Health Care Plan, Inc. v. Bahou

92 A.D.2d 142, 459 N.Y.S.2d 497, 1983 N.Y. App. Div. LEXIS 16602
CourtAppellate Division of the Supreme Court of the State of New York
DecidedFebruary 28, 1983
StatusPublished
Cited by3 cases

This text of 92 A.D.2d 142 (Health Care Plan, Inc. v. Bahou) is published on Counsel Stack Legal Research, covering Appellate Division of the Supreme Court of the State of New York primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Health Care Plan, Inc. v. Bahou, 92 A.D.2d 142, 459 N.Y.S.2d 497, 1983 N.Y. App. Div. LEXIS 16602 (N.Y. Ct. App. 1983).

Opinion

OPINION OF THE COURT

Dillon, P. J.

The principal issue to be decided on this appeal is whether respondent, in his capacity as President of the Civil Service Commission, improperly calculated for the year 1980 the State’s employer contribution to the cost of health insurance coverage for employees enrolled in the optional benefit plan administered by petitioner Health Care Plan, Inc. (HCP). Special Term found that he did, and we agree.

For many years the State has provided a basic, Statewide health insurance plan (State-wide plan) for its employees (Civil Service Law, art XI). To effectuate the plan, respondent is authorized to purchase contracts from qualified insurance carriers (Civil Service Law, § 162). More recently, on the premise that health maintenance organizations provide an efficient means of delivering health care services, both the Federal and State Governments have encouraged their growth (US Code, tit 42, § 300e; Public Health Law, art 44).

[144]*144The Federal Health Maintenance Organizations Act (US Code, tit 42, § 300e et seq.) requires that States, as a condition of receiving certain Federal grants, offer their employees the option of membership in a health maintenance organization as an alternative to traditional health benefit plans and directs the Secretary of Health and Human Services (Secretary) to prescribe regulations to implement the statutory purpose (US Code, tit 42, § 300e-9, subd [a], par [1]). The regulations require that the terms of such offer be “no less favorable” with respect to the State’s monetary contribution than that made to a non-health maintenance organization plan (42 CFR 110.808[a]; 110.801).

Subdivision 1 of section 167 of the Civil Service Law requires the State to pay the full cost of premium or subscription charges for coverage of employees enrolled in the State-wide plan and 75% of such cost for coverage of dependents of those employees. The statute further provides, in relevant part: “The state shall contribute toward the premium or subscription charges for the coverage of each state employee * * * who is enrolled in an optional benefit plan and for the dependents of such state employee * * * the same dollar amount which would be paid by the state for the premium or subscription charges for the coverage of such state employee * * * and his dependents if he were enrolled in the basic, statewide health insurance plan”. Although regulations to implement the State statutory scheme have been proposed, they have not been promulgated.

HCP is a health maintenance organization established under the Not-For-Profit Corporation Law. It is authorized to provide an optional benefit health insurance plan to which State employees began to subscribe in 1978. It is not disputed that health maintenance organizations, including HCP, provide a broader range of benefits than the Statewide plan, and thus the total cost of coverage under the HCP plan ordinarily will be greater. Each employee member of HCP pays the difference between the total cost and the amount contributed by the State.

Before respondent can compute in a given year the State’s contribution on behalf of members of HCP, he must [145]*145first determine the amount to be contributed under the State-wide plan. The premium or subscription charges of the latter are based upon claim experience, and when claims for a prior year were less than anticipated when the premium was established for that year, the State-wide plan insurance carriers refund the overpayment of premiums to the State health insurance fund in which such sums are retained “as a special reserve for adverse fluctuation in future charges” (Civil Service Law, § 167, subd 6). In succeeding years, respondent is authorized to take such refunds into account when establishing the State’s contribution under the State-wide plan (Insurance Law, § 221, subd 9).

The claim experience in the State-wide plan in 1977 demonstrated that the State’s contribution for that year was more than required to meet the costs of the plan. In effect, the State had overpaid premiums on behalf of Statewide plan subscribers, thus generating refunds from the insurance carriers.

In 1980 respondent determined that the State’s contribution to the State-wide plan would include those refunds, with the balance to be met from moneys appropriated to the State health insurance fund. In determining the cost per member, respondent did not consider the refunds, but divided only the amount appropriated by the number of State-wide plan members. The quotient was then used as the measure of the State’s contribution on behalf of members of HCP. The contribution to HCP was substantially less, of course, than would have been made had the refunds been included in the formula. Thus, it is said, members of HCP were required to pay a higher share of premium charges for coverage in 1980, and other State employees were discouraged from enrolling or remaining in HCP.

In this CPLR article 78 proceeding, the petition seeks:

1. a determination that respondent unlawfully computed the State’s contribution to HCP and that employees enrolled in HCP are entitled to further contribution from the State;

2. a direction that respondent recompute the contribution to HCP in accordance with Federal and State law; and

[146]*1463. a direction that over a reasonable time the State’s contribution be increased to make up the deficiency.

Special Term adjudged, on the basis that the refunds were generated in a year “prior to the inception of the HCP” that “petitioners” were entitled to recover an amount equal to the amount of the refunds “computed in the 1980 rate for State contributions to the Statewide plan carriers.” The judgment further directs that such sums be paid to HCP and that HCP “shall be allowed to pass its saving * * * on to its participating members.” Special Term denied petitioners’ request that respondent be ordered to compute the State’s contribution to HCP in accordance with Federal regulations promulgated by the Secretary, and also denied petitioners’ application to compel respondent to pay counsel fees. Respondent appeals and petitioners cross-appeal.

We first dispose of respondent’s argument that petitioners have no standing to bring this proceeding. Petitioner HCP and the subscriber petitioners have demonstrated that calculation of the State’s contribution to HCP on behalf of its members is within the zone of interest protected by State and Federal law, and that miscalculation of such contribution may leave them aggrieved (see Matter of Dairylea Coop, v Walkley, 38 NY2d 6).

Turning to the merits, respondent asserts that his method of calculating the State’s contribution to HCP is in conformity with the mandate of subdivision 1 of section 167 of the Civil Service Law. We disagree. There can be no doubt as to the statute’s import; it is to ensure that the State’s contribution on behalf of members of an optional benefit plan is to be neither more nor less than that contributed under the State-wide plan. The claim experience in the State-wide plan in 1977 demonstrated that the State’s contribution for that year was more than required to meet the costs of the plan. Since, the State was required in that year to contribute to optional benefit plans the same dollar amount paid into the State-wide plan, it follows that the optional benefit plans were also overpaid.

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Bluebook (online)
92 A.D.2d 142, 459 N.Y.S.2d 497, 1983 N.Y. App. Div. LEXIS 16602, Counsel Stack Legal Research, https://law.counselstack.com/opinion/health-care-plan-inc-v-bahou-nyappdiv-1983.