Electrical Workers Insurance Fund v. Sebelius

906 F. Supp. 2d 707, 2012 WL 5363509, 2012 U.S. Dist. LEXIS 156867
CourtDistrict Court, E.D. Michigan
DecidedOctober 30, 2012
DocketCase No. 08-14738
StatusPublished

This text of 906 F. Supp. 2d 707 (Electrical Workers Insurance Fund v. Sebelius) is published on Counsel Stack Legal Research, covering District Court, E.D. Michigan primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Electrical Workers Insurance Fund v. Sebelius, 906 F. Supp. 2d 707, 2012 WL 5363509, 2012 U.S. Dist. LEXIS 156867 (E.D. Mich. 2012).

Opinion

OPINION AND ORDER GRANTING DEFENDANT’S MOTION TO DISMISS [51]

NANCY G. EDMUNDS, District Judge.

This matter comes before the Court on Defendant’s motion to dismiss [51]. Plaintiff Electrical Workers Insurance Fund (“Fund”) is a jointly administered trust fund that provides health benefits to active and retired members of the Electrical Workers Local Union No. 58. It brought this lawsuit against the Secretary of Health and Human Services (“HHS” or the “Secretary”)1 challenging the Secretary’s refusal to allow the Fund to submit a December 6, 2007 reimbursement claim in the amount of approximately $400,000 for prescription drug benefits paid on behalf of its participants under Medicare Part B through the Indirect Payment Procedure authorized by and implemented in 42 U.S.C. § 1395u(b)(6)(B); 42 C.F.R. § 424.66. (Pl.’s Am. Compl., ¶¶ 23-32). Plaintiffs lawsuit sought declaratory, injunctive, and mandamus relief; specifically: (1) “a judgment declaring that the Fund is entitled to reimbursement, pursuant to 42 U.S.C. § 1395u(b)(6)(B) and 42 C.F.R. § 424.66 (“the Indirect Payment Procedure”), for benefit payments made by the Fund that were payable under the Medicare Act;” (2) “a writ of mandamus ordering and directing the HHS and its authorized representatives to accept the Fund’s claims for reimbursement for Part B drug claims ... for processing and payment under the Indirect Payment Procedure;” and (3) “an order enjoining Defendant [HHS] from refusing to consider such claims under the Indirect Payment Procedure.” (Pl.’s Am. Compl., ¶ 15.)

After the Fund filed this action, Defendant HHS reconsidered its earlier position and determined that the Indirect Payment Procedure (“IPP”) process would be appropriate under the criteria set forth in 42 U.S.C. § 1395u(b)(6)(B) and 42 C.F.R. § 424.66. It acknowledged to this Court [709]*709that it did not currently have an IPP in place to permit group health plans, like the Plaintiff Fund, to use that process. Thus, in response to the Fund’s motion for summary judgment, HHS requested a voluntary remand so it could implement an IPP process like the one Plaintiff Fund was seeking and also develop policy and guidance regarding that IPP process. (Doc. No. 24, 2/15/10 Opin. at 5.)

On February 15, 2010, this Court granted Defendant HHS’s motion for a voluntary remand, denied Plaintiff Fund’s motion for summary judgment, stayed this action pending the publication and implementation of an IPP, and ordered that Defendant HHS comply with 42 U.S.C. § 1895u(b)(6)(B) and 42 C.F.R. § 424.66 in implementing the IPP and developing policy and guidance regarding the process. (Id. at 1, 12.) The Court clarified that “[t]he purpose of the remand” was to allow “HHS to devise a process by which [the Fund] can submit its Medicare Part B claims for reimbursement consistent with 42 U.S.C. § 1395u(b)(6)(B) and 42 C.F.R. § 424.66.” (Id. at 8 n. 9.) It further clarified that it would be “improper for this Court to dictate the specific manner for HHS to devise such an IPP.” (Id.)

On April 20, 2012, in response to a motion filed by Plaintiff Fund, this Court lifted the stay in this matter for the limited purpose of allowing Defendant HHS to file a motion to dismiss. (Doc. No. 49, 4/20/12 Order.) Defendant HHS’s motion is now before the Court. Because Plaintiff Fund received all the relief it is entitled to in its lawsuit and there is nothing further to litigate, this case is dismissed as moot. Defendant’s motion to dismiss is GRANTED.

I. Facts

The Court is familiar with the background and procedural facts stated in its February 25, 2010 Opinion and Order, 2010 WL 728934 [24] and above. The following statutory and regulatory background and additional facts are also relevant to HHS’s motion to dismiss.

A. The Medicare Program

The Medicare program provides health insurance benefits to eligible aged and disabled persons. See Title XVIII of the Social Security Act, 42 U.S.C. § 1395, et seq. The program consists of four main parts: Parts A, B, C, and D. This case arises under Part B, which is a voluntary health insurance program subsidized by enrollee premiums and appropriated monies. Id. at §§ 1395j, 1395o, 1395r, 1395t. Part B provides payment for the services of physicians and other health practitioners, as well as a variety of “medical and other health services,” which include a very limited category of outpatient drugs. Id. at §§ 1395k(a)(l), 1395x(s); 42 C.F.R. § 414.701. See also 42 C.F.R. Part 410 (scope of Part B benefits).

HHS, through the Centers for Medicare & Medicaid Services (“CMS”), contracts with local private insurance “carriers” to administer the Part B claims process. 42 U.S.C. § 1395u; 42 C.F.R. § 421.200. A claim for Medicare Part B reimbursement must be timely submitted to the Medicare contractor. 42 C.F.R. §§ 424.32(a)(4), 424.44. Each Part B claim for items or services furnished by a physician or supplier must be supported by sufficient information and documentation for the Medicare contractor to determine whether the items or services are covered and the amount of any payment deemed owing. 42 U.S.C. § 1395i(e);2 42 C.F.R.

[710]*710§ 424.5(a)(6).3

Wisconsin Physicians Service Insurance Corporation (“WPS”) has entered into such a contract with CMS to serve as a contractor for Medicare Part B retiree health coverage in Michigan and certain other states. (Am. Compl., ¶ 8.)

B. Indirect Payment Process (“IPP”)

CMS created an Indirect Payment Process (“IPP”) in 1969, and amended that process in 1986, to allow a broader class of Complementary Insurers to submit Médicare Part B claims for reimbursement.

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Bluebook (online)
906 F. Supp. 2d 707, 2012 WL 5363509, 2012 U.S. Dist. LEXIS 156867, Counsel Stack Legal Research, https://law.counselstack.com/opinion/electrical-workers-insurance-fund-v-sebelius-mied-2012.