Potts v. Rawlings Co.

897 F. Supp. 2d 185, 2012 WL 4364451, 2012 U.S. Dist. LEXIS 137802
CourtDistrict Court, S.D. New York
DecidedSeptember 25, 2012
DocketNo. 11 Civ. 907(JPO)
StatusPublished
Cited by28 cases

This text of 897 F. Supp. 2d 185 (Potts v. Rawlings Co.) is published on Counsel Stack Legal Research, covering District Court, S.D. New York primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Potts v. Rawlings Co., 897 F. Supp. 2d 185, 2012 WL 4364451, 2012 U.S. Dist. LEXIS 137802 (S.D.N.Y. 2012).

Opinion

MEMORANDUM OPINION AND ORDER

J. PAUL OETKEN, District Judge:

This case is a putative class action by enrollees in Medicare Advantage plans [188]*188seeking a declaratory judgment that, pursuant to New York State General Obligation Law § 5-335 (“GOL § 5-335”), the Defendant Medicare Advantage organizations and their agents do not have a right to seek reimbursement of monies that Plaintiffs received in settlements of lawsuits. Plaintiffs also assert a claim for violation of the New York deceptive business practices statute, N.Y. Gen. Bus. L. § 349 (“GBL § 349”).

Plaintiffs originally filed this action in New York State Supreme Court for New York County. Defendants removed the case to this Court pursuant to the Class Action Fairness Act, 28 U.S.C. § 1332(d), as well as on the grounds that the claims arise under certain provisions of the Medicare Act and implicate the Federal Officer removal statute, 28 U.S.C. § 1442(a)(1). Defendants now move to dismiss the case for lack of subject matter jurisdiction and for failure to state a claim upon which relief can be granted, pursuant to Rules 12(b)(1) and 12(b)(6) of the Federal Rules of Civil Procedure.

For the reasons that follow, Defendants’ motion to dismiss the case is granted.

I, Background

A. Medicare Provisions at Issue

This case concerns Medicare Advantage organizations acting as “secondary payers” under the Medicare Act.

1. Medicare Secondary Payer Act

The Medicare Secondary Payer (“MSP”) Act was enacted in 1980 in an effort to contain the costs of the Medicare program. See Bird, v. Thompson, 315 F.Supp.2d 369, 371 (S.D.N.Y.2003). Under these provisions, Medicare is, in certain circumstances, considered a “secondary payer” in relation to other sources, which are considered “primary payers.” Specifically, under 42 U.S.C. § 1395y(b)(2)(A), payment by Medicare “may not be made” to the extent that “payment has been made or can reasonably be expected to be made under a workmen’s compensation law or plan of the United States or a State or under an automobile or liability insurance policy or plan (including a self-insured plan) or under no fault insurance.” However, when these primary payers cannot pay for particular services “promptly,” Medicare may make payment, conditioned upon reimbursement by the primary payer. 42 U.S.C. § 1395y(b)(2)(B)(i). The statute provides that “[a] primary plan, and an entity that receives payment from a primary plan, shall reimburse the appropriate [Medicare] Trust Fund for any payment made by the Secretary [of the Department of Health and' Human Services (“HHS”) (the “Secretary”) ] under this subchapter with respect to an item or service if it is demonstrated that such primary plan has or had a responsibility to make payment with respect to such item or service.” 42 U.S.C. § 1395y(b)(2)(B)(ii).

In practice, this system works as follows: In a situation where another party is ultimately responsible for paying the healthcare costs of a Medicare enrollee, the money may not be available at the time the services are provided. For example, if an enrollee is injured in an accident caused by a third party tortfeasor, that tortfeasor (or its insurer) is ultimately responsible for the payment of the enrollee’s healthcare costs as a result of the accident. But the enrollee will not likely receive the proceeds of any settlement with, or judgment against, the tortfeasor in time to , pay her hospital bills. In such a situation, Medicare will pay the hospital bills on the condition that either the tortfeasor reimburse the Medicare Trust Fund directly, or the enrollee reimburse the Trust Fund, to the extent she has already received monies from the tortfeasor.

[189]*189The Medicare Act provides that “the United States may bring an action against any or all entities that are or were required or responsible ... to make payment with respect to the same item or service (or any portion thereof) under a primary plan.” 42 U.S.C. § 1395y(b)(2)(B)(iii). The statute also establishes “a private cause of action for damages (which shall be in an amount double the amount otherwise provided) in the case of a primary plan which fails to provide for primary payment (or appropriate reimbursement) in accordance” with the statute. 42 U.S.C. § 1395y(b)(3)(A).

2. Medicare Advantage Program

This case involves benefits received under the Medicare Advantage (“MA”) program, which is set forth in Part C of the Medicare Act. See 42 U.S.C. §§ 1395w-21-1395w-29. Under this part, Medicare enrollees may elect to receive their benefits from private insurers, called MA organizations, rather than from the government. MA organizations enter into contracts with the Center for Medicare and Medicaid Services (“CMS”), the branch of HHS that administers the Medicare program. Under these contracts, CMS pays an MA organization a fixed amount for each enrollee, per capita, and the MA organization must provide the same (or more) benefits and services that the enrollee would receive under traditional Medicare. See 42 U.S.C. § 1395w-22(a)(1)-(3). See generally Matthews v. Leavitt, 452 F.3d 145, 147 n. 1 (2d Cir.2006) (describing legislative history and provisions of Medicare Part C).

The Medicare Advantage statutes incorporate many of the MSP provisions into the MA organization context. Specifically, the statute provides:

Notwithstanding any other provision of law, a [MA] organization may (in the case of the provision of items and services to an individual under a [MA] plan under circumstances in which payment under this subchapter is made secondary pursuant to section 1395y(b)(2)) of this title charge or authorize the provider of such services to charge, in accordance with the charges allowed under a law, plan, or policy described in such section—
(A) the insurance carrier, employer, or other entity which under such law, plan, or policy is to pay for the provision of such services, or
(B) such individual to the extent that the individual has been paid under such law, plan, or policy for such services.

42 U.S.C. § 1395w-22(a)(4).

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Cite This Page — Counsel Stack

Bluebook (online)
897 F. Supp. 2d 185, 2012 WL 4364451, 2012 U.S. Dist. LEXIS 137802, Counsel Stack Legal Research, https://law.counselstack.com/opinion/potts-v-rawlings-co-nysd-2012.