Maione v. Dr. James McDonald

Background

Scott Maione and Tasha Ostler sued state and county officials on behalf of their three children. The complaint alleged violations of the United States and New York State Constitutions related to Medicaid reimbursements. After earlier rulings and an appeal, only two claims remained. Both sought prospective injunctive relief, meaning court orders intended to prevent future violations:

1. A cost-sharing claim alleging that the defendants provided Medicaid benefits through an insurance arrangement that required the children’s family to pay costs such as co-pays and other expenses. 2. An Early and Periodic Screening, Diagnostic, and Treatment claim alleging that the defendants violated federal law by failing to reimburse medically necessary expenses.

The plaintiffs filed a Third Amended Complaint after the court’s 2024 ruling. The state and county defendants filed separate motions to dismiss under Federal Rules of Civil Procedure 12(b)(1) and 12(b)(6). Rule 12(b)(1) concerns the court’s power to hear a claim, including whether a dispute remains live. Rule 12(b)(6) tests whether the complaint plausibly alleges a claim for relief.

Cost-Sharing Claim

The defendants argued that the cost-sharing claim was moot, meaning that changed circumstances had eliminated the live dispute. The court agreed. The Third Amended Complaint stated that the family was no longer enrolled in the prior hybrid insurance arrangement and was instead enrolled in a Medicaid managed-care health maintenance organization. The complaint also stated that under that plan the family had no out-of-pocket costs, did not have to cost-share, and could visit doctors without paying.

The defendants submitted additional evidence that the family enrolled in a Medicaid managed-care plan effective February 1, 2024, and that enrollees in that plan did not pay premiums or co-pays. The plaintiffs did not submit evidence contradicting those facts. The court found that the family enrolled in the managed-care plan and did not pay premiums or co-pays under it. Because the family was no longer subject to the alleged cost-sharing, the court held that the cost-sharing claim was moot and that it lacked subject-matter jurisdiction over the claim.

The court also ruled that, even if the cost-sharing claim were not moot, it would fail under Rule 12(b)(6). The plaintiffs relied primarily on past payments and made only conclusory allegations about future cost-sharing. The court held that those allegations did not plausibly show a real and immediate threat of future injury, particularly because the family’s current plan did not require cost-sharing.

EPSDT Claim

The court dismissed the EPSDT claim under Rule 12(b)(6). The only allegation concerning ongoing or future harm was that violations of federal medical law continued. The court found that allegation too conclusory. The plaintiffs otherwise relied on alleged failures to reimburse expenses around 2011 and 2014 and did not allege a recent unlawful failure to reimburse medically necessary expenses or facts showing that similar conduct was likely to happen again.

The court also stated that allegations about co-pays did not support the EPSDT claim because the EPSDT program does not reimburse co-pays. The state and county defendants’ motions were therefore granted as to the EPSDT claim.

Other Rulings

The court again dismissed claims against defendants in their individual capacities because the plaintiffs had not plausibly alleged the defendants’ personal involvement in the alleged constitutional violations. The court also dismissed the request for attorney’s fees under 42 U.S.C. § 1988 because the plaintiffs’ substantive claims had been dismissed and they were not prevailing parties.

The plaintiffs requested permission to file a Fourth Amended Complaint. The court denied that request because the plaintiffs had already amended three times, had not cured previously identified deficiencies, and had not shown that another amendment would cure the problems identified in the motions or the opinion.

Disposition

Judge Kenneth M. Karas concluded that this was the second explicit adjudication of the plaintiffs’ claims for prospective injunctive relief on the merits. The Third Amended Complaint was dismissed with prejudice. The court’s conclusion states that the defendants’ motions were granted with prejudice. The Clerk was directed to terminate the motions, mail a copy of the opinion to the plaintiff, and close the case.