Verdant Health Commission v. Burwell

127 F. Supp. 3d 1116, 2015 U.S. Dist. LEXIS 116506, 2015 WL 5124031
CourtDistrict Court, W.D. Washington
DecidedSeptember 1, 2015
DocketNo. C14-5108RBL
StatusPublished
Cited by2 cases

This text of 127 F. Supp. 3d 1116 (Verdant Health Commission v. Burwell) is published on Counsel Stack Legal Research, covering District Court, W.D. Washington primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Verdant Health Commission v. Burwell, 127 F. Supp. 3d 1116, 2015 U.S. Dist. LEXIS 116506, 2015 WL 5124031 (W.D. Wash. 2015).

Opinion

[1118]*1118ORDER ON MOTIONS FOR SUMMARY JUDGMENT

RONALD B. LEIGHTON, District Judge.

The plaintiffs challenge the DHHS Secretary’s decision to exclude certain. low-income populations from Medicare reimbursement calculations. The Medicare formula includes patient days for individuals “eligible for medical assistance under a state plan approved under subchapter XIX.” 42 U.S.C. § 1395ww(d)(5)(vi)(II). (Medicaid eligible patients). Additionally, there is another category of patient population “regarded” as Medicaid eligible: patient days served as part of a demonstration project authorized by Section 1115 of the Social Security Act. 42 U.S.C. § 1315(a).

The first issue presented by this appeal is the proper interpretation of the term “eligible for medical assistance” under an approved State plan. This precise question was answered by the Ninth Circuit in University of Washington Medical Center v. Sebelius, 634 F.3d 1029 (9th Cir.2011) (“UW-I”). Seventeen of the plaintiffs in that case are plaintiffs in this case. They seek to distinguish or overturn UW-I on three bases: (1) this case involves a different time period; (2) UW-I was wrongly decided; and (3) there is a split within the Circuit on this question that can only be resolved by an en banc Ninth Circuit decision.

Plaintiffs’ second argument focuses on the fairness of the distinction between § 1115 demonstration project populations (“regarded as eligible”) and other, similarly-situated needy patients (not “regarded as eligible”). UW-I does not address this second argument, and the plaintiffs did not raise it to the Administrative Court below.

The resolution of the parties’ competing summary judgment motions is little more than a hitching post to rest the horses for another assault on the Ninth Circuit. This Court’s contribution (for lack of a better term) is to recount the history of legislative, regulatory and judicial pronouncements on these subjects, and to try and predict the final outcome. For the reasons outlined below, the Defendant’s Motion for Summary Judgment [Dkt. # 26] is GRANTED, and the Plaintiffs’ Motion for Summary Judgment [Dkt. # 11] is DENIED.

BACKGROUND

A. Medicare and Medicaid: Legislative and Regulatory Pronouncements

Medicare is a health insurance program that pays for covered medical care primarily to aged and disabled persons. 42 U.S.C. § 1395 et seq. Medicaid is a cooperative federal-state program that provides health care to indigent persons who are aged, blind, disabled, or members of families with dependent children. 42 U.S.C. §§ 1396 et seq. Medicaid is financed jointly by the federal and state governments, and is administered by the states according to federal guidelines. Id.; 42 C.F.R. § 430.0. Each state participating in the Medicaid program must submit to the Secretary a state plan meeting Medicaid’s statutory and regulatory requirements. 42 U.S.C. § 1395a. The state’s plan must obtain the. Secretary’s approval in order for the state to participate in Medicaid. States have discretion to determine the type and range of services covered, rules of eligibility, and payment levels for services. 42 C.F.R. § 430.0. Accordingly, Medicaid programs vary from state to state, both with respect to persons and services covered, and to the scope and duration of benefits. Legacy Emanuel Hospital and Health Center v. Shalala) 97 F.3d 1261 (9th Cir.1996).

Prior to 1983, the Medicare program reimbursed hospital services on a “reason[1119]*1119able cost” basis. 42 U.S.C. § 1395f(b). Since 1983, Medicare has reimbursed hospitals’ operating costs prospectively, under the Prospective Payment System (PPS). Payments are based upon what it would cost an efficient hospital to treat a patient with a given diagnosis. See the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA), codified at 42 U.S.C. § 1395ww (2006). Hospitals are paid a fixed amount for each patient based on one of approximately 490 diagnosis-related groups (DRG), subject to certain payment adjustments. 42 U.S.C. § 1395ww(d)(1)-(d)(4); 42 C.F.R. Part 412.

In 1983, Congress determined that hospitals that served a disproportionately large number of low-income patients incurred costs that were not met by the standard PPS calculation. Accordingly, Congress authorized the Secretary to provide an adjustment — the “Disproportionate Share Hospital” Adjustment (DSH) — to hospitals serving a disproportionate share of low-income persons. 42 U.S.C. § 1395ww(d)(5)(F)(i)(I). A designated fiscal intermediary (usually an insurance company) calculates these DSH payments on the basis of the hospitals’ “disproportionate share percentage.” Id. § 1395ww(d)(5)(F)(vi). In part, this calculation requires the fiscal intermediary to determine the proportion of low-income patient days in the Medicare population the hospital served, a proportion known as the Medicaid fraction, or Medicaid proxy. Id. § 1395ww(d)(5)(F)(vi)(II).1

In 1986, Congress enacted the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA included a provision creating and defining DSH adjustments. Congress directed the Secretary to provide a DSH- adjustment to PPS payments for hospitals serving a disproportionately large number of low-income patients and prescribed a specific adjustment method.

Until 1998, the Secretary included in the Medicaid fraction all patient days during which a patient was entitled to Medicaid, but interpreted the rule to exclude days of patients who were Medicaid eligible, but for which the state did not actually make payments (for example, where' the state capped the number of patient days). In 1998, following adverse court rulings (including Legacy Emanuel), the Secretary amended this rule to provide for computation of DSH reimbursements on the basis of patients’ eligibility for Medicaid assistance, regardless of actual payment. 42 C.F.R. § 412.106(b)(4)(i).

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Cooper Hospital University Medical Center v. Burwell
179 F. Supp. 3d 31 (District of Columbia, 2016)
Owensboro Health, Inc. v. Burwell
132 F. Supp. 3d 900 (W.D. Kentucky, 2015)

Cite This Page — Counsel Stack

Bluebook (online)
127 F. Supp. 3d 1116, 2015 U.S. Dist. LEXIS 116506, 2015 WL 5124031, Counsel Stack Legal Research, https://law.counselstack.com/opinion/verdant-health-commission-v-burwell-wawd-2015.