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DiCrescenzo v. Unitedhealth Group Inc.

United States District Court, D. Hawaii

December 23, 2015

RICHARD DICRESCENZO, Plaintiff,
v.
UNITEDHEALTH GROUP INCORPORATED, UNITEDHEALTHCARE, INC., UNITEDHEALTHCARE INSURANCE COMPANY, and JOHN DOES 1-99; JANE DOES 1-99; DOE ENTITIES 1-20; and DOE GOVERNMENTAL UNITS 1-10, Defendants.

ORDER GRANTING DEFENDANTS’ MOTION FOR PARTIAL DISMISSAL OF PLAINTIFF’S AMENDED COMPLAINT

Derrick K. Watson United States District Judge

Plaintiff Richard DiCrescenzo is a disabled and elderly Hawaiʻi resident who requires skilled nursing and personal assistant services. The gravamen of DiCrescenzo’s Amended Complaint is that Defendants UnitedHealth Group, Incorporated, UnitedHealthcare, Inc., and UnitedHealthcare Insurance Company (collectively, “Defendants” or “UHC”) have failed to consistently provide 13 hours per week of personal assistant services, which is the amount that DiCrescenzo’s treating providers have repeatedly ordered and which is a covered benefit under the State of Hawaii’s Medicaid Plan and QUEST Expanded Access Program. Dkt. No. 45. Count I of the Amended Complaint purports to assert a claim under 42 U.S.C. § 1983 for alleged violations of the Medicaid Act. Dkt. No. 45 at 33-36.

Before the Court is Defendants’ Motion For Partial Dismissal of Plaintiff’s Amended Complaint. Dkt. No. 46. Because DiCrescenzo has failed to allege facts linking the State to Defendants’ decision to provide DiCrescenzo with less than 13 hours per week of personal assistant services, the Court GRANTS Defendants’ Motion [Dkt. No. 46] and DISMISSES Count I.

BACKGROUND

I. Factual Summary[1]

DiCrescenzo suffered grievous injuries, including severe traumatic brain injury, in 1979 after being struck by a drunk driver. Am. Compl. ¶ 15. Following the 1979 crash, DiCrescenzo was deemed fully disabled within the meaning of 29 U.S.C. § 705, 42 U.S.C. § 12102, and 42 U.S.C. §§ 416, 421. Am. Compl. ¶ 16. DiCrescenzo is eligible for coverage under the State of Hawaii’s Medicaid Plan. Am. Compl. ¶ 17.

Prior to February 2009, DiCrescenzo received services that the State of Hawai’i Department of Human Services (“Department” or “DHS”)[2] had determined were the minimum medically necessary to ensure his personal safety and independence. Am. Compl. ¶ 43. These services included: (1) skilled nursing services for medication management; and (2) personal assistants to maintain DiCrescenzo’s apartment in a hygienic state and to escort him to the pharmacy, the grocery store, and doctor’s appointments. Am. Compl. ¶ 43.

In February 2009, UHC contracted with DHS to provide or arrange medical assistance for aged, blind, and disabled Medicaid beneficiaries. Am. Compl. ¶ 21. Following DiCrescenzo’s enrollment with UHC, UHC continued to provide DiCrescenzo with personal assistance services consistent with what he had been previously provided under the State’s fee-for-service program. Am. Compl. ¶ 44.

In 2010, DiCrescenzo suffered a second brain injury, which worsened his functional disabilities. Am. Compl. ¶ 45. DiCrescenzo’s treating providers recommended, and UHC initially provided, 13 hours per week of personal assistance services (Level I). Am. Compl. ¶¶ 47, 49. In September 2011, however, UHC terminated this coverage, despite no change in DiCrescenzo’s physical condition or enrollment status. Am. Compl. ¶ 49. UHC continued to refuse this coverage from September 2011 until April 20, 2012, causing various types of hardship on DiCrescenzo. Am. Compl. ¶ 53.

Since April 20, 2012, UHC has reinstated some of the personal assistant services hours to which DiCrescenzo claims entitlement, but has fallen short of providing the minimal assistance of 13 hours per week that DiCrescenzo’s treating providers have repeatedly ordered he receive. Am. Compl. ¶¶ 47, 59, 65, 72, 82. At a September 16, 2015 assessment of DiCrescenzo’s needs, UHC confirmed that DiCrescenzo requires at least 10 hours per week of personal services and 2 hours per week of face-to-face skilled nursing services. Am. Compl. ¶¶ 7, 102. UHC, however, has not provided this amount or restored the 13 hours per week of personal assistance services that DiCrescenzo seeks and has denied and/or delayed reimbursement for expenses incurred by DiCrescenzo as a result of the continuing reduction of personal assistance services. Am. Compl. ¶¶ 7, 73, 81, 103.

II. Procedural History

On January 20, 2015, DiCrescenzo filed a Complaint for Declaratory and Injunctive Relief, and for Compensatory and Punitive Damages (“Complaint”), asserting various federal and state claims related to UHC’s provision of personal assistance services. Dkt. No. 9. Relevant to the instant Motion, Count I alleged a violation of Civil Rights under the Medicaid Act, 42 U.S.C. § 1983.

On May 13, 2015, UHC filed four motions for judgment on the pleadings, including a Motion for Judgment on the Pleadings for Count I (§1983) (“MJOP”). Dkt. No. 28. On September 16, 2015, the Court granted, among other things, Defendants’ MJOP because DiCrescenzo failed to allege facts sufficient to treat Defendants as state actors. Dkt. No. 44 at 15. In granting Defendants’ MJOP, the Court explained in relevant part that “DiCrescenzo has failed to allege facts establishing sufficient control by the State over the specific UHC conduct of which he complains.” Dkt. No. 44 at 15. The Court permitted DiCrescenzo to amend his Complaint as to the Section 1983 claim alleged in Count I. Dkt. No. 44 at 15.

On October 1, 2015, DiCrescenzo filed an Amended Complaint for Declaratory and Injunctive Relief, and For Compensatory and Punitive Damages (“Amended Complaint”). Dkt. No. 45. UHC moved for dismissal of Count I (§ 1983) of DiCrescenzo’s Amended Complaint. Dkt. No. 46. The ...


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