expands upon the Order, explaining the Court's reason for granting the Motion.

I. BACKGROUND

Plaintiff is a West Virginia Medicaid recipient diagnosed with gender dysphoria. Compl. ¶ 7, ECF No. 1. Defendants Jeffery H Coben, M.D. and Cynthia Beane are sued only in their official capacities as representatives of the West Virginia Department of Health and Human Resources (“DHHR”) and DHHR's Bureau for Medical Services (“BMS”) respectively. Id. ¶¶ 811. Defendant Aetna Better Health of West Virginia (“Aetna”) is a private company which contracts with DHHR to act as a managed care organization (“MCO”) providing medical benefits to certain West Virginia Medicaid recipients, including Plaintiff. Id. ¶¶ 12-14.

On December 23, 2022, Aetna denied Plaintiff's request for pre-approval of four surgical procedures recommended by her doctors to treat her gender dysphoria. Id. ¶ 18. Plaintiff appealed within Aetna's appeals system (pursuant to 42 C.F.R. § 438.402(a)) and was denied again on January 17, 2023. Id. ¶ 19. Accordingly, Plaintiff requested a fair hearing appeal to DHHR's Board of Review, pursuant to 42 U.S.C. § 1396a(3). Id. ¶¶ 20-21. On March 14, 2023, Board of Review State Hearing Officer Todd Thorton held that DHHR may not deny coverage of three of the four procedures “as cosmetic” because Plaintiff had “established the medical necessity of the surgical procedures.” Id. ¶ 35; Exhibit 4, ECF No. 1-4. The fourth procedure was denied as specifically not covered under Provider Manual Chapter 519.24. Id. In response, DHHR filed a purported appeal at the West Virginia Intermediate State Court of Appeals, pursuant to West Virginia Code §§ 9-213 (repealed effective May 23, 2023); 29A-5-4; 51-11-4(b)(4).

Contending this appeal was illegal, Plaintiff filed suit in this Court on June 23, 2023, and motioned for temporary and preliminary injunctive relief on June 28, 2023. ECF No. 6. Her Motion seeks a preliminary injunction “compelling Defendants to implement the DHHR Board of Review decision upholding Plaintiff's right to Medicaid pre-approval for three medically necessary surgical procedures.” Mem. Supp. Pl.'s Mot. at 1, ECF No. 7. Defendants responded, arguing variously that: (1) the Court lacks subject matter jurisdiction to exercise “appellate review” over the Board decision; (2) the Court should abstain pursuant to Rooker-Feldman, Younger, or Burford; (3) Plaintiff is seeking a disfavored “mandatory injunction” which would impermissibly change the status quo; (4) the Medicaid provisions Plaintiff seeks to have enforced do not confer a private right of action; (5) the “single state agency” Medicaid requirement does not prevent the Intermediate Court review; (6) Plaintiff has not shown a violation of her procedural or substantive due process rights; (7) Plaintiff has not shown a likelihood of suffering irreparable harm in the absence of preliminary relief; and (8) the balance of equities and public interest disfavors relief. See ECF Nos. 13 & 14.

The Court heard oral argument on the Motion on July 26, 2023. Accordingly, the matter has been fully briefed and is ripe for resolution.

II. LEGAL STANDARD

In deciding whether to issue a preliminary injunction, the Court recognizes that it “is an extraordinary remedy afforded prior to trial at the discretion of the district court that grants relief pendente lite of the type available after the trial.” Real Truth About Obama, Inc. v. FEC, 575 F.3d 342, 345 (4th Cir. 2009), vacated, 130 S.Ct. 2371 (2010), reinstated in part, 607 F.3d 355 (4th Cir. 2010) (citations omitted). “Granting the ultimate relief requested, even temporarily, at an early point in the case, often prior to the issues even being joined in the pleadings, seems rightly reserved for only the most compelling of cases.” Dewhurst v. Century Aluminum Co., 731 F.Supp.2d 506, 514 (S.D. W.Va. 2010). In order to obtain a preliminary injunction, a party must establish four elements: “[1] that he is likely to succeed on the merits, [2] that he is likely to suffer irreparable harm in the absence of preliminary relief, [3] that the balance of equities tips in his favor, and [4] that an injunction is in the public interest.” Winter v. Nat. Res. Def. Council, Inc., 555 U.S. 7, 20 (2008) (citation omitted). As such, the party seeking to obtain a “preliminary injunction must demonstrate by a clear showing that, among other things, it is likely to succeed on the merits at trial.” Dewhurst, 731 F.Supp.2d at 515 (internal quotation marks and citations omitted).

III. DISCUSSION

Not only have Defendants argued that Plaintiff does not meet the standard for a preliminary injunction, but they assert that this Court does not have jurisdiction to hear this case at all. The Court will consider the jurisdictional issues as a threshold matter, and then turn to the preliminary injunction standard below.

A. Subject Matter Jurisdiction

Federal district courts may exercise subject matter jurisdiction under 28 U.S.C. § 1331 when a case or controversy arises under federal law. Ms. Forloine has invoked this jurisdiction, asserting that the instant controversy arises under her right to a fair hearing under 42 U.S.C. § 1343(a) and § 1396a(a)(3) of the Medicaid Act. Her Complaint and Motion ask this Court to determine whether her fair hearing rights have been violated, pursuant to the Medicaid Act and related federal regulations. See Compl. ¶¶ 5, 56, 58-59 61-62; Mem. Supp. Pl.'s Mot. at 10-13 (discussing Plaintiff's theory as to how Defendants' actions violated her fair hearing rights). In response, Defendants argue that this is a smokescreen, and that Ms. Forloine is actually seeking appellate review of the Board decision by this Court. DHHR Defs.' Resp. at 4-5; Def. Aetna's Resp. at 5.

The Court disagrees. Ms. Forloine has adequately alleged a controversy arising under federal law, namely, her right to a fair hearing under the Medicaid Act. She does not assert, for example, that the Board decision was incorrect or invalid. She does not request that the Court review the underlying administrative record. Nor does she premise her requested relief upon a reconsideration of any of the issues argued before the Board. Rather, she asserts that Defendants' behavior in the wake of the Board decision violated her rights under the Medicaid Act and requests related relief. The Court finds that this is sufficient to invoke its subject matter jurisdiction under 28 U.S.C. § 1331.

B. Abstention Arguments

Defendants are positive that the Court should abstain from hearing this controversy, arguing three different forms of abstention are applicable. DHHR Defs.' Resp. at 5-9; Def. Aetna's Resp. at 5. The Court disagrees.

First, the DHHR Defendants argue that the Court should refrain from deciding this case as “there is an ongoing state judicial proceeding implicating important state interests.” DHHR Defs.' Resp. at 5-7 (citing Younger v. Harris, 571 U.S. 37 (1971)). Younger abstention applies when a court injunction would stay or enjoin a pending state proceeding which is either criminal, quasicriminal, or “uniquely in furtherance of the state courts' ability to perform their judicial functions.” Air Evac EMS, Inc. v. McVey, 37 F.4th 89, 96 (4th Cir. 2022) (quoting Younger, 571 U.S. at 7879, 81). “[I]f the case falls into one of the three settled categories, courts should go on to determine if federal involvement will in fact put comity at risk, but if the case does not, courts need go no further, they can properly entertain their federal-question jurisdiction.” Jonathan R. v. Justice, 41 F.4th 316, 329 (4th Cir. 2022) (citing Sprint Communications, Inc. v. Jacobs, 571 U.S. 69, 81 (2013)). While there is a pending state civil proceeding in this case, it cannot be characterized as “quasi-criminal.” Nor does an appeal of a Medicaid eligibility determination implicate the state court's ability to perform its judicial functions. Accordingly, Younger abstention is inapplicable.

Second, all three Defendants have argued that Rooker-Feldman doctrine impedes Ms. Forloine's suit, as this Court lacks appellate jurisdiction over the Board decision. DHHR Defs.' Resp. at 4-5; Def. Aetna's Resp. at 5. The Court disagrees. Rooker-Feldman doctrine “strips federal courts of subject-matter jurisdiction when ‘state-court losers complain[] of injuries caused by state-court judgments' in district courts.” Jonthan R., 41 F.4th at 339 (quoting Exxon Mobil Corp. v. Saudi Basic Indus. Corp., 544 U.S. 280, 284 (2005)). Most obviously, Ms. Forloine is not a “state-court loser”-she won her appeal to the Board. She is not asking this Court to review any of the substantive issues or administrative procedure employed by the Board. Simply put, because Plaintiff is not seeking review of the of the Board decision, the Court finds that Rooker-Feldman is inapplicable.

Burford abstention involves the rare situation in which a federal court may abstain from exercising jurisdiction “when the availability of an alternative, federal forum threaten[s] to frustrate the purpose of a state's complex...