American Chiropractic Ass'n v. Shalala

108 F. Supp. 2d 1, 2000 U.S. Dist. LEXIS 11127, 2000 WL 1133276
CourtDistrict Court, District of Columbia
DecidedJuly 7, 2000
DocketCIV.A. 98-2762 SSH
StatusPublished
Cited by6 cases

This text of 108 F. Supp. 2d 1 (American Chiropractic Ass'n v. Shalala) is published on Counsel Stack Legal Research, covering District Court, District of Columbia primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
American Chiropractic Ass'n v. Shalala, 108 F. Supp. 2d 1, 2000 U.S. Dist. LEXIS 11127, 2000 WL 1133276 (D.D.C. 2000).

Opinion

OPINION AND ORDER

STANLEY S. HARRIS, District Judge.

Before the Court are defendant’s motion to dismiss, plaintiffs opposition, defendant’s reply thereto, and various filings related to the briefing of the motion to dismiss. 1 Upon consideration of these submissions and plaintiffs amended complaint, the Court grants defendant’s motion with respect to Count I, and directs the parties to submit supplemental memo-randa with respect to the administrative adjudication of the claims alleged in Counts II-V. Although findings of fact and conclusions of law are unnecessary on decisions of motions under Rule 12 or 56, see Fed.R.Civ.P. 52(a); Summers v. Department of Justice, 140 F.3d 1077, 1079-80 (D.C.Cir.1998), the Court nonetheless sets forth its reasoning.

*3 I. BACKGROUND

Plaintiff American Chiropractic Association (“ACA”) brings this action against the Secretary of Health and Human Services (the “Secretary”) on behalf of chiropractors who are members of its organization. Plaintiff alleges that certain chiropractic services are not being provided or made available to Medicare beneficiaries to the extent required by statute.

A. Overview of the Medicare Program

Established in 1965 under Title XVIII of the Social Security Act, 42 U.S.C. § 1395 et seq., the Medicare program provides government-subsidized health insurance for elderly and disabled individuals. Part A of title XVIII provides basic coverage for certain hospital and hospital-related services, home health services, and hospice care. See 42 U.S.C. § 1395c. Part B of title XVIII provides supplemental insurance coverage, and is financed jointly by contributions from the federal government and voluntary premium payments from en-rollees. See id. §§ 1395j, 1395k. Under Parts A and B, Medicare pays for covered services on a “fee-for-service” basis.

In addition to the fee-for-service system under Parts A and B, Congress established a managed care system involving health maintenance organizations (“HMOs”) and competitive medical plans (“CMPs”) in 1982. See id. § 1395mm. Under this system, Medicare beneficiaries can receive their benefits through HMOs or organizations meeting certain criteria enumerated in 42 U.S.C. § 1395mm(b)(2). Eligible organizations are required to provide coverage for all services covered under Parts A and B. See id. § 1395mm(e)(2)(A). Medicare pays the participating organizations a monthly, predetermined amount for each enrollee, regardless of whether the enrollee receives services, pursuant to “risk contracts” entered into between the Secretary and the organization. See id. § 1395mm(g)(3).

The HMO/CMP program is gradually being phased out in favor of the “Medicare + Choice” (“M + C”) program. See id. § 1395mm(k)(l). In 1997, Congress established the M + C program as a new “Part C” to title XVIII. See id. §§ 1395w-21 — 1395w-28. In order to be eligible for Part C coverage, an individual must be entitled to benefits under Part A and enrolled under Part B. See id. § 1395w-21(a)(3). Eligible individuals can elect to receive benefits under an M + C plan from an M + C organization as an alternative to coverage under Parts A and B. See id. § 1395w-21(a)(l). An M + C plan may be any of the following: a “coordinated care plan” which provides services through a defined network of providers, as in the case of a health maintenance organization (“HMO”); a “medical savings plan” under which M + C organizations provide deductible insurance coverage and funds are deposited in a “Medical Savings Account”; and a “private fee-for-service plan” operated by an M + C organization, under which enrollees may receive services from providers willing to accept the organization’s payment rates, and payments are made on a fee-for-service basis. Id. § 1395w-21(a)(2). Under all of these M + C plans, Medicare pays a fixed amount to the organization on behalf of the enrollee, regardless of whether the enrollee receives services. See id. § 1395w-23. M + C organizations are required to provide coverage for all benefits covered under Parts A and B. See id. § 1395w-22(a).

B. Medicare Coverage for Chiropractic Services

Part B provides coverage for, inter alia, “physician services.” Id. § 1395k(a)(2)(B)(i). When Medicare was originally established, “physician services” did not include services provided by a chiropractor. However, in 1972, Congress amended the definition of “physician” to include chiropractors for certain limited services. As a result of this amendment, a physician authorized to provide a covered physician service now includes:

*4 a chiropractor who is licensed as such by the State (or in a State which does not license chiropractors as such, is legally authorized to perform the services of a chiropractor in the jurisdiction in which he performs such services), and who meets uniform minimum standards promulgated by the Secretary, but only for the purpose of subsections (s)(l) and (s)(2)(A) of this section and only ivith respect to treatment by means of manual manipulation of the spine (to correct a subluxation) which he is legally authorized to perform by the State or jurisdiction in which such treatment is provided.

Id. § 1395x(r)(5)(emphasis added). Thuá,, Medicare provides coverage for manual manipulations / of the spine to correct a subluxation (hereinafter “manual manipulations”) performed by chiropractors. As discussed below, the parties disagree over the scope of this coverage. Plaintiff argues that Medicare covers only those manual manipulations performed by chiropractors, while defendant argues that it covers manual manipulations performed by chiropractors, as well as by other qualified practitioners meeting the definition of a physician for the purpose of rendering “physician services,” such as doctors of medicine or osteopathy. See id. § 1395x(r)(l).

In § 4204(f) of the Omnibus Budget Reconciliation Act of 1990 (“OBRA”), Congress required the Secretary to “conduct a study of the extent to which health maintenance organizations with contracts under [42 U.S.C. § 1395mm] make available to enrollees entitled to benefits under title XVIII of [the Social Security] Act chiropractic services that are covered under such title.” Pub.L. No. 101-508, § 4204(f), 104 Stat. 1388, 112 (1990), as amended by Pub.L. No. 103-432, § 157, 108 Stat. 4398, 4442 (1994).

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Related

Eisenberg v. Social Security Administration
703 F. Supp. 2d 27 (District of Columbia, 2010)
American Chiropractic Ass'n v. Leavitt
431 F.3d 812 (D.C. Circuit, 2005)
American Chiropractic Ass'n, Inc. v. Shalala
131 F. Supp. 2d 174 (District of Columbia, 2001)

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Bluebook (online)
108 F. Supp. 2d 1, 2000 U.S. Dist. LEXIS 11127, 2000 WL 1133276, Counsel Stack Legal Research, https://law.counselstack.com/opinion/american-chiropractic-assn-v-shalala-dcd-2000.