Massachusetts Ass'n of Health Plans v. Murphy

27 Mass. L. Rptr. 68
CourtMassachusetts Superior Court
DecidedApril 12, 2010
DocketNo. 101377BLS2
StatusPublished
Cited by1 cases

This text of 27 Mass. L. Rptr. 68 (Massachusetts Ass'n of Health Plans v. Murphy) is published on Counsel Stack Legal Research, covering Massachusetts Superior Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Massachusetts Ass'n of Health Plans v. Murphy, 27 Mass. L. Rptr. 68 (Mass. Ct. App. 2010).

Opinion

Neel, Stephen E., J.

Plaintiffs Massachusetts Association of Health Plans (MAHP) and associated individual health plans (Plans) seek an order enjoining defendant Joseph G. Murphy, Commissioner of Insurance (Commissioner), from prohibiting or preventing the Plans from charging and collecting increased rates from small group and individual subscribers effective April 1, 2010. On that date the Commissioner disapproved most of the Plans’ proposed new rates for those subscribers, calling the rate increases “unreasonable in relation to the benefits provided and excessive.” Plaintiffs allege that his disapproval was arbitrary, capricious, without authority, and unconstitutionally confiscatory. Their complaint claims that, absent immediate relief from the Court, the Plans will suffer substantial collective losses that will deplete their reserves, weaken their financial stability, and in some instances threaten their near-term solvency.

What the plaintiffs in effect request is that the Court, at this early stage, approve — through a preliminary injunction, pending a trial and final judgment— the rate increases which the Plans seek to charge small group and individual subscribers. After hearing, and review and consideration of the memoranda, affidavits, and other materials submitted, the Court declines to grant the plaintiffs’ request, and instead directs plaintiffs to exhaust their administrative remedies before seeking judicial relief. That course — required by Massachusetts law in all but rare circumstances, which as discussed below are not present here — will allow the Plans to develop an adequate factual record, and seek timely relief, through the administrative hearing process. If the Plans do not obtain from that process the relief they seek (and it is within their power to have that decision sixty days from today), they may appeal that final administrative decision to Superior Court under the state’s administrative procedure act, G.L.c. 30A.

Because plaintiffs have not exhausted their administrative remedies, and because they have not demonstrated that they are otherwise entitled to injunctive relief, their motion for preliminary injunction will be denied.

BACKGROUND

The Plans are health maintenance organizations or health care insurers (HMOs) that offer health insurance to small groups and individuals in the Commonwealth (sometimes referred to as the merged market) pursuant to G.L.c. 176G.2 Together, the Plans provide coverage to about 93% of the merged market.3

The Legislature has created a comprehensive statutory structure to regulate the provision of health insurance. Premiums, or rates, to be charged by HMOs to consumers, including the merged market, are governed by G.L.c. 176G, §16, which reads, in pertinent part, as follows:

The subscriber contracts, rates and evidence of coverage shall be subject to the disapproval of the commissioner. No such contracts shall be approved if the benefits provided therein are unreasonable in relation to the rate charged, nor if the rates are excessive, inadequate or unfairly discriminatory.

Prior to February 10, 2010, 211 CMR 43.08, promulgated under the authority of G.L.c. 176G, §17, provided that “(e]ach HMO shall submit proposed rates and benefits, or changes thereof, on or before their effective dates and at least at the beginning of each calendar year. Submissions are subject to the Commissioner’s disapproval if the benefits and rates do not meet the requirements of M.G.L.c. 176G, §16.” On February 10, 2010, Governor Deval Patrick publicly announced that he was “directing the Commissioner of Insurance, on an emergency basis, to require health insurance companies to file any increases or changes to rates before they take effect and to disapprove the increases if they are unreasonable or excessive. Any increases significantly higher than the current level of medical cost inflation, which today is 3.2 percent, will be challenged.” Kluft Aff., Ex. A.

On that same day, the Commissioner promulgated, on an emergency basis, an amendment to 211 CMR 43.08 (the amended regulation). The amended regulation provides that “in the case of small group health coverage rate increases or changes to small group rating factors . . . with effective dates on or after April 1, 2010, [proposed rates] shall be filed at least 30 days before their effective dates. Filings are subject to the Commissioner’s disapproval if the benefits and rates do not meet the requirements of M.G.L.c. 176G, §16.” The amended regulation further provides that a submission does not constitute a complete filing unless it includes an actuarial memorandum and specified categories of additional documentation.4 Of considerable importance to the motion before the Court, the amended regulation also contains the following provision:

If the Commissioner disapproves a filing, he shall notify the HMO in writing no later than the effective date of the rates or changes, and he shall state the reason(s) for the disapproval. The HMO may request a hearing on the disapproval to be held within 30 days of the notice by filing a written request with the Division of Insurance for a hearing within 15 days of its receipt of such notice. The Commissioner shall issue a written decision within 30 days after the conclusion of the hearing. The HMO may not implement the disapproved rates, or changes at any time unless the Commissioner reverses the disapproval after a hearing or unless a Court vacates the Commissioner’s decision.

[70]*70Also on February 10, 2010, the governor filed legislation proposing that “if a carrier files for an increase in a small group product’s base rate over the prior year’s base rate by an amount that is more than 150 percent of the prior calendar year’s percentage increase in the consumer price index for medical care services5 . . . [the rate] shall be presumptively disapproved as excessive by the commissioner ...” Complaint, para. 35.

On February 24, 2010, the Deputy Commissioner issued Filing Guidance Notice 2010-A (Guidance) which provides, among other things, that “Health Plans may not increase a rate from the prior year if the filing is disapproved. For example, if a group policy is renewing on April 1st, and the March 1st filing for April rates is disapproved, the prior April’s rates must stay in effect until such time, if any, that the Health Plan’s filing is deemed not disapproved.” (Emphasis in original.)

On or about March 1, 2010, the Plans submitted to the Commissioner their respective small group and individual proposed rate increases, to be effective April 1, 2010 (the submitted rates), accompanied by actuarial memoranda certifying that the submitted rates were in compliance with the provisions of G.L.c. 176G, §16. See, e.g., Trocki Aff., para. 25. Nearly all of the submitted rates represent an increase over the Plans’ April 2009 rates in excess of 150% of the prior year’s Medical CPI.

On March 25, 2010, the Deputy Commissioner of Insurance orally communicated to each Plan that the Division of Insurance would recommend that the Commissioner disapprove the submitted rates as excessive and unreasonable. See, e.g., Trocki Aff., para. 28. Among the reasons stated for this recommendation was that the increases were above the 2009 Medical CPI increase for the New England region, which he stated to be 5.1%.6 See, e.g., id.

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Related

Massachusetts Ass'n of Health Plans v. Murphy
27 Mass. L. Rptr. 77 (Massachusetts Superior Court, 2010)

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Bluebook (online)
27 Mass. L. Rptr. 68, Counsel Stack Legal Research, https://law.counselstack.com/opinion/massachusetts-assn-of-health-plans-v-murphy-masssuperct-2010.