Coventry Health Care of Mo., Inc. v. Nevils

581 U.S. 87, 137 S. Ct. 1190, 197 L. Ed. 2d 572, 26 Fla. L. Weekly Fed. S 531, 85 U.S.L.W. 4193, 2017 WL 1377380, 2017 U.S. LEXIS 2614
Supreme Court of the United States·Decided April 18, 2017·No. No. 16–149.·Published·Cited by 28 cases

Opinions

Justice GINSBURG delivered the opinion of the Court.

In the Federal Employees Health Benefits Act of 1959 (FEHBA), 5 U.S.C. § 8901 et seq., Congress authorized the Office of Personnel Management (OPM) to contract with private carriers for federal employees' health insurance. § 8902(a), (d). FEHBA contains a provision expressly preempting state law. § 8902(m)(1). That provision reads:

"The terms of any contract under this chapter which relate to the nature, provision, or extent of coverage or benefits (including payments with respect to benefits) shall supersede and preempt any State or local law, or any regulation issued thereunder, which relates to health insurance or plans."

Contracts OPM negotiates with private carriers provide for reimbursement and subrogation. Reimbursement requires an insured employee who receives payment from another source (e.g., the proceeds yielded by a tort claim) to return healthcare costs earlier paid out by the carrier. Subrogation involves transfer of the right to a third-party payment from the insured employee to the carrier, who can then pursue the claim against the third party. Several States, however, Missouri among them, bar enforcement of contractual subrogation and reimbursement provisions.

The questions here presented: Does FEHBA's express-preemption prescription, § 8902(m)(1), override state law prohibiting subrogation and reimbursement; and if § 8902(m)(1) has that effect, is the statutory prescription consistent with the Supremacy Clause, U.S. Const. Art. VI, cl. 2 ? We hold, contrary to the decision of the Missouri Supreme Court, that contractual subrogation and reimbursement prescriptions plainly "relate to ... payments with respect to benefits," § 8902(m)(1) ; therefore, by statutory instruction, they override state law barring subrogation and reimbursement. We further hold, again contrary to the Missouri Supreme Court, that the regime Congress enacted is compatible with the Supremacy Clause. Section 8902(m)(1) itself, not the contracts OPM negotiates, triggers the federal preemption. As Congress directed, where FEHBA contract terms "relate to the nature, provision, or extent of coverage or benefits (including payments with respect to benefits)," § 8902(m)(1) ensures that those terms will be uniformly enforceable nationwide, free from state interference.

I

A

FEHBA "establishes a comprehensive program of health insurance for federal employees." Empire Healthchoice Assurance, Inc. v. McVeigh, 547 U.S. 677, 682, 126 S.Ct. 2121, 165 L.Ed.2d 131 (2006). As just noted, supra, at 1194, FEHBA

*1195contains an express-preemption provision, § 8902(m)(1). FEHBA assigns to OPM broad administrative and rulemaking authority over the program. See §§ 8901 - 8913. OPM contracts with private insurance carriers to offer a range of healthcare plans. §§ 8902, 8903.

OPM's contracts with private carriers have long included provisions requiring those carriers to seek subrogation and reimbursement. Accordingly, OPM has issued detailed regulations governing subrogation and reimbursement clauses in FEHBA contracts. See 5 C.F.R. § 890.106 (2016). Under those regulations, a carrier's "right to pursue and receive subrogation and reimbursement recoveries constitutes a condition of and a limitation on the nature of benefits or benefit payments and on the provision of benefits under the plan's coverage." § 890.106(b)(1).

In 2015, after notice and comment, OPM published a rule confirming that "[a] carrier's rights and responsibilities pertaining to subrogation and reimbursement under any [FEHBA] contract relate to the nature, provision, and extent of coverage or benefits (including payments with respect to benefits) within the meaning of" § 8902(m)(1). § 890.106(h). Such "rights and responsibilities," OPM's rule provides, "are ... effective notwithstanding any state or local law, or any regulation issued thereunder, which relates to health insurance or plans." Ibid. Its rule, OPM explained, "comports with longstanding Federal policy and furthers Congres[s'] goals of reducing health care costs and enabling uniform, nationwide application of [FEHBA] contracts." 80 Fed.Reg. 29203 (2015) (final rule).

B

Respondent Jodie Nevils is a former federal employee who enrolled in and was insured under a FEHBA plan offered by petitioner Coventry Health Care of Missouri.1 Nevils v. Group Health Plan, Inc., 418 S.W.3d 451, 453 (Mo.2014) (Nevils I ). When Nevils was injured in an automobile accident, Coventry paid his medical expenses. Ibid. Nevils sued the driver who caused his injuries and recovered a settlement award. Ibid. Based on its contract with OPM, see App. to Pet. for Cert. 129a-130a, Coventry asserted a lien for $6,592.24 against part of the settlement proceeds to cover medical bills it had paid. Nevils I, 418 S.W.3d, at 453. Nevils repaid that amount, thereby satisfying the lien. Ibid.

Nevils then filed this class action against Coventry in Missouri state court, alleging that Coventry had unlawfully obtained reimbursement. Ibid. Nevils premised his claim on Missouri law, which does not permit subrogation or reimbursement in this context, see, e.g., Benton House, LLC v. Cook & Younts Ins., Inc., 249 S.W.3d 878, 881-882 (Mo.App.2008). Coventry countered that § 8902(m)(1) makes subrogation and reimbursement clauses in FEHBA contracts enforceable notwithstanding state law.

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Coventry Health Care of Mo., Inc. v. Nevils, 581 U.S. 87, 137 S. Ct. 1190, 197 L. Ed. 2d 572, 26 Fla. L. Weekly Fed. S 531, 85 U.S.L.W. 4193, 2017 WL 1377380, 2017 U.S. LEXIS 2614 (2017).

581 U.S. 87 (Coventry Health Care of Mo., Inc. v. Nevils) — published by Counsel Stack Legal Research, free access to 12M+ legal documents.

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