Vista Health Plan v. HHS

29 F.4th 210
CourtCourt of Appeals for the Fifth Circuit
DecidedMarch 17, 2022
Docket20-50963
StatusPublished
Cited by1 cases

This text of 29 F.4th 210 (Vista Health Plan v. HHS) is published on Counsel Stack Legal Research, covering Court of Appeals for the Fifth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Vista Health Plan v. HHS, 29 F.4th 210 (5th Cir. 2022).

Opinion

Case: 20-50963 Document: 00516243790 Page: 1 Date Filed: 03/17/2022

United States Court of Appeals for the Fifth Circuit United States Court of Appeals Fifth Circuit

FILED March 17, 2022 No. 20-50963 Lyle W. Cayce Clerk

Vista Health Plan, Incorporated; Vista Service Corporation,

Plaintiffs—Appellants,

versus

United States Department of Health and Human Services; Xavier Becerra, Secretary, U.S. Department of Health and Human Services; Centers for Medicare and Medicaid Services; Seema Verma, Administrator of the Centers for Medicare and Medicaid Services,

Defendants—Appellees.

Appeal from the United States District Court for the Western District of Texas USDC No. 1:18-CV-824

Before Higginbotham, Stewart, and Wilson, Circuit Judges. Cory T. Wilson, Circuit Judge: The United States Department of Health and Human Services (HHS) implements a risk-adjustment program under the Patient Protection and Affordable Care Act (ACA) in states that choose not to implement the program themselves. The risk-adjustment program is designed to redistribute actuarial risk among health insurance plans so that sicker-than- Case: 20-50963 Document: 00516243790 Page: 2 Date Filed: 03/17/2022

No. 20-50963

average individuals can obtain affordable healthcare. To effectuate the program, HHS created a three-step risk-adjustment methodology. In March 2018, a district court in New Mexico vacated HHS’s risk-adjustment rules for benefit years 2014 through 2018 to the extent the rules relied on the third step of HHS’s methodology. In response, HHS stated that it would not collect or pay specified risk-adjustment amounts but would issue additional guidance in the near future. In July 2018, HHS announced that it would republish the previously adopted risk-adjustment rule for the 2017 benefit year. For the 2018 benefit year, HHS promulgated a new rule in December 2018. Once the new rules were published, Vista Health Plan, Inc., a small health insurance company in Texas, was assessed risk-adjustment fees that exceeded its premium revenue, causing the company to cease operations. The company and its parent, Vista Service Corporation, (collectively, Vista) sued HHS, HHS Secretary Alex Azar, the Centers for Medicare and Medicaid Services (CMS), and CMS Administrator Seema Verma (collectively, the HHS Defendants), challenging the risk-adjustment program and the repromulgation of the 2017 and 2018 Final Rules. The district court granted summary judgment for the HHS Defendants on eight of nine claims asserted by Vista and remanded the only remaining claim to HHS. We affirm the court’s summary judgment in favor of the defendants. I. A. The underlying facts are undisputed. Among other provisions, the ACA prohibits insurers from denying coverage or charging higher premiums based on health status. See generally King v. Burwell, 576 U.S. 473, 479–84 (2015) (summarizing the background and purpose of the ACA). Because sicker individuals generally incur higher costs for insurers, insurers are

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disincentivized from enrolling such individuals without charging higher premiums. To counteract this, Congress enacted 42 U.S.C. § 18063, which directs HHS to establish a permanent risk-adjustment program. Under the risk-adjustment program, fees are assessed against plans with healthier-than-average enrollees in a given state, and then payments are made to plans with sicker-than-average enrollees in that state to redistribute actuarial risk. Congress designed the risk-adjustment program to be administered by the States. Some states opted not to do so, and in those states, Congress directed HHS to operate the program. 42 U.S.C. § 18041(c)(1)(B)(ii). To assess actuarial risk, Congress directed HHS to “establish criteria and methods” for the risk-adjustment program. 42 U.S.C. § 18063(b). In turn, HHS created a three-step risk-adjustment methodology: First, for each individual enrolled in an insurer’s plan, an actuarial risk score is computed using demographic and diagnostic data to determine the predicted cost of insuring that enrollee. 78 Fed. Reg. 15,410, 15,419 (Mar. 11, 2013). Second, the risk scores for each enrollee in a plan are aggregated to determine the plan’s average risk score. Id. at 15,432. Third, a plan’s risk score is multiplied by the statewide average premium, yielding the dollar amount that a given insurer will pay as a charge or receive as a payment, for that plan for that year. See id. at 15,430–34; N.M. Health Connections v. U.S. Dep’t of Health & Hum. Servs., 946 F.3d 1138, 1148–50 (5th Cir. 2019) (detailing the risk adjustment program methodology). HHS has used an annual rulemaking process to refine its risk-adjustment rules, but it has not reconsidered its overarching methodology anew each year. In March 2018, a district court in New Mexico vacated HHS’s risk- adjustment rules for benefit years 2014 through 2018 to the extent they relied on the statewide average premium (the third step of the risk-adjustment

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methodology). See Minuteman Health, Inc. v. U.S. Dep’t of Health & Hum. Servs., 312 F. Supp. 3d 1164, 1207–12 (D.N.M. 2018), rev’d, 946 F.3d 1138 (10th Cir. 2019). Just prior, in January 2018, a district court in Massachusetts ruled in favor of HHS on the same issue. See Minuteman Health, Inc. v. U.S. Dep’t of Health & Hum. Servs., 291 F. Supp. 3d 174, 198–205 (D. Mass. 2018). Addressing the conflicting judgments, HHS issued a press release on July 7, 2018, advising insurers that “the New Mexico district court’s ruling . . . bar[red] [HHS] from collecting or making payments under the current methodology, which uses the statewide average premium.” Two days later, HHS stated it “w[ould] not collect or pay the specified amounts,” but it “w[ould] inform stakeholders of any update to the status of collections or payments at an appropriate future date.” HHS added that “[a]dditional guidance w[ould] be issued in the near future regarding 2017 benefit year appeals and reporting of risk adjustment transfer amounts by issuers.” Urged by members of Congress (among various other entities) “to act with the utmost urgency to resolve the $10.4 billion hold on the risk adjustment program,” HHS issued a memorandum on July 27, 2018, stating that it would republish the previously adopted risk-adjustment program rule for the 2017 benefit year. The republished rule “utilize[d] statewide average premium for the 2017 benefit year as set forth in the rules published on March 23, 2012 . . . and March 8, 2016.” Three days later, HHS published the 2017 Final Rule, which adopted “the HHS-operated risk adjustment methodology previously published at 81 [Fed. Reg.] 12204 for the 2017 benefit year with an additional explanation regarding the use of statewide average premium and the budget neutral nature of the program.” HHS clarified that the “rule d[id] not make any changes to the previously published HHS-operated risk adjustment methodology for the 2017 benefit year.” HHS did not follow the notice-and-public-comment procedures outlined in the Administrative Procedure Act (APA) when it republished the 2017 rule. See 5 U.S.C. § 553.

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For the 2018 benefit year, HHS published a proposed rule on August 10, 2018, following the APA’s notice-and-public-comment procedures.

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Vista Health Plan v. HHS
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Bluebook (online)
29 F.4th 210, Counsel Stack Legal Research, https://law.counselstack.com/opinion/vista-health-plan-v-hhs-ca5-2022.