## Facts

- Medicaid-eligible minor children and an advocacy organization sued Texas officials responsible for administering the state Medicaid EPSDT program, seeking declaratory and injunctive relief.
- EPSDT is a mandatory Medicaid service for participating states and must furnish preventive screening and necessary treatment for eligible children, including dental care adequate in amount, duration, and scope.
- Before 1979, Texas’s EPSDT dental coverage included annual routine dental examinations and a broader set of preventive and restorative services.
- Following 1979 state budget reductions, Texas changed routine dental examinations from annual to once every three years, allowing additional visits only for “emergency, obvious need, or medical necessity.”
- Texas also eliminated eight previously covered dental services, including topical fluoride treatment and certain restorative procedures (including root canals).
- Plaintiffs presented evidence, including expert testimony, that minimally acceptable preventive dental care for children requires annual examinations and basic preventive and restorative services.
- The district court ruled Texas’s revised EPSDT dental program failed to meet federal Medicaid requirements and ordered compliance-related relief.
- The district court also conditioned pro hac vice admission of certain out-of-state plaintiffs’ counsel on an agreement not to seek attorney’s fees.
- Both sides appealed, placing the EPSDT compliance ruling and the fee-waiver admission condition before the Fifth Circuit.

## Issues

1. Whether Texas’s EPSDT dental program, after limiting routine examinations to once every three years and eliminating key services, complied with federal Medicaid requirements for EPSDT services.
2. Whether a district court may condition pro hac vice admission of out-of-state counsel on a waiver of potential attorney’s fees under 42 U.S.C. § 1988.

## Decision

- The Fifth Circuit affirmed the determination that Texas’s reduced EPSDT dental program did not comply with federal Medicaid requirements.
- The court held that a triennial routine examination schedule, combined with the removal of significant preventive and restorative services, failed to provide dental care sufficient in amount, duration, and scope to achieve EPSDT’s preventive and treatment objectives.
- The court rejected state budget constraints as a justification for providing mandatory Medicaid services below federal minima.
- The Fifth Circuit reversed the district court’s pro hac vice fee-waiver condition and remanded for attorney’s fee proceedings without that condition.
- Disposition: affirmed in part, reversed and remanded in part.

## Legal Principles

- A participating state must provide EPSDT services meeting federal standards of sufficiency in amount, duration, and scope, including dental services adequate for prevention and necessary treatment for children.
- Limiting routine pediatric dental examinations to once every three years, while restricting additional care to emergencies and eliminating key preventive/restorative services, can violate EPSDT’s “early and periodic” and treatment-oriented requirements.
- A state’s fiscal constraints do not excuse noncompliance with mandatory Medicaid service obligations once the state elects to participate in Medicaid.
- A federal court may not condition pro hac vice admission on counsel’s waiver of statutory attorney’s fees under 42 U.S.C. § 1988 in litigation enforcing federal rights through 42 U.S.C. § 1983.

## Conclusion

The Fifth Circuit held that Texas’s post-budget-cut EPSDT dental program fell below federal Medicaid requirements by reducing routine exams and eliminating essential services, and it ruled that a district court cannot require out-of-state counsel to waive § 1988 attorney’s fees as a condition of pro hac vice admission, remanding for proper fee consideration.


Mitchell v. Johnston, 701 F.2d 337 (5th Cir. 1983)