## Facts

- Missouri’s Medicaid program previously covered durable medical equipment (DME) as a stand-alone benefit for all recipients, including disabled adults who relied on items such as wheelchairs, repairs, orthotics, parenteral nutrition, augmentative communication devices, and hospital beds.
- In 2005, citing budget constraints, Missouri repealed the statutory authorization for stand-alone DME coverage for all recipients and limited DME coverage primarily to specific groups (including blind persons, pregnant persons, needy children, and individuals receiving home health services).
- Missouri then adopted a September 2005 emergency regulation that reinstated some DME coverage but sharply curtailed stand-alone DME for many adult categorically needy recipients, including the plaintiffs.
- Disabled adult Medicaid recipients sued the Director of the Missouri Department of Social Services in his official capacity, seeking to enjoin enforcement of the emergency regulation.
- Plaintiffs asserted the regulation conflicted with federal Medicaid requirements, including the comparability requirement and the reasonable-standards requirement in 42 U.S.C. § 1396a.
- The district court denied a preliminary injunction, concluding the regulation was consistent with the Medicaid Act.
- Plaintiffs took an interlocutory appeal from the denial of preliminary injunctive relief.

## Issues

1. Whether Medicaid’s comparability requirement, 42 U.S.C. § 1396a(a)(10)(B), is enforceable by individual recipients under 42 U.S.C. § 1983.
2. Whether Missouri’s emergency DME regulation likely conflicts with, and is preempted by, Medicaid’s reasonable-standards requirement, 42 U.S.C. § 1396a(a)(17).
3. Whether the district court erred in denying a preliminary injunction given the plaintiffs’ showing on likelihood of success.

## Decision

- The court held it had appellate jurisdiction over the denial of preliminary injunctive relief.
- The court concluded the comparability provision invoked by plaintiffs did not provide an individually enforceable right under § 1983 for their claim.
- The court held plaintiffs showed a likelihood of success on a Supremacy Clause conflict-preemption claim based on the reasonable-standards requirement, § 1396a(a)(17).
- The court vacated the order denying a preliminary injunction and remanded for the district court to consider the remaining preliminary-injunction factors (irreparable harm, balance of harms, and public interest) under the Eighth Circuit’s Dataphase framework.

## Legal Principles

- Not every Medicaid state-plan requirement creates a privately enforceable right under 42 U.S.C. § 1983; a plaintiff must identify a clear and unambiguous rights-conferring provision.
- A state Medicaid policy may be enjoined under the Supremacy Clause if it conflicts with federal Medicaid requirements (conflict preemption).
- The Medicaid reasonable-standards requirement, 42 U.S.C. § 1396a(a)(17), constrains state discretion by requiring that standards governing the extent of medical assistance be reasonable and consistent with Medicaid’s objectives.
- For preliminary injunctions in the Eighth Circuit, courts apply the Dataphase factors, including likelihood of success on the merits as a key consideration.

## Conclusion

The Eighth Circuit determined that disabled adult recipients were likely to succeed on the claim that Missouri’s categorical DME restrictions conflicted with Medicaid’s reasonable-standards requirement, vacated the denial of preliminary injunctive relief, and remanded for consideration of the remaining injunction factors.


Lankford v. Sherman, 451 F.3d 496 (8th Cir. 2006)