AI Generated Opinion Summaries

This summary was computer-generated without any editorial revision. It is not official, has not been checked for accuracy, and is NOT citable.

Facts

• Plaintiffs, representing a certified class of pharmacists, contended they were not properly reimbursed for their services under Medicaid, arguing that the New Mexico Human Services Department (HSD) and managed care organizations (MCOs), which administered Medicaid for the State of New Mexico, were required to pay them in accordance with NMSA 1978, Section 27-2-16(B) but refused to do so. The transition from a fee-for-service model to a managed care model led to disputes over reimbursement rates and the applicability of Section 27-2-16(B) to the new managed care contracts.

Procedural History

• District Court, Bernalillo County: Dismissed claims against MCOs and HSD for violation of Section 27-2-16(B), breach of contract, third-party beneficiary breach of contract, unjust enrichment, declaratory relief, and injunctive relief.
• Court of Appeals of New Mexico: Affirmed in part, reversed in part, and remanded for further proceedings.

Parties' Submissions

• Plaintiffs: Argued they were not properly reimbursed according to Section 27-2-16(B), and that their contracts with MCOs and HSD's contracts with MCOs entitled them to certain reimbursements. They also claimed unjust enrichment on the part of the MCOs and sought declaratory and injunctive relief.
• Defendant-Appellee (HSD): Contended that Plaintiffs waived any claim to additional reimbursement by entering into contracts with MCOs and that retroactive federal approval of reimbursement rates was sufficient.
• Defendant-Appellee/Cross-Appellant (MCOs): Argued that Section 27-2-16(B) did not apply to managed care and that Plaintiffs were not intended third-party beneficiaries of the contracts between HSD and the MCOs. They also contested the class certification.

Legal Issues

• Whether Section 27-2-16(B) confers an implied cause of action for participating Medicaid pharmacists against MCOs.
• Whether Plaintiffs waived their rights to additional reimbursement by entering into contracts with MCOs.
• Whether Plaintiffs can bring a breach of contract claim against HSD and a third-party beneficiary contract claim against MCOs.
• Whether Plaintiffs' class was properly certified.

Disposition

• The Court of Appeals held that Section 27-2-16(B) does confer an implied cause of action against MCOs, reversed the district court's dismissal of Plaintiffs' breach of contract and third-party beneficiary claims, and affirmed the district court's denial of declaratory and injunctive relief and the class certification.

Reasons

• The Court of Appeals found that Section 27-2-16(B) applies to the MCOs and managed care, creating an implied cause of action for pharmacists. It also held that Plaintiffs did not waive their rights under Section 27-2-16(B) by contracting with MCOs, as their participation in managed care was mandated by HSD, and their contracts included provisions consistent with Section 27-2-16(B). The court further determined that Plaintiffs could bring a breach of contract claim against HSD and a third-party beneficiary claim against the MCOs, as the contracts were intended to benefit them by ensuring compliance with Section 27-2-16(B). The court also affirmed the class certification, finding that the class met the requirements of Rule 1-023 NMRA and that no due process rights were violated in the certification process.