GHS Health Maintenance Organization, Inc. v. United States

76 Fed. Cl. 339, 2007 U.S. Claims LEXIS 116, 2007 WL 1160323
CourtUnited States Court of Federal Claims
DecidedApril 17, 2007
DocketNos. 01-517C, 05-371C, 05-963C
StatusPublished
Cited by8 cases

This text of 76 Fed. Cl. 339 (GHS Health Maintenance Organization, Inc. v. United States) is published on Counsel Stack Legal Research, covering United States Court of Federal Claims primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

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GHS Health Maintenance Organization, Inc. v. United States, 76 Fed. Cl. 339, 2007 U.S. Claims LEXIS 116, 2007 WL 1160323 (uscfc 2007).

Opinion

OPINION

HORN, Judge.

These cases come before the court upon the parties’ cross-motions for summary judgment. Plaintiffs are three health benefits carriers (collectively, the “carriers”) — GHS Health Maintenance Organization, Inc., doing business as BlueLincs HMO (BlueLincs), Texas Health Choice, L.C. (Texas Health), and Scott' & White Health Plan (Scott & White). These cases involve contracts between the carriers and the United States Office of Personnel Management (OPM) for health care benefits to federal employees. OPM is the federal agency responsible for administering the Federal Employees Health Benefits Act (FEHBA), codified at 5 U.S.C. §§ 8901-8914 (2000). The FEHBA governs all health plans servicing federal employees.

These cases focus on each plaintiffs last year of participation in the Federal Employees Health Benefits Program (FEHBP). As discussed more fully below, each year during a carrier’s participation in the program, OPM and the carrier engage in a process to reconcile the current year’s premium rates with the premium rates the contractor is charging the lower of two similarly sized subscriber groups (SSSGs). This is because the premium rates charged by carriers at the beginning of a contract year are only estimates of what a carrier’s rates are projected to be for that year. The reconciliation results in a finding either that the government paid the carrier too much or too little. If it is determined that the estimated rates were higher than the actual rates the carrier should have been paid, the carrier refunds the government the difference. If it is determined that the estimated rates were lower than the actual rates the carrier should have been paid, the government pays the carrier the difference.

Whether this payment or recoupment as a result of the reconciliation process should occur .in a carrier’s last year of participation in the program is the issue before the court. Included in all FEHBP contracts is a mandatory clause, titled “Accounting and Price Adjustment (Jan 1998),” which contains a paragraph known as the “Final Year Regulation.” The Final Year Regulation states that: “In the event this contract is not renewed, neither the Government nor the Carrier shall be entitled to any adjustment or claim for the difference between the subscription rates pri- or to rate reconciliation and the actual subscription rates.” 48 C.F.R. § 1652.216-[342]*34270(b)(6) (Oct. 1, 1998). Accordingly, in the last year of participation in the FEHBP, if the government overpays, the clause contemplates no recoupment for its losses from a carrier through the reconciliation process and, similarly, if the government underpays, the clause anticipates no recoupment to the contractor for its losses through the reconciliation process.

In their complaints before this court, the plaintiffs argue that 48 C.F.R. § 1652.216-70(b)(6), promulgated by OPM, conflicts with the statute, 5 U.S.C. § 8902(i) (2000), which requires that: “Rates charged under health benefits plans described by section 8903 or 8903a of this title shall reasonably and equitably reflect the cost of the benefits provided.” The plaintiffs argue that the Final Year Regulation, incorporated into the plaintiffs’ contracts, violates the statute and, therefore, results in a breach of the plaintiffs’ contracts. Each plaintiff seeks monetary damages for the government’s alleged breach of contract. The plaintiffs also seek a declaratory judgment, asking this court to invalidate 48 C.F.R. § 1652.216—70(b)(6) either in whole, or as applied to each plaintiffs contract with OPM. Specifically, plaintiff BlueLincs seeks $369,127.00 for breach of contract, while plaintiff Texas Health seeks $622,246.00, and plaintiff Scott & White seeks $3,625,782.00. For the reasons discussed below, this court finds that 48 C.F.R. § 1652.216-70(b)(6) conflicts with 5 U.S.C. § 8902(i). The court, therefore, grants the plaintiffs’ motions for summary judgment and denies the defendant’s cross-motion for summary judgment.

FINDINGS OF FACT

Procedural History

Only BlueLincs initially filed its case in the United States Court of Federal Claims, which became case no. 01-517C, and the lead case of these consolidated cases. Case no. 01-517C, however, was stayed in this court at the request of the parties, pending resolution of procedural issues in the other two cases, which plaintiffs initially filed in different federal district courts.

Texas Health initially filed its case in January, 2003, in the United States District Court for the Eastern District of Texas. In June, 2003, the government moved to dismiss or transfer the case to the United States Court of Federal Claims, arguing that the District Court lacked jurisdiction to hear the plaintiffs claims. A Magistrate Judge of the District Court recommended that the District Court deny the government’s motion. See Texas Health Choice, L.C. v. U.S. Office of Pers. Mgmt., No. Civ. A. 9:03CV14, 2004 WL 3266033, at *6-7 (E.D.Tex. Feb.12, 2004). The District Court adopted the Magistrate Judge’s recommendation and denied the government’s motion to dismiss or transfer. The government appealed the District Court’s decision to the United States Court of Appeals for the Federal Circuit.

Finding that Texas Health’s contract was controlled by the Contract Disputes Act, 41 U.S.C. §§ 601-613 (2000), the Federal Circuit reversed the Texas District Court in Texas Health Choice, L.C. v. Office of Personnel Management, 400 F.3d 895 (Fed.Cir.), reh’g and reh’g en banc denied (2005). The Federal Circuit found:

We agree with OPM that under the CDA, the Court of Federal Claims has exclusive jurisdiction over Texas Health’s suit against OPM relating to the validity of the Final Year Regulation incorporated into the FEHBA contract as Clause 3.2(b)(6). That is because Texas Health’s claim is related to the FEHBA contract. “The CDA exclusively governs Government contracts and Government contract disputes.” Cecile Indus., Inc. v. Cheney, 995 F.2d 1052, 1055 (Fed.Cir.1993).

Texas Health Choice, L.C. v. Office of Pers. Mgmt., 400 F.3d at 898. The Federal Circuit stated: “That Texas Health’s complaint, literally read, sought only to invalidate the Final Year Regulation, as opposed to recover the $622,246 reconciliation amount, is of no consequence to the question of jurisdiction because the complaint relates to a dispute implicating a contract with the Government.” Id. at 900.

Thus, the Federal Circuit referred jurisdiction to the United States Court of Federal Claims to hear the plaintiffs claim, and review the validity of the regulation as it applied to the final year of participation in the [343]*343program by a health benefits carrier.

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76 Fed. Cl. 339, 2007 U.S. Claims LEXIS 116, 2007 WL 1160323, Counsel Stack Legal Research, https://law.counselstack.com/opinion/ghs-health-maintenance-organization-inc-v-united-states-uscfc-2007.