Health Insurance Ass'n of America, Inc. v. Shalala

23 F.3d 412, 126 A.L.R. Fed. 793, 306 U.S. App. D.C. 104, 1994 U.S. App. LEXIS 10733, 1994 WL 180090
CourtCourt of Appeals for the D.C. Circuit
DecidedMay 13, 1994
DocketNos. 92-5196, 92-5197
StatusPublished
Cited by106 cases

This text of 23 F.3d 412 (Health Insurance Ass'n of America, Inc. v. Shalala) is published on Counsel Stack Legal Research, covering Court of Appeals for the D.C. Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Health Insurance Ass'n of America, Inc. v. Shalala, 23 F.3d 412, 126 A.L.R. Fed. 793, 306 U.S. App. D.C. 104, 1994 U.S. App. LEXIS 10733, 1994 WL 180090 (D.C. Cir. 1994).

Opinions

Opinion for the Court filed by Circuit Judge WILLIAMS.

Concurring opinion filed by Circuit Judge HENDERSON.

Opinion concurring in part and dissenting in part by Chief Judge MIKVA.

STEPHEN F. WILLIAMS, Circuit Judge:

The appellants in these two consolidated, cases raise facial challenges to five Medicare regulations promulgated by the Health Care Financing Administration (“HCFA”) on behalf of the Secretary of Health and Human Services. They also contend that' even if the regulations are valid, the Secretary is attempting to give improper retroactive effect to four of them. In a comprehensive opinion, the district court upheld all five regulations and rejected the appellants’ retroactivity arguments. Blue Cross & Blue Shield Ass’n v. Sullivan, 794 F.Supp. 1166 (D.D.C.1992). We affirm in part. We conclude that two of the five regulations go beyond the Secretary’s statutory authority and hence are in[414]*414valid. We also disagree with the district court’s retroactivity analysis.

I. The Statutory Framework

Medicare is a system of federally funded health insurance for the aged, the disabled, and people suffering from end-stage renal disease. Many people covered by Medicare are also eligible for benefits under group health plans provided by employers. For its first fifteen years, Medicare paid for services without regard to whether they were also covered by an employer group health plan. As a cost-cutting measure, however, Congress eventually enacted a series of amendments designed to make Medicare a “secondary” payer with respect to such plans. These amendments have been codified at 42 U.S.C. § 1395y(b), which is referred to as the “Medicare as Secondary Payer” (“MSP”) statute.

The structure of the MSP statute is relatively simple. Paragraph (1) imposes certain requirements on employer group health plans.1 A nondiscrimination provision, for instance, insists that plans other than those provided by small employers must provide the same benefits under the same conditions to aged employees (and to aged spouses of employees) as to other employees and spouses. 42 U.S.C. § 1395y(b)(1)(A)(i)(II) (Supp. IV 1992). In addition, when someone age 65 or older is covered by an employer group health plan by reason of his current employment (or the current employment of his spouse), the plan “may not take into account” that his age entitles him to Medicare benefits. Id. § 1395y(b)(l)(A)(i)(I). The effect of this is to nullify any plan provision that would “carve out” expenses covered by Medicare and thus, in effect, make the plan’s coverage secondary to Medicare’s.2 Somewhat similar provisions deal with people suffering from end-stage renal disease. See id. § 1395y(b)(l)(C). With exceptions not relevant here, large group health plans also “may not take into account” that an employee or a member of his family is entitled to Medicare benefits by reason of disability. Id. § 1395y(b)(l)(B).

Paragraph (2) then makes Medicare the “secondary” payer with respect to coverage required under paragraph (1), and spells out the means by which that purpose is to be realized. Subparagraph (A) prohibits Medicare from making any payment, other than a conditional one, for any item or service to the extent that “payment has been made [under a group plan], or can reasonably be expected to be made [under a group plan], with respect to the item or service as required under paragraph (1)”. Id. § 1395y(b)(2)(A)(i). Subparagraph (B) then explains what it means for a payment to be conditional; in a clause headed “Primary Plans”,3 it declares that any Medicare payment under the circumstances described in subparagraph (A) “shall be conditioned on reimbursement to the appropriate Trust Fund ... when notice or other information is received that payment for such item or service has been or could be made under such subparagraph.” Id. § 1395y(b)(2)(B)(i). In order to recover conditional payments, the next clause continues, “the United States may bring an action against any entity which is required or responsible under this subsection to pay with respect to such item or service (or any portion thereof) under a primary plan_” Id. § 1395y(b)(2)(B)(ii). Indeed, when an employer group health plan [415]*415“fails to provide for primary payment (or appropriate reimbursement) in accordance with ... paragraphs (1) and (2)(A)”, a private party or the federal government can sue for double damages. Id. § 1395y(b)(3)(A). In addition, the federal government is subrogat-ed (to the extent of any payment for an item or service to which subparagraph (2) (A) applies) “to any right under this subsection of an individual or any other entity to payment with respect to such item or service under a primary plan.” Id. § 1395y(b)(2)(B)(iii).

II. The Challenged Regulations

Acting as the Secretary’s delegate, HCFA has promulgated regulations to carry out the MSP statute. The appellants, the Health Insurance Association of America and the Blue Cross and Blue Shield Association, both challenge three regulations as going beyond the Secretary’s statutory authority, and each challenges one that the other does not attack. All parties agree that we are to uphold each regulation unless it contradicts “the unambiguously expressed intent of Congress” or is not a “reasonable interpretation” of an ambiguous statutory provision. Chevron U.S.A. v. Natural Resources Defense Council, 467 U.S. 837, 842-43, 844, 104 S.Ct. 2778, 2782, 81 L.Ed.2d 694 (1984).

A. CFR § U11.2h(e) — third-party administrator liability.

Both appellants are associations of health-insurance companies whose members often enter into contracts with employers or employer group health plans. Under some of these contracts, the companies underwrite some or all of the health plan’s benefits. Frequently, however, employers self-insure, and hire one of the appellants’ member companies merely to perform administrative services such as adjudicating claims and writing benefit cheeks drawn on accounts stocked with the' employer’s money. “[Ajlthough there are variations in these [administrative-services] contracts,” explains amicus curiae the Self-Insurance Institute of America (“SIIA”), “administrators customarily do not pay the financial obligations of their plan customers from their own funds or commingle plan funds with their own funds.” Brief of Amicus Curiae SIIA 12 (emphasis in original); cf. Joint Appendix (“J.A.”) 290-98 (sample administrative-services contract).

Nonetheless, HCFA believes that these third-party administrators are “required or responsible under [the MSP statute] to pay ... under a primary plan” within the meaning of 42 U.S.C. § 1395y(b)(2)(B)(ii), and hence that they are subject to suit by HCFA for recovery of conditional payments. Though HCFA’s regulations did not explicitly take this position until 1989, 42 CFR § 411

Free access — add to your briefcase to read the full text and ask questions with AI

Related

John Bejarano v. William Reubart
136 F.4th 873 (Ninth Circuit, 2025)
Reidinger v. Zendesk, Inc.
N.D. California, 2021
Davita Inc. v. Virginia Mason Memorial
981 F.3d 679 (Ninth Circuit, 2020)
Little v. Frederick
W.D. Louisiana, 2020
(PC) Ramirez v. Brown
E.D. California, 2019
Community Health Systems, Inc. v. Burwell
113 F. Supp. 3d 197 (District of Columbia, 2015)
National Restaurant Association v. Solis
870 F. Supp. 2d 42 (District of Columbia, 2012)
Select Specialty Hospital - Akron, LLC v. Sebelius
820 F. Supp. 2d 13 (District of Columbia, 2011)
St. Luke's Hospital v. Sebelius
611 F.3d 900 (D.C. Circuit, 2010)

Cite This Page — Counsel Stack

Bluebook (online)
23 F.3d 412, 126 A.L.R. Fed. 793, 306 U.S. App. D.C. 104, 1994 U.S. App. LEXIS 10733, 1994 WL 180090, Counsel Stack Legal Research, https://law.counselstack.com/opinion/health-insurance-assn-of-america-inc-v-shalala-cadc-1994.