Full opinion text
MEMORANDUM OPINION THOMAS A. WISEMAN, JR., Senior District Judge. In this class-action challenge to Tennessee’s managed care program, TennCare, Plaintiffs allege that the defendants, Tennessee officials charged with implementing TennCare (hereinafter referred to collectively as the “State,” in the singular), failed to provide early and periodic screening, diagnosis and treatment (“EPSDT”) services to Tennessee children (ages 21 and under) covered by TennCare, in violation of the Medicaid Act. Shortly after the lawsuit was filed in early 1998, the parties jointly filed a Consent Decree (Doc. No. 12 ) (“Decree”) under which they have been operating, and sporadically litigating, throughout the nearly fourteen years since its entry. I. PROCEDURAL BACKGROUND The case has a lengthy and tortuous procedural history, much of which has been exhaustively detailed in prior orders and opinions and will not be restated here. A brief summary of relatively recent events may prove helpful, however. In September 2009, this Court (Haynes, J. ) entered a Memorandum Opinion and Order (ECF Nos. 1328, 1329) denying the State’s first motion to vacate the Consent Decree, filed in November 2006 (ECF No. 738). In that motion, the State argued that its consent to the entry of the Decree was expressly premised upon the assumption that the Adoption Assistance Act and the EPSDT statutes and regulations were enforceable under 42 U.S.C. § 1983, but that “recent controlling precedent” from the Sixth Circuit, specifically Westside Mothers v. Olszewski, 454 F.3d 532 (6th Cir.2006) (“Westside Mothers II ”), had established that the referenced statutory provisions were not, as a matter of law, individually enforceable through an action brought pursuant to 42 U.S.C. § 1983. The State immediately appealed the denial of its motion, and on November 30, 2010, 626 F.3d 356 (6th Cir.2010), the Sixth Circuit entered an opinion reversing in part the district court’s denial of the motion, and remanding the matter for reassignment to a different judge and reconsideration of the State’s motion to vacate in light of the court’s holding. The matter was reassigned to the undersigned. After additional briefing by both parties, this Court has, by separately entered Memorandum Opinion and Order, granted in part and denied in part the first motion to vacate. The Court determined that a limited number of paragraphs of the Consent Decree were rendered invalid and unenforceable as a result of Sixth Circuit precedent, but that the Decree as a whole, and the principal provisions in it, remained enforceable. Meanwhile, shortly after remand, the State filed a second motion to vacate, this one styled Motion to Vacate All Injunctive Relief, Terminate the Decree and Dismiss the Case (ECF No. 1465). This more recent motion is premised, not on a legal argument that the Consent Decree was itself unenforceable as a result of changes in the law, but instead on the State’s claim that it was in substantial compliance with the Decree’s requirements and therefore entitled to a declaration that the Decree had expired in accordance with its terms. Specifically, the 116th paragraph of the Decree provides that the Decree shall expire “upon proof that [the State has] reached an Adjusted Periodic Screening Percentage (‘APSP’) of 80% and a Dental Screening Percentage (‘DSP’) of 80% [as those terms are defined in the Decree], and [is] in current, substantial compliance with the [other] requirements” set forth in the Decree. The Plaintiffs filed their response in opposition to the motion to vacate (EOF No. 1472). The parties conducted expedited discovery, and the matter proceeded to an evidentiary hearing on the State’s motion beginning on October 31, 2011. Over the course of the next month, both parties presented witnesses and documentary evidence. In addition, both parties submitted pre-and post-hearing Proposed Findings of Fact and Conclusions of Law. The question presented at the hearing and by the State’s motion is whether the State is in substantial compliance with those portions of the Consent Decree that were not vacated by the ruling on the first motion to vacate. Based upon the Court’s consideration of all the documentary proof as well as the testimony of witnesses and their credibility, and for the reasons set forth herein, the Court finds that the State has established that it has met the criteria set forth in the Decree for expiration thereof by its terms. The motion to vacate the Consent Decree will therefore be granted. II. FINDINGS OF FACT AND CONCLUSIONS OF LAW A. Overview of TennCare and Its EPSDT Program The Consent Decree requires Tennessee’s Medicaid managed-care program, known as TennCare, to implement the early and periodic screening, diagnosis and treatment (“EPSDT”) requirements established by the federal Medicaid Act and implementing federal regulations. As the Court has previously explained: EPSDT covers a broad range of services. As the name suggests, the purpose of EPSDT is to ensure that all Medicaid-eligible children receive regular screening, vision, hearing, dental and treatment services consistent with established pediatric standards. The Federal Code requires that the children receive “such other necessary health care, diagnostic services, treatment, and other measures ... to correct or ameliorate defects and physical and mental illnesses under the State plan.” 42 U.S.C. § 1396d(r)(5). The purpose of EPSDT is to ensure that underserved children receive preventive health care and follow-up treatment. EPSDT is premised on the idea that early detection of problems will lead to treatment of minor problems before they become major healthcare issues. By preemptively screening, diagnosing and treating current problems, EPSDT staves off larger healthcare problems in the future, and ultimately results in a more efficient and effective healthcare system with a proactive, comprehensive, and long-term focus. John B. v. Menke, 176 F.Supp.2d 786, 790 (M.D.Tenn.2001). In 2001, after a three-week hearing, the Court determined that the State was at that time not in compliance with the Consent Decree. The State’s prior non-compliance having been adjudicated by the Court and admitted by State officials in 2001, and because the Court’s 2001 Findings of Fact and Conclusions of Law have never been disturbed on appeal, the State bears the burden of proving, by a preponderance of the evidence, that changed circumstances compel the conclusion that the State is now in substantial compliance with the Decree. In its effort to meet that burden, the State called eight witnesses: Pamela Baggett, Director of TennCare Services, Tennessee Department of Health; John Couzins, Director of External Quality Review, Q-Source; Dr. Deborah Gatlin, Chief Medical Officer, Department of Children’s Services; Darin Gordon, Director, Bureau of TennCare; Dr. Wendy Long, Chief Medical Officer, Bureau of TennCare; Margaret O’Kane, President, National Committee for Quality Assurance (“NCQA”); Lynn Pollard, Nurse Consultant Manager, Department of Children’s Services; and Dr. Michael Lu, Associate Professor, Department of Obstetrics & Gynecology, David Geffen School of Medicine at UCLA. The Court found each of these witnesses to be credible within the scope of their areas of knowledge and expertise, and earnestly concerned about the welfare of children generally. Based to a large extent upon their testimony, as well as the documentary evidence introduced by these witnesses, the Court finds and rules as follows. TennCare currently covers approximately 1.2 million people, of whom approximately 750,000 are children under the age of 21. (ECF No. 1526, at ¶4 (Agreed Factual Stipulations).) Approximately 7,500 children enrolled in TennCare are in the custody of the Department of Children’s Services (“DCS”). (ECF No. 1526, at ¶ 7.) TennCare services are offered pursuant to contracts the Bureau of TennCare has entered with Managed Care Organizations (“MCOs”). In each of the three grand divisions of the State (East, Middle and West), two MCOs provide medical and behavioral healthcare services to TennCare enrollees: UnitedHealtheare and Blue Cross Blue Shield of Tennessee in East and West Tennessee, and UnitedHealthcare and Amerigroup in Middle Tennessee. In addition, BlueCross BlueShield of Tennessee administers TennCare Select, which operates in all three grand divisions to serve certain special populations such as children receiving Supplemental Security Income and children in state custody. (ECF No. 1526, at ¶ 9.) The MCOs in turn contract with the healthcare providers — for example, doctors, hospitals, therapists, residential treatment providers — who provide medical and behavioral healthcare services to TennCare enrollees. (Vol. 2 (Long), at 303.) TennCare pharmacy benefits are “carved out” of the package of benefits administered by the MCOs. (Id. at 304.) The State contracts with a Pharmacy Benefits Manager (“PBM”), SXC Health Solutions, that administers TennCare coverage of prescription drugs. (ECF No. 1526, at ¶ 10.) TennCare dental benefits are also “carved out” of the package of benefits which the MCOs administer. (Vol. 2 (Long), at 306.) The State contracts with a Dental Benefits Manager (“DBM”), Delta Dental, for the provision of dental services to children under age 21. (EOF No. 1526, at ¶ 11; Vol. 2 (Long), at 306.) The current DBM in turn contracts with dentists who provide dental services to Tenn-Care enrollees under age 21. (Vol. 2 (Long), at 306.) Each TennCare enrollee is assigned to an MCO upon enrollment, and each enrollee has a primary care provider (“PCP”) — a pediatrician, family practitioner, or nurse practitioner — who is responsible for coordinating the child’s healthcare. To ensure that health care providers are qualified, each MCO is required to have a process for credentialing the providers with whom it contracts. (Vol. 2 (Long), at 309.) When more specialized care is necessary, the PCP is to refer the child to an appropriate specialist. (Vol. 2 (Long), at 324.) As noted above, TennCare children in DCS custody are all assigned to a single MCO, TennCare Select, which provides both medical and behavioral services. (Vol. 5 (Pollard), at 1032.) While DCS also provides some limited behavioral services through DCS-contracted providers to children in custody, approximately 85 percent of children in DCS custody receive all of them behavioral care through TennCare Select. (Id. at 1033.) The core elements of the State’s EPSDT program, as required by federal law and the Consent Decree, are (1) outreach to make sure that enrollees and parents are aware of the availability and importance of screening services, (2) early and periodic screening to detect physical or mental problems, and (3) appropriate diagnosis and treatment services to address those problems. (Vol. 2 (Long), at 321.) 1. EPSDT Outreach TennCare, the MCOs, the Department of Health (“DOH”), and the Department of Human Services (“DHS”), among others, collaborate to ensure that enrollees and parents are made aware of the importance and the availability of EPSDT services. (Vol. 2 (Long), at 324-25.) Families with children enroll in TennCare at the county offices maintained by DHS. (Vol. 2 (Long), at 325.) During the enrollment process, DHS provides information to families concerning the available benefits and the importance of accessing preventive services. (Vol. 2 (Long), at 325.) Specifically, families are urged to take them children to the doctor for a checkup (ie., a screening). (See DX 114 (TENNderCare Brochure); Vol. 2 (Long), at 326.) Upon enrollment, all TennCare families receive a welcome letter from TennCare that includes a section informing them of the availability of free screening services (both medical and dental), and urging them to make an appointment with their primary care provider for a checkup and to obtain any needed immunizations. (See DX 59 (Welcome to TennCare Letter); Vol. 2 (Long), at 326-27.) The MCOs also send parents and members a member handbook, which contains detailed information on the availability and importance of getting children screened. (Vol. 2 (Long), at 327.) In addition, the MCOs separately call the parents of all newly enrolled children on TennCare in order to inform them of the availability of free checkups, dental care, and immunizations, and to urge them to make an appointment with their primary care provider for the first screening. (See Vol. 2 (Long), at 327-28; DX 77 (United Healthcare call script).) The parents of all children enrolled in TennCare receive quarterly newsletters from them MCO which include a reminder of the importance and the availability of free screening services. (See, e.g., DX 67 (Quarterly Newsletter); Vol. 2 (Long), at 328.) The parents of all children enrolled in TennCare receive an annual postcard around the child’s birthday reminding them that the child is due for a screen. (See, e.g., DX 88 (Annual Postcard Reminder); Vol. 2 (Long), at 329.) If the date for a child’s screen has passed and the child has not come in for a screen, the MCO sends another reminder, emphasizing the importance of getting a checkup and the fact that it is free. (See, e.g., DX 92 (Reminder Mailing); Vol. 2 (Long), at 330.) TennCare separately sends a notice emphasizing the importance of scheduling a checkup and urging the parents to do so if the child has gone a year without a screen. (See DX 100 (TennCare Reminder Mailing); Vol. 2 (Long), at 331.) Finally, the MCOs send yet another reminder if the child has not accessed any TennCare services in a year. (See, e.g., DX 99 (Overdue Notice); Vol. 2 (Long), at 331.) Children enrolled in TennCare who are not up-to-date on their screens are also the subject of a home-visit program conducted by DOH, through its TENNderCare Community Outreach Program. Utilizing a list provided monthly by TennCare, community-outreach workers attempt face-to-face communication with the child’s family regarding the availability and importance of free EPSDT screens, dental screens and benefits, and transportation services. (Vol. 8 (Baggett), at 1743-44.) All of the written materials sent out by TennCare and the MCOs are reviewed by TennCare for readability, and are written at no greater than a 6th-grade reading level. (Vol. 2 (Long), at 332.) All Tenn-Care materials are printed in both English and Spanish. (Vol. 2 (Long), at 333.) All written materials include telephone numbers that enrollees can call if they are having difficulty understanding the material. (Id.) The State has collaborated with appropriate agencies and advocacy organizations to ensure that outreach efforts appropriately target illiterate, blind, deaf, and limited-English enrollees and their parents. (Vol. 2 (Long), at 333; see also Vol. 8 (Baggett), at 1734-36 (discussing activities of the DOH’s community outreach program targeted to these enrollees).) With respect to the children in state custody, DCS ensures that resource families (i.e., foster families, relative placements, etc.) are informed about the health services available for children in state custody, that they know how to access those services, and that they understand the importance of EPSDT. (See DX 199 (Coordinating Health Services for My Children) (DCS resource guide); see also Vol. 5 (Pollard), at 1072-73 (explaining that DCS expects resource families to be advocates for the health-care needs of their children, and that DCS provides training, information, and support regarding accessing health services).) DOH’s outreach efforts consist of three components: (1) a community-outreach program that is operated in each of the DOH’s thirteen regions across the State; (2) the EPSDT Call Center, which makes phone calls to all newly enrolled or newly re-certified TennCare families with children under the age of twenty-one; and (3) the Prenatal Call Center, which attempts phone contact with newly enrolled pregnant women. (Vol. 8 (Baggett), at 1692.) The community-outreach program is a grassroots effort conducted at the community level within the thirteen DOH regions across the State, utilizing personnel devoted exclusively to EPSDT outreach activities. (Vol. 8 (Baggett), at 1724-26.) Each region’s outreach activities are directed to specified target age groups within the under-twenty-one population, to target populations with particular characteristics, broadly to TennCare enrollees, and to the general public. (Id. at 1725-28, 1730-38); see also DX 40 (TENNderCare Program 2010 Annual Community Outreach Report at 1-4.) For example, TENNderCare community outreach efforts targeted to pregnant teenagers involve collaboration with schools, community pregnancy resource centers and other teen-oriented community agencies, and other DOH-administered programs to provide information regarding prenatal care and the availability and importance of EPSDT benefits for the pregnant teen herself, as well as to her baby after birth. (Vol. 8 (Baggett), at 1737-38.) The community outreach activities of the thirteen regions are tracked and are compiled on a statewide cumulative basis in Community Outreach Reports that are generated quarterly and annually. (Vol. 8 (Baggett), at 1728-29; see also DX 40 (TENNderCare Program 2010 Annual Community Outreach Report).) The EPSDT Outreach Call Center, operated out of the DOH Central Office, makes phone calls to all newly enrolled or newly recertified TennCare families with children under the age of twenty-one. (Vol. 8 (Baggett), at 1749 — 50, 1756.) All newly enrolled or newly recertified families with children under age twenty-one on each of the weekly lists provided to the Call Center by TennCare are the subject of up to three attempted contacts, as necessary, with the initial attempt made within one week of receipt of the list and all three contact attempts made within two weeks. (Vol. 8 (Baggett), at 1757-58.) The attempts are made using telephone numbers recently reported by the family during the eligibility process. (Id. at 1756, 1758; DX 38, at 7 (TENNderCare Program 2010 Annual EPSDT Call Center Report).) During these calls, families are provided with information about the TENNderCare program and services available, including free checkups and dental benefits. (Vol. 8 (Baggett), at 1751.) Each enrollee successfully contacted is offered assistance in scheduling an EPSDT screen with the child’s primary care provider or a local health department, and transportation assistance for those appointments. (Id.) The activities of the Call Center are tracked and are compiled in quarterly and annual reports. (Id. at 1752-53; see DX 38 (2010 Annual EPSDT Call Center Report); DX 36 (First Quarter 2011 EPSDT Call Center Report).) The DOH also provides outreach to pregnant women through a centralized Nursing or Prenatal Call Center. (Vol. 2 (Long), at 337-38.) The Call Center attempts to contact each of the women on TennCare’s weekly list of newly enrolled pregnant women. (Id. at 338; Vol. 8 (Baggett), at 1715-16.) When contact is made, information is provided regarding the availability of prenatal care for the woman and EPSDT services for her child upon birth, the availability of TennCare dental benefits if the pregnant woman is under age 21, along with education intended to promote a healthy pregnancy. (Id. at 1716-18.) If the woman has not already scheduled a prenatal care appointment, the Prenatal Call Center offers assistance in making that appointment, and will attempt, if the woman agrees, to make the appointment via a three-way call with the provider’s office or by contacting the office the next day, followed by appointment confirmation to the pregnant woman. (Id. at 1716-17.) The activities of the Prenatal Call Center are tracked by codes entered by the operators in a call-center database and are compiled into both quarterly and annual reports. (Id. at 1718-19; see DX 42 (2010 Annual Nursing Call Center Report).) All pregnant women on each of the weekly lists provided to the Call Center by TennCare are the subject of actual contact or at least three contact attempts, with the initial attempt made within one week of receipt of the list and all three contact attempts made within two weeks. (Vol. 8 (Baggett), at 1721,1723-24.) In the case of pregnant women, the federal Centers for Medicare and Medicaid Services (“CMS”) allow states the option of implementing a prenatal presumptive-eligibility process, which Tennessee has elected to do in order to facilitate early entry into prenatal care. (Vol. 2 (Long), at 336-37.) Under the presumptive-eligibility process, a woman may go to any of 120 county health department clinic sites to confirm her pregnancy with a pregnancy test, or to present verification of pregnancy that was confirmed by another health-care provider, and then may be presumptively enrolled in TennCare that same day. (Id. at 337; see also Vol. 8 (Baggett), at 1695, 1697-99.) The woman completes a one-page application, and can simply self-attest to the information required (with the exception of pregnancy). (Vol. 2 (Long), at 337; Vol. 8 (Baggett), at 1697-98; DX 276 (Medicaid Presumptive Eligibility application).) If it appears that the woman would be eligible based on the information she provides, she is enrolled in TennCare immediately, enabling her to access to the full range of TennCare benefits. (Vol. 2 (Long), at 337; Vol. 8 (Baggett), at 1698-1700.) A copy of the presumptive-eligibility form is provided to the woman as temporary proof of her eligibility for TennCare through the presumptive-eligibility process, with the form itself reflecting the certification that the woman is eligible for TennCare benefits. (Vol. 8 (Baggett), at 1699.) That same day, county health department staff enter information reflecting the pregnant woman’s eligibility into a presumptive-eligibility system, and that information is uploaded the same night to the TennCare eligibility database. (Id.) Accordingly, in addition to viewing a woman’s presumptive-eligibility form itself, a provider can verify the existence of the TennCare eligibility of a presumptively eligible woman by accessing the TennCare Bureau’s online eligibility database, which also indicates the MCO to which the woman has been assigned. (Id. at 1699-1700.) The only difference between an enrollee enrolled through the presumptive-eligibility process and someone enrolled through the standard DHS enrollment process is that presumptive eligibility expires after forty-five days, during which time the pregnant woman must go to the DHS county office and complete the standard enrollment process in order to maintain eligibility after expiration of the forty-five days. (Id. at 1700-01.) County health department staff will assist the presumptively eligible pregnant woman with the DHS application process, completing as much information as possible on the application form and faxing the dated and signed application to the local DHS office in order to preserve the date of application as the effective date of eventual regular TennCare eligibility. (Id. at 1702-03.) The presumptively eligible woman must then go to the DHS office to complete the application process (id. at 1703-04) which, under federal regulation, may take up to forty-five days. 42 C.F.R. § 435.911. Pursuant to public-health nursing protocols issued by DOH, on the same day a pregnant woman submits her application and is determined to be presumptively eligible, county health department staff offer assistance to the woman in scheduling an appointment with a prenatal-care provider. (Vol. 8 (Baggett), at 1696, 1704; Vol. 2 (Long), at 338.) If the woman declines that scheduling assistance, she will be given a list of prenatal-care providers in the area. (Vol. 8 (Baggett), at 1704.) In addition, during this initial contact with the county health department, the presumptively eligible woman is provided with a supply of prenatal vitamins and is counseled regarding the availability of prenatal care, the availability of EPSDT services if the pregnant woman is herself under age twenty-one, the availability and importance of EPSDT services for the infant after birth, and the importance of healthy behaviors during pregnancy. (Id. at 1707-OS.) Representatives of TennCare, DOH, and the TennCare MCO maternity/OB case-management programs comprise the Maternity Workgroup Collaborative, whose activities focus on ensuring awareness on the part of pregnant women and obstetric providers of TennCare benefits and the services provided by the TennCare MCOs’ maternity case management programs. (Id. at 1708-09.) For example, the Maternity Workgroup Collaborative launched a campaign geared to both TennCare-enrolled pregnant women and providers to educate them about the expanded Tenn-Care smoking-cessation benefit for pregnant women. (Id. at 1713.) In addition, through the educational efforts of the Workgroup, obstetric providers have been supplied information regarding the services available for pregnant enrollees through the MCO maternity case-management programs, and a reference guide for those providers, combining the contact information for the MCO maternity case-management programs, has been developed and disseminated. (Id. at 1709-14.) Plaintiffs do not contest the evidence presented by the State regarding its extensive, expansive outreach efforts. Instead, Plaintiffs contend that the State has not established that these efforts are effective. Specifically, Plaintiffs assert that the State’s outreach efforts are flawed because the State makes no attempt to assess the effectiveness of any of its outreach efforts. (ECF No. 1563 (Pis.’ Post-Trial Br.), at ¶ 82.) Plaintiffs further object that Dr. Wendy Long’s testimony that she “believe[s]” the State’s outreach to be effective “as evidenced by the tremendous improvement in our screening rates [and] the huge volume of correspondence and calls and so forth” (Vol. 2 (Long), at 417) is conclusory and unsupported. The Court agrees that the State’s efforts are not without flaws and are likely in need of continued work and revision, particularly, as Plaintiffs argue, in the area of providing notice to teenagers and pregnant women. Policy arguments aside, however, Plaintiffs’ objections are somewhat beside the point, as the outreach provisions set forth in the Consent Decree do not require the State to certify or guarantee the effectiveness of its outreach efforts. Instead, the Decree requires the State to “adopt policies and procedures necessary to ensure that TennCare rules and guidelines” clearly require compliance with every outreach requirement under federal law. (Decree ¶ 39 (emphasis added).) The policies and procedures themselves must establish a goal that the outreach efforts be “aggressive!] and effective!],” and that the outreach media otherwise conform with federal mandates, such as through the use of “clear and non-technical terms,” the use of outreach systems designed to reach individuals who are illiterate, blind, deaf, or who do not understand English; offering transportation services; informing families of the cost of services, if any, “establishing criteria for determining when an MCO may be required to target specific informing activities to particular ‘at risk’ groups”; offering information on covered services to pregnant teenagers who enter TennCare through presumptive eligibility, and offering assistance in making a timely first prenatal appointment, and so forth. (Id. ¶ 39(a)-(p).) The “Outreach Performance Standard” set forth in the Decree simply obligates the State to achieve and maintain “outreach efforts designed to reach all members of the plaintiff class with information and materials” in conformity with the federal requirements as set forth in paragraphs 39(a)-(p) of the Decree. (Id. ¶ 40.) The Court finds that the evidence offered by the State demonstrates that the appropriate policies and procedures are in effect, and that the State is in the process of maintaining outreach efforts in compliance with the Decree. The Court finds it problematic that the State makes no real effort to track the effectiveness of its outreach efforts, but cannot find that the State’s myriad outreach efforts are not designed to reach all members of the plaintiff class. 2. EPSDT Screening An EPSDT screen consists of five elements: (i) a comprehensive health and developmental history; (ii) a comprehensive unclothed physical exam; (iii) appropriate immunizations according to age and health history; (iv) appropriate laboratory tests (including an assessment of blood levels of lead); and (v) appropriate health education. (See, e.g., DX 3 (TennCare Standard Operating Procedure (hereinafter “TSOP”) 036, Addendum 3) at 2; DX 50 (Form Contractor Risk Agreement (hereinafter “MCO Contract”)) § 2.7.6.3.3.) In addition, TennCare children receive vision, hearing, and dental screens at appropriate intervals. TennCare has adopted the periodicity schedule for physical health screening (i.e., the schedule for when over the course of childhood periodic physical checkups should take place) recommended by the American Academy of Pediatricians. (See, e.g., DX 49a (TennCare Rule 1200-13-13-.04(b)(8)) at 38; DX 3 (TSOP 036, Addendum 3); MCO Contract § 2.7.6.3.2 (adopting periodicity schedules); DX 159 (Periodicity Schedule for Checkups and Screenings adopted by the State); DX 160 (Recommendations from EPSDT Screening Guidelines Committee regarding Developmental/Behavioral Screening); Vol. 2 (Long), at 322.) TennCare has adopted the periodicity schedule for dental services recommended by the American Academy of Pediatric Dentists, and has adopted the periodicity schedules for vision and hearing screenings recommended by a committee of experts in those fields. (See DX 161 (Recommendations from EPSDT Screening Guidelines Committee regarding Hearing and Vision Screenings).) All TennCare screening services are provided upon request at no cost to the enrollee, without any requirement for prior approval, regardless of whether the screen takes place in accordance with the periodicity schedule or is in addition to the checkups recommended under the periodicity schedule. There is no dispute that an enrollee can get screened simply by calling his primary care provider and scheduling an appointment. (Vol. 2, at 339 (Long).) Under contract with TennCare, DOH provides EPSDT screening services at all of its county health department clinic sites across the State and has a participating provider agreement with each of the Tenn-Care MCOs to provide those screens. (Vol. 8 (Baggett), at 1692-93.) Under an agreement between DOH and DCS, the county health departments perform EPSDT screens for all children in state custody (with the exception of Davidson County, where children in custody receive their EPSDT screens from a pediatric medical group). (Vol. 2 (Long), at 339^10; Vol. 8 (Baggett), at 1693; Vol. 5 (Pollard), at 1046t47; DX 193 (DCS/DOH Agreement).) When a screen is performed at a county health department clinic, a form, referred to as the “PCP letter” (DX 194), is completed reflecting the results and is sent to the child’s primary care provider and to DCS if the child is in state custody. (Vol. 8 (Baggett), at 1747; Vol. 5 (Pollard), at 1052.) Immunizations are also available at no cost to TennCare children at all county health departments. (Vol. 8 (Baggett), at 1693.) DOH undertakes an annual quality improvement review of medical records across all of its regions to verify the presence of documentation that the PCP letter was sent and to evaluate the provision of EPSDT screens to ensure that all required components were covered. (Id. at 1748-49 (Baggett); Vol. 9 (Baggett), at 1798-99.) CMS requires each state to report two different measures for determining the numbers of children who receive EPSDT screens under the state’s Medicaid program: a screening ratio and a participant ratio. (Vol. 2 (Long), at 340.) Paragraph 46 of the Decree adopts the first of these measures, the screening ratio, as the “baseline periodic screening ratio” for purposes of this case. (Decree ¶46.) The baseline periodic screening ratio is calculated by dividing the total number of screens received by all enrollees under twenty-one during the year in question by the total number of screens expected to be provided to enrollees under twenty-one during that year. (See DX 250 (CMS 416 Instructions); Vol. 2, at 342 (Long) (describing methodology).) For the most recent complete year, FY 2010, the State reported a baseline periodic screening ratio of ninety-nine percent to CMS. (See DX 243 (2010 CMS 416 Report) at Line 7.) Also in accordance with paragraph 46 of the Consent Decree, TennCare annually conducts a medical record review in order to adjust the baseline periodic screening ratio to reflect the extent to which Tenn-Care enrollees receive all of the required components of an EPSDT screen. (Vol. 2 (Long), at 322-23 (describing the required components of an EPSDT screen); id. at 352-53 (describing the annual record review and adjustment of the screening ratio).) To conduct this review, a team of TennCare nurses selects at random a statistically valid sample of encounters coded as screens, obtains the underlying medical records from the doctors who provided those checkups, and reviews the records to determine whether all of the required components of an EPSDT screen were provided and documented. (Id. at 353-54.) From this review, an overall proportion of required components is calculated and that proportion is then multiplied by the baseline periodic screening ratio to produce an adjusted periodic screening percentage (APSP). (Id. at 354.) For the most recent complete year, FY 2010, the overall component compliance rate was 92.19 percent, and the adjusted periodic screening percentage was 91.3 percent. (See DX 149 (FY 2010 EPSDT Medical Record Review Report) at 4; Vol. 2 (Long), at 355.) Over the ten years since 2001, the State’s adjusted periodic screening percentage has risen from 31.8 percent to the current rate of 91.3 percent. (See DX 149 (FY 2010 EPSDT Medical Record Review Report) at 4.) The dental screening percentage for FY 2010 was 81 percent, up from 80 percent in FY 2009. (PX 2063 (FFY2010 Dental Screening and Participation); Vol. 2 (Long), at 357.) The screening percentage for TennCare children in DCS custody has consistently reached or exceeded 95 percent. (See generally Vol. 5 (Pollard), at 1055-64 (explaining tracking and calculation of screening ratio for children in DCS custody).) DCS has a policy of taking all children for an EPSDT screen within thirty days of their entering custody, and has implemented a tracking system (“TFACTS database”) for monitoring and reporting the screening status of the children in custody. The TFACTS report dated October 26, 2011 showed that 96.42 percent of Plaintiff class members who had been in DCS custody for more than thirty days, who were not on runaway status, and for whom there was no good-cause exception on record, were up-to-date on their annual EPSDT screen. The same TFACTS report indicated that 99.6 percent of those screens were complete, seven-component screens. (DX 196 (October 2011 DCS EPSDT Medical Screening Summary Report); Vol. 5 (Pollard), at 1055-62, 1067.) According to the State’s witness, Lynn Pollard, two-thirds of the 3.6 percent of children listed as not up to date on their EPSDT screens in October 2011 had come due for a screen within a month of the report, and likely were not captured as up to date on their screens simply because documentation of the screens had not yet been entered into the TFACTS system. (Vol. 5 (Pollard), at 1055-63.) The remaining third, or approximately 1.2 percent, were not accounted for. According to Dr. Long, the State has consistently calculated its screening rates on an aggregate basis across its eligible population of children, without capping screens according to the number of screens recommended by the periodicity schedule as applicable to an individual child. (See Vol. 2 (Long), at 342-49 (describing calculation methodology); Vol. 3 (Long), at 659-60 (identifying minor changes in methodology, none of which altered the aggregate nature of the calculation).) CMS has confirmed to the State that other states use the same aggregate approach because an individualized approach (like that suggested by Plaintiffs’ expert, Dr. Ray) would not be practicable. (Vol. 2 (Long), at 350-51.) Plaintiffs maintain that the State’s screening performance remains inadequate, based on perceived flaws in the State’s methodology for calculating the screening ratio. In short, Plaintiffs’ expert Dr. Rose Ray testified that the State’s reported screening ratio is significantly inflated, because the numerator of the fraction overcounts screens, while the denominator undercounts the total expected number of screens. Dr. Ray’s proposed methodology, however, used a formula for computing these percentages that is peculiar to her and not used by CMS or by any other Medicare agency in the country. The Court rejects the testimony of Dr. Ray and accepts the testimony of Defendants’ witnesses regarding the appropriate methodology for calculating the screening ratio. 3. EPSDT Diagnosis and Treatment In addition to screening, TennCare children are entitled to receive, free of charge, all medically necessary covered diagnosis and treatment services. Medical necessity is determined on a case-by-case basis in accordance with the State’s regulatory definition of medical necessity. (TennCare Rules Chapter 1200-13-16.) In general, a covered service will be medically necessary if it is (a) recommended by the child’s physician, (b) required in order to diagnose or treat an enrollee’s medical condition, (c) known to be safe and effective and not experimental or investigational, and (d) the least costly alternative course of diagnosis and treatment adequate to treat the child’s condition. (Tenn-Care Rule 1200 — 13—16—.05(1); Vol. 2 (Long), at 359.) TennCare’s medical-necessity rule expressly provides that it must be implemented consistent with federal law, including all EPSDT requirements. (TennCare Rule 1200-13-16-.02; Vol. 2 (Long), at 360.) TennCare will remain obligated to continue to cover all medically necessary diagnosis and treatment services after the Decree is vacated; the State maintains that it has no plans to cut EPSDT services to children. (See Vol. 9 (Gordon), at 1821-22,1861.) MCO contracts require that the MCOs abide by EPSDT requirements in determining medical necessity. (Vol. 2 (Long), at 360-61.) Further, in training provided to the MCOs, TennCare emphasizes that medical-necessity determinations must comply with EPSDT requirements. (Id.) In practice, the vast majority of diagnosis and treatment services are provided to TennCare enrollees automatically, without any medical-necessity review, when the service is ordered by a licensed provider. (Vol. 2 (Long), at 363-64.) The MCOs subject only a small percentage of services to prior authorization under which MCO approval is required before the service will be covered. (Id.) When prior authorization is required, the ordering physician must provide the MCO with information explaining why the service is needed. In most cases, a routine fax or telephone call from the doctor’s office suffices to ensure approval of the service. In the small percentage of cases where the MCO has concerns notwithstanding the information provided, the case will be elevated to an MCO doctor, who will consult with the ordering physician in an effort to determine together the appropriate course of treatment for the patient. (Id. at 369.) In most of that small percentage of cases, the MCO doctor and the treating physician will reach a consensus; in the few cases where they do not, the MCO may deny the request for prior authorization. (Id. at 370.) When a request for prior authorization is denied, TennCare will issue a notice with instructions that the denial may be appealed simply by calling a toll-free number. (Id. at 371.) If an appeal is taken, TennCare will ask the MCO to reconsider the denial by having a different physician review the case. (Id.) If the reconsidering physician agrees with the treating physician, the service will be covered. (Id. at 371-72.) If the reconsidering physician agrees with the original MCO physician, the TennCare appeals unit will send the case to an independent medical consultant under contract with TennCare for another level of review. (Id. at 372.) Again, if the independent medical consultant agrees with the treating physician, the service will be covered. (Id. at 373.) If the independent medical consultant agrees with the MCO physicians, the appeal will be heard by an administrative law judge who will decide, based on the evidence, whether the requested service is medically necessary. (Id. at 373-74.) The appeal system is governed by the terms of the decree entered in Grier v. Emkes, No. 79-3107 (M.D.Tenn.) (Nixon, J.). (Vol. 2 (Long), at 374.) Under this system, an MCO’s denial of a service ordered by a licensed physician or other provider based on lack of medical necessity will be sustained only if no fewer than three different reviewing physicians (including one who is independent of the MCO) all agree that the service is not medically necessary. The same appeals process governs medical-necessity determinations for drugs that are not included on TennCare’s list of preferred drugs. (Id. at 375-79.) The Pharmacy Benefits Manager is required to process prior-authorization requests within 24 hours. (Id. at 379.) For immediate authorization, the prescribing physician may call the Pharmacy Benefits Manager instead of faxing a prior-authorization request. (Vol. 2 (Long), at 380.) Under the Grier Consent Decree, even if a prescription is denied for lack of prior authorization, a pharmacist may provide an enrollee with a 72-hour emergency supply while waiting for the prescribing physician to provide more information to demonstrate medical necessity. (Id.) Plaintiffs focus their critique of the State’s provision of diagnostic and treatment services on the State’s failure adequately to track follow-up care. While the State’s failure to track is concerning, Plaintiffs have not successfully linked a supposed obligation to track with any particular requirement expressed in the Decree. Further, Plaintiffs’ complaint that TennCare pediatricians are not “up to speed on developmental issues in children” (ECF No. 1563, at 73), as a result of which autism and other developmental disabilities allegedly go undiagnosed, is actually a critique of the medical-care delivery system generally, and one that affects all children in Tennessee regardless of whether they are covered by TennCare. Plaintiffs also contend that there is a state-wide dearth of TennCare specialists in behavioral health and other areas. Besides the fact that the network-adequacy requirements in the Consent Decree have been determined to be unenforceable pursuant to Sixth Circuit precedent, Plaintiffs have not established that dearth of specialists is a problem peculiar to TennCare patients. 4. Monitoring & Oversight of the EPSDT Program Although the State does not implement all the different monitoring and tracking measures Plaintiffs and their experts recommend, the State does use a number of objective measurements to judge its performance. For instance, in 2006, Tennessee became the first state in the country to require that all of its MCOs obtain full accreditation by the National Committee for Quality Assurance (“NCQA”). (Vol. 3 (O’Kane), at 505; Vol. 2 (Long), at 402.) NCQA is a nonprofit organization that is devoted to improving the quality of health care around the country. (Vol. 3 (O’Kane), at 481-82; Vol. 2 (Long), at 310.) NCQA accreditation is an independent, nationally recognized standard for evaluation of health-care plans. (Vol. 2 (Long), at 402.) To receive NCQA accreditation, a health plan must undergo a rigorous review of its policies and procedures, and then of the plan’s performance as tracked according to precise, standardized, carefully constructed measures that enable comparisons between plans and across States. (Id. at 310-11; Vol. 3 (O’Kane), at 501-04; DX 10 (NCQA Health Plan Accreditation); DX 11 (2011 NCQA Health Plan Accreditation Requirements).) Two of the State’s three MCOs have achieved NCQA’s highest overall accreditation rating (“excellent”), and the third received NCQA’s second highest accreditation status (“commendable”). (DX 295 (Accreditation Status Update) at 2; Vol. 2 (Long), at 384.) All three of Tenn-Care’s MCOs have earned the highest rating — four stars — for both “access to needed care and ... good customer service” and for “qualified providers.” (DX 295 (Accreditation Status Update) at 1, 2; Vol. 2 (Long), at 384-85.) In addition to NCQA accreditation, TennCare requires its MCOs to report all of the Healthcare Effectiveness Data and Information Set (“HEDIS”) measures related to the provision of care to children (as well as many related to adults). (Vol. 3 (O’Kane), at 486 (identifying some measures relevant to children); Vol. 17 (Long), at 3671-73.) HEDIS measures are standardized national metrics developed and superintended by the NCQA that enable TennCare to track the performance of the MCOs in a variety of measured healthcare outcomes over time, to compare the performance of the State’s MCOs to each other, and to compare the performance of the MCOs to national averages and benchmarks for Medicaid managed care programs across the country. (Vol. 3 (O’Kane), at 489 (noting that standardized calculation permits “very little room for interpretation” and avoids “problems with comparing one ... level of performance to another”); Vol. 2 (Long), at 387.) HEDIS measures are all independently validated by NCQA-certified HEDIS auditors. (Vol. 2 (Long), at 387; Vol. 3 (O’Kane), at 498.) In general, TennCare’s most recent HEDIS results compare favorably to national Medicaid averages. (Vol. 2 (Long), at 389.) They compare even more favorably to the Southeastern regional averages. (Vol. 3 (O’Kane), at 506-07.) In particular, TennCare’s HEDIS scores for access to and availability of care for children, timeliness and frequency of prenatal care, child immunization rates, and effectiveness of behavioral health are all comparable, and in most cases exceed the national Medicaid average. (DX 151 (TennCare 2011 HEDIS/CAHPS Annual Report) at 24-28; Vol. 2 (Long, at 388-93).) Over time, many of TennCare’s HEDIS scores related to the provision of healthcare services to children have improved, generally reflecting a steady increase in the quality and accessibility of medically necessary diagnosis and treatment services for TennCare children. (See DX 153 (2010 HEDIS/CAHPS Summary and Trending Report) at 20-27; Vol. 2 (Long), at 394-96; Vol. 3 (O’Kane), at 505-06; cf. Vol. l(Ray), at 184 (acknowledging that Tennessee’s rates of EPSDT screenings and prenatal services improved each year from 2007 through 2010).) Plaintiffs discount both the HEDIS measures and NCQA accreditation on the basis that HEDIS only measures process and policy rather than health outcomes or actual compliance with the policies and procedures that are in place. Plaintiffs further argue that the HEDIS measures and NCQA accreditation are only partial measures because the MCOs do not manage the “carve-outs” of dental, pharmacy, and treatment of behavioral problems. The Court rejects the Plaintiffs’ arguments on the basis that the State has complied with — and gone beyond — the measurements required by CMS. Moreover, while the State’s performance certainly still has room for improvement, the measures in place have documented steady improvement in nearly every area related to EPSDT services over time. More accurate and precise methods of assessment could certainly be imagined and implemented, but there is nothing in federal law or the Consent Decree that requires more precise assessment. In addition to HEDIS and NCQA accreditation, TennCare also requires the MCOs to report results on the Consumer Assessment of Healthcare Providers and Systems (“CAHPS”) set of standardized surveys, which measures enrollees’ satisfaction with their care. (Vol. 2 (Long, at 396-97); see also Vol. 3, at 499-500 (O’Kane).) CAHPS reporting is another component of NCQA accreditation. (Vol. 2 (Long), at 396.) The CAHPS child Medicaid measures for “Getting Needed Care” show that 84 to 86 percent of TennCare recipients report that they always or usually get the care they need for their children, compared to only 77 percent of Medicaid recipients nationally who report that they always or usually get the care they need for their children. (DX 151 (2011 HEDIS/CAHPS Annual Report) at 36-37; Vol. 2 (Long), at 398.) Similarly, 90 to 92 percent of TennCare recipients report that they always or usually get the care they need for their children quickly, compared to only 86 percent of Medicaid recipients nationally. (2011 HEDIS/CAHPS Annual Report at 36-37; Vol. 2 (Long), at 398; see also id. 458-61 (discussing DX 209, the 2010 results of an annual University of Tennessee study assessing opinions about certain aspects of TennCare, indicating that 88 percent of households perceived the care their children received on Tenn-Care in 2010 as excellent or good, compared to 76 percent in 1998, with 43 percent giving “excellent” ratings in 2010 compared to 27 percent in 1998).) Plaintiffs’ expert, Dr. Darren DeWalt, dismissed the favorable CAHPS results as entirely unreliable based on his assertion that people will register satisfaction with services even if the healthcare they actually receive is “crummy.” (Vol. 7 (DeWalt), at 1411.) This criticism is somewhat beside the point insofar as CAHPS surveys are not intended to measure the quality of healthcare provided, but consumers’ satisfaction with their overall experience in the receipt of healthcare. Plaintiffs cannot successfully dispute the fact that the recent CAHPS results indicate that an overwhelming majority of class members are satisfied that their children are getting needed care, and getting it quickly. TennCare contracts with an External Quality Review Organization (“EQRO”), currently Qsource, to provide extensive independent monitoring and review of the performance of the MCOs. (Vol. 2 (Long), at 398-99; Vol. 4 (Couzins), at 867-72.) Among other things, the EQRO specifically reviews MCOs’ compliance with their contractual obligations, including but not limited to those addressing EPSDT and the Consent Decree in this case. (Vol. 2 (Long), at 399; Vol. 4 (Couzins), at 867-69, 884-85, 914-15.) Specifically, for purposes of this case and the Decree, the EQRO rigorously reviews the compliance of each health plan, in each region of the State, with the paragraphs governing outreach, screening, diagnosis, and treatment, aggregating its findings, good and bad, in an “EPSDT Summary Report” it provides the State annually. (Vol. 4 (Couzins), at 884-85, 903-11, 914-15; DX 30 (EPSDT Summary Report); see also DX 12 (2011 Annual Quality Survey).) The EQRO reviews compliance in reference to an MCO’s policies and procedures, combined with random sampling of select medical files to confirm that the MCO is in fact implementing its policies and procedures on the ground. (Vol. 2 (Long), at 399-400; Vol. 4 (Couzins), at 903-11.) In addition to the above-referenced measures, TennCare’s Quality Oversight Unit works with the EQRO to identify opportunities for improvement and to develop a quality strategy for the State. (Vol. 2 (Long), at 407-08; Vol. 4 (Couzins), at 875-76; see also DX 11 (NCQA Accreditation Requirements) (describing NCQA’s evaluation of a plan’s “Quality Management and Improvement (QI)” for purposes of accreditation).) Through the Quality Oversight Unit’s Quality Strategy for Medicaid, TennCare reports to CMS annually on the various quality measures reported by the EQRO and NCQA. (Vol. 2 (Long), at 407-09.) In approving TennCare’s 2011 Quality Strategy for Medicaid, CMS recognized TennCare’s “exemplary commitment to the quality of care received by [the State’s] Medicaid beneficiaries.” (DX 249 (CMS Approval Letter); Vol. 2 (Long), at 409-10.) The State is also required by the Decree to file Semi-Annual Reports (SARs) with the Court, and to provide copies to the Plaintiffs, regarding Defendants’ compliance with the terms of the Decree. (Decree ¶ 105.) These reports are to contain information validated by the applicable audit and testing procedures outlined in the Decree, and must accurately and fully reflect the status of the state’s compliance. (Id.) The SARs have been promptly and consistently filed on July 31 and January 31 of each year, and Plaintiffs do not contend that Defendants have failed to comply with this requirement. The Comptroller of the Treasury of Tennessee conducts periodic audits of the Department of Finance and Administration, a portion of which includes a review of Tenn-Care. In the most recent audit, the Comptroller concluded, based upon his review of reports submitted by the MCOs to TennCare, the independent evaluations of the EQRO, the reports detailing the MCOs’ HEDIS and CAHPS results, and their NCQA accreditation, that TennCare had in place an “appropriate process ... to monitor the quality of care.” (DX 247 (2011 Performance Audit, Department of Finance and Administration) at 103.) In addition, based on a random sample of service denials by the MCOs, the Comptroller’s audit concluded that the MCOs were meeting their obligations related to the denial of services. (Id. at 119.) TennCare presented other evidence of its efforts to ensure the MCOs’ provision of EPSDT services in compliance with the Decree and federal law. An example of these efforts include TennCare’s regular monitoring of individual service appeals in order to identify any MCO practices that may inappropriately erect obstacles to the provision of medically necessary diagnosis and treatment services to TennCare children. (Vol. 2 (Long), at 405, 447.) In addition, TennCare regularly analyzes performance measures based upon encounter data to assess effectiveness of care and to identify opportunities for continuous quality improvement in the delivery of diagnosis and treatment services to TennCare children. (Id. at 400-02 (describing Health Care Informatics Unit).) Tenn-Care regularly communicates with Tenn-Care providers, both individually and through provider organizations such as the Tennessee Chapter of the American Academy of Pediatrics, the Tennessee Medical Association, and the Tennessee Hospital Association, in an effort to identify any MCO practices that may inappropriately erect obstacles to the provision of medically necessary diagnosis and treatment services to TennCare children. (Id. at 316, 404-05.) TennCare regularly monitors the activities of DCS with respect to those TennCare services that DCS is responsible for providing to TennCare children in custody. (Id. at 424 (describing EQRO monitoring), id. at 453-54 (describing TennCare monitoring of DCS and MCOs); Vol. 3 (Long), at 607 (same).) And DCS likewise regularly monitors its providers and its processes to ensure that TennCare children in custody are receiving medically necessary medical and behavioral health services. For example, DCS utilizes a number of different tools to monitor and enforce the services provided to children in custody by DCS-contraeted providers, including by requiring national accreditation and appropriate licensing, performance-based contract monitoring, Program Accountability Reviews, unannounced site visits, Assessment of Service Quality (“ASQ”) reviews, reviews of individual cases through caseworkers’ twice-monthly visits with children, and utilization reviews conducted by the DCS regions and DCS Central Office. (See Vol. 8 (Gatlin), at 1546-54; see also id. at 1560 (describing Psychiatric Acute Care Coordination (“PACC”) process developed by DCS in conjunction with TennCare Select to coordinate services of children entering and exiting acute-care psychiatric hospitals).) TennCare’s witness persuasively attested to them conclusion that monitoring, oversight, and experience within DCS demonstrate that there are no systemic barriers precluding children in custody from accessing needed behavioral and mental healthcare for children in custody. The record before the Court confirms that, compared with its performance in 1998, TennCare has dramatically improved the provision of medical services to its enrollees in every respect. (See Vol. 2 (Long), at 456-57 (noting more demanding requirements for participating MCOs, carved-out pharmacy and dental benefits, increased focus on outreach, new call center and community outreach contracts, better monitoring through NCQA and HEDIS measures, an improved appeals system, and improved medical necessity rules).) Testimony presented at trial demonstrated that no other state’s EPSDT program surpasses that of Tennessee in any salient respect. To the contrary, Plaintiffs’ own expert witness, Manny Martins, former TennCare Director, testified that TennCare’s EPSDT program was better than most, if not all, other states’ EPSDT programs even in 2004 (when he was the TennCare Director), and Tenn-Care’s EPSDT program has only continued to improve since that time. (Vol. 11 (Martins), at 2406-07.) The Director of the TennCare Bureau, Darin Gordon, testified that, regardless of whether the Consent Decree remains in effect, TennCare will continue to employ independent, nationally recognized third-party monitoring and oversight tools, including NCQA accreditation, HEDIS reporting, and EQRO review to ensure that children continue to receive the services to which they are entitled under federal law. (Vol. 9 (Gordon), at 1819-20, 1822.) The credibility of this testimony is strongly confirmed by the fact that TennCare employs these measures for adults even though the State is not subject to any judicial decree governing the care provided to adults. (Id. at 1819-20.) B. Compliance with Specific Paragraphs of the Decree As both parties recognize, perfection cannot be the standard by which a program as large and complex as TennCare’s EPSDT program is judged, for problems will invariably and necessarily arise from time to time in any such program. Instead, the State’s substantial compliance must be assessed based upon whether the State has a sound system in place, one pursuant to which problems can be reliably identified and addressed as they arise. Based on the evidence presented at trial, the Court concludes that TennCare easily satisfies this standard, and the Court, as set forth below, finds that Defendants are in substantial compliance with virtually every operative paragraph of the Consent Decree. The State is in substantial compliance with the requirements of paragraph 39 and its subparts, pertaining to the outreach and informing requirements of federal law. Specifically, as the factual summary set forth above indicates, TennCare has adopted policies and procedures for aggressively and effectively informing enrollees of the existence of the EPSDT program and the availability of specific screening and treatment services. The policies in place require the use of clear and non-technical terms, in oral and written form, to ensure that information about the program is clear and easily understandable. The State has implemented outreach procedures for informing individuals who are illiterate, deaf, blind or cannot understand English about the EPSDT program, and performs outreach to inform all eligible individuals and their biological or foster parents about what services are available under EPSDT, the importance of preventive health care, where services are available and how to obtain them, that assistance with transportation and sche