Health Insurance Plan of Greater New York, Inc. v. United States

62 Fed. Cl. 33, 2004 U.S. Claims LEXIS 223, 2004 WL 1941214
CourtUnited States Court of Federal Claims
DecidedAugust 31, 2004
DocketNos. 97-187C, 01-148C
StatusPublished
Cited by12 cases

This text of 62 Fed. Cl. 33 (Health Insurance Plan of Greater New York, 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.

Bluebook
Health Insurance Plan of Greater New York, Inc. v. United States, 62 Fed. Cl. 33, 2004 U.S. Claims LEXIS 223, 2004 WL 1941214 (uscfc 2004).

Opinion

OPINION

ALLEGRA, Judge.

This contract case involves the Federal Employees Health Benefits Program (FEHB Program) and is before the court following a trial in Washington, D.C. At issue is whether the defendant, the United States, breached its FEHB Program contracts with plaintiff, Heath Insurance Plan of Greater New York, Inc. (HIP-NY), by failing to pay all the [35]*35premiums that were due for contract years 1988 through 1996.

I. FINDINGS OF FACT

Based on the record, including the parties’ stipulations, the court finds as follows:

A. Background: The FEHB Program.

In 1959, Congress passed the Federal Employees Health Benefits Act (FEHB Act), Pub.L. No. 86-382, 73 Stat. 708 (codified at 5 U.S.C. § 8901-15 (1994)1), to provide heath insurance benefits to civilian federal government employees through contracting with prepaid health plans, including health maintenance organizations (HMOs), such as HIP-NY. Since 1978, the Office of Personnel Management (OPM) has administered the FEHB Program. See Civil Service Reform Act of 1978, Pub.L. No. 95-454, § 906(a), 92 Stat. 1111, 1224-25. Under the FEHB Act, OPM is authorized to contract with qualified carriers offering health benefit plans for renewable term of at least one year. 5 U.S.C. § 8902(a). Through negotiations, OPM sets the amount of premiums paid to each plan on a per subscriber basis, known as the “subscriber rate,” for both “self-only” and “self- and-family” enrollees. Along with many other carriers, HIP-NY’s plan rates are set using the “community rate” method, under which the rate of payment is based “on a per member per month capitation rate or its equivalent that applies to a combination of the subscriber groups for a comprehensive medical plan carrier.” 48 C.F.R. § 1602.170-2 (2004).2

A Federal employee or annuitant selects a health benefits plan and is “enrolled” therein. These enrollees and the government then make contributions into the Employees Heath Benefit Fund (“the Fund”), which is maintained by OPM. Any agency that fails to withhold the proper health benefits contributions from an enrollee is, nonetheless, responsible for ensuring that the full amount of the owed contribution is deposited into the Fund. 5 C.F.R. § 890.502(c). The FEHB Act provides that, in addition to contributions for health benefits, the enrollees and the government must contribute amounts, in the same ratio as their contributions for health benefits, necessary to cover the administrative costs of the program and to provide for a contingency reserve — not to exceed 1 percent of the enrollee’s contribution is set aside for the former and not to exceed 3 percent thereof for the latter. 5 U.S.C. § 8909(b). The statute further provides that “from time to time and in amounts it considers appropriate,” OPM “may transfer unused funds for administrative expenses to the contingency reserves of the plans then under contract,” in which case, the contingency reserve is credited “in proportion to the total amount of the subscription charges paid and accrued to the plan for the contract term immediately before the contract term in which the transfer is made.” Id. The contingency reserve also includes “income derived from dividends, rate adjustments, or other refunds made by a plan.” Id.

The preferred minimum balance for a contingency reserve for a community rated plan is one month’s subscription charges at the average recurring monthly rate paid from the Fund for the plan during the most recent contract period. 5 C.F.R. § 890.503(c)(2). Amounts that exceed the preferred minimum balance for the contingency reserve may be used to “defray increases in future rates, or may be applied to reduce the contributions of enrollees and the government to, or to increase the benefits provided by, the plan from which the reserves are derived.” 5 U.S.C. § 8909(b); see also 5 C.F.R. § 890.503(c)(2). When a community rated plan’s contingency reserve exceeds the preferred minimum balance, the plan “may request OPM to pay to the plan a portion of the reserve not greater than the excess of the contingency reserve over the preferred [36]*36minimum balance.” 5 C.F.R. § 890.503(c)(4). In that event, “[t]he carrier shall state the reason for the request” and “OPM will decide whether to allow the request in whole or in part and will advise the plan of its decision.” Id. OPM “may authorize such other payments from the contingency reserve as in the judgment of OPM may be in the best interest of employees and annuitants enrolled in the program” and “[a] carrier for a plan may apply to OPM at any time for a payment from the contingency reserve when the carrier has good cause,” such as “variations from expected community rates.” 5 C.F.R. § 890.503(c)(5).3

The FEHB Act authorizes OPM to prescribe regulations for the operation of the FEHB Program, most of which are contained in FPM Supplement 890-14 Under this supplement, OPM “has overall responsibility for administration of the law,” including the responsibility for “depositing withholdings and contributions, remitting premiums to carriers, and accounting for the fund.” FPM Supp. 890-1, § S2-2(a)(4). Federal agencies participating in the program are responsible for: (i) “designating a health benefits officer and, at the employing office levels, health benefits officials;” (ii) “determining eligibility or ineligibility of employees and registering eligible employees (including determining acceptability of belated enrollments and changes of enrollment);” (iii) “insuring that registration forms are properly completed, including the employee’s social security number;” (iv) “processing health benefits actions and determining proper effective dates;” (v) “maintaining a controlled system of transmitting health benefits forms to carriers;” (vi) “remitting and accounting for withholdings and contributions;” and (vii) “maintaining and certifying necessary records.” FPM Supp. 890-1, § S2-3a. Finally, the supplement indicates that each carrier is responsible for “contacting agency payroll offices to reconcile enrollment records” and “maintaining financial and statistical records and reporting on operation of its plan.” FPM Supp. 890-1, § S2-4a.

Under the program, within 31 days after becoming eligible, an employee must either select a plan with which to enroll or elect out of the FEHB Program. FPM Supp. 890-1, § 5-la.

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Bluebook (online)
62 Fed. Cl. 33, 2004 U.S. Claims LEXIS 223, 2004 WL 1941214, Counsel Stack Legal Research, https://law.counselstack.com/opinion/health-insurance-plan-of-greater-new-york-inc-v-united-states-uscfc-2004.