The underlying dispute involves B.C., a minor diagnosed with Autism Spectrum Disorder and Severe Intellectual Disability, whose physicians determined he needed inpatient treatment at the Kennedy Krieger Institute's Neurobehavioral Unit in Baltimore. KKI requested a per diem rate of $7,500, with the requested reimbursement at 85% of billed charges. Virginia's Department of Medical Assistance Services countered at $1,000 per diem. In continued negotiations, KKI offered to accept the Maryland Medicaid contracted per diem rate of $5,487.42 reimbursed at 100%, and Virginia offered to pay 60% of the Maryland Medicaid per diem. Negotiations stalled. B.C.'s admission was cancelled, and his mother Stella Croffe — suing individually and as his guardian — alleged he went more than six months without necessary treatment, with B.C. allegedly experiencing increased aggression and risk of harm to himself and caregivers.
Croffe brought four claims under the Medicaid Act, 42 U.S.C. section 1396 et seq., enforced through section 1983: the reasonable-promptness provision (section 1396a(a)(8)), the equal-access provision (section 1396a(a)(30)(A)), the comparability provision (section 1396a(a)(10)(B)), and the Early and Periodic Screening, Diagnostic and Treatment provision (section 1396a(a)(43)(C)). The court, applying Medina v. Planned Parenthood South Atlantic, 606 U.S. 357 (2025), held that none of the four provisions satisfy the two-part test for privately enforceable rights: clear and unambiguous rights-creating language, and an unmistakable focus on individuals like the plaintiff.
The court's analysis turned on Medina's explicit rejection of mandatory terms as rights-creating language. The court noted that Medina held that words such as "must," "provide," and "shall," even when applied to individuals, do not constitute clear and unambiguous rights-creating language sufficient to support a private suit under section 1983. The court contrasted those terms with the language of the Federal Nursing Home Reform Act, which Medina identified as a model: provisions expressly titled "Requirements relating to residents' rights" and "General rights," with text stating that "[a] nursing home must protect and promote the rights of each resident, including the following rights."
The ruling also addressed the Fourth Circuit's prior precedent directly. The court noted that the Fourth Circuit had previously held in Doe v. Kidd, 501 F.3d 348 (4th Cir. 2007), that section 1396a(a)(8) created an enforceable right, but that decision relied on the Blessing framework, which Medina expressly repudiated. The court stated that Medina reversed the Fourth Circuit and rejected reliance on "must" and "shall" as rights-creating — the precise basis of Doe — and therefore held that Medina abrogates Doe's applicability. A recent decision from the same district, Nansemond Indian Nation v. Virginia, 795 F. Supp. 3d 733 (E.D. Va. 2025), had already reached the same conclusion on section 1396a(a)(8).
The court also dismissed Croffe's individual-capacity claims for lack of standing. Injuries she raised in her opposition brief — emotional distress and interference with parental decision-making — were not alleged in the complaint, and the court declined to consider them, citing the rule that a complaint may not be amended by briefs in opposition to a motion to dismiss.
Dismissal was with prejudice. The court held that amendment would be futile given the Supreme Court's holding in Medina, and noted that when a state violates Medicaid Act conditions, the remedy Congress contemplated is federal action to terminate funds to the state, not private litigation.