Appeal of Ethel Bolden Mary Dyer v. Blue Cross & Blue Shield Association, Inc.

848 F.2d 201, 270 U.S. App. D.C. 144, 1988 U.S. App. LEXIS 6413, 1988 WL 50170
CourtCourt of Appeals for the D.C. Circuit
DecidedMay 17, 1988
Docket87-5012
StatusPublished
Cited by36 cases

This text of 848 F.2d 201 (Appeal of Ethel Bolden Mary Dyer v. Blue Cross & Blue Shield Association, Inc.) is published on Counsel Stack Legal Research, covering Court of Appeals for the D.C. Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Appeal of Ethel Bolden Mary Dyer v. Blue Cross & Blue Shield Association, Inc., 848 F.2d 201, 270 U.S. App. D.C. 144, 1988 U.S. App. LEXIS 6413, 1988 WL 50170 (D.C. Cir. 1988).

Opinion

Opinion for the Court filed by Senior Circuit Judge MacKINNON.

MacKINNON, Senior Circuit Judge:

Two classes of former enrollees in the Blue Cross and Blue Shield Association (“Blue Cross”) Government-Wide Service Benefit Plan, who withdrew from the Plan or changed plans prior to May 1, 1985, bring this action to compel their inclusion in a $784 million refund by Blue Cross of excess contingency reserve funds, which refund is presently limited to enrollees who were subscribers in a Blue Cross plan as of May 1, 1985. Plaintiffs contend that the decision of the Office of Personnel Management (“OPM”) to approve the refund proposal was “arbitrary, capricious and an abuse of discretion or otherwise not in accordance with law.” 5 U.S.C. § 706(2)(A). The district court upheld the decision by OPM, concluding that limiting the refund to those enrolled in Blue Cross as of May 1, 1985 was rational and supported by the record. Bolden v. Blue Cross and Blue Shield Association, 669 F.Supp. 1096, 1106 (D.D.C.1986). We affirm.

I. Background

A. Statutory Framework

In 1959, Congress created a subsidized health insurance program as a benefit for civilian employees and annuitants of the federal government. Federal Employees Health Benefits Act of 1959, 5 U.S.C. §§ 8901 et seq. (“the Act”). With almost 300 plans participating the program is competitive. During a four week “open sea *203 son” each year, federal employees and annuitants can compare and change plans. 5 U.S.C. § 8905(e); 5 C.F.R. § 890.301(d).

Under the Act, the Office of Personnel Management is given broad authority to administer the Federal Employees Health Benefits Program (“the Program”). OPM contracts with insurance carriers to provide health insurance benefits and each year renegotiates the coverage and rates based upon prior experience and insurance industry practice. 5 U.S.C. § 8902(i). OPM attempts to set the rates of the various plans so they will be sufficient to cover future claims and overhead costs and maintain surplus funds for unexpected costs. 5 U.S. C. §§ 8902(i), 8909(b).

“Reserves” are required to be established to meet anticipated claims. 5 U.S.C. § 8909(b); 5 C.F.R. § 890.503. Many uncertain factors affect program costs, such as the number of enrollees who will move in and out of a plan and the amount and cost of health care services that enrollees will require. GAO Report, App. 705; S.Rep. No. 468, 86th Cong., 1st Sess. 18 (1959). These uncertainties make it improbable that any premium rates negotiated by OPM will exactly equal future costs. The reserves can be drawn upon when health care claims exceed annual program income. Program reserves are held partly by the government in “contingency reserves” which are earmarked for each carrier, and partly by the participating carriers in a “special reserve.”

After the premium rates are set for the next contract year, OPM determines the amount of the government’s contributions. 5 U.S.C. § 8906. The part of the premium not paid by the government is withheld from the pay of each enrolled employee and from the annuity of each enrolled annuitant. 5 U.S.C. § 8906(d). The set premium may not be changed during the contract year. Employees and annuitants receive the contract benefits during the year at the contracted rate whether costs and claims are unexpectedly high, requiring a charge against reserves, or low, resulting in a surplus. 5 U.S.C. § 8902(i).

Government and enrollee contributions to the Employees Health Benefits Fund, which is controlled by OPM, 5 U.S.C. § 8909(a), may be used for three purposes. First, a percentage, not to exceed one percent of all contributions, determined by OPM, is used to pay OPM’s administrative expenses. 5 U.S.C. § 8909(b)(1).

Second, a percentage, not to exceed three percent of all contributions, determined by OPM, may be used to establish a contingency reserve for each plan. 5 U.S.C. § 8909(b)(2). Contingency reserve funds may be used to compensate for underestimates of claims costs and may be transferred to a plan’s special reserve if underestimated claims create a deficit in the special reserve. 5 C.F.R. § 890.503(c). Similarly, excess special reserves may be transferred to a plan’s contingency reserve. 5 U.S.C. § 8909(b); 5 C.F.R. § 890.503(c)(1)(v). Contingency reserves may be used, at OPM’s discretion, for three purposes: (1) to defray increases in future rates; (2) to reduce the contributions of the government and enroll-ees; or (3) to increase the benefits provided by a plan. 5 U.S.C. § 8909(b).

Third, the remaining contributions by en-rollees to each plan are paid into that plan’s special reserves, which are used to pay enrollees’ health insurance claims. Surplus or deficit special reserves are carried over each year and become a factor in determining the appropriate rate for the following year. 41 C.F.R. § 16-4.152-1(b)(2). OPM may lower enrollees’ premium rates to draw down a plan’s surplus special, or it may increase rates to recover from a deficit reserve balance. In both cases it is the subscribers who are enrolled for the current contract year that benefit or suffer.

B. Factual Background

Unanticipated large cost increases in the medical field and high use of health care services by enrollees created financial problems for health plans in the early 1980’s. Blue Cross had a $150 million deficit in its Federal Employee Health Benefit Plan (the “Plan”) special reserve by the end of 1981. In response to the deficits, OPM introduced major cost containment, benefit reduction *204

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Bluebook (online)
848 F.2d 201, 270 U.S. App. D.C. 144, 1988 U.S. App. LEXIS 6413, 1988 WL 50170, Counsel Stack Legal Research, https://law.counselstack.com/opinion/appeal-of-ethel-bolden-mary-dyer-v-blue-cross-blue-shield-association-cadc-1988.