Full opinion text
ORDER GRANTING IN PART AND DENYING IN PART DEFENDANT’S AMENDED MOTION TO DISMISS AND CERTIFICATION FOR INTERLOCUTORY APPEAL MARTINEZ, District Judge. TABLE OF CONTENTS I. FACTUAL AND PROCEDURAL BACKGROUND............................593 A. The Medicaid Act......................................................593 B. The Administration of Medicaid in Texas..................................593 C. The Parties ...........,...............................................594 D. Plaintiffs’ Claims.......................................................594 II. DEFENDANT’S RULE 12(b)(1) MOTION....................................596 A. Article III Standing and Prudential Considerations.........................596 B. Recipient Plaintiffs’ Standing to Sue......................................598 C. Provider Plaintiffs’ Standing to Sue ......................................604 D. Equal Access’s Standing to Sue..........................................606 E. Plaintiffs’ Standing to Assert Their Supremacy Clause Claim................607 III. DEFENDANT’S RULE 12(b)(6) MOTION....................................609 A. Analytical Standard....................................................609 B. The Equal Access Provision.............................................611 C. The Quality of Care Provision ...........................................614 D. The Comparability Provision ............................................616 E. The Equity Provision...................................................618 F. The Statewideness Provision ............................................619 G. The Reasonable Promptness Provision....................................620 H. The Actuarial Soundness Provision.......................................622 I. Cognizable Supremacy Clause Claim .....................................623 J. Cognizable Equal Protection Clause Claim................................624 K. Declaratory Judgment Relief............................................625 IV. PRINCIPLES OF JUDICIAL ADMINISTRATION — THE FREW CLASS.....626 V. CERTIFICATION FOR INTERLOCUTORY APPEAL........................627 VI. CONCLUSION............................................................627 On this day, the Court considered the following: (1) Defendant Albert Hawkins’ (“Defendant”) “Amended Motion to Dismiss,” filed on May 18, 2005; (2) Plaintiffs Equal Access for El Paso, Inc.; El Paso County Hospital District d/b/a R.E. Tho-mason General Hospital; El Paso First Health Plans, Inc.; Dr. Jose Luna, Jr.; Monica Rivero, individually and as next Mend of Kevin Rivero; Patricia Duarte Melendez, individually and as next Mend of Orandie Jahssar Melendez-Duarte and Osnar Joshua Melendez; Jessilyn Nagel, as next Mend of Heidi and McKenna Armstrong; and Ruth Gallegos’s, individually and as next Mend of Amber Villegas, (collectively “Plaintiffs”) “Joint Response to Defendant Albert Hawkins’s Amended Motion to Dismiss” (“Amended Motion to Dismiss”), filed on June 14, 2005; and (3) Defendant’s “Reply on Amended Motion to Dismiss,” filed on July 6, 2005 in the above-captioned cause. The Court also considered the oral arguments of counsel submitted at a status conference held on February 14, 2005. After due consideration, the Court is of the opinion that Defendant’s Amended Motion to Dismiss should be granted in part and denied in part for the reasons set forth below. The Court is also of the opinion that the above-captioned cause should be certified for interlocutory appeal to the Court of Appeals for the Fifth Circuit. I. FACTUAL AND PROCEDURAL BACKGROUND This case concerns alleged violations of the Medicaid Act, 42 U.S.C. § 1396, et seq. Specifically, Plaintiffs — comprised of (1) Medicaid recipients in El Paso County, Texas (“El Paso”); (2) Medicaid providers in El Paso; and (3) an association purporting to represent the interests of Medicaid recipients and providers in El Paso — are alleging that low Medicaid payment rates have impeded the access of El Paso Medicaid recipients to the medical services guaranteed by the Medicaid Act. A. The Medicaid Act “In the Social Security Amendments of 1965, Congress established Title XIX, commonly referred to as the ‘Medicaid Act.’ ” Evergreen Presbyterian Ministries Inc. v. Hood, 235 F.3d 908, 914 (5th Cir.2000) (citing Pub.L. No. 89-97, 79 Stat. 286 (1965)). The Medicaid Act established a medical assistance program (“Medicaid”) cooperatively funded by federal and state governments, which is designed to ensure the provision of medical services to disabled individuals and families with dependent children. Pis.’ First Am. Compl., at 7, ¶ 19. A state’s participation in Medicaid is voluntary, but a participating state must adhere to the requirements of the Medicaid Act in order to receive federal funding. Evergreen, 235 F.3d at 915. One such requirement is that a state must submit a state plan to the Health Care Financing Administration for approval. Id. “A state plan is a ‘comprehensive written statement’ submitted by the state describing the nature and scope of the state’s Medicaid program.” Id. (citing 42 C.F.R. § 430.10). “The Medicaid Act sets out a laundry list of ... items that must be contained within a valid state plan.” Id. at 915 (citing 42 U.S.C. § 1396a(a) (2000)). Plaintiffs’ claims include alleged violations of six of these requirements for a state Medicaid plan contained within the Medicaid Act. Texas has chosen to participate in Medicaid and has designated the Texas Health and Human Services Commission (“HHSC”), over whom Defendant Albert Hawkins is the commissioner, to administer the state’s Medicaid plan. Id. B. The Administration of Medicaid in Texas HHSC pays Medicaid providers through two programs: (1) a traditional “fee-forserviee” program; and (2) payments to managed care providers based on capitation rates. Pis.’ First Am. Compl., at 3, ¶¶ 3-4. Under the fee-for-service program, health care professionals are reimbursed based on fee schedules established by HHSC, schedules that break down medical procedures into discreet codes, which in turn are each assigned a monetary value. Id. at 3, ¶ 3. In addition to the fee-fpr-serviee program, HHSC administers payments to certain managed care. providers, such as health maintenance organizations (“HMOs”), through capitation rates, which are fixed amounts paid to participating providers on a per-member, per-month basis. Border Rate Report, at 3-4. C. The Parties Plaintiffs, who are suing Defendant in his official capacity as Commissioner of HHSC, are comprised of three distinct classes. The first class consists of a collection of Medicaid recipients residing in El Paso, Texas (collectively “Recipient Plaintiffs”). Recipient Plaintiffs are suing as individuals on their own behalf and on behalf of their respective children. The second class consists of a doctor providing services to Medicaid recipients, an HMO, and a county hospital district (collectively “Provider Plaintiffs”). Provider Plaintiff Jose Luna, Jr., M.D. is suing on his own behalf and on behalf of his Medicaid recipient patients. Provider Plaintiff El Paso First Health Plans, Inc. (“El Paso First”) is an HMO that is suing on its own behalf and on behalf of its Medicaid recipient enrollees. Provider Plaintiff El Paso Hospital District d/b/a R.E. Thomason General Hospital (“Thomason”) owns and operates R.E. Thomason Hospital, an urban hospital, El Paso First Plans, Inc., and Thomason Cares Inc., a health organization that provides physician services. Thomason also employs health care professionals. Thomason is suing on its own behalf and on behalf of its Medicaid recipient patients. The third class consists solely of Equal Access for El Paso, Inc. (“Equal Access”), a non-profit corporation “composed of individuals interested in the provision of health care in El Paso.” Pis.’ First Am. Compl., at 5, ¶ 10. Equal Access is suing on behalf of its members, many of whom it alleges are “Medicaid recipients and other health care professionals and other providers who are directly and adversely impacted by HHSC’s actions.” Id. D. Plaintiffs’ Claims Plaintiffs filed suit against Defendant in federal court on October 23, 2003 and subsequently amended their complaint on June 24, 2004. Generally, Plaintiffs allege that HHSC’s setting of deficient Medicaid reimbursement and capitation rates has prevented Medicaid recipients in El Paso from obtaining adequate access to medical services, in violation of certain provisions of the Medicaid Act, the Supremacy Clause, and the Equal Protection Clause. The alleged lack of access to adequate medical services is a result of the fact that inadequate Medicaid payment rates, when combined with El Paso’s unique payor mix, have created an incentive (1) for physicians to practice in communities other than El Paso and (2) for physicians practicing in El Paso County to seek out patients covered by employer-sponsored insurance. Pis.’ First Am. Compl., at 14, ¶ 42. Specifically, Plaintiffs’ amended complaint sets forth eight claims, alleging six violations of the federal Medicaid Act under 42 U.S.C. § 1983 (“ § 1983”), violations of the Supremacy Clause, and a Fourteenth Amendment Equal Protection violation. Plaintiffs’ first count alleges that HHSC’s Medicaid payment rates for the El Paso area: (1) are deficiently priced to enlist enough providers so that care and services are available to the Medicaid recipients residing in the El Paso area to the extent care and services are available to the general (non-Medicaid) population in the El Paso area; and (2) are “not consistent with efficiency, economy, and quality of care,” in violation of 42 U.S.C. § 1396a(a)(30)(A) and 42 C.F.R. § 447.204. Pls.’ First Am. Compl., at 21, ¶ 44. Plaintiffs’ second count alleges that medical assistance available to El Paso Medicaid recipients is less in “amount, duration, and scope” than assistance made available to Medicaid recipients and “other individuals in other geographic areas,” resulting in the denial of equal treatment and comparable care, contrary to 42 U.S.C. § 1396a(a)(10)(B) and 42 C.F.R. §§ 440.230 and 440.240. Id. at 22, ¶48. Plaintiffs’ third count alleges that HHSC’s Medicaid plan’s distribution of federal and state funds, in conjunction with the “lack of adequate funds from local sources in the El Paso region,” has resulted in the “lowering of the amount, duration, scope and quality of care and service” made available to Plaintiffs, in violation of 42 U.S.C. § 1396a(a)(2). Id. at 22-23, ¶ 51. Plaintiffs’ fourth count alleges that HHSC failed to operate and administer the state Medicaid plan under equitable standards that are mandatory throughout the state, in violation of 42 U.S.C. § 1396a(a)(1) and 42 C.F.R. § 431.50(b)(1). Id. at 23, 1154. In connection therewith, Plaintiffs also argue that it is inequitable for Texas to benefit from the poverty level in El Paso through increased federal funding while HHSC fails to ensure that El Paso receives proper and timely services through appropriate funding. Id. at 22-23, ¶ 54. Plaintiffs’ fifth count alleges that medical assistance made available to Plaintiffs and other El Paso Medicaid recipients is not furnished with reasonable promptness to all eligible individuals, in violation of 42 U.S.C. § 1396a(a)(8) and 42 C.F.R. § 435.930. Id. at 24, ¶ 57. Plaintiffs’ sixth count alleges that HHSC has failed to establish capitation rates on an actuarially sound basis and concludes that HHSC’s contracts with managed care organizations therefore violate 42 U.S.C. § 1396b(m)(2)(A)(iii). Pis.’ First Am. Compl., at 25, ¶ 60. Plaintiffs’ seventh count alleges that House Bill 1 (“HB1”) of the 78th Texas Legislature and HHSC’s practices in administering Medicaid in El Paso County violate the Supremacy Clause of the U.S. Constitution due to inconsistencies with 42 U.S.C. §§ 1396a(a)(30)(A), (a)(10)(B), (a)(2), (a)(1), (a)(8), and 1396b(m)(2)(A)(iii). Id. at 25, ¶23. Finally, Plaintiffs’ eighth count alleges that HHSC does not treat El Paso Medicaid enrollees equally when compared with other individuals in Texas, in that Medicaid recipients in El Paso receive much less funding per person than the average Medicaid recipient in Texas, in violation of the Equal Protection Clause of the Fourteenth Amendment. Id. at 26, ¶ 66. As a result of the aforementioned alleged violations, Plaintiffs seek injunctive and declaratory relief pursuant to § 1983, Title 28 of United States Code § 2201, and Federal Rule of Civil Procedure 57. On May 18, 2005, Defendant filed an Amended Motion to Dismiss contending that all Plaintiffs lack standing to maintain any of the above-listed causes of action, mandating a dismissal pursuant to Federal Rule of Civil Procedure 12(b)(1) (“Rule 12(b)(1)”) for lack of subject-matter jurisdiction. Alternatively, Defendant argues that Plaintiffs fail to state a claim under any of the above-listed causes of action, requiring dismissal pursuant to Federal Rule of Civil Procedure 12(b)(6) (“Rule 12(b)(6)”). Defendant also asks the Court to find that the minor plaintiffs’ (“Plaintiff-children”) claims are barred because of an ongoing class action. Finally, Defendant asks the Court, in the event of a denial of its motion to dismiss, to certify this case for interlocutory appeal to the Court of Appeals for the Fifth Circuit. The Court will address each of Defendant’s arguments in turn. II. DEFENDANT’S RULE 12(b)(1) MOTION A. Article III Standing and Prudential Considerations The federal judicial power extends only to actual “cases” and “controversies.” U.S. Const, art. Ill, § 2, cl. 1. Thus, it is well-settled that the Court may act only “in the context of a justiciable case or controversy.” Securities Exch. Comm’n v. Med. Comm. for Human Rights, 404 U.S. 403, 407, 92 S.Ct. 577, 30 L.Ed.2d 560 (1972) (internal quotations and citation omitted). “The several doctrines that have grown up to elaborate that requirement are ‘founded in concern about the proper — and properly limited — role of the courts in a democratic society.’ ” Allen v. Wright, 468 U.S. 737, 750, 104 S.Ct. 3315, 82 L.Ed.2d 556 (1984) (quoting Warth v. Seldin, 422 U.S. 490, 498, 95 S.Ct. 2197, 45 L.Ed.2d 343 (1975)). “[T]he core component of standing is an essential and unchanging part of the case-or-controversy requirement of Article III.” Lujan v. Defenders of Wildlife, 504 U.S. 555, 560, 112 S.Ct. 2130, 119 L.Ed.2d 351 (1992). The term standing refers to “whether [a] particular plaintiff is entitled to an adjudication of the particular claims asserted.” Allen, 468 U.S. at 752, 104 S.Ct. 3315. “[I]t is the burden of the party who seeks the exercise of jurisdiction in his favor ... clearly to allege facts demonstrating that he is a proper party to invoke judicial resolution of the dispute.” United States v. Hays, 515 U.S. 737, 743, 115 S.Ct. 2431, 132 L.Ed.2d 635 (1995) (internal quotations and citations omitted). Standing is composed of both constitutional Article III requirements and prudential considerations. Elk Grove Unified Sch. Dist. v. Newdow, 542 U.S. 1, 124 S.Ct. 2301, 2308, 159 L.Ed.2d 98 (2004). 1. Article III Requirements “[T]he irreducible constitutional minimum of standing contains three elements.” Lujan, 504 U.S. at 560, 112 S.Ct. 2130. First, a plaintiff must show he has suffered an injury-in-fact. Id. That is, a plaintiff must allege, and ultimately prove, that he has suffered a harm that is eoncrete and particularized and actual and imminent, not merely conjectural or hypothetical. Steel Co. v. Citizens for a Better Env’t, 523 U.S. 83, 103, 118 S.Ct. 1003, 140 L.Ed.2d 210 (1998); Lujan, 504 U.S. at 560, 112 S.Ct. 2130. Second, the plaintiff must demonstrate a causal connection between the injury and the defendant’s alleged conduct. Lujan, 504 U.S. at 560, 112 S.Ct. 2130. This means that the injury must be one that is fairly traceable to “the challenged action of the defendant, and not injury that results from the independent action of some third party not before the court.” Simon v. E. Ky. Welfare Rights Org., 426 U.S. 26, 41-42, 96 S.Ct. 1917, 48 L.Ed.2d 450 (1976). The “fairly traceable” standard does not require that a defendant’s conduct be the sole cause of the plaintiffs injury. See Etuk v. Slattery, 936 F.2d 1433, 1441 (2nd Cir.1991) (finding the causation prong satisfied and noting that, “[wjhile perhaps not the sole cause, the alleged improper conduct of the [Defendant] plainly constituted a primary factor in the harm that plaintiffs contend they have suffered and will continue to suffer”). Third, “it must be likely, as opposed to merely speculative, that the injury will be redressed by a favorable decision.” Lujan, 504 U.S. at 561, 112 S.Ct. 2130 (internal quotations and citations omitted). “To survive a motion to dismiss, a plaintiff ‘must allege facts from which it reasonably could be inferred that, absent the [defendant’s conduct], there is a substantial probability that ... if the court affords the relief requested, the asserted [injury] will be removed.’ ” Nat’l Wrestling Coaches Ass’n v. Dep’t of Educ., 366 F.3d 930, 944 (D.C.Cir.2004) (quoting Warth, 422 U.S. at 504, 95 S.Ct. 2197 (1975)). Plainly, the relief sought must redress the injury suffered by the plaintiff. Steel Co., 523 U.S. at 107, 118 S.Ct. 1003 (“Relief that does not remedy the injury suffered cannot bootstrap a plaintiff into federal court; that is the very essence of the redressability requirement.”). Reference to mere possibilities that a favorable decision from the court would provide redress for a plaintiffs injuries is insufficient to satisfy the redressability prong. Nat’l Wrestling Coaches Ass’n, 366 F.3d at 942 (noting that an associational plaintiffs reliance on the possibility that a favorable decision would confer “better odds” that its members’ injuries would be redressed fell far short of the standard set by other cases where the redressability prong was satisfied). 2. Prudential Standing Requirements “Beyond the constitutional requirements, the federal judiciary has also adhered to a set of prudential principles that bear on the question of standing.” McClure v. Ashcroft, 335 F.3d 404, 411 (5th Cir.2003) (citation omitted). Prudential considerations encompass both third-party standing and standing for associations to sue on behalf of their members. a. Third-Party Standing Ordinarily, a plaintiff must assert his own legal rights and cannot rest his claims on the rights of third-parties. Powers v. Ohio, 499 U.S. 400, 410, 111 S.Ct. 1364, 113 L.Ed.2d 411 (1991). However, some litigants may bring an action on behalf of third-parties if three criteria are satisfied. Id. First, “[t]he litigant must have suffered an ‘injury in fact,’ thus giving him or her a ‘sufficiently concrete interest’ in the outcome of the issue in dispute[.]” Id. (citation omitted). Second, the litigant must have a close relation to the third-party. Id. Third, “there must exist some hindrance to the third party’s ability to protect his or her own interests.” Id. b. Associational Standing Similarly, an association or organization has standing to bring suit on behalf of its members if three criteria are met. Hunt v. Wash. State Apple Adver. Comm’n, 432 U.S. 333, 343, 97 S.Ct. 2434, 53 L.Ed.2d 383 (1977). First, members of the organization must otherwise have standing to sue in their own right. Id. Second, the interests the organization seeks to protect must be germane to the organization’s purpose. Id. Third, “neither the claim asserted nor the relief requested requires the participation of individual members in the lawsuit.” Id. The first two requirements are Article III case or controversy requirements, while the third requirement is a prudential limitation that may be abrogated by congressional action. United Food & Commercial Workers Union Local 751 v. Brown Group, Inc., 517 U.S. 544, 555-56, 558, 116 S.Ct. 1529, 134 L.Ed.2d 758 (1996). As an overall principal, at the pleading stage, a plaintiffs complaint must “sufficiently [allege] a redressable injury-in-fact which is causally connected to the alleged conduct of [a defendant].... ‘[G]eneral factual allegations of injury resulting from the defendant’s conduct may suffice, for on a motion to dismiss we presume that general allegations embrace those specific facts that are necessary to support the claim.’ ” Meadowbriar Home for Children v. Gunn, 81 F.3d 521, 529 (5th Cir.1996) (quoting Lujan, 504 U.S. at 561, 112 S.Ct. 2130). The Court will now proceed to determine each class of plaintiffs standing to sue in light of the applicable law, as well as the standing of all the plaintiffs to assert their Supremacy Clause claim. B. Recipient Plaintiffs’ Standing to Sue 1. Injury-in-fact Defendant contends that Recipient Plaintiffs lack standing to bring any of the causes of action brought asserted to the Medicaid Act. Both parties concede that Recipient Plaintiffs have alleged an injury-in-fact in that Recipient Plaintiffs represent that they have experienced difficulties in accessing medical assistance in the El Paso area. This lack of access is manifested in difficulty encountered in obtaining appointments from a medical provider that accepts Medicaid, excessively long waiting periods while in providers’ offices, and a complete lack of certain medical services for Medicaid recipients in the El Paso area resulting in Recipient Plaintiffs’ need to travel to other parts of the state to receive the services. Additionally, Plaintiffs allege an overall shortage of medical service professionals (whether or not they accept Medicaid patients) in the El Paso area, a problem which Plaintiffs indicate arguably implies that El Paso physicians have migrated to other areas of Texas. See Pis.’ First Am. Compl., at 10, ¶ 25 (claiming that one Recipient Plaintiffs “problems stems from lack of physicians and therapists in the El Paso area”); id. at 10, ¶ 26 (alleging that one Recipient Plaintiffs “problems stem form the lack of physicians and dentists in the El Paso area”). At issue is whether, at this stage of the litigation, Recipient Plaintiffs have adequately pled the causation and redressability requirements necessary for standing to sue for their alleged injuries comprising difficulties in accessing medical services paid for by Medicaid funds. 2. Causation Recipient Plaintiffs allege that their difficulties in obtaining adequate access to medical care is the result of “extremely low payment schedules under Medicaid.” Pis.’ First Am. Compl., at 10, ¶ 25. Hence, Recipient Plaintiffs attempt to attribute their injuries to HHSC, which sets the Medicaid reimbursement and capitation rates for the state of Texas. A concept integral to Plaintiffs’ causation theories is described by the term “payor mix.” “Payor mix” refers to the percentage of residents in a particular geographic area that have employer-provided insurance, are covered by Medicaid, or are uninsured, respectively. Pis.’ First Am. Compl., at 20, ¶ 40. According to Plaintiffs, other counties in Texas, though similar in size to El Paso, have payor mixes more favorable to medical providers. Id. That is, these counties have a higher percentage of residents with private insurance coverage, coverage which reimburses providers at higher rates than Medicaid. Plaintiffs allege that low payment rates have resulted in inadequate access to medical services for El Paso Medicaid recipients through two distinct intermediate mechanisms: (1) creating an incentive for health care professionals in El Paso to curtail their participation in Medicaid or drop out completely; and (2) creating an incentive for health care professionals in El Paso to relocate to other parts of the state. Although Plaintiffs assert these causal mechanisms jointly, the Court will examine each mechanism separately for the sake of clarity. However, if the Court determines that Plaintiffs’ injuries are fairly traceable to HHSC’s conduct through the first mechanism, the Court need only analyze the second mechanism to determine whether it renders Plaintiffs’ overall causation theory too speculative. The Court will begin by analyzing the first causation mechanism, the curtailment and termination of the participation of El Paso medical professionals in Medicaid. Defendant argues that Plaintiffs’ claims are indistinguishable from the claims of the plaintiffs in Allen v. Wright, 468 U.S. 1250, 105 S.Ct. 51, 82 L.Ed.2d 942 (1984), and in Simon v. E. Ky. Welfare Rights, 426 U.S. 26, 96 S.Ct. 1917, 48 L.Ed.2d 450 (1976). In Allen, parents of black public school children brought a nation-wide class action against the Internal Revenue Service (“IRS”), alleging that the IRS had “not adopted sufficient standards and procedures to fulfill its obligation to deny tax-exempt status to racially discriminatory private schools.” 468 U.S. at 739, 104 S.Ct. 3315. As a result of the IRS’s aetions, the parents alleged harm in the form of interference with their children’s abilities to receive an education in desegregated public schools. Id. at 739-40, 104 S.Ct. 3315. However, the Court held that the chain of causation between the IRS’s alleged conduct and desegregation at the plaintiffs’ schools was “attenuated at best.” Id. at 757, 104 S.Ct. 3315. The Court held that it was speculative (1) “whether withdrawal of a tax exemption from any particular school would lead the school to change its policies;” and (2) “whether, in a particular community, a large enough number of the numerous relevant school officials and parents would reach decisions that collectively would have a significant impact on the racial composition of public schools.” Id. at 758,104 S.Ct. 3315. In Simon, indigents and organizations composed of indigents brought suit against the Secretary of the Treasury and the Commissioner of the IRS, alleging that the IRS violated the Internal Revenue Code and the Administrative Procedure Act “by issuing a Revenue Ruling allowing favorable tax treatment to a nonprofit hospital that offered only emergency-room services to indigents.” 426 U.S. at 29, 96 S.Ct. 1917. The Simon plaintiffs alleged that the IRS’s Revenue Ruling “had ‘encouraged’ hospitals to deny services to indigents.” Id. at 42, 96 S.Ct. 1917. However, the Court held that it was speculative “whether the denials of service specified in the complaint fairly can be traced to [the IRS’s] ‘encouragement’ or instead result from decisions made by the hospitals without regard to the tax implications.” Id. at 42-43, 96 S.Ct. 1917. As the Allen Court explained in its discussion of Simon, “the causal connection [in Simon ] depended on the decisions hospitals would make in response to withdrawal of tax-exempt status, and those decisions were sufficiently uncertain to break the chain of causation between the plaintiffs’ injury and the challenged Government action.” Allen, 468 U.S. at 759, 104 S.Ct. 3315. In the instant case, like in Allen and Simon, Plaintiffs’ causation theory (focusing on their first causal mechanism) requires the Court to engage in speculation to some extent. In order to conclude that HHSC’s setting of low payment rates results in a denial of access, the Court must assume that higher rates would have discouraged medical providers from curtailing or terminating their involvement in Medicaid. To make this assumption, like in Allen and Simon, the Court must speculate as to the actions of an independent third party. Like the schools in Allen and the hospitals in Simon, the Court must assume that medical providers, if given higher payment rates, would have chosen to maintain their current levels of involvement in Medicaid. This assumption is made more difficult in light of the fact that the Medicaid Act does not quantify the level at which a state must set payment rates in order to comply with its requirements. In fact, as long as HHSC pays Medicaid providers one dollar less than private insurance pays, medical professionals would arguably have an incentive to prefer private insurance. Therefore, it is difficult to know whether the increased rates would have provided a sufficient incentive for medical providers to continue participation in Medicaid. Additionally, the Court must assume that a large enough percentage of providers would have decided to continue their participation in Medicaid to bring about a significant impact on the level of access to medical services for El Paso Medicaid recipients. See Allen, 468 U.S. at 758, 104 S.Ct. 3315 (requiring the plaintiffs to show that if the IRS had adequately enforced anti-discrimination policies it would have had a “significant impact on the racial composition of .public schools”) (emphasis added). Finally, like in Simon, the Court must speculate whether the decisions of Medical providers to decrease involvement in Medicaid was a result of low payments or of independent factors. Although the circumstances in Allen and Simon'were arguably similar to the instant case, the Court finds that they are distinguishable, in part because of the characteristics of the Medicaid Act. Specifically, a portion of 42 U.S.C. § 1396a(a)(30)(A), which portion the Court will refer to as the “Equal Access Provision,” actually requires the result that medical services must be available to Medicaid recipients in a geographic area “at least to the extent that such care and services ... are available to the general population in a geographic area.” See Clark v. Richman, 339 F.Supp.2d 631, 633 (stating that “the equal access provision is results-oriented”). Therefore, although a statute cannot relax the requirements of Article III standing, the terms of the statute informs the Court’s counterfactual speculation. Literal compliance with the Equal Access Provision by its very terms requires a certain amount of access to medical services that Plaintiffs claim does not currently exist. Therefore, it is less tenuous for the Court to speculate that compliance with the statute would have resulted in better access to healthcare, when compared with the degree of speculation required of the Allen and Simon Courts. Furthermore, other courts have recognized the connection between access to medical services and low reimbursement rates, a connection made by the Equal Access Provision itself. See Okla. Chapter of the Am. Acad, of Pediatrics v. Fogarty, 366 F.Supp.2d 1050, 1106-07 (N.D.Okla. 2005) (“While there is no established percentage for sufficient Medicaid reimbursement rates under federal law, rates which consistently fall well below what is allowed under Medicare, let alone under private insurance, have been shown to be inadequate to attract enough providers....”); Memisovski v. Maram, No. 92 C 1982, 2004 WL 1878332, at *42 (N.D.Ill. Aug.23, 2004) (stating that “[r]ates and equal access [to medical services] simply cannot be divorced”) (unpublished opinion); Clayworth v. Bonta, 295 F.Supp.2d 1110, 1116 (E.D.Cal.2003) (finding that Medicaid recipient plaintiffs presented sufficient evidence that some Medicaid providers would cease participating in Medicaid or refuse to take new patients if rates were reduced), rev’d on other grounds, 140 Fed. Appx. 677 (9th Cir.2005); Thomas v. Johnston, 557 F.Supp. 879, 903-04 (W.D.Tex. 1983) (reasoning that “[t]he link between the adequacy of reimbursement rates paid to providers and the adequacy of care provided to Medicaid recipients is quite obvious”). Invariably, the link between a lack of access and low reimbursement rates (to the extent a court explains the connection) is through the mechanism of low reimbursement rates creating an incentive for medical professionals to curtail or terminate their participation in Medicaid. See, e.g., Fogarty, 366 F.Supp.2d at 1063 (finding that Oklahoma pediatricians choose not to participate in Medicaid due to low reimbursement rates); Clayworth, 295 F.Supp.2d at 1116 (deciding that the plaintiffs had presented sufficient evidence that some California Medicaid providers would cease participating in the state’s program or curtail their participation if the reimbursement rates were reduced by 5%). Although several courts have found a sufficient connection between reimbursement rates and a lack of medical services, one unique feature of Plaintiffs’ claims is that they attribute their injuries in part to El Paso’s unique payor mix. In addition to enabling (as a necessary factor) the second mechanism, Plaintiffs allege that El Paso’s payor mix contributes to the first mechanism’s unique effect on the El Paso area because medical professionals who remain in El Paso have an increased financial incentive to terminate involvement in Medicaid, when compared with professionals in regions with more favorable payor mixes. Pis.’ First Am. Compl., at 3, ¶ 3. This incentive is a result of the fact that an El Paso provider who accepts Medicaid patients is forced to accept the lower paying patients as a larger portion of the provider’s business. Pis.’ First. Am. Compl., at 3, ¶3. However, Plaintiffs do not allege that the payor mix is a result of HHSC’s actions. The fact that Plaintiffs’ own complaint admits that the independent factor of El Paso’s unique payor mix contributes to their lack of access militates against a finding that Recipient Plaintiffs’ injuries are fairly traceable to low rates. However, at least one court has found that an allegation about the effects of the payor mix is not fatal to a plaintiffs allegation that low reimbursement rates caused a denial of access to medical care. See Fogarty, 366 F.Supp.2d at 1064-65 (finding that the “high percentage” of Medicaid recipients in rural Oklahoma counties contributed to the effects of low reimbursement rates on access to medical services in those counties). In addition, the “fairly traceable” standard does not require that a defendant’s conduct be the sole cause of the plaintiffs injury. See Etuk, 936 F.2d at 1441 (finding it sufficient that the defendant’s conduct was a “primary factor” in the plaintiffs injuries). Therefore, although it is a close question, the Court finds that Plaintiffs’ allegation about the effects of the payor mix does not alter its conclusion that Recipient Plaintiffs’ injuries are fairly traceable to HHSC’s conduct through the first mechanism. For similar reasons, the Court finds that Plaintiffs second alleged mechanism, also dependent on El Paso’s payor mix, does not render Plaintiffs’ causation theory too speculative. Thus the Court finds that Plaintiffs’ alleged lack of access to medical services is fairly traceable to HHSC’s conduct. 3. Redressability To redress the alleged violations of the Medicaid Act, Plaintiffs seek an injunction enjoining HHSC from failing to comply with the Medicaid Act, and specifically from failing to set payment rates in El Paso sufficiently “to enlist enough providers so that care and services are available to Plaintiffs at least to the extent that such care and services are available to the general population.” Pls.’ First Am. Compl., at 27. In order to evaluate Plaintiffs’ allegations of redressability, it is necessary to understand the relief mechanisms through which Plaintiffs claim their injury will be redressed by a favorable decision. Similarly to their causation theory, Plaintiffs’ redressability theory again relies on two mechanisms: (1) if HHSC raises Medicaid payment rates, medical professionals already in El Paso will decide to begin or increase their involvement in Medicaid; or (2) if HHSC raises payment rates, medical professionals will decide to return to El Paso. Again, the Court will begin by analyzing the merits of Plaintiffs’ redressability argument by focusing on the first redressability mechanism in isolation. In order to conclude that Plaintiffs’ requested relief would result in better access to medical services, Plaintiffs ask the Court to engage in speculation similar to that required of the Court in its causation analysis. Specifically, the Court must conclude that raising Medicaid payment rates would result in (1) medical professionals deciding to begin or increase their involvement in Medicaid and (2) enough professionals making this decision to significantly impact Recipient Plaintiffs’ access to medical services. However, once again the Court’s speculation is aided by the requirements of the Equal Access Provision. Plaintiffs’ requested relief, by definition, will result in increased access to medical services. Although the Equal Access Provision cannot lower the constitutional requirements of redressability, it is by its nature results-oriented. See Clark v. Richman, 339 F.Supp.2d 631, 633 (stating that “the equal access provision is results-oriented”). Additionally, as discussed above, other courts have found similar claims to meet the requirements of redressability. See supra p. 18 (listing cases that have found claims alleging inadequate reimbursement rates sufficient to meet the requirements of Article III standing). Therefore, the Court finds that it is not too speculative to conclude that a favorable decision would redress Recipient Plaintiffs’ injuries through the first redressability mechanism. Additionally, the Court finds that Plaintiffs’ second redressability mechanism does not render Plaintiffs’ overall redressability theory too speculative. Therefore, the Court finds that it is likely that Recipient Plaintiffs’ injuries will be redressed by the requested relief. Thus, Recipient Plaintiffs meet all three requirements of Article III standing to allege that low Medicaid payment rates have resulted in their lack of access to medical services. C. Provider Plaintiffs’ Standing to Sue Provider Plaintiffs assert claims both on their own behalf and on behalf of the Medicaid recipients they serve. The Court concludes that Provider Plaintiffs’ have standing to sue on their own behalf, but not on behalf of their patients. 1. Provider Plaintiffs’ Standing on Their Own Behalf Plaintiffs allege that Provider Plaintiffs have suffered the following injurles as a result of low Medicaid payment rates: (1) Provider Plaintiffs provide medical services for inadequate payment rates; (2) Provider Plaintiffs are “incapable of serving the existing Medicaid population in El Paso”; (8) Provider Plaintiffs’ “Medicaid Recipient patients are deprived of their right to receive safe, timely, and adequate medical care”; (4) Plaintiff Thomason “is unable to provide [adequate] services to its Medicaid recipient patients”; and (5) Plaintiff El Paso First is unable “to develop the kind of provider base necessary to ensure that Medicaid recipients have access to Medicaid services equivalent to that of non-Medicaid recipients.” Pis.’ First Am. Compl., at 13-15. Defendant argues that the first three injuries asserted by Provider Plaintiffs, as well as Plaintiff Thomason’s alleged injury, involve the denial of access to medical services to Provider Plaintiffs’ patients rather than to Provider Plaintiffs themselves. Similarly, Defendant argues that the injury asserted by El Paso First is an injury to its members. As a result, Defendant asserts that Provider Plaintiffs cannot meet the requirements of standing because they are asserting the injuries of their patients or members. See Cent. & Sw. Srvs., Inc. v. U.S. Envtl. Prot. Agency., 220 F.3d 683, 699 (5th Cir.2000) (stating that “a party may not base its Article III standing on alleged injuries to others”). However, in addition to the allegations more directly implicating their patients’ interests, Provider Plaintiffs also allege that HHSC’s payment rates, which are paid to Provider Plaintiffs, are inadequate. Pis.’ First Am. Compl., at 13, ¶ 30. This is an injury to Provider Plaintiffs themselves. See Clayworth, 295 F.Supp.2d at 1116 (stating that Medicaid providers would “suffer concrete injury” as a result of a reimbursement rate cut if allowed to go into effect); see also Evergreen, 235 F.3d at 928 (addressing whether Medicaid providers have a private right of action to challenge a reimbursement rate cut as a violation of § 30(A) without addressing the providers’ standing). Therefore, the Court holds that Provider Plaintiffs’ injuries are sufficiently particularized. Additionally, Plaintiffs do not contest that Provider Plaintiffs meet the requirements of causation and redressability. Furthermore, the Court finds that the allegedly inadequate payment rates received by Provider Plaintiffs are fairly traceable to HHSC’s actions and that it is not too speculative to conclude that a favorable decision would result in higher rates. Low rates themselves are the injury to Provider Plaintiffs. Therefore, the Court is not required to engage in the same speculation required in its causation and redressability analysis of Recipient Plaintiffs’ injuries. Thus, Provider Plaintiffs have properly asserted standing with respect to their claims that they perform medical services for inadequate rates. 2. Provider Plaintiffs’ Third-Party Standing As discussed above, Provider Plaintiffs have alleged an injury-in-fact to themselves, namely, inadequate payment rates. Additionally, Defendant does not contest the fact that Provider Plaintiffs have a close relationship with their patients. Therefore, the only remaining issue for the Court to decide is whether there exists some hindrance to Provider Plaintiffs’ patients’ abilities to protect their own interests. Powers, 499 U.S. at 410, 111 S.Ct. 1364. This inquiry requires the Court to examine “the likelihood and ability of the third.parties ... to assert their own rights.” Id. at 414, 111 S.Ct. 1364. Provider Plaintiffs allege that “the vast majority of their Medicaid recipient patients do not have access to the level of information necessary to assert their rights, and even if they did have such information, they lack the resources to assert their rights.” Pls.’ First Am. Compl., at 14, ¶ 30. This assertion is a mere legal conclusion that is insufficient to support third-party standing. See Fernandez-Montes v. Allied Pilots Ass’n, 987 F.2d 278, 284 (5th Cir.1993) (stating that “eonclusory allegations or legal conclusions masquerading as factual conclusions will not suffice to prevent a motion to dismiss”). Provider Plaintiffs do not allege what kind of information Provider Plaintiffs have that their patients lack. In contrast, in Clayworth the Medicaid providers, who were suing to enjoin a state-wide rate cut of 5%, specifically alleged that they were the ones “who [knew] the relationship of reimbursement to service and to their costs.” Clayworth, 295 F.Supp.2d at 1118. As a result, the providers in Clayworth were “in a far better position to evaluate the State’s decisional process and the data relied upon by the State in determining reimbursement rates.” Id. The only cognizable claim any plaintiffs assert is Recipient Plaintiffs’ claim that HHSC’s payment rates violate the Equal Access Provision of the Medicaid Act. See infra Part III (analyzing Plaintiffs’ claims to determine whether they survive Defendant’s Rule 12(b)(6) motion to dismiss). Unlike the providers in Clayworth, Provider Plaintiffs do not allege that they are in a better position to compare the access to medical services of Medicaid recipients in El Paso with the access of the general population in El Paso. See infra Part 111(B)(2) (explaining the nature of a cognizable Equal Access Provision claim). Additionally, the bare assertion that patients lack resources is insufficient, in and of itself, to establish third-party standing. Cf Powers, 499 U.S. at 415, 111 S.Ct. 1364 (noting several specific “practical barriers to suit by the [third-party jurors whose interests the plaintiffs seek to represent]” such as the difficulty “for an individual juror to show a likelihood that discrimination against him at the voir dire stage will recur”). Simply put, Provider Plaintiffs have provided the Court with no significant information about the likelihood and abilities of Provider Plaintiffs’ patients to assert their own rights. In fact, the claims in this case brought by several El Paso Medicaid recipients (and an organization partially comprised of Medicaid recipients) undermine the argument that Medicaid recipients do not have the incentive or ability to bring claims on their own behalf. Therefore, prudential considerations require the Court to hold that Provider Plaintiffs have not established standing to assert any claims on behalf of their patients. D. Equal Access’s Standing to Sue The Court finds that Equal Access has alleged sufficient facts to establish standing pursuant to the three Hunt factors. Under the first Hunt factor, to establish associational standing Equal Access must allege that the members of its organization would otherwise have standing to sue in their own right. Hunt, 432 U.S. at 343, 97 S.Ct. 2434. Plaintiff Equal Access seeks to sue “on behalf of its members, many of whom are Medicaid recipients and health care professionals and other providers who are directly and adversely impacted by HHSC’s actions, and on behalf of the its [sic] member health care professionals’ and providers’ patients.” Pis.’ First Am. Compl., at 10, ¶ 5. The Court has found that Recipient Plaintiffs have standing to challenge their access to medical services resulting from allegedly inadequate Medicaid payment rates. It has also determined that Provider Plaintiffs have standing to challenge the allegedly inadequate payment rates they receive. Equal Access alleges that its members include those who have suffered the same injuries as Recipient Plaintiffs and Provider Plaintiffs. Pis.’ First Am. Compl., at 10, ¶ 5. Therefore, Equal Access satisfies the first Hunt factor. Under the second Hunt factor, the interests Equal Access seeks to protect in bringing its claims must be germane to the organization’s purpose. Hunt, 432 U.S. at 343, 97 S.Ct. 2434. Equal Access alleges that “[t]he purpose of Plaintiff Equal Access is to develop health care resources and access to health care in El Paso County.” Pis.’ First Am. Compl., at 10, ¶ 5. Recipient Plaintiffs sue to remedy the alleged injury of a lack of access to medical services. The interest of access to medical services is Equal Access’s stated goal. Therefore, Equal Access satisfies the second Hunt factor. Under the third Hunt factor, Equal Access must show that neither the claims it asserts nor the relief it requests requires the participation of its individual members. Hunt, 432 U.S. at 343, 97 S.Ct. 2434. In Clayworth, the court granted associational standing in part because “no showing on damages” and no “individual proof by beneficiary members” would be required. Clayworth, 295 F.Supp.2d at 1119. Similarly, in the instant case Medicaid recipients and providers do not seek individualized damages. Rather, they seek injunctive and declaratory relief. Additionally, Plaintiffs’ claims will not necessarily require the proof of individual Medicaid recipients and providers. Therefore, Equal Access satisfies the third Hunt factor. Thus, the Court finds that Plaintiff Equal Access satisfies the three Hunt factors and has standing to sue on behalf of its member Medicaid recipients and providers. E. Plaintiffs’ Standing to Assert Their Supremacy Clause Claim Plaintiffs’ Supremacy Clause claim alleges that both (1) HB1 of the 78th Texas Legislature (the General Appropriations Act) and (2) HHSC’s “regulations, policies, practices and procedures for administering Medicaid services in El Paso County” violate the Supremacy Clause of the U.S. Constitution. Pis.’ First Am. Compl., at 25, ¶ 63. Plaintiffs seek relief for these alleged violations “under 42 U.S.C. § 1983.” Id. at 26, ¶ 64. The Court will analyze each claim in turn to determine if Plaintiffs have adequately established standing. 1. House Bill 1 Plaintiffs allege that HB1 violates the Supremacy Clause in that it conflicts with several provisions of the Medicaid Act. In Planned Parenthood of Houston & Southeast Tex. v. Sanchez, 403 F.3d 324 (5th Cir.2005), the Fifth Circuit recognized a claim that Rider 8 to the Texas General Appropriations Act was preempted by the Medicaid Act. Unlike the Planned Parenthood plaintiffs, the plaintiffs in the instant case do not allege that a specific portion of HB1 conflicts with the Medicaid Act. The U.S. Supreme Court has stated that “state law is nullified to the extent that it actually conflicts with federal law.” Fidelity Federal Sav. & Loan Ass’n v. de la Cuesta, 458 U.S. 141, 152, 102 S.Ct. 3014, 73 L.Ed.2d 664 (1982). Plaintiffs’ Supremacy Clause claim would result in a partial nullification of HB1 to the extent that it sets inadequate payment rates. Id. However, unlike the plaintiffs claiming a conflict with the Medicaid Act in Planned Parenthood, Plaintiffs have not identified a portion of HB1, which, if nullified, would redress their alleged injuries. Furthermore, it is purely speculative whether the legislature would appropriate more money in the future as a result of the nullification of some unspecified portion of HB1. See Henderson v. Stalder, 287 F.3d 374, 381 (5th Cir.2002) (holding that a plaintiff lacked standing to challenge the funding to the “Choose Life” message because even it was declared unconstitutional, the plaintiffs “complained of injury would not be redressed as that remedy will not provide [the plaintiff] a forum in which to express her pro-choice viewpoint”). In fact, Plaintiffs state that they are not “asking for abrogation of HB1.” Pis.’ Joint Resp. to Def. Albert Hawkins’ Am. Mot. to Dismiss (hereinafter “Joint Resp.”), at 9, ¶ 24. Plaintiffs’ actual grievance appears to be directed at the manner in which HHSC implements HB1, rather than at the legislature’s appropriation of resources to Medicaid. See Pis.’ First Am. Compl., at 19, ¶ 39 (stating that “Defendant is ultimately responsible for implementing these Acts of the Legislature by setting the Medicaid budget for the Texas Health and Human Services Commission”); Joint Resp., at 10, ¶24 (responding to Defendant’s contention that Plaintiffs’ challenge to portions of HB1 would result in the nullification of those portions by restating their claims that Texas “must administer a state plan that meets federal requirements”) (emphasis added). Plaintiffs have neither adequately specified which portions of HB1 violate the Medicaid Act, nor have they shown how the nullification of a portion of HB1 is likely to redress any of their alleged injuries. Furthermore, Plaintiffs do not seek the nullification of a portion of HB1. Therefore, Plaintiffs have failed to meet their burden of establishing standing for their claim that HB1 violates the Medicaid Act. 2. HHSC’s Implementation of Medicaid In addition to challenging HB1, Plaintiffs also allege that HHSC’s “regulations, policies, practices and procedures for administering Medicaid services in El Paso” violate the Supremacy Clause. Pis.’ First Am. Compl., at 25, ¶ 73. Specifically, Plaintiffs allege that HHSC’s setting of low payment rates violates the Medicaid Act. As discussed above, the Court has determined that Plaintiffs’ have suffered injuries-in-fact that are fairly traceable to HHSC’s setting of rates, the same injuries and conduct challenged by Plaintiffs’ Supremacy Clause claim. See supra Part 11(B)(2), (C)(1) (explaining why Recipient Plaintiffs and Provider Plaintiffs meet the first two prongs of Article III standing). Additionally, if Plaintiffs are successful, it is not too speculative to determine that a declaration of the invalidity of HHSC’s practices would result in the redress of Plaintiffs’ alleged injuries, a lack of access to medical services in the case of Recipient Plaintiffs, and the receipt of payment for services provided at inadequate rates in the case of Provider Plaintiffs. See supra Part 11(B)(3), (C)(1) (explaining why Recipient Plaintiffs and Provider Plaintiffs meet the requirements of constitutional redressability). Therefore, Plaintiffs have standing to allege that HHSC’s implementation of Medicaid violates the Supremacy Clause in that it is inconsistent with certain provisions of the Medicaid Act. Having determined that Recipient Plaintiffs, Provider Plaintiffs, and Plaintiff Equal Access have standing, the Court will proceed to examine Defendant’s Motion to Dismiss pursuant to Rule 12(b)(6). III. DEFENDANT’S RULE 12(b)(6) MOTION Plaintiffs sued and seek recovery under six separate provisions of the Medicaid Act, the Equal Protection clause of the U.S. Constitution, and the Supremacy Clause of the U.S. Constitution. Defendant alleges (1) that the Medicaid Act provisions do not create a private right of action and (2) that each of Plaintiffs’ eight counts fails to state a cognizable claim. A. Analytical Standard 1. 12(b)(6) Standard Generally Rule 12(b)(6) permits the dismissal of a complaint if it “fail[s] to state a claim upon which relief can be granted.” Fed. R. Civ. P. 12(b)(6). When presented with a Rule 12(b)(6) motion, the Court must accept all well-pleaded facts in the complaint as true and construe all reasonable inferences in the light most favorable to the plaintiff. Baker v. Putnal, 75 F.3d 190, 196 (5th Cir.1996). A plaintiff must plead specific facts in his complaint; conclusory allegations are insufficient to survive a Rule 12(b)(6) motion to dismiss. See Kaiser Aluminum & Chemical Sales, Inc. v. Avondale Shipyards, Inc., 677 F.2d 1045, 1050 (5th Cir.1982) (citing Associated Builders, Inc. v. Ala. Power Co., 505 F.2d 97, 100 (5th Cir.1974)) (stating that “we do not accept as true conclusionary allegations in the complaint”). The Court then must determine whether the facts alleged, if true, would entitle the plaintiff to some form of relief. Harris v. Hegmann, 198 F.3d 153, 156 (5th Cir.1999). Importantly, a Rule 12(b)(6) motion “tests only the formal sufficiency of the statements of the claims for relief. It is not a procedure for resolving contests about the facts or the merits of the case.” Jolly v. Klein, 923 F.Supp. 931, 942 (S.D.Tex.1996). Thus, “[n]ormally, in deciding a motion to dismiss for failure to state a claim, courts must limit their inquiry to the facts stated in the complaint and the documents either attached to or incorporated in the complaint.” Lovelace v. Software Spectrum Inc., 78 F.3d 1015, 1017 (5th Cir.1996). Rule 12(b)(6) motions are “viewed with disfavor and [are] rarely granted.” Kaiser, 677 F.2d at 1050. The Court may dismiss a complaint pursuant to Rule 12(b)(6) only if it is convinced that the plaintiff cannot prove any set of facts in support of his claim that would entitle him to relief. Hishon v. King & Spalding, 467 U.S. 69, 73, 104 S.Ct. 2229, 81 L.Ed.2d 59 (1984). Specifically, the Court may dismiss a complaint pursuant to Rule 12(b)(6) only if it finds “either (1) ‘the lack of a cognizable legal theory’ or (2) ‘the absence of sufficient facts alleged under a cognizable legal theory.’ ” Meador v. Oryx Energy Co., 87 F.Supp.2d 658, 661 (E.D.Tex. 2000) (citing Balistreri v. Pacifica Police Dep’t, 901 F.2d 696, 699 (9th Cir.1988)). At some level, the facts alleged must relate to the legal theories pled by a plaintiff or otherwise allege a claim based on a cognizable, though perhaps unstated, legal theory. See In re Colonial Mortgage Bankers Corp., 324 F.3d 12, 15 (1st Cir.2003) (noting that in applying the Rule 12(b)(6) standard, “[the court] assume[s] the truth of all well-pleaded facts and indulgefs] all reasonable inferences that fit the plaintiffs stated theory of liability”); see also Ramming v. United States, 281 F.3d 158, 162 (5th Cir.2001) (“[W]hen considering a Rule 12(b)(6) motion to dismiss for failure to state a claim, the district court must examine the complaint to determine whether the allegations provide relief on any possible theory.”). With respect to Plaintiffs’ claims under the Medicaid Act, Defendant argues that Plaintiffs have failed to state a cognizable legal theory because the provisions of the Medicaid Act pursuant to which Plaintiffs have sued do not create private rights of action. With respect to all of Plaintiffs’ claims, Defendant argues that Plaintiffs’ complaint does not state a cognizable claim because the facts alleged do not support a cognizable legal theory. 2. The Standard for Determining if a Statute Confers a Private Right of Action In order to state a cognizable legal theory, plaintiffs must demonstrate that the law provides them both a right and a remedy. Section 1983 provides a remedy to vindicate certain federal rights by providing for liability against “[e]very person who, under color of any statute, ordinance, regulation, custom, or usage, of any State or Territory or the District of Columbia, subjects, or causes to be subjected, any citizen of the United States or other person within the jurisdiction thereof to the deprivation of any rights, privileges, or immunities secured by the Constitution and laws.” 42 U.S.C. § 1983. Section 1983’s provision for liability extends to rights conferred by federal statutes. Maine v. Thiboutot, 448 U.S. 1, 12-13, 100 S.Ct. 2502, 65 L.Ed.2d 555 (1980). However, § 1983 requires a plaintiff to assert a “violation of a federal right, not merely a violation of federal law. ” Blessing v. Freestone, 520 U.S. 329, 340, 117 S.Ct. 1353, 137 L.Ed.2d 569 (1997). In determining whether a particular federal statutory provision gives rise to a federal right, courts traditionally look at the following three factors: First Congress must have intended that the provision in question benefit the plaintiff. Second, the plaintiff must demonstrate that the right assertedly protected by the statute is not so “vague and amorphous” that its enforcement would strain judicial competence. Third, the statute must unambiguously impose a binding obligation on the States. In other words, the provision giving rise to the asserted right must be couched in mandatory, rather than precatory, terms. Id. at 340-41, 117 S.Ct. 1353 (internal citations and quotations omitted). Recently, the Supreme Court has clarified the traditional Blessing analysis by emphasizing that actions brought under § 1983 require nothing “short of an unambiguously conferred right.” Gonzaga Univ. v. Doe, 536 U.S. 273, 283, 122 S.Ct. 2268, 153 L.Ed.2d 309 (2002). The Gonzaga Court rejected the view of some courts “allowing plaintiffs to enforce a statute under § 1983 so long as the plaintiff falls within the general zone of interest that the statute is intended to protect.” Id. In other words, it is “rights, not the broader or vaguer ‘benefits’ or ‘interests,’ that may be enforced under the authority of that section.” Id. The Gonzaga Court held that the Supreme Court’s “implied right of action cases should guide the determination of whether a statute confers rights enforceable under § 1983.” Id. The initial inquiry “is to determine whether or not a statute ‘confers rights on a particular class of persons.’ ” Id. at 285, 122 S.Ct. 2268 (quoting California v. Sierra Club, 451 U.S. 287, 294, 101 S.Ct. 1775, 68 L.Ed.2d 101 (1981)). Critical to this determination is an inquiry into whether the statute contains “rights-creating language.” Id. at 284, 122 S.Ct. 2268. As an example of such a statute, the Gonzaga Court proffered Title IX of the Education Amendments of 1972, which states: “No person in the United States shall, on the basis of sex, ... be subjected to discrimination under any education program or activity receiving Federal financial assistance.” Id. (quoting 20 U.S.C. § 1681(a)) (emphasis in Gonzaga). The Gonzaga Court emphasized that Title IX is “phrased in terms of the person benefit-ted.” Id. If a plaintiff establishes that a statute creates a federal right, “the State may rebut this presumption by showing that Congress ‘specifically foreclosed a remedy under § 1983.’ ” Id. at 285 n. 4, 122 S.Ct. 2268 (quoting Smith v. Robinson, 468 U.S. 992, 1004-05, 104 S.Ct. 3457, 82 L.Ed.2d 746 (1984)). The state can meet this burden “either expressly, through specific evidence fro