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Delivery[Boumediene Gelpi]

Delivery[Boumediene Gelpi]

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Published by: John E. Mudd on Mar 24, 2011
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586 F.Supp.2d 22 Page 1586 F.Supp.2d 22
(Cite as: 586 F.Supp.2d 22)
United States District Court,D. Puerto Rico.CONSEJO DE SALUD PLAYA DE PONCE,et.al., Plaintiffsv.Johnny RULLAN, Secretary of Health of theCommonwealth of Puerto Rico,Defendant.
Civil Nos. 06-1260(GAG), 06-1524(GAG).
Oct. 10, 2008.As Corrected Nov. 10, 2008.
Two federally qualified healthcenters sought injunctive relief ordering theSecretary of Health of Commonwealth of PuertoRico to issue them prospective Medicaid"wraparound" payments.
United States District Court for theDistrict of Puerto Rico, Gustavo A. Gelpí, J., held that Puerto Rico was an incorporatedterritory of the United States.Ordered accordingly.West Headnotes
[1]Health 468
198Hk468 Most Cited CasesPurpose of Medicaid program is to providemedical assistance to indigent families withdependent children, as well as indigent disabled,blind, and aged individuals. Medicaid Act, §1901 et seq.,42 U.S.C.A. § 1396 et seq.
[2]Health 462
198Hk462 Most Cited CasesThe Commonwealth of Puerto Rico is a state for purposes of the Medicaid statute. Medicaid Act,§ 1901 et seq.,42 U.S.C.A. § 1396 et seq.
375k8 Most Cited CasesUnder the "
Insular Cases
doctrine," onlyfundamental constitutional rights extend tounincorporated United States territories,whereas in incorporated territories allconstitutional provisions are in force.
375k33 Most Cited CasesCommonwealth of Puerto Rico was anincorporated territory of the United States, suchthat its citizens were entitled to all, rather thanjust fundamental, constitutional guarantees,even though Congress had never enacted anyaffirmative language to that effect, given thesequence of legislative actions that hadincorporated the territory de facto; from ajudicial perspective, Puerto Rico was one whichCongress had chiseled in the very image andlikeness of the United States system of government and laws, and contrary to otheterritorial islands where Congress hadannounced and began to relinquish sovereignty,in the case of Puerto Rico, it had done exactlythe contrary in exponentially increasingconstitutional terms. 
 Agustin Diaz-Garcia, Ponce, PR,Ignacio  Fernandez-De-Lahongr , Fernandez & Alcaraz,PSC, San Juan, PR, PHV JamesL. Feldesman,PHV RobertA. Graham, Feldesman, Tucker,Leifer, Fidell LLP, Washington, DC, for Plaintiffs. Arlene R. Perez-Borrero,Eduardo A. Vera- Ramirez,Luis A. Rodriguez-Munoz,Landron & © 2009 Thomson Reuters. No Claim to Orig. US Gov. Works.
586 F.Supp.2d 22 Page 2586 F.Supp.2d 22
(Cite as: 586 F.Supp.2d 22)
Vera LLP, Guaynabo, PR,Luis F. Zayas-Marxuach, Almeida & Davila, P.S.C.,Francisco  A. Ojeda-Diez, P.R. Department of Justice-Federal Litigation,Patricia Lorenzi, Delgado &Fernandez, San Juan, PR, for Defendant.
 GUSTAVO A. GELPÍ, District Judge.In this case the plaintiffs, three federallyqualified health centers, seek injunctive relief from the Court ordering the Secretary of Healthof the Commonwealth of Puerto Rico to issue tothem prospective Medicaid "wraparound"payments, pursuant to42 U.S.C. § 1396a(bb)(5).
See Plaintiffs' Motion in Compliance ... and Renewed Motion for Preliminary Injunction
(Docket No. 127);
Opinion and Order of June 4,2008 denying defendant's motion for summaryjudgment 
(Docket No. 99)).The Secretary of Health, represented by theAttorney General of the Commonwealth,nonetheless contends that the Medicaid"wraparound" statute, as applied to Puerto Rico,is unenforceable. He argues that the statutoryprovision violates the Constitution's SpendingClause,U.S. Const. Art. I § 8, cl. 1, insofar asthe numerous amendments to the Medicaidstatute have significantly altered the way theprogram works. At the time the Commonwealthelected to participate in the Medicaid program itcould not have foreseen the devastatingeconomic consequences resulting from statutorydirectives it is now unable to comply with.
SeeDefendant's Opposition to Plaintiffs' Motion for Renewed Preliminary Injunction
(Docket No.133) at 24-26.The Secretary further argues that Puerto Ricocannot be treated by Congress in a mannedisparate to the States. Following the passage byCongress of Law 600 in 1950, and subsequentlyLaw 447 in 1952, Puerto Rico enacted its ownConstitution, thus obtaining the degree of autonomy and independence normallyassociated with the States of the Union.Consequently, Supreme Court jurisprudencetreating Puerto Rico disparately from Statespremised on the
Insular Cases
doctrine isanachronistic and, thus, no longer applicable.
at 26-28.The court certified these constitutionalchallenges to the Attorney General of the UnitedStates, noting that the federal government'sposition would be essential to the court's ruling. [FN1] 
 28 U.S.C. § 2403;Fed.R.Civ.P.  51(b). The court also afforded the parties time tofurther address these issues which are clearlydispositive of the merits of the injunctive relief sought.
See Orders
of October 2, 2008 (DocketNos. 135 and 136). The Attorney General dulyresponded to the Court's certification
order (Docket No. 144), as did the plaintiffs (DocketNo. 148).[FN2]FN1.The court notes that the twoconsolidated cases at hand are presentlynot the only "wraparound" paymentlitigation cases in this district wherethese same constitutional issues havebeen raised.
See also Atlantic Medical Center, Inc. v. Commonwealth of PuertoRico,
06- 1291(GAG) (Docket No. 398at 24-27).FN2.The Attorney General does notaddress the merits of the constitutional© 2009 Thomson Reuters. No Claim to Orig. US Gov. Works.
586 F.Supp.2d 22 Page 3586 F.Supp.2d 22
(Cite as: 586 F.Supp.2d 22)
arguments. Rather, he posits that theCommonwealth Secretary's challengehas been improperly raised, given that inthe summary judgment context he didnot present any constitutional arguments.This is correct. However, the argumentsraised by the Secretary in his summaryjudgment motion focused on whether theCommonwealth as a matter of fact wasin compliance with the federal statute atissue. Now the plaintiffs have moved for preliminary injunctive relief and theCommonwealth, in turn, has raised theconstitutional arguments as a defense.This is certainly not improper given thatthe Court must now consider evidence asto each of the four requisites necessaryfor an injunction to issue, to wit, (i)plaintiffs' likelihood of success on themerits, (ii) the potential of irreparableharm to plaintiffs, (iii) the effect of aninjunction to defendant, and, (iv) theeffect of an injunction to the public.
Cir.2008).Before addressing plaintiffs' contentions,however, it is essential to first provide somebackground on the Medicaid "wraparound"statute as it pertains to Puerto Rico. 
The Medicaid Wraparound Statute and itsApplicability to Puerto Rico
 [1][2] The Medicaid program,42 U.S.C. § 1396
begun in 1965, is jointly supported withfederal and state funds and directly administeredby state governments. Its purpose is to providemedical assistance to indigent families withdependent children, as well as indigent disabled,blind, and aged individuals.
F.3d 56, 61 (1st Cir.2005). The Commonwealthof Puerto Rico is a "state" for purposes of theMedicaid statute,42 U.S.C. § 1301;
.A state need not participate in the Medicaidprogram. However, once it opts to do so, it mustcomply with all federal requirements. TheCommonwealth of Puerto Rico opted toparticipate in the Medicaid program.
at 61-62.One requirement of the Medicaid program,relevant here, is that participating jurisdictionsmust provide federally-qualified health center services.42 U.S.C. §§ 1396a(a)(10)(A);1396d(a)(2)(C);
Plaintiffs here are "federally-qualified healthcenters" ("FQHCs") operating in Puerto Rico,which receive grants under Section 330 of thePublic Health Service Act and serve medicallyunderserved areas.42 U.S.C. § 254b.Federal law regulates how FQHCs receivepayment of services provided to Medicaidpatients.
EffectiveJanuary 1, 2001, Congress established a newpayment system known as the "ProspectivePayment System" ("PPS").42 U.S.C. § 1396a(bb)(2)-(3);
Applying a mathematical formula set by thestatute, each participating jurisdiction wasinitially required to make a baseline calculationfor Medicaid reimbursement to FQHCs. Theinitial calculation was to take into accountFQHC data from 1999, 2000 and 2001. Eachsubsequent year each jurisdiction has toprospectively revise its data for that particular year's FQHC Medicaid reimbursements.
© 2009 Thomson Reuters. No Claim to Orig. US Gov. Works.

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