UNITEDSTATESDISTRICTCOURT SOUTHERNDISTRICTOFNEWYORK ------------------------------------- x ANGIECRUZ,I.H.,AR'ESKPAKA,and .K.L :CP...C:UKIO:STIB'UHL>ehc.>.1 Lv.L themselvesandallotherssimilarly situated, Plaintiffs, -v-HOWARDZUCKER,asCommissionerofthe DepartmentofHealth[oftheStateof NewYork], Defendant. ------------------------------------- x JEDS.RAKOFF,U.S.D.J. 14-cv-4456(JSR) OPINION Theintersectionofourcognitionwithouremotionsisboththe essenceofourhumanityandthesourceofouranxiety.Accordingto theplaintiffsinthisclassaction,someonewhoisbornwiththe physicalequipmentofonesexbutemotionallyidentifiesassomeoneof theoppositesexsufferssevereanxietyandemotionaldistressthat may,however,bemateriallyalleviatedbyavailablemedical procedures.PlaintiffsfurthercontendthatNewYorkwronglydenies Medicaidcoverageformanysuchprocedures,regardingthemasmerely "cosmetic"orthelike.TheimmediatequestionbeforetheCourtis whethertheplaintiffsherecansueforredressofthisallegedwrong. TheCourtconcludesthattheycan. PlaintiffAngieCruz,nowfiftyyearsold,allegesthatshewas assignedmaleatbirthbuthasidentifiedasfemalesinceshewasten yearsold.SeeAmendedClassActionComplaintdatedMarch27,2015, ECFNo.27("Am.Compl.") 91,93.Shebegantakinghormonesasa teenagerinanefforttobringherphysicalappearanceintoalignment Case 1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 1 of 29withhergenderidentityandhasundergonehormonetherapyformuchof heradultlife,purchasingherhormonessometimesfromdoctorsand pharmaciesanasome t:..Lmesoncnescrt=t=L.Iu. 34 - ::is..A.1 thou'::::lhLhl;:; therapyhasgivenherbodyamorefeminineappearance,shestill experiencesintensedistressandinterferencewithhercapacityfor normalactivityasaresultofthemismatchbetweenherbodyandher identity.Id. 96,99,104-05.Cruzisa"categoricallyneedy" Medicaidrecipient,meaningthatshemeetsoneofnineeligibility categoriessetforthinthefederalMedicaidAct,42U.S.C. 1396a(a)(10)(A)(i).Id. 29,91. PlaintiffAr' esKpaka,alsoacategoricallyneedyMedicaid recipient,allegesthat,althoughbornwithamalebody,shehas identifiedasfemalesinceshewasthreeyearsold.Id. 136.Asan adolescent,shehidhergenderidentityfromhermotherandbrothers until,atagetwenty-one,shewasforcedtomoveoutofhermother's homeandbecamehomelessforseveralmonths.Id. 137.Nowtwenty-three,sheisundergoinghormonetherapybutstillstruggleswith depressionrelatingtohergenderidentity.Id. 136,138,140. PlaintiffRiyaChristieallegesthat,growingupinJamaica,she facedviolencebecauseofhergenderexpressionandsufferedfrom severedepressionandsuicidalthoughts.Id. 149-50.Attheageof twenty-one,shemovedtotheUnitedStatesandwasgrantedasylumon thegroundthathergenderidentitymadeitunsafeforhertoreturn home.Id. 152.Nowtwenty-three,shecontinuestoexperiencepain andanxietyasaresultoftheincongruencebetweenherbodyandher 2 Case 1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 2 of 29genderidentity.Id. 159.She,likeCruzandKpaka,isa categoricallyneedyMedicaidrecipient.Id. 136. Eachofthethreenamedplaintiffsinthisclassactlonhasbeen diagnosedwithGenderDysphoria("GD")(formerlyknownasGender IdentityDisorder).1 Id. 95,138,155.TheyallegethatGDis recognizedbythemedicalcommunityas"'anidentifiable,severeand incapacitatingdisease.'"Id. 80(quotingD.Barish&B.Sharma, MedicalAdvancesinTranssexualismandtheLegalImplications,24Am. J.ForensicMed.&Pathology100,101(2003)).Itisdefinedinthe latesteditionoftheAmericanPsychiatricAssociation'sDiagnostic andStatisticalManualofMentalDisorders("DSM-V")asa"marked incongruencebetweenone'sexperienced/expressedgenderandassigned gender,"asmanifestedbyatleasttwoofthefollowing:(i)a"marked incongruencebetweenone'sexperienced/expressedgenderandprimary and/orsecondarysexcharacteristics... ";(ii)a"strongdesiretobe ridofone'sprimaryand/ orsecondarysexcharacteristics ... ";(iii)"a strongdesirefortheprimaryand/orsecondarysexcharacteristicsof theothergender";(iv)a"strongdesiretobeoftheothergender... "; (v)a"strongdesiretobetreatedastheothergender... ";and(vi)a "strongconvictionthatonehasthetypicalfeelingsandreactionsof theothergender... "Id. 82(quotingDSM-V302. 06,302. 85).The DSM-VfurtherspecifiesthatGDis"associatedwithclinically significantdistressorimpairmentinsocial,occupational,orother importantareasoffunctioning."Id. 1 Oneoftheoriginalnamedplaintiffs,I.H.,subsequentlywithdrewas 3 Case 1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 3 of 29Plaintiffsallegethat,inordertoalleviatetheprofound psychologicalsufferingandsocialandoccupationalimpairmentthat theyexperienceasaresultOLtheirGD,theyneedcertaintreatments tofacilitatetheirtransitionstothegenderwithwhichthey identify.Thetreatmentstheyseekincludebreastaugmentation,facial feminizingsurgery,chondrolarngoplasty(commonlyreferredtoas "trachealshave"),bodysculptingprocedures,andelectrolysis.Id. 101,141,157.Plaintiffsallegethatthesetreatmentsaresafe, effective,andmedicallynecessary.Id. 83-88.However,plaintiffs allege,theyhavebeendeniedaccesstotheneededtreatmentsbecause suchtreatmentsareexcludedfromcoverageunderNewYorkState's Medicaidprogram.Id. 103,143,158. Priorto1998,medicalcoveragewasavailableunderNewYork's MedicaidprogramforthetreatmentofGD,includinghormonetreatment andsexreassignmentsurgery.Id. 2.However,in1998,theNewYork StateDepartmentofHealth("DOH"),whichisresponsiblefor administeringthestate'sMedicaidprogram,promulgated18N.Y.C.R.R. 505.2(1),whichbarredpaymentforall"care,services,drugsor suppliesrenderedforthepurposesofgenderreassignment"treatment orfor"promoting"suchtreatment("Section505.2(1)").Id. OnJune19,2014,plaintiffsfiledaclassactioncomplainton behalfofthemselvesandallsimilarlysituatedindividualsagainst Dr.HowardZucker,actinginhisofficialcapacityasCommissionerof DOH,allegingthatSection505.2(1)violatesvariousprovisionsof classrepresentative.ECFNo.28. 4 Case 1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 4 of 29stateandfederallaw.ECFNo.1.OnAugust21,2014,theparties agreedtoaProvisionalStipulationandOrderofClassCertification, pursuanttowhichtheCourt aclass0, AllNewYorkStateMedicaidrecipientswhohavebeen diagnosedwithGenderIdentityDisorderorGenderDysphoria, andwhoseexpensesassociatedwithmedicallynecessary GenderIdentityDisorder- orGenderDysphoria-related treatmentarenotreimbursablebyMedicaidpursuantto18 N.Y.C.R.R.505.2(1). ECFNo.23.Subsequently,onDecember17,2014,DOHpublishedaNotice ofProposedRuleMakingthatproposedamendmentstoSection505.2(1) ("AmendedSection505. 2( 1) "). TheproposedAmendedSection505.2(1)liftedtheblanketbanon coveragefortreatmentofGD,makinghormonetherapyandgender reassignmentsurgeryavailabletocertainMedicaidrecipients.Am. Compl. 5;DeclarationofJohnGasiordatedApril17,2015,ECFNo. 31("GasiorDeel.")Ex.1.However,itpreservedtwoimportant coverageexclusions.First,itexcludedcoveragefor"cosmetic surgery,services,andprocedures,"whichitdefinedas"anything solelydirectedatimprovinganindividual'sappearance,"including butnotlimitedtocertainenumeratedproceduressuchasbreast augmentation,electrolysis,thyroidchondroplasty,andfacialbone reconstruction,reduction,orsculpturing(the"CosmeticProcedures Exclusion").GasiorDeel.Ex.1.Second,itdidnotprovidecoverage forhormonetherapyorgenderreassignmentsurgeryforindividuals undertheageofeighteen,orforgenderreassignmentsurgeryfor individualsundertheageoftwenty-onewheresuchsurgerywould 5 Case 1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 5 of 29resultinsterilization(the"YouthExclusion").Id. TheAmendedSection505.2(1)cameintoeffectonMarch11,2015. OnMarch27,2015,plaintiffsfiledtheirAmendedcomplalnt.Inlt, plaintiffsallegethattheAmendedSection505.2(1)violatesvarious provisionsofTitleXIXoftheSocialSecurityAct(the"Medicaid Act"),thePatientProtectionandAffordableCareAct("ACA"),andthe NewYorkStateConstitution.Specifically,plaintiffsassertsix causesofaction:(I)violationof42U.S.C.1396a(a)(10)(A)andits implementingregulation,42C.F.R.440.210(the"Availability Requirement"oftheMedicaidAct);(II)violationof42U.S.C. 1396a(a)(10)(B)anditsimplementingregulation,42C.F.R. 440. 240 (b)(the"ComparabilityRequirement"oftheMedicaidAct); (III)violationof42U.S.C.1396a(a)(17),1396a(a)(10)(B)(i)and theirimplementingregulation,42C.F.R.440.230(c)(the"Reasonable StandardsRequirement"oftheMedicaidAct);(IV)violationofArticle I,Section11oftheNewYorkStateConstitution,whichguarantees equalprotectionofthelaws;(V)Section1557oftheACA,42U.S.C. 18116,whichprohibitssexdiscriminationintheprovisionof healthcare;and(VI)violationof42U.S.C.1396a(a)(43),which requiresstatestoprovide"earlyandperiodicscreening,diagnostic, andtreatmentservices"foreligiblepersonsundertheageoftwenty-one(the"EPSDTRequirement"oftheMedicaidAct).2 2 Plaintiffs'sixthcauseofactioncitestheAvailabilityand ComparabilityRequirements,42U.S.C.1396a(a)(10).SeeAm.Compl.177.However,plaintiffsrepresentedintheiroppositionto defendant'smotionthattheyintendedtocitetheEPSDTRequirement, 42U.S.C.1396a(a)(43),whichisreferencedinotherparagraphsof 6 Case 1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 6 of 29DefendantmovedtodismisstheAmendedComplaint.By"bottom line"OrderdatedJune26,2015,theCourtgrantedinpartanddenied inpartdefendant's ECFNO.46. e=p1al=sthe reasonsforthoserulings. Asdiscussedabove,intheirAmendedComplaint,plaintiffsallege violationsofvariousprovisionsofthefederalMedicaidAct.Medicaid isacooperativestateandfederalbenefitprogramdesignedtoprovide necessarymedicalservicesto"needypersonsofmodestincome."Cmty. HealthCtr.v.Wilson-Coker,311F.3d132,134(2dCir.2002). "'Statesneednotparticipateintheprogram,butiftheychoosetodo so,theymustimplementandoperateMedicaidprogramsthatcomplywith detailedfederallymandatedstandards.'"Cmty.HealthCareAss'nof N.Y.v.Shah,770F.3d129,135(2dCir.2014)(quotingThreeLower Cnties.Cmty.HealthServs.,Inc.v.Maryland,498F.3d294,297(4th Cir.2007)(internalquotationmarksomitted)).Statesthatelectto receivefederalMedicaidfundsmustsubmitaplandetailinghowthey willspendsuchfundstotheCentersforMedicareandMedicaid Services,afederalagencywithintheDepartmentofHealthandHuman Services.Wilson-Coker,311F.3dat134(citing42U.S.C.1396, 1396a).StateMedicaidplansaresubjecttoextensiverequirements, fourofwhicharerelevanthere. theAmendedComplaint.ReadingtheAmendedComplaintasawholeand drawingallinferencesinplaintiffs'favor,itisclearthatthe citationtoSection1396a(a)(10)wasmerelyascrivener'serror,and theCourtwilltreatitassuch.Becauseofthiserror,defendantdoes notmakeanyargumentwithrespecttotheEPSDTRequirement.Defendant hasnotbeenprejudicedbyplaintiffs'error,however,astheCourt findsthattheEPSDTRequirementgivesrisetoaprivaterightof 7 Case 1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 7 of 29Availability.TheAvailabilityRequirementprovidesthatastate planformedicalassistance"mustprovide...formakingmedical s s ~ s t n c e ava1lable[toallcategorlcallyneedylr1dlvlduals], includingatleast"certainenumeratedtypesofcareandservices, includinginpatientandoutpatienthospitalservices,laboratoryand x-rayservices,nursingfacilityservices,andphysicians'services. 42U.S.C.1396a(a)(10)(A),42U.S.C.1396d(a).Categoricallyneedy individualsarethosemeetingoneofnineeligibilitycriteria,which include,forexample,receiptofsupplementalsecurityincomebenefits andhavinganincomethatdoesnotexceed133percentofthepoverty line.42U.S.C.1396a(a)(10)(A)(i)(I)- (IX). Theimplementingregulation,42C.F.R.440.210,requiresthe Stateplantoprovidecategoricallyneedyindividualswiththe "servicesdefinedin440.10through440.50[and]440.70."Those provisions,inturn,furtherdefinethetypesofservicesthatmustbe provided.Forexample,"inpatienthospitalservices"aredefinedas servicesthat"(1)areordinarilyfurnishedinahospitalforthecare andtreatmentofinpatients;(2)arefurnishedunderthedirectionof aphysicianordentist;and(3)arefurnishedinan[appropriateand approved]institution... "42C.F.R.440.10 (a).Similarly,"physicians' services"aredefinedas"servicesfurnishedbyaphysician-[w]ithin thescopeofpracticeofmedicineorosteopathyasdefinedbyState law;and...[b] yorunderthepersonalsupervisionofanindividual action.Seeinfra. 8 Case 1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 8 of 29licensedunderStatelawtopracticemedicineorosteopathy."42 C.F.R.440.50(a). Theimplementingregulations~ u r t h r provide,lnre1evantpart: (b)Eachservicemustbesufficientinamount,duration,and scopetoreasonablyachieveitspurpose. (c)TheMedicaidagencymaynotarbitrarilydenyorreduce theamount,duration,orscopeofarequiredserviceunder 440.210and440.220toanotherwiseeligiblebeneficiary solelybecauseofthediagnosis,typeofillness,or condition. (d)Theagencymayplaceappropriate basedonsuchcriteriaasmedical utilizationcontrolprocedures. 42C.F.R.440.230. limitsona necessity service oron Comparability.TheMedicaidAct'sComparabilityRequirement providesthat"themedicalassistancemadeavailabletoany [categoricallyneedyindividual]...shallnotbelessinamount, duration,orscopethanthemedicalassistancemadeavailabletoany othersuchindividual."42U.S.C.1396a(a)(1)(B)(i).Its implementingregulationprovidesthatthestate's"planmustprovide thattheservicesavailabletoany[categoricallyneedy]individual... areequalinamount,duration,andscopeforallbeneficiarieswithin the[categoricallyneedy]group."42C.F.R.440.240(b).Thepurpose oftheComparabilityRequirementistomakeclearthat"statesmaynot providebenefitstosomecategoricallyneedyindividualsbutnotto others."Rodriguezv.CityofNewYork,197F.3d611,615(2dCir. 1999). 9 Case 1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 9 of 29EPSDT.TheMedicaidActfurtherrequiresastateplanformedical assistancetoprovide"earlyandperiodicscreening,diagnostic,and treatmentservices,"includingregularscreeningforphyBlcaland mentalillnessesandconditions,toeligibleindividualsundertheage oftwenty-one.42U.S.C.1396a(a)(43),1396d(r).Inaddition,the stateplanmustprovide"[s]uchothernecessaryhealthcare, diagnosticservices,treatment,andothermeasures...tocorrector amelioratedefectsandphysicalandmentalillnessesandconditions discoveredbythescreeningservices,whetherornotsuchservicesare coveredundertheStateplan."42U.S.C.1396d(r)(5). ReasonableStandards.Finally,theMedicaidActrequiresthatthe stateplanmust"includereasonablestandards...fordetermining eligibilityforandtheextentofmedicalassistanceundertheplan which[]areconsistentwiththeobjectivesof[theMedicaidAct]."42 U.S.C.1396a(a)(17).Thissubsectionfurthersetsforthcertain requirementsforthe"reasonablestandards"thatthestatemustadopt, suchasthetypesofincomeandresourcesthatthestatemaytakeinto accountindeterminingeligibility.Id. Plaintiffs'claimsallegingviolationsoftheAvailability Requirement(CountI),theComparabilityRequirement(CountII),and theEPSDTRequirement(CountVI)ofthefederalMedicaidActare broughtpursuantto42U.S.C.1983("Section1983"),whichprovides: Everypersonwho,undercolorofanystatute,ordinance, regulation,custom,orusage,ofanyStateorTerritoryor theDistrictofColumbia,subjects,orcausestobe subjected,anycitizenoftheUnitedStatesorotherperson withinthejurisdictionthereoftothedeprivationofany rights,privileges,orimmunitiessecuredbythe 10 Case 1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 10 of 29Constitutionandlaws, inanactionatlaw, proceedingforredress ... shallbeliabletothepartyinjured suitinequity,orotherproper 42U.S.C.1983.Inhismotiontodismiss,defendantarguedthat Section1983doesnotcreateaprivaterightofactiontoenforce theseprovisions,andthereforethatplaintiffs'CountsI,II,andVI mustbedismissedforfailuretostateaclaim. InMainev.Thiboutot,theSupremeCourtheldthattheSection 1983remedyencompassesrightsconferredbyfederalstatutes.448U.S. 1,4(1980).Nonetheless,"[i]nordertoseekredressthrough1983, aplaintiffmustasserttheviolationofafederalright,notmerely aviolationoffederallaw."Blessingv.Freestone,520U.S.329,340 (1997).Indeterminingwhetheraparticularstatutoryprovisiongives risetoafederalright,courtsapplyathree-prongedtest:(1) "Congressmusthaveintendedthattheprovisioninquestionbenefit theplaintiff";(2)"theplaintiffmustdemonstratethattheright assertedlyprotectedbythestatuteisnotso'vagueandamorphous' thatitsenforcementwouldstrainjudicialcompetence";and(3)"the statutemustunambiguouslyimposeabindingobligationontheStates," meaningit"mustbecouchedinmandatory,ratherthanprecatory, terms."Id.at340-41.Iftheplaintiffdemonstratesthatthefederal statutecreatesanindividualright,thedefendantmanynonetheless rebutthepresumptionthatsuchrightisenforceableviaaSection 1983actionbyshowingthatCongress"specificallyforeclosedaremedy under1983,"eitherexpresslyor"impliedly,bycreatinga comprehensiveenforcementschemethatisincompatiblewithindividual 11 Case 1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 11 of 29enforcementunder1983."Id.at341(internalquotationmarksand citationsomitted).Thistestisknownasthe"Blessing"test. InGonzagaUniversityv.Doe,theSupremeCourt withrespecttothefirstprongoftheBlessingtest,it"reject[ed] thenotionthatourcasespermitanythingshortofanunambiguously conferredrighttosupportacauseofactionbroughtunder1983." 536U.S.273,283(2002).Itwasinsufficient,theCourtheld,that the"plaintifffallswithinthegeneralzoneofinterestthatthe statuteisintendedtoprotect."Id.at283.TheCourtreaffirmedthat "unlessCongress'speak[s]withaclearvoice,'andmanifestsan 'unambiguous'intenttoconferindividualrights,federalfunding provisionsprovidenobasisforprivateenforcementby1983."Id.at 280(quotingPennhurstStateSchoolandHospitalv.Halderman,451 U.S.1,17,28andn.21(1981)). InarguingthatprovisionsoftheMedicaidActcitedby plaintiffsdonotcreateprivaterightsofactionunderSection1983, defendantreliesheavilyonCasillasv.Daines,580F.Supp.2d235, 242(S.D.N.Y.2008).Theplaintiffinthatcase,TerriCasillas,wasa NewYorkStateMedicaidrecipientwhohadbeendiagnosedwithGD,and whosephysicianshadrecommendedthatsheundergohormonetherapy, orchiectomy(removalofthetestes) ,andvaginoplasty(removalofthe penisandcreationofavagina).Id.at237-38.Shebroughtanaction underSection1983challengingtheoriginalSection505.2(1)underthe AvailabilityandComparabilityRequirementsoftheMedicaidAct.3Id. 3 CasillasalsobroughtaSection1983claimallegingthatSection 12 Case 1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 12 of 29at241-44.Thecourtgranteddefendant'smotionforjudgmentonthe pleadings,holdingthatneitherprovisioncreatedarightenforceable underSection1983. WithrespecttotheAvailabilityRequirement,Casillasheldthat neitherthefirstnorthesecondprongoftheBlessingtestwasmet. Astothefirstprong,itheldthat,althoughtheAvailability Requirementmayconfercertainrightsoncertainclassesofpersons, itdidnotunambiguouslyconfertherightthatplaintiffasserted, namelytherighttoreceivethespecifictreatmentsforGDthathad beendeemedmedicallynecessarybyherphysicians.Id.at241-43.The courtreasonedthattheAvailabilityRequirementrequiresstatesto providecoverageforcertainbroadcategoriesofmedicalservices,but doesnot"mandatethataparticularlevelortypeofcaremustbe provided."Id.at242.Insofinding,itreliedonSupremeCourt's decisioninBealv.Doe,432U.S.438(1977),forthepropositionthat "nothinginthestatutesuggeststhatparticipatingstatesare requiredtofundeverymedicalprocedurethatfallswithinthe delineatedcategoriesofmedicalcare."Id.(quotingBeal,4 3 2U.S.at 444)(alterationomitted). TheCasillascourtfurtherreasonedthattherightthatplaintiff assertedwasinconsistentwiththeAvailabilityRequirement's implementingregulation,whichallowsstatesto"'placeappropriate 505.2(1)violatedtheReasonableStandardsRequirement.Casillas,580 F.Supp.2dat245-46.Becauseplaintiffsinthiscasebringtheir claimrelatingtotheReasonableStandardsRequirementunderthe SupremacyClauseratherthanSection1983,thisportionofthe Casillasdecisionisnotdirectlyrelevant. 13 Case 1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 13 of 29limitsonaservicebasedonsuchcriteriaasmedicalnecessityoron utilizationcontrolprocedures.'"Id.(quoting42C.F.R. 440.230(d)).Thesecriteria,thecourtheld, the referenceto"utilizationcontrolprocedures,""capture[]concepts thatdonotrelatetothecareofanyoneparticularpatientbutlooks toactualorexpectedutilizationoverabroaderpopulation,"andthus indicatethattheAvailabilityRequirementisintendedtoprescribe standardswithwhichthestateplanmustcomplyratherthantocreate individualrights.Id. AstothesecondprongoftheBlessingtest,Casillasfurther heldthatthephrase"utilizationcontrolprocedures"was"so'vague andamorphous'thatitsenforcementwouldstrainjudicialcompetence." Id.at243(quotingBlessing,520U.S.at340-41).Thisterm,the courtnoted,is"susceptibletomultipleplausibleinterpretationsand lacksafixedmeaning."Id.Moreover,itnoted,theregulationpermits astatetorelyonotherunspecifiedcriteriaincrafting"appropriate limits"onmedicalservices,therebycompoundingthevagueness problem.Id. AlthoughinnowaybindingonthisCourt,Casillasisentitledto thisCourt'srespectfulattention.Butintheend,theCourtfinds itselfindisagreementwiththatdecision'sreasoningandconclusions. Inparticular,theCourtconcludesthattheAvailabilityRequirement unambiguouslyconfersoncategoricallyneedyindividualsanindividual 14 Case 1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 14 of 29righttothemedicalservicesdescribedinthestatuteandits implementingregulations.Gonzaga,536U.S.at280. Asaninitialmatter,Casillas'srelianceonBealismlsp1aced. ThatcaseconcernedaPennsylvaniaregulationthatlimitedMedicaid coverageforabortionstothosethathadbeencertifiedbythe recipient'sphysiciansasmedicallynecessary.Beal,432U.S.at441-42.Inholdingthatthechallengedregulationdidnotviolatethe MedicaidAct,theSupremeCourtfocusedonthefactthattheexcluded procedureswerenotmedicallynecessary.Id.at440(describingthe questionpresentedaswhethertheMedicaidActrequiresstatesto "fundthecostofnontherapeuticabortions"(emphasisadded)).It expresslynotedthatdenialofmedicallynecessarytreatmentwould poseaverydifferentquestion:"Althoughseriousstatutoryquestions mightbepresentedifastateMedicaidplanexcludednecessarymedical treatmentfromitscoverage,itishardlyinconsistentwiththe objectivesoftheActforaStatetorefusetofundunnecessarythough perhapsdesirablemedicalservices."Id.at444-45(emphasisadded).4 Here,bycontrast,plaintiffsallegethatthetreatmentstheyseekare medicallynecessary,andonamotiontodismiss,theCourtmustaccept thatallegationastrue. 4 JusticeBrennan,joinedbyJusticeMarshallandJusticeBlackmunin dissent,interpretedtheMedicaidActtorequirecoverageevenfor electiveabortions.Id.at449(Brennan,J.,dissenting).Asrelevant here,JusticeBrennaninterpretedtheMedicaidActtoleavedecisions regardingmedicaltreatmenttothedoctorandpatient,notthestate: "theveryheartofthecongressionalschemeisthatthephysicianand patientshouldhavecompletefreedomtochoosethosemedical proceduresforagivenconditionwhicharebestsuitedtotheneedsof thepatient."Id.at450(Brennan,J.,dissenting). 15 Case 1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 15 of 29RegardingthefirstprongoftheBlessingtest,thelanguageof theAvailabilityRequirementisexpresslyaddressedtotheneedsof indJ.Vl.dUa.LMed.1.cal.d.bene.I:l.ciaries:"[ci].SL.aceplan...mu::sLpLuvlcte:tor makingmedicalassistanceavailable...toallindi victuals"whomeet certaineligibilityrequirements.42U.S. C.13 96a (a)( 10)(A).Thisis preciselythe"unmistakablefocusonthebenefitedclass"thatthe SupremeCourt,inGonzaga,heldwouldevinceCongress'sintentto createanindividualright.536U.S.at284(citationandinternal quotationmarksomitted).Indeed,theThirdCircuithasfoundthat "the'individualfocus'of[theAvailabilityRequirement]is unmistakable."Sabreeexrel.Sabreev.Richman,367F.3d180,190(3d Cir.2004). AlthoughtheSecondCircuithasnothadoccasiontoconsiderthis question,ithasheldthatasimilarlywordedprovisionofthe MedicaidActcreatedaprivatelyenforceableright.SeeRabinv. Wilson-Coker,362F.3d190(2004).TheprovisionatissueinRabin grantedasix-monthextensionofeligibilityformedicalassistance, providedtherecipientcompliedwithcertainreportingrequirements: "[E]achStateplanapprovedunderthissubchaptermust providethateachfamilywhichwasreceivingaidpursuantto aplanoftheStateinatleast3ofthe6months immediatelyprecedingthemonthinwhichsuchfamilybecomes ineligibleforsuchaidshallremaineligiblefor assistanceundertheplanduringtheimmediately succeeding6-monthperiod." Id.at194(quoting42U.S.C.1396r-6(b)).TheSecondCircuitfound that,byfocusingonindividual(orfamily)entitlementsratherthan high-levelprogrammaticrequirements,Congressintendedtocreatean 16 Case 1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 16 of 29enforceableright.Id.at201-02.Giventhegrammaticalsimilarity betweenthisprovisionandtheAvailabilityRequirement,itfollows thattheAvailabilityRequirementalsoevincescongressiona1lntentto createanenforceableright. ContrarytoCasillas,nothingabouttheexistenceofthisright isinconsistentwiththe"appropriatelimitsnclauseofthe implementingregulations.42C.F.R.440.230(d).Thatclausesimply providesthat,likemostrights,therighttothemedicalservices describedintheAvailabilityRequirementisnotabsolute.Rather,it issubjecttolimitsthatthestatemayenact,consistentwiththe discretionvestedinthestatebythestatute.Thatdiscretionisnot boundless.Thestatemayenactonly"appropriatenlimits,mustprovide servicesthatare"sufficientinamount,duration,andscopeto reasonablyachieve[their]purpose,nand"maynotarbitrarilydenyor reducetheamount,duration,orscopeofarequiredservice...toan otherwiseeligiblebeneficiarysolelybecauseofthediagnosis,type ofillness,orcondition.n42C.F.R.440.230(b)-(d).These provisionsdefinethecontoursoftheright;theydonotnegateits existence. Noristhisrightso"vagueandamorphousnastobejudicially unmanageableunderthesecondprongoftheBlessingtest.The AvailabilityRequirementanditsimplementingregulationssetforthin detailtheservicesthatstatesmustprovidetotheirneedyresidents, andstates'compliancewiththeserequirementsisobjectively measureable.SeeWatsonv.Weeks,436F.3d1152,1161(9thCir.2006) 17 Case 1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 17 of 29("[Sections1396a(a)(10)and1396d(a)supplyconcreteandobjective standardsforenforcement;theyarehardlyvagueandamorphous."). CaS1llaSrOUDdthattheterm-utlllzatloncontrol dB usedintheimplementingregulations,wasnotjudiciallymanageable. Casillas,580F.Supp.2dat243.Butcourtshavehadnotrouble adjudicatingwhetheraparticularregulationisavalidutilization controlprocedure.Forexample,inDeLucav.Hammons,927F.Supp.132 (S.D.N.Y.1996),plaintiffschallengedaregulation,whichthestate defendedasautilizationcontrolprocedure,thatlimitedhome-care servicesfornewMedicaidrecipientstotwenty-eighthoursperweek. Id.at134.Thecourtfoundthatthisarbitrarycapwas"not appropriateinthatitdiscriminatesamongapplicantsand intentionallyfailstotakeintoaccounttheamountofservicesthat havebeendeterminedtobenecessaryforthehealthandsafetyof thepatient."Id.at136.Seealso,e.g.,Davisv.Shah,No.12-CV-6134CJS,2013WL6451176,at*12(W.D.N.Y.Dec.9,2013)(holding thatregulationlimitingaccesstomedicallynecessaryorthopedic shoesandcompressionstockingsbasedondiagnosiswasnotvalid utilizationcontrolprocedure);Laddv.Thomas,962F.Supp.284,294 (D.Conn.1997)(holdingthatrequirementthatMedicaidrecipients submitrequestsforpriorauthorizationofdurablemedicalequipment tovendorwasavalidutilizationcontrolprocedure). Casillasfurtherexpressedconcernthattheimplementing regulationpermitsastateagencytoplace"appropriatelimits"on servicesbasedonunspecifiedothercriteria.Tobesure,this 18 Case 1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 18 of 29provisiongrantsthestateaconsiderablemeasureofdiscretion.It doesnot,however,rendertheassertedrightentirelystandardless. Forexample,alimitationbasedongenuinehealthandsafetyconcerns wouldmostlikelybean"appropriatelimit,"whereasonebasedsolely onanimustowardsadisfavoredclassmostcertainlywouldnot.Nothing aboutthisdeterminationstretchestheboundsofjudicialcompetence. Finally,regardingthethirdprongoftheBlessingtest,the AvailabilityRequirementisframedinmandatoryterms.Itprovides thatstateplans"must"makeavailabletheservicesdescribed. Provisionoftheseservicesisnotoptional.Accordingly,theCourt findsthatallthreeBlessingfactorsaremetandtheAvailability RequirementcreatesanindividualrightenforceableunderSection 1983.5 5 Insoholding,theCourtjoinstheoverwhelmingmajorityofcourts, bothbeforeandafterGonzaga,thathaveconsideredthisquestion.See Watsonv.Weeks,436F.3d1152,1159-60(9thCir.2006)("Nocircui_t_ courthasheldthatsection1396a(a)(10)doesnotcreateasection 1983right.");Sabreeexrel.Sabreev.Richman,367F.3d180(3dCir. 2004);S.D.exrel.Dicksonv.Hood,391F.3d581,603(5thCir. 2004);PediatricSpecialtyCare,Inc.v.ArkansasDep'tofHuman Servs.,293F.3d472,478-79(8thCir.2002);WestsideMothersv. Haveman,289F.3d852,862-63(6thCir.2002);MillerbyMillerv. Whitburn,10F.3d1315,1319(7thCir.1993);Crawleyv.Ahmed,No. 08-14040,2009WL1384147,at*19(E.D.Mich.May14,2009);Michelle P.exrel.Deisenrothv.Holsinger,356F.Supp.2d763,767(E.D.Ky. 2005);HealthCareForAll,Inc.v.Romney,No.CIV.A.00-10833-RWZ, 2004WL3088654,at*2(D.Mass.Oct.1,2004);Memisovskiexrel. Memisovskiv.Maram,No.92C1982,2004WL1878332,at*11(N.D.Ill. Aug.23,2004);KennyA.exrel.Winnv.Perdue,218F.R.D.277,294 (N.D.Ga.2003);DajourB.v.CityofNewYork,No.00CIV.2044,2001 WL830674,at*8(S.D.N.Y.July23,2001);cf.Brysonv.Shumway,308 F.3d79,88-89(1stCir.2002)(holdingthatsimilarlyworded provisionofMedicaidActcreatesprivatelyenforceableright);Doe1-13By&ThroughDoe,Sr.1-13v.Chiles,136F.3d709,719(11thCir. 19 9 8)(same). 19 Case 1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 19 of 29WithrespecttotheComparabilityRequirement,theCourtalso findsthatallthreeBlessingfactorsaremet.First,thestatutory languageissquarelydirectedtowardindividualrights:"them e d ~ c lassistancemadeavailabletoany[categoricallyneedyindividual] shallnotbelessinamount,duration,orscopethanthemedical assistancemadeavailabletoanyothersuchindividual."42U.S. C. 1396a(a)(1)(B)(i).Theimplementingregulationsfurtherprovidethata stateMedicaid"planmustprovidethattheservicesavailabletoany individualinthefollowinggroupsareequalinamount,duration,and scopeforallbeneficiarieswithinthegroup:(1)Thecategorically needy.(2)Acoveredmedicallyneedygroup."42C.F.R.440.240(b). Theseprovisions,likethoseoftheAvailabilityRequirement,focuson theparticularservicesthatindividualbeneficiariesareentitledto receive,notonthebroaderstructureoftheMedicaidprogramasa whole,andthusevincecongressionalintenttocreateindividual rights. Inholdingotherwise,theCasillascourtreliedonRodriguezv. CityofNewYork,197F.3d611(2dCir.1999).InRodriguez,NewYork hadelectedtoprovidecertaintypesofpersonalcareservicesto individualswithdisabilities,whichwerenotamongtheservicesit wasrequiredtoprovideundertheAvailabilityRequirement.Id.at 613.Plaintiffscontendedthat,undertheComparabilityRequirement, thestatewasrequiredtoprovide"safetymonitoring,"adifferent servicethatplaintiffsallegedwascomparabletothepersonalcare servicesthatthestatehadchosentocover.Id.at616.TheSecond 20 Case 1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 20 of 29Circuitrejectedplaintiffs'argument,notingthat"[a]holdingtothe contrarywouldcreateadisincentiveforstatestoprovideservices opt1onalunderreaerallawlestacourLdeemother~ e r v l c e 'comparable'tothoseprovided...therebyincreasingthecostsofthe optionalservices."Id. TherightassertedinRodriguezisverydifferentfromtheright assertedhere.TheRodriguezplaintiffssoughtaccesstoaspecific servicethatthestatewasnotrequiredtoprovideandthatithadnot chosentoprovidetoanyone.Here,bycontrast,plaintiffsallegethat thespecifictreatmentstheyseekarealreadyprovidedtoother Medicaidrecipientsbuthavebeendeniedtothemonthebasisoftheir GDdiagnosesalone.This,theyallege,demonstratesthattheservices theyreceiveunderNewYork'sMedicaidprogramarenot"equalin amount,duration,andscope"tothosereceivedbyothercategorically needyindividuals.42C.F.R.440.240(b). InCasillas,thecourtfoundthattherightassertedbyplaintiff would,asinRodriguez,createadisincentiveforstatestoprovide specifictreatments:"thestatewouldhavetoconsiderotherpossible diagnosesforwhichthetreatmentmightbeprescribedbeforedeciding whethertomakeitavailableforanysinglecondition."Id.at244. Whilethatmaybethecase,requiringthestatetoundertakesuch considerationsisentirelyconsistentwiththepurposeofananti-discriminationprovision.InenactingtheComparabilityRequirement, Congressmadeclearthatthestatesmaynotblithelyprovideservices tosomeoftheirneedyresidentswhiledenyingthesameservicesto 21 Case 1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 21 of 29otherswhoareequallyneedy.Thus,thisisnotareasontofindthat theComparabilityRequirementdoesnotgiverisetoanindividual right. TheComparabilityRequirementalsosatisfiesthesecondandthird prongsoftheBlessingtest.Thestandardsetforthinthestatute thatservicesprovidedtosomecategoricallyneedyindividualsmaynot be"lessinamount,duration,orscope"thanthoseprovidedtoothers isneithervaguenoramorphous.42U.S.C.1396a(a)(1)(B)(i).And bydirectingthatservices"shall"becomparable,Congressmadeclear thatthisrequirementwasmandatoryandbindingonthestates. Accordingly,theCourtfindsthattheComparabilityRequirement createsanenforceableindividualright.6 Finally,althoughdefendantmakesnoargumentregardingtheEPSDT Requirement,seesupranote2,theCourtfindsthattheEPSDT RequirementisalsoprivatelyenforceableunderSection1983.As numerouscourtshaveheld,theEPSDTRequirement(1)isunmistakably focusedontherightsofMedicaid-eligibleyouthtoreceivethe enumeratedservices,(2)providesdetailed,objective,andmanageable standards,includingspecificservicesthatmustbeprovided,and(3) isbindingonstates.See,e.g.,DajourB.v.CityofNewYork,No.00 Civ.2044,2001WL830674,at*8-*10(S.D.N.Y.July23,2001);see 6 Numerousothercourtshavesoheld.See,e.g.,Davisv.Shah,No. 12-CV-6134CJS,2013WL6451176,at*12(W.D.N.Y.Dec.9,2013); MichelleP.exrel.Deisenrothv.Holsinger,356F.Supp.2d763,767 (E.D.Ky.2005);HealthCareForAll,Inc.v.Romney,No.CIV.A.00-10833-RWZ,2004WL3088654,at*2(D.Mass.Oct.1,2004);Antricanv. Buell,158F.Supp.2d663,672(E.D.N.C.2001)aff'dsubnom. Antricanv.Odom,290F.3d178(4thCir.2002). 22 Case 1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 22 of 29alsoSalazarv.DistrictofColumbia,729F.Supp.2d257,269(D.D.C. 2010). BecausethecourtroundthattheAvailab:LLLLy,Comparab:Ll:Lty,and EPSDTRequirementscreateprivaterightsenforceableviaSection1983, theCourtdeniedtheportionofdefendant'smotionseekingtodismiss CountsI,II,andVI. Withrespecttocertainofplaintiffs'otherclaims,however,the Courtfoundthatdefendant'smotionhadmerit,atleastinpart. Regardingplaintiffs'claimthatAmendedSection505.2(1)violatesthe ReasonableStandardsRequirement(CountIII),thisclaimisbrought pursuanttotheSupremacyClauseoftheUnitedStatesConstitution. SeeU.S.Const.art.VI.7 Inhismotion,defendantarguedthatthe SupremeCourt'srecentopinioninArmstrongv.ExceptionalChild Center,Inc.,135S.Ct.1378(2015),establishesthatplaintiffshave nocauseofactionundertheSupremacyClausetoenforcethe ReasonableStandardsRequirement. InArmstrong,theCourtheldthattheSupremacyClausedoesnot conferaprivaterightofaction.Id.at1384.Furthermore,although federalcourtshaveinherentauthoritytoenjoinunconstitutional actionsbystateandfederalofficials,thatauthority"issubjectto expressandimpliedstatutorylimitations."Id.at1385.Specifically, 7 PlaintiffsalsoallegethattheAvailabilityandComparability Requirements(CountsIandII)arepreemptedbytheSupremacyClause. BecausetheCourtfindsthatplaintiffshaveaprivaterightofaction toenforcetheseprovisionsunderSection1983,itdoesnotaddress whethertheymayalsobringtheirclaimspursuanttotheSupremacy Clause. 23 Case 1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 23 of 29whereastatute"implicitlyprecludesprivateenforcement,"a plaintiff"cannot,byinvokingourequitablepowers,circumvent AtissueinthatcasewasSection30(A)oftheMedicaidAct, whichrequiresstateplansto: providesuchmethodsandproceduresrelatingtothe utilizationof,andthepaymentfor,careandservices availableundertheplan...asmaybenecessarytosafeguard againstunnecessaryutilizationofsuchcareandservices andtoassurethatpaymentsareconsistentwithefficiency, economy,andqualityofcareandaresufficienttoenlist enoughproviderssothatcareandservicesareavailable undertheplanatleasttotheextentthatsuchcareand servicesareavailabletothegeneralpopulationinthe geographicarea... 42U.S. C.13 96a (a)( 3 O)(A).TheCourtheldthatSection3 O (A)isnot privatelyenforceablebecause,first,thestatuteprovidesanexpress methodofenforcement,namelywithholdingofMedicaidfundsbythe SecretaryofHealthandHumanServices.Id.at1385(citing42U.S.C. 1396c).Thecreationofanadministrativeremedy,theCourtheld, evincedCongress'sintenttoprecludeprivateenforcement.Second,the CourtfoundthatSection30(A)wasnotamenabletoprivateenforcement becauseitsmandatewasso"judgment-laden,""broad[],"and "complex[]"astobe"judiciallyunadministrable."Id. LikeSection30(A),theReasonableStandardsRequirementis subjecttoanexpressadministrativeenforcementmechanism,viz., defundingbytheSecretaryofHealthandHumanServices.42U.S.C. 1396c.Furthermore,thisprovisionconsistsofabroadgrantof discretiontothestatestoimplement"reasonablestandards...for 24 Case 1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 24 of 29determiningeligibilityforandtheextentofmedicalassistanceunder theplan"thatare"consistentwiththeobjectivesof[theMedicaid Act]."42U.S.C.l396a(a)(l7).er.Watson,436Y.3dat1162 ("Section1396a(a)(17)isageneraldiscretion-grantingrequirement thatastateadoptreasonablestandards.").LikeSection30(A),it focusesonprogrammaticaspectsofthestateplanasawhole,rather thanonthespecificbenefitsthatmustbeaccordedtoindividuals. Therefore,theCourtconcludedthattheReasonableStandards RequirementisnotprivatelyenforceableunderArmstrong.Accordingly, theCourtgranteddefendant'smotiontodismissCountIII. TurningtoCountV,defendantarguedinhismotionthat plaintiffsfailedtostateaclaimforviolationofSection1557of theACAwithrespecttotheYouthExclusion.Section1557provides that"anindividualshallnot...beexcludedfromparticipationin,be deniedthebenefitsof,orbesubjectedtodiscriminationunder,any healthprogramoractivity"thatreceivesfederalfundingonthebasis ofcertaincriteria,includingsex.42U.S.C.18116.Onamotionto dismissunderRule12(b)(6),acourtmustassesswhetherthecomplaint "contain[s]sufficientfactualmatter,acceptedastrue,to'statea claimtoreliefthatisplausibleonitsface.'"Ashcroftv.Iqbal, 556U.S.662,678(2009)(quotingBellAtl.Corp.v.Twombly,550U.S. 544,570(2007)).DefendantarguesthattheYouthExclusiondraws distinctionsonthebasisofage,notsex,andthereforedoesnot violatethisprovision. 25 Case 1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 25 of 29PlaintiffsrespondthattheYouthExclusiondiscriminatesonthe basisofsexintwoways:"(1)thatcertainservicesareavailableto non-i::;ransgenaerpeop1-eDuedeniedcut.ra_ns9enderpeuplewhere medicallynecessary;or(2)thatregardlessoftheavailabilityof thesetreatmentstopeoplegenerally,thesecoverageexclusionshavea disparateimpactontransgenderpeopleforwhomtheseservicesare medicallynecessary."Plaintiffs'OppositiontoDefendant'sMotionto DismissdatedMay8,2015,ECFNo.34,at19.8 However,plaintiffsfailtoallegeanyfactsinsupportofeither theory.9 Mostnotably,plaintiffsfailtoallegethatthetreatments barredbytheYouthExclusionareavailabletonon-transgenderyouth. Intheabsenceofsuchanallegation,defendant'sfailuretomakesuch servicesavailabletotransgenderyouthcannotconstitutesex discrimination.Thus,althoughtheCourtiscognizantoftheprinciple that"[c]omplaintsallegingcivilrightsviolationsmustbeconstrued especiallyliberally,"UnitedStatesv.CityofNewYork,359F.3d83, 91(2dCir.2004),herethereisnothingtoconstrue.Accordingly,the Courtgranteddefendant'smotiontodismissClaimVoftheAmended 8 Itisnotsettledwhetheradisparateimpactclaimiscognizable underSection1557oftheACA.SeeRumblev.FairviewHealthServs., No.14-CV-2037SRN/FLN,2015 at*12(D.Minn.Mar.16, 2015) 9 TheonlyfactualallegationintheAmendedComplaintrelatingto treatmentoftransgenderyouthisthat"numerousrespectedclinics aroundtheUnitedStatesprovidemedicalservicesforpeoplediagnosed withGD/GIDwhoareundertheageofeighteen."Am.Compl. 89.This allegationcannotsupportplaintiffs'claimofdiscrimination. 26 Case 1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 26 of 29complaintwithrespecttotheYouthExclusionforfailuretostatea claim. Defendantalsoarguedinhismotionthatplaintiffsfalledto stateaclaimforviolationoftheComparabilityRequirementbecause theyfailedtopleadsufficientfactualsupportfortheircontention thattheyhavenotreceivedcomparableservices.However,plaintiffs clearlyallegethatdefendantprovidesmedicalcoveragetosimilarly situatedMedicaidrecipientssufferingfromconditionsotherthanGD forthesurgicalproceduresandothertreatmentsthataredeniedto themunderAmendedSection505.2(1),andciteaprovisionoftheDOH regulationssupportingthatcontention.Am.Compl. 107,146,160 (citing18N.Y.C.R.R.533.5).Theseparagraphsadequatelyplead violationsoftheComparabilityRequirement,astheyallegethat defendanthasprovidedmedicallynecessaryprocedurestosome individualsbutnottoothers.SeeProvidencePediatricMed.Daycare, Inc.v.Alaigh,799F.Supp.2d364,374(D.N.J.2011)(denyingmotion todismisswhereplaintiffsallegedthatcertain"childrenarenot receivingthoseservicesthattheirphysicianshavedesignatedas medicallynecessary"). Defendantfurtherarguedthatplaintiffs'claimswithrespectto theCosmeticProceduresExclusionarenotyetripeforadjudication becauseplaintiffsfailedtopleadthattheyhaverequestedandbeen deniedanyoftheproceduresbarredbyAmendedSection505.2(1)."A claimisnotripeforadjudicationifitrestsuponcontingentfuture eventsthatmaynotoccurasanticipated,orindeedmaynotoccurat 27 Case 1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 27 of 29all."Texasv.UnitedStates,523U.S.296,300(1998)(internal quotationmarksomitted).However,courtswithinthiscircuitdonot require"afutilegestureasaprerequisiteforadjudicatlonln federalcourt."Desideriov.Nat'lAss'nofSec.Dealers,Inc.,191 F.3d198,202(2dCir.1999)(quotingWilliamsv.Lambert,46F.3d 1275,1280(2dCir.1995)).AmendedSection505.2(1),byitsplain terms,excludescoveragefortheproceduresdeemed"cosmetic."See AmendedSection505.2(1)(4)(statingthat"[p]aymentwillnotbemade" for"cosmeticsurgery,services,andproceduresincludingbutnot limitedto"theenumeratedprocedures).Furthermore,theDepartmentof Health'sMedicaidUpdatemakesclearthat"paymentwillnotbemade for"theservicesdeemed"cosmetic."DeclarationofArthurBiller datedMay8,2015,Ex.2,at16.Therefore,theCourtfindsthatany attempttoseekcoveragefortheso-called"cosmetic"serviceswould havebeena"futilegesture"andwasnotrequiredtorender plaintiffs'claimsripeforadjudication. Accordingly,theCourtdenieddefendant'smotiontodismiss plaintiffs'claimsregardingtheCosmeticProceduresExclusionas unripe. Finally,defendantarguedinhismotionthatplaintiffs'Claim IV,forviolationoftheequalprotectionprovisionsoftheNewYork StateConstitution,isbarredbytheEleventhAmendmenttotheUnited StatesConstitutionbecauseitassertsapurelystatelawclaim againstastateofficial.SeeConcourseRehab.&NursingCtr.,Inc.v. DeBuono,179F.3d38,44(2dCir.1999);MorningsideSupermarketCorp. 28 Case 1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 28 of 29v.NewYorkStateDep'tofHealth,432F.Supp.2d334,339(S.D.N.Y. 2006)(dismissingstatelawclaimsagainstDOHofficialasbarredby argument.SeeTranscriptdatedMay22,2015,ECFNo.41,at6:18. Accordingly,theCourtgranteddefendant'smotiontodismissCountIV oftheAmendedComplaint.10 Fortheforegoingreasons,theCourt,byOrderdatedJune26, 2015,dismissedClaimsIIIandIV,andalsodismissedClaimVwith respecttotheYouthExclusion,butotherwisedenieddefendant's motiontodismisstheAmended Dated:NewYork,NewYork July:tj_,2015 Complaint. ~ - U.S.D.J. 10 Defendantraisedseveralotherargumentsforthefirsttimeinhis replypapers.Becausetheseargumentswerenotraisedinhisopening brief,theywerewaived,andtheCourtdoesnotaddressthem.See Knipev.Skinner,999F.2d708,711(2dCir.1993)("Argumentsmaynot bemadeforthefirsttimeinareplybrief."). 29 Case 1:14-cv-04456-JSR Document 52 Filed 07/29/15 Page 29 of 29