Health Care Service Corp. v. Califano

466 F. Supp. 1190, 1979 U.S. Dist. LEXIS 14472
CourtDistrict Court, N.D. Illinois
DecidedFebruary 13, 1979
Docket78 C 3228
StatusPublished
Cited by6 cases

This text of 466 F. Supp. 1190 (Health Care Service Corp. v. Califano) is published on Counsel Stack Legal Research, covering District Court, N.D. Illinois primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Health Care Service Corp. v. Califano, 466 F. Supp. 1190, 1979 U.S. Dist. LEXIS 14472 (N.D. Ill. 1979).

Opinion

*1191 MEMORANDUM OPINION

FLAUM, District Judge:

The instant action for declaratory and injunctive relief challenges the award of a five-year contract for the administration of over a billion dollars of medical benefits in the Illinois Part B Medicare Program. Plaintiff Health Care Service Corporation [HCSC] and intervening plaintiff Continental Casualty Company [CNA] challenge the award to a data processing firm, E.D.S. Federal Corporation [EDSF]. Before the court are the parties’ cross motions for summary judgment. 1 Fed.R.Civ.P. 56. Jurisdiction is predicated on 28 U.S.C. §§ 1331, 1361, 2201 & 2202. Inasmuch as the court concludes that there are no issues of material fact and that judgment as a matter of law must be entered in defendants’ favor, defendants’ motion is granted. After a brief statement of the uncontested facts, the court will consider the legal issues presented.

The provisions at issue here are part of a comprehensive scheme to provide health care for the aged enacted in part under the Social Security Act Amendments of 1965. 2 Under those amendments, Congress instituted two distinct health care plans. The so-called Part A Medicare plan provides for basic hospital and related care. 3 The second program, Part B Medicare, which is at issue here, is a voluntary supplemental program for services of doctors and other health care professionals. Such services are not covered under the Part A plan. 4 Under the plan, individuals pay premiums which are matched or exceeded by the federal government. 5

The 1965 enactments provided that Part B medical benefits would be administered by “carriers.” 42 U.S.C. § 1395u(f). Under the relevant section, the term carrier was defined to include private insurers, group health plans and voluntary benefit insurance plans “lawfully engaged” in providing or paying for health services in return for periodic payments from subscribers or policy holders. 6 The carrier requirement was fashioned to make the expertise of the private insurance companies available for the following functions: determination of reasonable charges for covered services; monitoring of physician charges and services; and the institution and maintenance of procedures to resolve payment disputes.

In 1972, Congress amended the Medicare Act. Pub.L.No. 92-603, 86 Stat. 1329, October 30, 1972. Section 222 of the amendment, 42 U.S.C. § 1395b — 1, in part authorized the Secretary of Health, Education, and Welfare to conduct experiments related to fixed-price and performance incentive contracts “through grants to public or nonprofit private agencies, institutions, and organizations or contracts with public or private agencies, institutions, and organizations.” 42 U.S.C. § 1395b — 1(a)(1). Thus, the 1972 amendment makes no reference to “carriers” as defined in 42 U.S.C. *1192 § 1395u(f). It is the resultant tension between these two statutes which forms the principal issue of this case.

Pursuant to its experimental authority under section 1395b-l, the Secretary issued on March 31, 1978 a Request for Proposal [RFP] for administration of the Part B program for the entire State of Illinois through a competitive, fixed-price approach. The RFP was intended to serve a dual function. It was designed to test the effect of merging carrier territories (Cook County and the remainder of the State) and the cost-benefit of price competition among carriers in a medium claims volume territory. Thus, the experiment sought to consolidate claims territory and discover the effect of a fixed-price contract as opposed to the prior cost reimbursement contracts. The proposed contract was to cover a period from July 1, 1978 to September 30, 1983. The RFP outlined a transition and implementation period of nine months, from July 1, 1978 to March 31, 1979, for Cook County and for twelve months, from July 1, 1978 to July 1, 1979, for the remainder of the state.

Among the five bidders responding to the RFP were plaintiff HCSC, intervening plaintiff, CNA, and the awardee, EDSF. 7 HCSC has been the Medicare Part B carrier for Cook County since Medicare’s inception on July 1, 1966. It is a non-profit corporation organized under an Illinois law which in 1977 administered benefit programs covering over three million subscribers. 8 CNA, also an Illinois corporation, presently administers the Medicare Part B plan for the rest of the State. Both CNA and HCSC administer the plans under cost reimbursement contracts. 9 The parties do no dispute that CNA and HCSC are “carriers” under 42 U.S.C. § 1395u(f). EDSF is a wholly-owned Texas subsidiary of Electronic Data Systems, also a Texas corporation. EDSF has had experience as a Medicaid health insurer in Texas. Further, EDSF has performed as a medicaid fiscal agent and a health care electronic data processor subcontractor in certain states.

Prior to the issuance of the formal request, HCSC was notified through its Vice President by a letter dated March 1, 1978 that the RFP would “not be limited to existing Medicare contractors.” He was further advised that third party payers and the offers of data processing firms “who have the necessary technical expertise, resources, and ability to assume and complete the functions of a Medicare carrier” would be considered. On March 7, 1978 the Blue Cross Association was similarly notified. The RFP was formally made available to bidders on March 31. By its terms, it informed them such firms would be considered., In April, 1978 all Medicare Part B contractors were sent letters advising in the above language of the scope of consideration.

On or about May 31, 1978 five offerors submitted their proposals. In late June, the Department of Health, Education, and Welfare [H.E.W.] announced that it had awarded the contract to EDSF. Hence, when the instant lawsuit was filed on August 14, EDSF was six weeks into the implementation period. 10

*1193 Three issues are raised by the above. First, whether plaintiffs’ protest of the scope of the bidding was timely. Second, whether the award of the contract to EDSF was not lawful because that entity was not a “carrier” within the meaning of section 1395u(f)' and because EDSF had no prior experience as a carrier.

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Bluebook (online)
466 F. Supp. 1190, 1979 U.S. Dist. LEXIS 14472, Counsel Stack Legal Research, https://law.counselstack.com/opinion/health-care-service-corp-v-califano-ilnd-1979.