Vista Health Plan, Inc. and Integranet Provider Organization, Inc. v. Texas Health and Human Services Commission, Texas Department of Human Services, Texas Department of Health, and Texas Rehabilitation Commission

CourtCourt of Appeals of Texas
DecidedMay 20, 2004
Docket03-03-00216-CV
StatusPublished

This text of Vista Health Plan, Inc. and Integranet Provider Organization, Inc. v. Texas Health and Human Services Commission, Texas Department of Human Services, Texas Department of Health, and Texas Rehabilitation Commission (Vista Health Plan, Inc. and Integranet Provider Organization, Inc. v. Texas Health and Human Services Commission, Texas Department of Human Services, Texas Department of Health, and Texas Rehabilitation Commission) is published on Counsel Stack Legal Research, covering Court of Appeals of Texas primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

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Vista Health Plan, Inc. and Integranet Provider Organization, Inc. v. Texas Health and Human Services Commission, Texas Department of Human Services, Texas Department of Health, and Texas Rehabilitation Commission, (Tex. Ct. App. 2004).

Opinion

TEXAS COURT OF APPEALS, THIRD DISTRICT, AT AUSTIN

NO. 03-03-00216-CV

Vista Health Plan, Inc. and Integranet Provider Organization, Inc., Appellants

v.

Texas Health and Human Services Commission, Texas Department of Human Services, Texas Department of Health, and Texas Rehabilitation Commission, Appellees

FROM THE DISTRICT COURT OF TRAVIS COUNTY, 201ST JUDICIAL DISTRICT NO. GN1-03928, HONORABLE PAUL DAVIS, JUDGE PRESIDING

MEMORANDUM OPINION

This is an interlocutory appeal from a grant of a plea to the jurisdiction, which stems

from a dispute about the administration of the state’s Medicaid managed care program.1 See Tex.

Civ. Prac. & Rem. Code Ann. § 51.014(a)(8) (West Supp. 2004) (allowing interlocutory appeals

1 Medicaid is a cooperative program between the federal government and the states whereby the federal government agrees to pay a specified percentage of a state’s expenditure for the provision of health care to needy individuals if the state agrees to establish a Medicaid plan satisfying certain federal requirements. See 42 U.S.C.A. §§ 1396-1396v (West 2003). Texas’s Medicaid program includes a managed care program—a “health delivery system in which the overall care of a patient is coordinated by or through a single provider or organization”—which is known as State of Texas Access Reform, or “STAR.” 1 Tex. Admin. Code § 353.402(25) (2004); see also id. §§ 353.2(13), .402(41) (2004). from order granting plea to jurisdiction). Appellee the Texas Department of Health2 contracted with

HMO Blue, Inc. (“Blue”) to provide comprehensive health care services to qualified Medicaid-

eligible recipients. Blue, in turn, subcontracted with appellants Vista Health Plan, Inc. and Integranet

Provider Organization, Inc. (collectively, “Vista”), to provide Medicaid managed care services to

Blue’s members. After a contract dispute arose between Blue and Vista about Vista’s contractual

liability for some of Blue’s members, Vista sued Blue for breach of contract and both Blue and the

state agencies for declaratory relief. Vista sought a judgment declaring erroneous the state agencies’

interpretation of their rules and applicable statutes, which were pivotal to its dispute with Blue. The

parties filed competing motions for summary judgment; the state agencies also filed a plea to the

jurisdiction. The trial court granted Blue’s motion for summary judgment and the state agencies’

plea to the jurisdiction. Only the trial court’s grant of the plea to the jurisdiction is before us on

appeal.3 We hold that no controversy existed between Vista and the state agencies once the court

granted summary judgment in favor of Blue. The trial court therefore properly refused to exercise

jurisdiction in the declaratory-judgment action against the state agencies. Accordingly, we will

affirm the trial court’s order granting the state agencies’ plea to the jurisdiction and dismissing

Vista’s claims against them.

2 The Texas Department of Health, the Texas Department of Human Services, and the Texas Rehabilitation Commission were all agencies within the Texas Health and Human Services Commission. Tex. Gov’t Code Ann. § 531.001 (West Supp. 2004). The agencies have since been abolished, and their powers, duties, and functions have been transferred to various other agencies within the commission. Act of June 2, 2003, 78th Leg., R.S., ch. 198, § 1.26, 2003 Tex. Gen. Laws 611, 641. For convenience, we will refer to the agencies and the commission collectively as the “state agencies,” unless our discussion requires us to distinguish among them. 3 The summary judgment is not yet a final judgment because some of Vista’s claims against Blue, which are not germane to this appeal, were not resolved by the summary judgment and remain pending in the trial court.

2 BACKGROUND

The underlying dispute in this case involves the Texas Medicaid program and how

it is funded. The department of health contracted with Blue, as a managed care organization, to

provide comprehensive health care services to Medicaid-eligible recipients under the state’s STAR

program. Blue, in turn, contracted with Vista to provide Medicaid services to Blue’s members.

Under the terms of Blue’s subcontract with Vista, Vista was paid on a per-patient or “capitated”

basis, defined in the contract as “a payment system which pays to Medical Group [Vista] a fixed

actuarially determined amount per month . . . in lieu of fee-for-service payments.”4 Blue adjudicated

and processed the Medicaid claims and informed Vista of the amount of money needed to pay those

claims. Vista ensured that an appropriate amount of money was available in a designated bank

account for Blue to pay the medical providers.

In October 2001, a dispute arose between Blue and Vista over whether Vista was

legally obligated to pay the claims of a special class of patients—newborn children weighing 1,200

grams or less at birth. Vista stopped providing funds for those patients and accused Blue of paying

between $10,000,000 and $12,000,000 in claims for ineligible Medicaid recipients. According to

4 Under a “capitated” payment system, the health care provider is paid a fixed, pre- determined amount per patient, which does not vary no matter how much care the patient requires. Allison Overbay & Mark Hall, Insurance Regulation of Providers that Bear Risk, 22 Am. J. L. & Med. 361, 363 (1996). Capitated payment arrangements are termed “full risk”; that is, Vista bears the risk that the capitated payment received for an insured member may be insufficient to cover that member’s medical needs for any given month. David M. Studdert, Direct Contracts, Data Sharing and Employee Risk Selection: New Stakes for Patient Privacy in Tomorrow’s Health Insurance Markets, 25 Am. J. L. & Med. 233, 236 (1999).

3 Vista, these children should have been covered by either Medicare5 or another type of Medicaid

program—a fee-for-service program,6 as opposed to the managed care program Vista contracted to

provide. In the alternative, Vista contended that the capitated method of payment was not reasonable

for the medical care required by premature infants and therefore violated federal and state law, which

mandate that reimbursement rates be based on sound actuarial principles. The state agencies were

implicated, according to Vista, because they were responsible for administering the Medicaid

program in Texas and for determining eligibility to receive Medicaid coverage.

Vista sued Blue for breach of contract and both Blue and the state agencies for

declaratory and injunctive relief. Vista sought a declaration that (1) the state agencies’ interpretation

and application of law as to the eligibility of newborn infants who are eligible for Medicaid was

invalid; (2) such an interpretation impaired Vista’s contract with Blue; (3) Medicaid was the payor

of last resort; (4) assuming the contracts did impose the risk of providing health care to these

newborn infants, the original capitation rates were unreasonable and actuarially unsound because

they did not factor in the increased cost of caring for certain newborns; and (5) Blue’s contract with

the state and Blue’s subcontract with Vista violated federal law. Essentially, Vista sought a

declaration that the Medicaid statutes and rules, if properly interpreted, absolved it from paying the

5 Medicare is administered by the federal government and provides health insurance for the aged and disabled. See 42 U.S.C.A. §§ 1395-1395ggg (West 2003).

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