Blue Cross of Massachusetts, Inc. v. Commissioner of Insurance

392 Mass. 178
Massachusetts Supreme Judicial Court·Decided June 11, 1984·Published·Cited by 1 cases

Opinion

Hennessey, C.J.

The plaintiffs are nonprofit corporations which provide coverage for certain hospital and medical services to their subscribers. Through their joint “Medex” program, they provide Medicare supplement coverage, which covers certain deductibles and copayments for which Medicare beneficiaries are otherwise responsible. By regulation of the Commissioner of Insurance (Commissioner), nongroup Medicare [179] supplement coverages must provide that “benefits will be auchanged to match any changes in [Medicare] cost sharing.” 211 Code Mass. Regs. § 47.07 (1980). The plaintiffs’ Medex certificates so provide. Thus, when Medicare benefits are decreased under Federal regulations, the amount of the benefits which the plaintiffs must pay to their subscribers under their Medicare supplement coverage automatically increases.

The approval of the Commissioner is required before changes in Medex rates can become effective. G. L. c. 176A, § 6. In the spring of 1982, the Commissioner approved an increase in Medex rates, effective June 1, 1982. The rates submitted by the plaintiffs and approved by the Commissioner were based on “the assumption that they [would] remain in effect for each subscriber for a full 12-month period.” In calculating the rates, the plaintiffs projected an increase in the Medicare inpatient hospital deductible and related copayments, effective January 1, 1983.2 In addition, the rates reflected a projected increase in the cost of physicians’ services coinsurance coverage,3 due to projected increased claim incidence and projected increased average cost per claim. However, no change in the type of physicians’ services subject to the Medicare coinsurance requirement was anticipated.

When the plaintiffs submitted their rates in the spring of 1982, the Medicare statute provided, as an exception to the physicians’ services coinsurance requirement, for payment of 100% of expenses incurred for inpatient services of pathologists and radiologists. By an amendment to the statute, effective October 1, 1982, this exception was deleted. See Tax Equity and Fiscal Responsibility Act of 1982, Pub. L. 97-248, § 112, [180] 96 Stat. 324, 340 (1982), amending 42 U.S.C. § 13957(a) (1) (1976). Thus Medicare beneficiaries or their supplemental coverage carriers became responsible for twenty per cent of the charges for these services. By virtue of the Commissioner’s regulation, as reflected in Medex certificates, the plaintiffs were required to cover their subscribers for these costs. In addition, late in 1982, the plaintiffs learned that the increase in the Medicare inpatient hospital deductible and related copayments, effective January 1, 1983, would be slightly greater than anticipated.

On December 3, 1982, the plaintiffs submitted for the Commissioner’s approval the revised rates at issue in this appeal, to be effective February 1, 1983. The revised rates included an increase to cover payments required by the increase in the inpatient hospital deductible and related copayments, as well as an increase to cover payments for twenty per cent of charges for inpatient services of radiologists and pathologists. The Commissioner disapproved the rate revision as being prematurely filed, relying on the requirement of G. L. c. 176A, § 6, that rates approved under that section “shall continue in effect for not less than twelve months after [the] effective date [thereof].” The Commissioner subsequently approved the plaintiffs’ annual rate revision, effective July 1, 1983, which included an increase for the unanticipated increment of the increase in the inpatient hospital deductible and related copayments, and an increase to cover the cost of coinsurance for inpatient services of radiologists and pathologists, both derived in the same manner as that used in the proposed rates at issue in this appeal.

The plaintiffs brought a petition before a single justice of this court, pursuant to G. L. c. 176A, § 6, for review of the Commissioner’s disapproval of their proposed February 1, 1983, rate revision. The parties jointly stipulated to the facts, and the plaintiffs moved for summary judgment. After hearing, the single justice entered summary judgment for the Commissioner. The plaintiffs appealed. We affirm.

We first address the Commissioner’s contention that the case is moot. Because the rates which became effective July 1,1983, [181] included the equivalent of the increases sought by the plaintiffs for February 1, 1983, it is only the rates for the intervening five-month period that are at issue. The Commissioner argues that the statute does not permit retroactive rate adjustment and that the case is therefore moot. We need not decide whether retroactive rate adjustment is permissible. If it is permissible, then the case is obviously not moot. If it is not permissible, then the case falls within the “capable of repetition, yet evading review” exception to the mootness doctrine. See, e.g., Boston Edison Co. v. Department of Pub. Utils., 375 Mass. 1, 6, cert, denied, 439 U.S. 921 (1978).

We turn now to the substantive issue presented by this appeal, that is, whether the Commissioner was correct in concluding that Medex rates cannot be revised before they have been in effect for twelve months. General Laws c. 176A, § 6, provides in pertinent part: “The contracts and rates [approved by the Commissioner under this section] . . . shall continue in effect for not less than twelve months after [the] effective date [thereof] and thereafter until any changes shall have been approved as provided above; except that an increase in benefits to subscribers may, with the approval of the commissioner, be allowed at any time ...” (emphasis supplied). The plaintiffs argue that the automatic increase in amounts payable under their contracts by virtue of the reduction in Medicare benefits is an “increase in benefits” within the meaning of the section and that the exception to the twelve-month bar should be read to permit a concomitant increase in rates.

The increase in the amounts payable by the plaintiffs is not an “increase in benefits.” The plaintiffs’ subscribers are entitled, under the terms of their Medex policies, to increased payments upon the happening of the contingency that Medicare payments are reduced. The increase is automatic; no permission of the Commissioner is necessary. Thus the increase is not within the purview of the exception. For this purpose, “benefits” must be taken to mean contractual entitlements.4 The plain[182] tiffs have not changed the terms of their policies; thus the contractual entitlements of their subscribers have not been increased.

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Blue Cross of Massachusetts, Inc. v. Commissioner of Insurance, 392 Mass. 178 (Mass. 1984).

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