Murphy ex rel. Murphy v. Minnesota Department of Human Services (260 F. Supp. 3d 1084, 2017)

MEMORANDUM OPINION AND ORDER

DONOVAN W. FRANK, United States District Judge

INTRODUCTION

This matter is before the Court on the Motion to Dismiss filed by Defendants the Minnesota Department of Human Services (“DHS”) and DHS Commissioner Emily Johnson Piper (“Commissioner Johnson Piper”) (collectively, “Defendants”). (Doc. No. 10.) For the reasons set forth below, the Court grants in part and denies in part the motion.

BACKGROUND

This case relates to an alleged denial of services under Minnesota’s Medicaid Disability Waivers and the resulting isolation and segregation of individuals with disabilities who seek greater integration into their communities. This case has been designated as related to Jensen v. Minnesota Department of Human Services, Civ. No. 09-1775 (D. Minn.). (Doc. No. 6.) Mikkelson v. Johnson Piper, Civ. No. 15-3439 (D. Minn.) (formerly Gnggenberger v. Minnesota), is also related to the Jensen case. (See Order, Mikkelson v. Johnson Piper, Civ. No. 15-3439 (D. Minn. Aug. 81, 2015), Doc. No. 4.) Many of the allegations, claims, and legal issues presented in this case are similar to those previously considered by the Court in its July 28, 2016 Order in Mikkelson. See Guggenberger v. Minnesota, 198 F.Supp.3d 973 (D. Minn. 2016). The Court will analyze the allegations and arguments specific to this case below, but also directs readers to. Guggen-berger for. additional background, on the relevant law underlying Plaintiffs’ claims.

1. Minnesota’s Residential Service System Under Medicaid Disability Waivers

Minnesota participates in the federal Medicaid program, a jointly-operated federal and state' program that provides “healthcare arid related services” to individuals with disabilities. (Doc. No. 33 (“Am. Compl.”) ¶ 32.) In particular, Minnesota offers Medicaid services-to individuals with disabilities in 'the. form of Medicaid Home and Community Based Disability Waivers (“Disability Waivers”). (Id. at 2, ¶¶ 21, 25.) According to Plaintiffs, states who participate in Medicaid must do so in accordance with federal law. (Id. ¶ 32.)

Plaintiffs allege that Disability Waivers in Minnesota “provide a comprehensive, cost-effective, home and community-based package of services,” including “direct care staffing, vocatjonal skills and employment assistance, environmental modifications and other assistive technology, transitional and housing assistance, and other services designed to help people with disabilities live in his or her own home and interact with the larger nondisabled community.” (Id. ¶¶ 33-34.) Plaintiffs assert that “[t]he Disability Waivers can fund a variety of residential services, including, individualized housing services.” (Id. ¶25.) According to Plaintiffs, before individuals receive Disability Waiver services, they must be assessed and deemed, qualified in order to be offered “Disability Waiver services as an alternative to services in an institution.” (Id. ¶ 68.)

Plaintiffs allege that Disability Waivers may be used to fund residential services in a number of different settings. (Id. ¶ 64.) One possible setting is a Community Residential Setting (“CRS”) facility. (Id. at 2, ¶ 64.) Plaintiffs explain that “CRS facilities contain up to five persons, all with disabilities, living in a residence, that is owned, leased, operated, and/or controlled by the same organization that provides the services.” (Id. ¶6.) Defendants oversee the licensure of CRS facilities pursuant to Minnesota Statute Chapter 245D. (Id. ¶64.) According to Plaintiffs, as of July 2016, nearly 13,800 Disability Waiver recipients in Minnesota resided in approximately 3,457 licensed CRS facilities. (Id. ¶ 65.)'

Plaintiffs allege that an alternative model involving individualized housing services exists under the Disability Waivers that would permit individuals to achieve greater integration in the community. (Id. ¶ 7; see also id. ¶¶ 80-83.) According to Plaintiffs, “individualized housing uses Disability Waiver services, including person-centered planning, to design and implement a customized setting for the individual to live, work, and enjoy leisure time in the most integrated setting.” (Id. ¶7.) Plaintiffs identify examples of services offered under Disability Waivers “that help individuals transition from less integrated settings into homes of their own.” (Id. ¶ 84.) For example, Plaintiffs identify Consumer Training and Education and Family Training and Counseling “which allows individuals to hire trained person-centered planners to help develop self-advocacy skills and create more individualized service plans, including a personal housing transition plan that will lay the foundation for a move, into a more integrated setting,” (Id. ¶ 84(a).) Plaintiffs also identify Housing Access Coordination and Transitional Services to assist with moving logistics. (Id. ¶ 84(b).) ...

Plaintiffs allege that DHS is the Minnesota state agency responsible for overseeing the state’s provision of Medicaid, including “Disability Waivers and residential services for persons with intellectual and developmental disabilities, traumatic brain injury, mental illness, and other disabilities.” . (Id. ¶ 21;) Plaintiffs further allege that Commissioner Johnson Piper administers and manages the Disability Waivers along with overseeing residential service providers such as those who operate CRS facilities. (Id. ¶ 23.)

Plaintiffs assert that “Defendants direct and manage counties,” otherwise known as “lead agencies,” to administer Disability Waiver services throughout the state. (Id. ¶27.) Lead agencies are involved in the initial assessment' for Disability Waiver services¡ and are required by Defendants “to develop a support plan for the individual'that identifies his or her needs and the types of services necessary and available to meet those needs.” (Id. ¶¶ 68-69.) According to Plaintiffs, “DHS regulates all individualized housing services for individuals with disabilities while primarily relying on individual counties and private service providers to provide.such services.” (Id. ¶ 88.) Plaintiffs assert that Defendants permit counties to exercise discretion over “whether to offer individualized housing services.” (Id. ¶ 27.) According to Plaintiffs, most counties do not offer such services. (Id.)

II. The Named Plaintiffs

Plaintiffs’ Amended Complaint is brought by three named Plaintiffs representing a putative class including “individuals who are receiving a [Disability Waiver] and are living in a [CRS] facility, but want to live elsewhere and be integrated into their community.” (Id. at 2.) Each named Plaintiff is an individual with one or more physical, developmental, or cognitive disabilities who receives a Disability Waiver. (Id. ¶¶ 1, 2, 29, 30, 31.)

Plaintiff Tenner Murphy (“Murphy”) alleges he is “stuck in the CRS facility because of Defendants’ failure to provide an informed choice of integrated alternatives.” (Id. ¶ 29(m).) Murphy asserts that his living environment is a segregated setting and that he primarily interacts with other individuals with disabilities and staff. (Id. ¶ 29(k).) Murphy alleges he typically “spends most of his time alone, even though he would prefer to interact with other people.” (Id. ¶ 29(g).) He asserts he is not able to control staff hiring or training and cannot decide who he will live with. (Id. ¶ 29(i).) He would prefer to select his own roommates. (Id. ¶ 29(j).) Murphy’s guardian “has asked several people at the lead agency about accessing more individualized housing options.” (Id. ¶ 29(k).) However, Murphy asserts that Defendants “have prevented [him] from choosing individualized housing services, such as a live-in caregiver that he can hire and train to help him more fully interact with his community and be as integrated as possible.” (Id. ¶ 29(m).)

Plaintiff Marrie Bottelson (“Bottelson”) “has lived in a CRS facility for about thirteen years” and “would like to hire her own staff and live in her own apartment.” (Id. ¶¶ 30(c), 30(g).) Bottelson contends that her ability to spend time in the community is “severely limited” due to staffing in her current residential setting. (Id. ¶¶ 30(e), 30(f).) Specifically, Bottelson “does not get out into the community nearly as much as she would if she were able to create her own schedule.” (Id.) According to Bottelson, “[f]or the past several years, she has asked ... different case managers ... to help her move into her own apartment.” (Id. ¶ 30(d).) Bottelson alleges she has requested such help from her case managers to access individualized housing options since as early as 2013. (Id. ¶¶ 30(i), 30(j').) She has been told by case managers “that individualized housing is not a possibility for her,” “that such housing was too hard to find,” and “that there are no other options for her.” (Id. ¶¶ 30(d), 30(i), 30(j).) Bottelson alleges she “needs person-centered planning to help her develop an individualized moving plan and other individualized housing services” to achieve her goals relating to her preferred living arrangement. (Id. ¶ 30(h).) She asserts that she met with a person-centered planner in July 2016 but “has not received all the necessary individualized housing services to help her find or develop alternatives to her current CRS facility.” (Id. ¶ 30(k).)

Bottelson’s current roommate and best friend, Plaintiff Dionne Swanson (“Swanson”), also alleges a need for “person-centered planning services, and other individualized housing services to help her create and execute a plan to live in the most integrated setting appropriate to her needs.” (Id. ¶¶ 30(h), 31, 31(e).) She has asked for such services “for a long time,” but “has not received them.” (Id. ¶ 31(f).) Swanson alleges she has been told by case managers that “she is not ‘independent enough’ for individualized housing,” even though Defendants have no such criteria. (Id. ¶ 31(b).)

As noted above, Plaintiffs assert that they want access to services offered under the Disability Waivers “to help them transition to more integrated settings.” (Id. ¶ 85.) Despite not receiving the requested individualized housing services described above, each Plaintiff alleges he or she “has not received a notice of denial or information regarding [their] due process rights in regards to [their] request for these services.” (Id. ¶ 29(n); see also id. ¶¶ 30(£), 31(f).)

III. Plaintiffs’ Claims

Notwithstanding the alleged availability of individualized housing services that would permit greater integration into the community, Plaintiffs state that “Defendants have failed to inform all persons receiving a Disability Waiver of individualized housing service options and have failed to explain how to access such services.” (Id. ¶28.) Similarly, Plaintiffs assert that “Defendants have ... failed to provide transition planning and support for such services.” (Id.) Finally, Plaintiffs contend that “Defendants have further failed to provide notices of denial or information regarding due process rights in regards to requests for these services.” (Id.) These collective failures form the basis of Plaintiffs’ claims, outlined below.

Plaintiffs assert that Defendants disproportionately rely on CRS facilities through their management of Disability Waiver services, leading Plaintiffs to reside in segregated settings. (Id. ¶ 4; see also id. ¶ 26.) According to Plaintiffs, “Defendants’ administration, operation, and oversight (or lack thereof) has led to a pervasive overreliance on segregated CRS facilities.” (Id. ¶ 13.) Plaintiffs allege that many CRS facilities are segregated settings according to DHS’s own definition. (Id. ¶¶ 5-6.) Under this definition, a segregated setting is one “populated exclusively or primarily with individuals with disabilities ... [and] characterized by regimentation in daily activities [and] limits on individuals’ ability to engage freely in community activities.” (Id. ¶ 5 (quoting Minnesota Olmstead Plan: Demographic Analysis, Segregated Settings Counts, Targets and Timelines, September 20, 2014, p. 8).) Plaintiffs assert that many CRS facilities sanctioned by Defendants meet this definition because they limit individual choices regarding free time, daily schedules, interaction with individuals outside of the facility, and who to live with. (Id. ¶ 6.) According to Plaintiffs, “staffing patterns, CRS house rules, and other administrative restrictions limit the scope and duration individuals can actually participate in everyday community activities.” (Id. ¶76.) In addition, Plaintiffs allege, “[m]any CRS residents are frequently forced to spend their time secluded in CRS facilities,” separated from their communities. (Id. ¶ 78.) Plaintiffs allege that “[t]his lack of interaction -with the larger community can be harmful.” (Id. ¶79.) In particular, Plaintiffs allege that “[f]or many residents, an unchanging daily routine causes their social and independent living skills to atrophy, leading to an even lower likelihood that they will ever transition to living and working in the community.” (Id.) According to Plaintiffs, these circumstances “also lead[] to lower self-esteem and lowered expectations of themselves.” (Id.)

In contrast with these settings, Plaintiffs allege that “[i]ndividuals who develop and live in individualized housing settings are given greater opportunities to interact and integrate themselves in the greater community” based on increased flexibility in schedules, roommate choices, staff hiring, and social opportunities with non-disabled individuals. (Id. ¶ 81.) In particular, Plaintiffs assert that “[p]ersons receiving individualized housing -services experience greater opportunities to interact with neighbors, meet and develop relationships with persons without disabilities, and build or maintain basic living skills in a manner that often is not possible in CRS facilities.” (Id, ¶ 83.)

According to Plaintiffs, “Defendants - have created, maintained, and over-relied on a residential service system that limits individual autonomy, choice, and integration” in violation of. the integration mandate of the Americans with Disabilities Act (“ADA”). (Id. ¶ 3.) Plaintiffs allege that Defendants have failed “to reasonably ■ modify its residential service system” in a manner that would permit Plaintiffs to live in the most integrated setting. (Id. ¶12.) According.to Plaintiffs, “Defendants currently approve some limited individualized ■ alternatives for a small number of Disability Waiver recipients.” (Id. ¶ 67.) However, Plaintiffs assert, “they have failed to recognize Plaintiffs’ individual choice and circum-stancés and have thus refused to ensure the residential service system provides services in the most integrated setting.” (Id.) In particular, Plaintiffs assert that “Defendants ' provide impermissible discretion to each lead agency” instead of “requiring] statewide access to individualized housing services.” (Id, ¶27.) Plaintiffs also assert that Defendants “have" failed to directly inform persons in CRS facilities about person-centered planning services and other individualized housing services that would allow them to move to .a more integrated setting.” (Id. ¶ 57.) According to Plaintiffs, they “are capable of and want to live in the most integrated setting appropriate to their needs and Defendant Piper can reasonably accommodate their requests.” (Id. ¶ 121.) .

In 2009, Plaintiffs allege, the number of CRS facility beds available statewide was capped by a legislative moratorium on the development of any new CRS facilities. (Id. ¶66.) Thus, Plaintiffs contend that Defendants have been aware since as early as 2009 “that individuals receiving Disability Waiver services need access .to individualized housing as an alternative to CRS facilities.” (Id,) Plaintiffs assert that Disability Waiver recipients receive information about available CRS facilities and case managers may take steps to locate CRS facility openings if none are available. (Id. ¶¶ 71-73.) However, Plaintiffs allege, “[c]ase managers rarely discuss integrated alternatives to CRS facilities.” (Id. ¶74.) Further, Defendants purportedly fail to inform Disability Waiver recipients “about more integrated alternatives to CRS facilities or information about how to access individualized housing services” or require case managers to provide this information. (Id, ¶¶71, 74.) Plaintiffs'also contend that “Defendants approve the funding of Disability Waiver services in CRS facilities while failing to ensure that such a setting is the most integrated setting appropriate for the individual.” (Id. ¶ 70.) - ;

Plaintiffs allege that they are entitled to use Disability Waiver services to hire a person-centered planner “in order to’ develop a comprehensive individualized transition plan to move to more integrated housing.” (Id. ¶ 10; see also ¶ 106.) According to Plaintiffs,- Commissioner Johnson Piper “has failed to establish administrative' procedures that ensure, individuals who-are qualified for and requesting services to help transition to a more integrated setting will actually receive those services.” (Id. ¶ 107.) In particular, Plaintiffs assert, Commissioner Johnson Piper has not required counties “to obtain, respond to, and act upon individual requests to use Disability Waiver services in more integrated settings.” (Id.) Plaintiffs allege that Defendants “have denied [them] the opportunity to find trained person-centered planners, to receive services from a person-centered planner in a timely fashion, or to receive any such services in order to develop and implement comprehensive individualized transition plans.” (Id. ¶ 11.) Plaintiffs assert, that “Defendants fail to ensure individuals have notice of, information regarding, or access to” services available under the Disability Waivers to facilitate a transition to a more integrated setting. (Id. ¶¶ 84-85.) Plaintiffs also allege that Commissioner Johnson Piper has not provided or required lead agencies to provide “notice of adverse action and opportunity to challenge the failure to provide ... individualized housing services.” (Id. ¶ 112.) According to Plaintiffs, “[b]e-cause these services are never offered or provided, Plaintiffs have no means of appealing or otherwise ' challenging DHS’s actions.” (Id. ¶ 85.)

Plaintiffs describe measures undertaken by Defendants in the areas of person-centered planning and integrated residential settings under Minnesota’s Olmstead Plan and Defendants’ Person-Centered, Informed Choice and Transition Protocols (“Protocols”). (See id. ¶¶ 53-62.) However, Plaintiffs assert that “[n]othing in the Protocols, the Olmstead Plan, or the [Olm-stead] Work Plans indicates how DHS will reduce its overreliance on CRS facilities by providing appropriate services to people entitled to more integrated alternatives than CRS facilities.” (Id. ¶ 61; see also id. ¶ 53.) In particular, Plaintiffs contend that the -Protocols “only provide generalized suggestions, rather than enforceable requirements,” so they are insufficient to ensure Plaintiffs have access to the individualized housing services they seek. (Id. ¶¶ 58-59; see also id. ¶ 88.) Plaintiffs also state that prior versions of the Olmstead Plan identified “specific individualized housing services” referred to as Individualized Housing Options, but assert that the current Olmstead Plan contains no such information. (Id. ¶ 60.)

Plaintiffs further allege that “Defendants have, promised ... to move' 5,547 people into more integrated settings” in the Olmstead Plan, but fail to specify “how or when this will happen, where these persons will come from, (including whether or not they will come from CRS settings), or how and if they will be informed of the purported options.” (Id. ¶ 62.) In short, Plaintiffs assert that “Defendants lack a working plan with accurate data, details, and measurable goals to ... fix its residential service system that over-relies on CRS' facilities to the detriment of integrated alternatives such as individualized housing services ... and ... [e]nsure [Plaintiffs] are receiving services in the most integrated settings.” (Id. ¶ 63.)

Plaintiffs allege that Defendants’ lack of management, planning, and oversight relating to individualized housing services has denied Plaintiffs access to such services and has resulted in “a severe shortage of individualized housing providers in the state.”- (Id. ¶¶ 89-90.) According to Plaintiffs, “Defendants have failed to implement individualized housing services as alternatives to CRS, or to ensure that its current service planning system requires even the consideration of .alternatives to CRS.” (Id. ¶ 91.) Relatedly,. Plaintiffs assert, Defendants have not “ensure[d] there is a sufficient capacity or planning for individualized housing services to allow persons with disabilities to find individualized housing and support to live in a setting more integrated than CRS facilities.” (Id.)

Plaintiffs assert the following claims against Commissioner Johnson Piper: (1) failure to furnish Medicaid services with reasonable promptness under 42 U.S.C. § 1396a(a)(8), enforced under 42 U.S.C. § 1983 (Count I); (2) violation of Plaintiffs’ Due Process rights under the Fourteenth Amendment and the Medicaid Act’s advance notice and fair hearing requirements, enforced under 42 U.S.C. § 1983 (Count II); and (3) violation of Title II of the ADA (Count III). (Id. ¶¶ 102-25.) Plaintiffs assert the following claim against all Defendants: violation of § 504 of the Rehabilitation Act (“RA”) (Count IV). (Id. ¶¶ 126-32.)

Plaintiffs assert their claims on behalf of themselves and a putative Class of similarly situated individuals. (See id. ¶¶ 92-101.) Plaintiffs assert that they and the Class “have a common remedy: modifications to Defendants’ residential service system to provide individuals with choices and prevent needless segregation of individuals in segregated residential settings.” (Id. ¶ 101.) Plaintiffs seek “an informed choice and realistic opportunity to receive residential services in the most integrated setting.” (Id. ¶ 4.) Plaintiffs seek declaratory and injunctive relief to remedy Defendants’ alleged violations of the law, attorney fees • and costs, and other relief deemed necessary to protect the rights of Plaintiffs and the Class. (See id. at Prayér for Relief ¶¶ 2-6.)

Specifically, Plaintiffs seek a declaratory judgment that: (1) Commissioner Johnson Piper is violating the Medicaid Act by not providing services with reasonable promptness and violating Plaintiffs’ Constitutional and Medicaid due process rights; and (2) Commissioner Johnson Piper is violating the ADA and Defendants are violating the RA by segregating Plaintiffs “while failing to provide them with individualized housing services for which they are eligible.” (Id. at Prayer for Relief ¶¶ 2-3.)

Plaintiffs seek injunctive relief requiring Defendants to: (1) “[pjromptly ensure every Disability Waiver recipient living in a CRS facility receives notice about eligibility for and access to individualized housing services, including person-centered planning;” (2) “[sjpecifically provide access and take prompt steps to make individualized housing services, including person-centered planning, available to Plaintiffs in a reasonable amount of time ... ”; and (3) “[tjake such other steps as necessary to enable Plaintiffs to receive residential services in the most integrated setting appropriate to their needs.... ” (Id. at Prayer for Relief ¶ 4.) Under items (2) and (3), above, Plaintiffs identify in detail the proposed relief they seek to modify the state’s residential service system. (Id. at Prayer for Relief ¶¶ 4(b)-4(c).) Defendants move to dismiss Plaintiffs’ claims under Rules 12(b)(1) and 12(b)(6) of the Federal Rules of Civil Procedure. (See Doc. No. 10.)

DISCUSSION

I. Legal Standard

A motion to dismiss under Federal Rule of Civil Procedure 12(b)(1) challenges the Court’s subject matter jurisdiction. To survive a motion to dismiss for lack of subject matter jurisdiction, the party asserting jurisdiction has the burden of proving jurisdiction. V S Ltd. P’ship v. Dep’t of Hous. & Urban Dev., 235 F.3d 1109, 1112 (8th Cir. 2000) (citation omitted). “Subject-matter jurisdiction is a threshold requirement which must be assured in every federal case.” Kronholm v. F.D.I.C., 915 F.2d 1171, 1174 (8th Cir. 1990).

A motion to dismiss for lack of subject matter jurisdiction may challenge a plaintiffs complaint either on its face or on the factual truthfulness of its averments. Osborn v. United States, 918 F.2d 724, 729 n.6 (8th Cir. 1990) (citations omitted). When a defendant brings a facial challenge — a challenge that, even if truthful, the facts alleged in a claim are insufficient to establish jurisdiction — a court reviews the pleadings alone, and the non-moving party receives the same protections as it would defending against a motion brought pursuant to Rule 12(b)(6). Id. (citation omitted). In a factual challenge to jurisdiction, the court may consider matters outside the pleadings, and the non-moving party does not benefit from the safeguards of Rule 12(b)(6). Id. at 728-30 n.4 (citations omitted) (holding that on a Rule 12(b)(1) motion challenging subject-matter jurisdiction, the court “has authority to consider matters outside the pleadings”).

In deciding a motion to dismiss pursuant to Rule 12(b)(6), a court assumes all facts in the complaint to be true and construes all reasonable inferences from those facts in the light most favorable to the complainant. Morton v. Becker, 793 F.2d 185, 187 (8th Cir. 1986). In doing so, however, a court need not accept as true wholly con-clusory allegations, Hanten v. Sch. Dist. of Riverview Gardens, 183 F.3d 799, 805 (8th Cir. 1999), or legal conclusions drawn by the pleader from the facts alleged, Westcott v. City of Omaha, 901 F.2d 1486, 1488 (8th Cir. 1990). A court may consider the complaint, matters of public record, orders, materials embraced by the complaint, and exhibits attached to the complaint in deciding a motion to dismiss under Rule 12(b)(6). Porous Media Corp. v. Pall Corp., 186 F.3d 1077, 1079 (8th Cir. 1999).

To survive a- motion to dismiss, a complaint must contain “enough facts to state a claim to relief that is plausible on its face.” Bell Atl. Corp. v. Twombly, 550 U.S. 544, 570, 127 S.Ct. 1955, 167 L.Ed.2d 929 (2007). Although a complaint need not contain “detailed factual allegations,” it must contain facts with enough specificity “to raise a right to relief above the speculative level.” Id. at 555, 127 S.Ct. 1955. As the United States Supreme Court reiterated, “[tjhreadbare recitals of the elements of a cause of action, supported by mere conclu-sory statements,” will not pass muster-under Twombly. Ashcroft v. Iqbal, 556 U.S. 662, 678, 129 S.Ct. 1937, 173 L.Ed.2d 868 (2009) (citing Twombly, 550 U.S. at 555, 127 S.Ct. 1955). In sum, this standard “calls for enough faet[s] to raise a reasonable expectation that discovery will reveal evidence of [the claim].” Twombly, 550 U.S. at 556, 127 S.Ct. 1955.

II. Justiciability

Defendants argue that Plaintiffs’ claims are non-justiciable for two reasons. First, Defendants assert that Plaintiffs lack standing to bring- their claims. Second, with respect to Plaintiffs’ claim under the Medicaid Act’s reasonable promptness requirement, Defendants argue that this claim is not ripe for review.

A. Standing

Defendants argue that Plaintiffs lack standing because they do not have a legally-protected interest in the provision of dedicated, trained, person-centered planners and therefore they fail to allege an injury in fact. Defendants also note that the Medicaid Act does not prohibit the provision of services in a congregate setting. Because the Secretary of the Department of Health and Human Services (“HHS”) has not determined that Plaintiffs’ residences aré not home and community-based settings under applicable federal regulations, Defendants argue that Plaintiffs cannot establish an imminent injury. In addition, Defendants argue that because one of the plaintiffs did receive person-centered-planning, she has no actual, concrete injury. Finally, Defendants argue that Plaintiffs cannot demonstrate redressability because it is wholly speculative that the services they seek will remedy the harm they allege.

Plaintiffs, on the other hand, argue that they have alleged a concrete injury — segregation — which is caused by Defendants and .which can be redressed by the requested relief. According to Plaintiffs,- the relief they seek includes: (1) reasonably prompt payment authorization and provision of services to develop individualized plans to move out of CRS facilities; and (2) reasonable modifications to the state’s residential service system so that they will have an opportunity to implement these plans. Plaintiffs contend that Defendants’ arguments regarding -standing ignore Plaintiffs’ fundamental injury of segregation.

“[Standing 'is a jurisdictional prerequisite that must be resolvéd before reaching the merits 'of a suit.” City of Clarkson Valley v. Mineta, 495 F.3d 567, 569 (8th Cir. 2007). “The party invoking federal jurisdiction bears the burden of establishing” standing. Lujan v. Defenders of Wildlife, 504 U.S. 555, 561, 112 S.Ct. 2130, 119 L.Ed.2d 351 (1992). The burden corresponds with the degree of evidence required at the relevant stage of litigation. Id. “Where ... a case is at the pleading stage, the plaintiff must ‘clearly ... allege facts demonstrating’ each element” of standing. Spokeo, Inc. v. Robins, — U.S. -, 136 S.Ct. 1540, 1547, 194 L.Ed.2d 635 (2016) (quoting Warth v. Seldin, 422 U.S. 490, 518, 95 S.Ct. 2197, 45 L.Ed.2d 343 (1975)). However, at this stage, “general factual allegations of injury ... may suffice.” Lujan, 504 U.S. at 561, 112 S.Ct. 2130; see also Iowa League of Cities v. E.P.A., 711 F.3d 844, 869 (8th Cir. 2013). If a plaintiff lacks standing, a district court has no subject matter jurisdiction over the matter and must dismiss the case. Young Am. Corp. v. Affiliated Comp. Servs., Inc., 424 F.3d 840, 843 (8th Cir. 2005).

. Article III of the Constitution limits the power of the federal courts to deciding only actual “cases” and “controversies.” U.S. Const., art. Ill, § 2, cl. 1. To establish .constitutional Article III standing, a plaintiff must demonstrate: (1) an injury-in-fact; (2) a causal connection between that injpy and the challenged conduct; and (3) the likelihood that a favorable. decision by the court will- redress the alleged injury. Lujan, 504 U.S. at 560, 112 S.Ct. 2130. These constitutional requirements of standing limit federal courts to deciding only cases where the plaintiffs can show a “personal injury fairly traceable to the defendant’s allegedly unlawful conduct and likely to be redressed by the requested relief.” Allen v. Wright, 468 U.S. 737, 751, 104 S.Ct. 3315, 82 L.Ed.2d 556 (1984).

The injury-in-fact requirement requires the plaintiff to demonstrate that he has experienced “an invasion of a legally protected interest which is (a) concrete and particularized, and (b) actual or imminent, not conjectural or hypothetical.” Lujan, 504 U.S. at 560, 112 S.Ct. 2130 (internal quotation marks and citations omitted). With respect to statutory violations, “Congress may ‘elevat[e] to the status of legally cognizable injuries concrete, de facto injuries that were previously inadequate in law.’” Spokeo, Inc., 136 S.Ct. at 1549 (quoting Lujan, 504 U.S. at 578, 112 S.Ct. 2130); see also Lujan, 504 U.S. at 578, 112 S.Ct. 2130 (noting as an example “injury to an individual’s personal interest in living in a racially integrated community”).

Where the, plaintiff alleges a statutory violation,, a concrete injury must still be established. Spokeo, Inc., 136 S.Ct. at 1549. However, the Supreme Court has explained that, “[although tangible injuries are perhaps easier to recognize, ... intangible injujies can nevertheless be concrete.” id A procedural violation may also meet the injury-in-fact -requirement “ ‘so long as the procedures in question are designed to protect some threatened concrete interest of [the petitioner] that is the ultimate basis .of his standing.’” Iowa League of Cities, 711 F.3d at 870-71 (quoting Lujan, 504 U.S. at 573 n.8, 112 S.Ct. 2130).

A plaintiff seeking injunctive relief must show that he “faces a threat of ongoing or future harm.” Park v. Forest Serv. of the United States, 205 F.3d 1034, 1037 (8th Cir. 2000). “Past exposure to illegal conduct does not in itself show a present case or controversy regarding in-junctive relief ... if unaccompanied by any continuing, present adverse effects.” O’Shea v. Littleton, 414 U.S, 488, 495-96, 94 S.Ct. 669, 38 L.Ed.2d 674 (1974). Likewise, a plaintiffs speculation that a future injury may occur is not sufficient to warrant injunctive relief. Id. at 497, 94 S.Ct. 669. A plaintiff must show that the threat of injury is “real and immediate,” Id. at 496, 94 S.Ct. 669.

The' Supreme Court has explained that “[w]hen the suit is one challenging the legality of government action or inaction” and “the plaintiff is himself an object of the action (or forgone action) at issue there is ordinarily little question that the action or inaction has caused him injury, and that a judgment preventing or requiring the action will redress it.” Lujan, 504 U.S. at 561-62, 112 S.Ct. 2130; see also Iowa League of Cities, 711 F.3d at 871. However, establishing redressability requires the plaintiff to show that it is “more than merely speculative that the relief requested would have any effect to redress the harm- to the plaintiff.” Young Am. Corp., 424 F.3d at 845 (quoting Hall v. LHACO, Inc., 140 F.3d 1190, 1196 (8th Cir. 1998)).

The primary injury Plaintiffs allege they are facing is segregation. While perhaps not tangible, this injury is indeed concrete and- particular < to Plaintiffs. Through the ADA and the RA, Congress has elevated the segregation of individuals .with disabilities “to the status of [a] legally cognizable injur[y].” See Spokeo, Inc., 136 S.Ct. at 1549 (quoting Lujan, 504 U.S. at 578, 112 S.Ct. 2130); see also Guggenberger, 198 F.Supp.3d at 1023-24 (providing an overview of relevant ADA and RA provisions). In the Amended Complaint,-Plaintiffs allege particular and personal examples of segregation. For example, Murphy asserts he “spends most of his time alone,” despite wishing “to interact with, other people.” (Am. Compl. ¶ 29(g).) Bottelson asserts that she “does not get out into, the community nearly as much as she would -if she were able to create her own schedule.” (Id. ¶ 30(f).) Swanson alleges that she has been told “she is not ‘independent enough’ for individualized housing,” and asserts a need for services so that she can “live in the most integrated setting, appropriate to her needs.” (Id. ¶¶ 31(b), 31(e).) Plaintiffs also allege that the injury of segregation can itself result in further harm for many individuals residing in CRS facilities, including diminishéd “social and independent living skills,” decreased likelihood of “living and working in the community” in the future, and “lower self-esteem and lowered expectations of themselves.” '(Id. ¶¶ 78-79.) These allegations sufficiently establish an injury-in-fact to support Plaintiffs’ claims under the ADA and the RA.

Plaintiffs’ concrete injury of segregation also supports standing to pursue their Medicaid Act and Due Process claims. As further discussed below, the Medicaid Act’s reasonable promptness and fair hearing requirements create privately enforceable rights that can be asserted in a § 1983 claim. Plaintiffs’ Amended Complaint illustrates how the alleged statutory violations of these provisions and the alleged violations of Plaintiffs’ Fourteenth Amendment Due Process rights correlate with the concrete injury they are facing through their ongoing segregation. In particular, Plaintiffs allege that they each receive a Disability Waiver to fund certain services. (Id. ¶ 2.) Plaintiffs allege that the services available under the Disability Waivers are “designed to help people with disabilities live in his or her own home and interact with the larger nondisabled community.” (Id. ¶¶ 33-34.) Plaintiffs also allege that specific Disability Waiver services, described as “individualized housing services,” exist that would permit them “to design and implement a customized setting for [them] to live, work, and enjoy leisure time in the most integrated setting.” (Id. ¶¶ 7, 82.) According to Plaintiffs, they are presently experiencing the concrete harm of segregation from their community because they are not receiving these services in a reasonably prompt manner (or at all) and’ have not received notice or information necessary to exercise their due process rights. Thus, Plaintiffs have standing to pursue these claims.

In light of the Court’s conclusions regarding Plaintiffs’ injury-in-fact, the Court concludes there is “little question” that Plaintiffs have adequately established causation and redressability at this stage. Lujan, 504 U.S. at 561-62, 112 S.Ct. 2130; see also Iowa League of Cities, 711 F.3d at 871. Plaintiffs allege numerous actions and inactions undertaken by Defendants that are causally connected to Plaintiffs’ failure to receive individualized housing services and their resulting segregation. For example, Plaintiffs contend that “Defendants approve the funding of Disability Waiver services in CRS facilities while failing to ensure that such a setting is the most integrated setting appropriate for the individual.” (Am. Compl. ¶70.) Plaintiffs also allege that Commissioner Johnson Piper “has failed to establish administrative procedures that ensure individuals who are qualified for and requesting services to help transition to a more integrated setting will actually receive those services.” (Id. ¶ 107.) Based on the detailed allegations in the Amended Complaint relating to Defendants’ role in overseeing the provision of Disability Waiver services throughout the state, Plaintiffs have established causation to support standing.

At the pleading stage, Plaintiffs have also adequately alleged that it is likely that their alleged injury will be redressed by the relief sought. Plaintiffs request declaratory and injunctive relief tied to Defendants’ purported violations of the Medicaid Act, the Fourteenth Amendment, the ADA, and the RA. In particular, Plaintiffs request an injunction that would require Defendants to provide prompt notice regarding the availability of individualized housing services to Disability Waiver recipients living in CRS facilities. (Am. Compl. at Prayer for Relief ¶ 4(a).) Plaintiffs also seek an order directing Defendants to “provide access and take prompt steps to make individualized housing services, including person-centered planning, available to Plaintiffs in a reasonable amount of time.” (Id. at Prayer for Relief ¶4⅛).) In addition, Plaintiffs request in-junctive relief requiring Defendants to take the necessary steps “to enable Plaintiffs to receive residential services in the most integrated setting appropriate to their needs.” (Id. at Prayer for Relief ¶ 4(c).) The Court is persuaded at this stage that these measures would likely redress Plaintiffs’ alleged harms. To be sure, Plaintiffs must ultimately provide evidence to support their allegations relating to the effectiveness of individualized housing services in leading to greater integration in the community. At this stage, however, Plaintiffs’ factual allegations suffice to establish standing.

In sum, the Court concludes that Plaintiffs have adequately established standing. With respect to each claim, Plaintiffs allege particular, concrete harms to their legally-protected interests which are caused by Defendants and likely to be redressed by the requested relief. In particular, the Court concludes that Plaintiffs have adequately established standing to pursue injunctive relief by alleging “ongoing ... harm” and “continuing, present adverse effects” of Defendants’ prior conduct. See Park, 205 F.3d at 1037; O’Shea, 414 U.S. at 495-96, 94 S.Ct. 669.

B. Ripeness

Defendants also question the justiciability of Plaintiffs’ Amended Complaint with respect to Count I, Plaintiffs’ Medicaid Act’s reasonable promptness claim. According to Defendants, this claim is not ripe because federal regulations relating to the provision of home and community-based waiver services have established a transition period for states to come into compliance with new regulations defining what constitutes a community-based setting. Defendants assert that Plaintiffs’ reasonable promptness claim is not ripe because the state is in the process of implementing a transition plan to come into compliance with these regulations, and the state does not need to establish compliance until the transition period is over.

Plaintiffs counter that their claims are ripe. Plaintiffs assert that they have alleged a direct injury, and the issues presented are fit for judicial review. Plaintiffs argue that Defendants’ violations of the reasonable promptness provision result in actual ongoing harms and do not depend on contingent future events. In addition, Plaintiffs suggest that Defendants have not articulated how further factual developments relating to the new federal regulations will address Plaintiffs’ claims under the reasonable promptness provision. Plaintiffs contend that their harms will continue to exist even if the HHS Secretary determines that the settings in which they reside are “community-based” under the 2014 rule.

As with standing, the ripeness doctrine ensures that a court’s exercise of jurisdiction meets both the constitutional requirements of Article III and prudential limitations. See Neb. Pub. Power Dist. v. MidAmerican Energy Co., 234 F.3d 1032, 1037 (8th Cir. 2000). The Supreme Court has explained:

[The ripeness doctrine’s] basic rationale is to prevent the courts, through avoidance of premature adjudication, from entangling themselves in abstract disagreements over administrative policies, and also to protect the agencies from judicial interference until an administrative decision has been formalized and its effects felt in a. concrete way by the challenging parties. The problem is best seen in a twofold aspect, requiring us to evaluate both the fitness of the issues for judicial decision and the hardship to the parties of withholding court consideration.

Abbott Labs. v. Gardner, 387 U.S. 136, 148-49, 87 S.Ct. 1507, 18 L.Ed.2d 681 (1967).

Under the fitness factor, “[t]he case is more likely to be ripe if it poses a purely legal question and is not contingent on future possibilities.” Pub. Water Supply Dist. No. 10 of Cass Cty. v. City of Peculiar, Mo., 345 F.3d 570, 573 (8th Cir. 2003); see also Parrish v. Dayton, 761 F.3d 873, 875-76 (8th Cir. 2014). Even if a dispute raises some contingencies, however, a court may properly exercise review “where an issue is -largely legal in nature, may be resolved without further factual development, or where judicial resolution will largely settle the. parties’ dispute,” Neb. Pub. Power, 234 F.3d at 1038, (citations omitted).

Under the hardship factor, a court may consider both financial harm and harm caused by “uncertainty-induced behavior modification in the absence of judicial review.” Iowa League of Cities, 711 F.3d at 867. The immediacy and directness of the harm is also relevant. See Abbott Labs., 387 U.S. at 152, 87 S.Ct. 1507. The ripeness factors “are weighed-on a sliding scale, but each must be satisfied ‘to at least a minimal degree.’ ’’ Iowa League of Cities, 711 F.3d at 867.

The Eighth Circuit has previously identified “the extent to which judicial intervention would interfere with administrative action” as a third relevant factor in the ripeness inquiry. Nat’l Right to Life Political Action Comm. v. Connor, 323 F.3d 684, 692-93 (8th Cir. 2003). An assertion Of ongoing agency action, however, will not always prevent the court’s exercise of jurisdiction. See 13B Charles Alan Wright et al., Federal Practice & Procedure § 3532.6 (3d ed. Apr. 2017 Update) (“[A]ny agency attempt to defeat review by the bare assertion that the agency position may some day change should be summarily rejected.”). In addition, “protracted inaction by state officials may itself be a wrong, or at least defeat any claim that a federal court should await further state developments.” Id. § 3532.3; see also Groome Resources Ltd., L.L.C. v. Parish of Jefferson, 234 F.3d 192, 199-200 (5th Cir. 2000). Further, ripeness is not automatically defeated by ongoing revision or implementation of an - administrative agency’s regulatory plan, see Ohio Envtl. Council v. U.S. Dist. Court, S. Dist. of Oh., E. Div., 565 F.2d 393, 397-98 (6th Cir. 1977), or by the possibility of future regulatory changes, see Am. Petroleum Inst. v. U.S. Envtl. Prot. Agency, 906 F.2d 729, 739-40 (D.C. Cir. 1990).

The Court concludes that Plaintiffs’ reasonable promptness claim is presently ripe for review. Under this claim, Plaintiffs present issues that are fit for. judicial review, and the Court is not persuaded that further factual developments will materially impact the Court’s analysis of this claim. Even if the CRS facilities in which Plaintiffs reside are eventually determined not to run afoul of the home and community-based service regulations regarding congregate settings, Plaintiffs presently have a viable claim based on Defendants’ failure to ensure prompt provision of individualized housing services under the Disability Waivers. Plaintiffs allege that Disability Waiver funds can be utilized “to design and implement a customized setting for the individual to.live, work, and enjoy leisure time in the most integrated setting.” (Am. Compl. ¶ 7.) Such a setting may also, include “homes of their own.” {Id, ¶ 84.)

Notwithstanding the ultimate determination under new federal regulations regarding whether the CRS facilities in which Plaintiffs reside are determined to be proper settings in which Disability Waiver funding can be utilized, Plaintiffs assert that these facilities are not the most-integrated setting for them at this time. {Id. ¶¶ 29(m), 30(f), 31(e).) The resolution of Plaintiffs’ claims, therefore, does not depend on further factual developments relating to the new federal regulations. In addition, as the Court detailed above, Plaintiffs have adequately alleged that they are presently facing direct, ongoing harms based on Defendants’ alleged failure to provide reasonably prompt access to Disability Waiver services that could facilitate their transition to more integrated settings. Plaintiffs acknowledge that Defendants have implemented certain plans and protocols in these areas, but allege that these measures are inadequate to remedy their alleged harms. (See id. ¶¶ 53-63.) Although Defendants are implementing a transition plan that may impact the Court’s evaluation of Plaintiffs’ reasonable promptness claim, the Court concludes this claim is ripe.

III. Plaintiffs’ Claims

A. Count I: Reasonable Promptness Under the Medicaid Act

Count I of Plaintiffs Amended Complaint alleges a violation of 42 U.S.C. § 1983 through failure to furnish services with reasonable promptness in violation of 42 U.S.C. § 1396a(a)(8). Defendants argue that Plaintiffs have failed to state a claim with respect to Count I,

The reasonable promptness requirement provides that “[a] State plan for medical assistance must ... provide that all individuals wishing to make application for medical assistance under the plan shall have opportunity to do so, and that such assistance shall be furnished with reasonable promptness to all eligible' individuals.” 42 U.S.C. § 1396a(a)(8). Payment for home and community-based Disability Waiver services is deemed “medical assistance” under the Medicaid Act. See 42 U.S.C. § 1396n(c)(l). Regulations also require the state to establish time standards to determine an individual’s eligibility for Medicaid in no more than ninety days and to “[f]ur-nish Medicaid promptly to beneficiaries without any delay caused by the agency’s administrative procedures.” See 42 .C.F.R. § 435.912; id. § 435.930; see also Doe ex rel. Doe v. Chiles, 136 F.3d 709, 717 (11th Cir. 1998); Boulet v. Cellucci, 107 F.Supp.2d 61, 72-73 (D. Mass. 2000).

Plaintiffs assert their reasonable promptness claim under 42 U.S.C. § 1983. Before proceeding to Defendants’ particular challenges to . Plaintiffs’; reasonable promptness claim, the Court incorporates and adopts its analysis and holding in Guggenberger and concludes that the reasonable promptness provision is privately enforceable under § 1983 for eligible individuals. See Guggenberger, 198 F.Supp.3d at 1006-07. Plaintiffs, current Disability Waiver recipients, may privately enforce their right to reasonably prompt medical assistance via § 1983 in this case.

Defendants raise numerous challenges to Plaintiffs’ claim alleging a violation of the Medicaid Act’s reasonable promptness requirement." First, Défen-dants assert that Plaintiffs’ reasonablé promptness claim is inadequately pled because Plaintiffs have failed to allege facts regarding how long they have waited for services. Defendants point' to cases in which plaintiffs alleged waiting several years for waiver services. Here, however, Defendants argue that Plaintiffs have made no such factual allegations. Second, Defendants assert that waiver services are not an entitlement, and guidance from the Center for Medicare and Medicaid ’ Services (“CMS”) suggests states cannot be held responsible for delays resulting from a lack of available providers. Defendants also reference the five-year transition period for bringing state Medicaid plans into compliance with the new federal regulations relating to . home.: and community based services and person-centered planning. Third, Defendants argue that Plaintiffs have failed to allege that “individualized housing services” were requested by Plaintiffs or authorized by counties. Defendants assert that “[without more detailed allegations regarding determination of need and prior authorization,” Plaintiffs’ reasonable promptness claim fails. (Doc. No. 24 at 5-6.) Fourth, Defendants acknowledge that the Medicaid Act defines “medical assistance” to include payment or provision of services or both, but argue that states need not provide all services.

Plaintiffs argue that they have pled a viable reasonable promptness claim. First, Plaintiffs argue that “Defendants’ inconsistent management of the [Disability Waiver program] ... prevents Plaintiffs from being authorized for receiving these services, let alone in a timely manner (and sometimes at all).” (Doc. No. 22 at 26.) Plaintiffs contend that they have adequately alleged that they made requests for services and have not received such services for varying periods of time or indefinitely. Second, Plaintiffs argue that the reasonable promptness requirement applies to both payment for and provision of services. Third, Plaintiffs argue that there is no particular time frame required to state a reasonable promptness claim. Plaintiffs also suggest that the deadline to comply with new federal regulations governing Disability Waivers does not make Defendants’ delay in this case reasonably prompt. Fourth, Plaintiffs argue that the reasonable promptness provision applies to Disability Waiver services even if they are not an absolute entitlement.

The Court again finds its prior analysis and reasoning in Guggenberger to be instructive. See generally Guggenberger, 198 F.Supp.3d at 1007-14. The plaintiffs in Guggenberger asserted a § 1396a(a)(8) reasonable promptness claim based on being placed on waiting lists for Disability Waiver services when funds were allegedly available to provide them with services. Id. at 1013. The Court summarized relevant caselaw pertinent to the reasonable promptness inquiry and identified multiple relevant “principles courts should consider when applying § 1396a(a)(8)’s requirement that medical assistance.‘shall be furnished with reasonable promptness to all eligible individuals’ in the context of Waiver Services,” Id. at 1012.

First, “individuals who qualify for Waiver Services do not have an absolute entitlement to such services.” Id. As numerous courts have determined, some limits on the allocation of Disability Waiver services may be appropriate and reasonable. See id. (citing Bertrand v. Maram, 495 F.3d 452, 457 (7th Cir. 2007); Bryson v. Shumway, 308 F.3d 79, 86 (1st Cir. 2002); Susan J. v. Riley, 254 F.R.D. 439, 448 (M.D. Ala. 2008); Makin ex rel. Russell v. Hawaii, 114 F.Supp.2d 1017, 1021-23 (D. Haw. 1999)). At the same time, “with respect to otherwise eligible individuals ... for whom funding is available, a state’s failure to fill available waiver slots or use funding appropriated for Waiver Services may violate the reasonable promptness requirement or at least raise questions as to whether such a violation has occurred.” Guggenberger, 198 F.Supp.3d at 1012 (citing Bryson, 308 F.3d at 89; Lewis v. New Mexico Dep’t of Health, 275 F.Supp.2d 1319, 1345 (D.N.M. 2003); Boulet, 107 F.Supp.2d at 78-89; Makin, 114 F.Supp.2d at 1028, 1031). In particular, “[b]ecause Medicaid regulations require the state to ‘[flurnish Medicaid promptly to beneficiaries without any delay caused by the agency’s administrative procedures,’ see 42 C.F.R. § 435.930, a state’s mismanagement of allocated funding, which leads to an unreasonable delay in the provision of services, may establish a violation of the reasonable promptness requirement.” Guggenberger, 198 F.Supp.3d at 1012. In Guggenberger, the Court determined under these principles that the plaintiffs plausibly stated a reasonable promptness claim based on the state defendants’ alleged mismanagement of available Waiver Services funding. Id. at 1013.

In this case, Plaintiffs are not on waiting lists but rather are actually enrolled recipients of a Disability Waiver. Their reasonable promptness claim rests on the allegedly unwarranted delay in receiving access to certain services available under the Disability Waivers. Along with the principles summarized above and discussed in Gug-genberger, Defendants have identified relevant HHS Guidance that provides additional principles to illuminate the Court’s analysis of this - claim. •See U.S. Dep’t of Health & Human Services, Olmstead Update No: 4, HCFA Update (Jan. 10, 2001) (“2001 HHS Guidance”), available at Doc. No. 13-1 at 36. According to this guidance, “[a] State is obliged to provide all people enrolled in the waiver with the opportunity for access to all needed services covered by the waiver and the Medicaid State plan.” Id. at 5. As with the placement of individuals onto Disability Waivers itself, however, states may reasonably limit access to services available under a waiver. Specifically, “[t]he State may impose reasonable and appropriate limits or utilization control procedures based on the need that individuals have for services covered under the waiver.” Id. at 5-6.

Thus, whether an individual has a right to receive a certain service “is dependent on a finding that the individual needs the service, based on appropriate assessment criteria that the State develops and applies fairly to all waiver enrollees.” Id. at 6. In addition, the HHS guidance acknowledges that, states may be limited in their ability to timely provide certain services based on constraints such as “supply of providers, or similar factors.” Id. While recognizing these limits, the 2001 HHS Guidance also notes the following important principle: “Once in the waiver, an enrolled individual enjoys protection against arbitrary acts or inappropriate restrictions, and the State assumes an obligation to assure the individual’s health and welfare.” Id. Ultimately, “the question of reasonable promptness is a difficult one,” and many variables must be considered to evaluate whether a state is providing needed Disability Waiver services in a reasonably prompt manner. See id. (noting variables including “[t]he urgency of an individual’s need, the health and welfare concerns of the individual, the nature of the services required, the potential need to increase the supply of providers, [and] the availability of similar or alternative services”).

At this stage, the Court concludes that Plaintiffs have stated a viable reasonable promptness claim based on Defendants’ alleged failure to ensure reasonably prompt access to the individualized housing services they seek. Defendants acknowledge that the particular services Plaintiffs identify in their Amended Complaint-Housing Access. Coordination and Transition Services and Family Training and Counseling — are available under the Disability Waivers. (Doc. No. 12 at 4-5.) Specifically, Defendants agree that “waiver services will cover the cost of a dedicated, professional person-centered planner.” (Doc. No. 12 at 12.) However, Defendants simply assert that they cannot be required to provide these services upon request. In particular, Defendants argue.that Plaintiffs fail to state a claim because they have not alleged the particular lengths of time they have been waiting and have not alleged that they were authorized by local agencies to receive the requested services.

First, the Court disagrees that individuals must allege a particular length of delay to adequately state a violation of the reasonable promptness provision. Here, Plaintiffs assert ¡that they have made requests for services and yet remain “stuck” in their current living arrangements. (See Am. Compl. 1fH.29(k), 29(m), 29(n), 30(d), 30(k), 30(ü), 31(e), 31(f).) Murphy asserts his guardian “has asked several people at the lead agency about accessing-more individualized housing options.” (Id ¶ 29(k).) Bottelson has similarly made requests of multiple case managers since at least 2013. (Id. ¶¶ 30(i), 30(j).) Swanson alleges she has asked for individualized housing services “for a long time” without receiving any. (Id ¶ 31(f).) Plaintiffs also allege that “Defendants currently approve some limited individualized alternatives for a small number of Disability Waiver recipients.” (Id ¶ 67.) The Court concludes that Plaintiffs’ allegations of seemingly arbitrary and inexplicable failures to adequately respond to requests for services adequately support a reasonable promptness claim..

Second, to the extent there remains any disagreement between the parties on this issue, the Court concludes that the reasonable promptness’ provision applies to both the payment for services and the provision of services themselves. Th’e Medicaid Act defines “medical assistance” as “payment of part or all of the cost of ...' care and services' or the care and services themselves, or both.... ” 42 U.S.C. § 1396d(a). The Court joins the numerous other courts interpreting this statutory provision who have determined that “Congress intended to clarify’ that where the Medicaid Act refers to the provision of services, a participating State -is required to provide (or ensure the provision of) services, not merely to pay for them.” O.B. v. Norwood, 838 F.3d 837, 843 (7th Cir. 2016) (quoting A.H.R. v. Washington State Health Care Auth., 2016 WL 98513, at *12 (W.D. Wash. Jan. 7, 2016)); see also Leonard v. Mackereth, 2014 WL 512456, at *6-7 (E.D. Penn. Feb. 10, 2014) (explaining how the legislative history underlying the amended definition of “medical assistance” supports this interpretation). While numerous factors, must be evaluated to determine whether certain services are being provided in a reasonably prompt manner, the statutory language clearly covers both funding and services.

Finally, the Court concludes that Plaintiffs’ failure to allege prior authorization for individualized housing services is not fatal to their claim. Critically, Plaintiffs appear- to agree that they have not been previously- authorized for the services they seek. However, the Court c