Health Republic Insurance Company v. United States

129 Fed. Cl. 757, 2017 U.S. Claims LEXIS 8, 2017 WL 83818
CourtUnited States Court of Federal Claims
DecidedJanuary 10, 2017
Docket16-259C
StatusPublished
Cited by8 cases

This text of 129 Fed. Cl. 757 (Health Republic Insurance Company 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 Republic Insurance Company v. United States, 129 Fed. Cl. 757, 2017 U.S. Claims LEXIS 8, 2017 WL 83818 (uscfc 2017).

Opinion

Section 1342 of the Patient Protection and Affordable Care Act, 42 U.S.C. § 18062; 46 C.F.R. pt. 153; Risk Corridors Program; RCFC 12(b)(1) Motion to Dismiss; Subject Matter Jurisdiction; Money-Mandating Statute and Regulation; Presently Due Money Damages; Ripeness; Agency Interpretation of Its Own Regulations; Requirement of Annual Risk Corridors Payments

OPINION AND ORDER

SWEENEY, Judge

Plaintiff Health Republic Insurance Company contends, for itself and on behalf of those similarly situated, that defendant United States has not fully paid the risk corridors payments to which it and other insurers are entitled under the Patient Protection and Affordable Care Act (“Affordable Care Act”), Pub. L. No. 111-148, 124 Stat. 119 (2010), and its implementing regulations. Defendant moves to dismiss plaintiffs - complaint for lack of subject matter jurisdiction pursuant to Rule 12(b)(1) of the Rules of the United States Court of Federal Claims (“RCFC”). As explained below, the court grants in part and denies in part defendant’s motion.

I. BACKGROUND

A. The Affordable Care Act

Congress enacted the Affordable Care Act in March 2010. 124 Stat. at 119. The Act includes “a series of interlocking reforms de *761 signed to expand coverage in the individual health insurance market.” King v. Burwell, - U.S. -, 135 S.Ct. 2480, 2485, 192 L.Ed.2d 483 (2015).

First, the Act bars insurers from taking a person’s health into account when deciding whether to sell health insurance or how much to charge. Second, the Act generally requires each person to maintain insurance coverage or make a 'payment to the Internal Revenue Service. And third, the Act gives tax credits to certain people to make insurance more affordable.

Id.; accord 26 U.S.C. §§ 36B, 5000A (2012); 42 U.S.C. § 300gg-1 (2012). “These three reforms are closely intertwined. ... Congress found that the guaranteed .issue and community rating requirements would not work without the coverage requirement. And the coverage requirement would not work without the tax credits.” King, 135 S.Ct. at 2487 (citation omitted).

In conjunction with these three reforms, the Affordable Care Act required the establishment of an American Health Benefit Exchange (“exchange”) in each state by January 1, 2014, to facilitate the purchase of “qualified health plans” by individuals and small businesses. 42 U.S.C. §§ 18031, 18041; accord King, 135 S.Ct. at 2485 (describing an exchange as “a marketplace that allows people to compare and purchase insurance plans”). Among other requirements, each “qualified health plan” offered on an exchange must provide a .package of “essential health benefits.” 42 U.S.C. § 18021(a)(1).

Thus, when enacted, the Affordable Care Act provided benefits and risks for health insurance companies (“insurers”). On the one hand, insurers would have access to a market of' previously uninsured individuals, which could result in the insurers attracting more customers. See King, 135 S.Ct. at 2485; accord 42 U.S.C. § 18091(2)(C) (“The requirement [to maintain insurance coverage], ’together with the other provisions of this Act, will add millions of new consumers to the health insurance market_”). On the other hand, because insurers lacked data “to predict the needs of the newly-insured" individuals, they would be hampered in their ability to “price [qualified health] plans to reflect the medical, costs associated with this new and untested marketplace.” Compl. ¶ 2; accord id. ¶ 26 (“[I]nsurers generally have less experience in how to accurately price policies in ’ the individual market rather than the group market, and no relevant experience estimating benefit utilization, risk pool composition, and medical spending costs for insurance policies to the post-[Affordable Care Act] market, which included a new demo■graphic and new mandatory coverage requirements.”). To mitigate the risk faced by insurers, the Affordable Care Act included three premium stabilization programs: a transitional reinsurance program, a permanent risk adjustment program, and a temporary risk corridors program. See id. ¶¶ 4, 20; 42 U.S.C. §§ 18061-18063.

The transitional reinsurance program required insurers to fund, for the three-year period beginning January 1, 2014, reinsurance entities that would make payments to insurers that covered high-risk individuals “for any plan year beginning” in the three-year period. 42 U.S.C. § 18061. The permanent risk adjustment program requires each state to “assess a charge oh health plans and health insurance issuers (with respect to health insurance coverage) ... if the actuarial risk of the enrollees of such plans or 'coverage for a year is less than the average actuarial- risk of all enrollees in all plans or coverage in such State for such year” and “provide a payment to health' plans and health insurance issuers (with respect to health insurance coverage) ... if the actuarial risk of the enrollees of such plans or coverage for a year is greater than the average actuarial risk of all enrollees in all plans and coverage in such State for such year ....” Id. § 18063.

The third program—the one at issue in this case—is the temporary risk ' corridors program. Pursuant to section 1342 of the Affordable Care Act:

The Secretary [of the Department of Health and Human Services (“HHS”) ] shall establish and administer a program of risk corridors for calendar years 2014, 2015, and 2016 under which a qualified health plan offered in the individual or small group market shall participate in a *762 payment adjustment system based on the ratio of the allowable costs of the plan to the plan’s aggregate premiums. Such program shall be based on the program for regional participating provider organizations under part D of title XVIII of the Social Security Act [42 U.S.C. 1395w-101 et seq.].

42 U.S.C. § 18062(a) (first alteration added). Section 1342 describes the methodology for collecting and making payments that HHS was required to adopt:

(1) Payments out
The Secretary shall provide under the program established under subsection (a) that if—

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Bluebook (online)
129 Fed. Cl. 757, 2017 U.S. Claims LEXIS 8, 2017 WL 83818, Counsel Stack Legal Research, https://law.counselstack.com/opinion/health-republic-insurance-company-v-united-states-uscfc-2017.