Moda Health Plan, Inc. v. United States

130 Fed. Cl. 436, 2017 U.S. Claims LEXIS 70, 2017 WL 527588
CourtUnited States Court of Federal Claims
DecidedFebruary 9, 2017
Docket16-649C
StatusPublished
Cited by16 cases

This text of 130 Fed. Cl. 436 (Moda Health Plan, 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
Moda Health Plan, Inc. v. United States, 130 Fed. Cl. 436, 2017 U.S. Claims LEXIS 70, 2017 WL 527588 (uscfc 2017).

Opinion

Patient Protection and Affordable Care Act § 1342; Risk Corridors; Presently-Due Money Damages; Ripeness; Chevron Deference; Appropriation Restriction Limiting Statutory Obligation; Judgment Fund; Implied-in-Fact Contract Created by Statute.

OPINION AND ORDER

WHEELER, Judge.

Plaintiff Moda Health Plan, Inc. (“Moda”) offers health insurance plans through Health Benefit Exchanges created under the Patient Protection and Affordable Care Act (“ACA”), Pub. L. No. 111-148, 124 Stat. 119 (2010). To encourage insurers like Moda to offer health insurance on the exchanges, the ACA created a system of risk corridors under which the Government would pay insurers if they suffered losses during the first three years of the ACA’s implementation (2014-2016). Conversely, insurers would pay the Government a percentage of any profits they received in each of these first three years. Moda suffered losses on its health insurance plans during 2014 and 2016. To date, the Government has paid 12.6 percent of Moda’s claimed risk corridors payment for 2014, and has made no risk corridors payments for 2016.

Moda brought this case in June 2016 to obtain full risk corridors payments for the 2014 and 2016 plan years — in total, over $214 million. Moda primarily alleges that the Government is liable for the payments under the ACA and its implementing regulations, and argues in the alternative that the ACA’s risk corridors program created an implied-in-fact contract between insurers and the Government. The Government has moved to dismiss this case under Rules 12(b)(1) and 12(b)(6) of the Court of Federal Claims (“RCFC”). It argues that the court lacks jurisdiction over this case because risk corridor payments are not “presently due,” and that the case is not ripe because the Government has until the end of 2017 to make full risk corridors payments. On the merits, the Government also argues mainly that (1) the risk corridors program is required to be budget-neutral, so the Government only owes risk corridors payments to the extent that profitable insurers pay money into the program; and (2) Congress’s failure to appropriate money for risk corridors payments constitutes either a repeal of the Government’s risk corridors obligations or an amendment that makes the program budget-neutral. The Government further argues that the ACA and its implementing regulations did not form a contract between insurers and the Government. Moda has cross-moved for partial summary judgment on the issue of liability.

The Court held oral argument on the cross-motions on January 13, 2017. After considering the parties’ arguments in court and in their filings, the Court finds that the Government has unlawfully withheld risk corridors payments from Moda, and is therefore liable. The Court finds that the ACA requires annual payments to insurers, and that Congress did not design the risk corridors program to be budget-neutral. The Government is therefore liable for Moda’s full risk corridors payments under the ACA. In the alternative, the Court finds that the ACA constituted an offer for a unilateral contract, and Moda accepted this offer by offering qualified health plans on the Health Benefit Exchanges. The Government’s motion to dismiss is therefore DENIED, and Moda’s cross-motion for partial summary judgment is GRANTED.

Background

Congress passed the ACA in 2010 in a dramatic overhaul of the nation’s healthcare system. Central to the Act’s infrastructure was a network of “Health Benefit Exchanges” (“Exchanges”) on which insurers would offer Qualified Health Plans (“QHPs”) to eligible purchasers. ACA §§ 1311, 1321, 42 U.S.C. §§ 18031, 18041 (2012). The ACA also *442 drastically enlarged the pool of eligible insurance purchasers. It expanded Medicaid eligibility, ACA § 2001, and provided subsidies to low-income insurance purchasers, ACA §§ 1401, 1402; 45 C.F.R. § 155.305(f), (g). It also prohibited insurers from denying coverage or setting increased premiums based on a purchaser’s medical history. ACA § 1201(2)(A); 42 U.S.C. §§ 300gg-1-300gg-5 (2012).

In short, the ACA created a tectonic shift in the insurance market. It gave insurers like Moda access to a large new customer base, but insurers also had to comply with the ACA’s rules if they wanted to offer QHPs on the Exchanges. To help insurers adjust to the Exchanges, Congress included three provisions in the ACA — commonly known as the “3Rs” — that reduced insurers’ risk: reinsurance, risk corridors, and risk adjustment. See ACA §§ 1341-43. The second of these 3Rs, the risk corridors program, is the subject of this case.

A Congress Creates the Risk Corridors Program

Section 1342 of the ACA sets out the risk corridors program. It reads as follows:

(a) IN GENERAL. — The Secretary 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 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.
(b) PAYMENT METHODOLOGY.—
(1) PAYMENTS OUT. — The Secretary shall provide under the program established under subsection (a) that if—
(A) a participating plan’s allowable costs for any plan year are more than 103 percent but not more than 108 percent of the target amount, the Secretary shall pay to the plan an amount equal to 50 percent of the target amount in excess of 103 percent of the target amount; and
(B) a participating plan’s allowable costs for any plan year are more than 108 percent of the target amount, the Secretary shall pay to the plan an amount equal to the sum of 2.5 percent of the target amount plus -80 percent of allowable costs in excess of 108 percent of the target amount.
(2) PAYMENTS IN. — The Secretary shall provide under the program established under subsection (a) that if—
(A) a participating plan’s allowable costs for any plan year are less than 97 percent but not less than 92 percent of the target amount, the plan shall pay to the Secretary an amount equal to 50 percent of the excess of 97 percent of the target amount over the allowable costs; and
(B) a participating plan’s allowable costs for any plan year are less than 92 percent of the target amount, the plan shall pay to the Secretary an amount equal to the sum of 2.5 percent of the target amount plus 80 percent of the excess of 92 percent of the target amount over the allowable costs.
(c)DEFINITIONS. — In this section:
(1) ALLOWABLE COSTS.—
(A) IN GENERAL.

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Cite This Page — Counsel Stack

Bluebook (online)
130 Fed. Cl. 436, 2017 U.S. Claims LEXIS 70, 2017 WL 527588, Counsel Stack Legal Research, https://law.counselstack.com/opinion/moda-health-plan-inc-v-united-states-uscfc-2017.