medicare

Advocate Christ Medical Center v. Becerra

Issues

Are patients “entitled to” SSI benefits when they are eligible for SSI benefits or when they are receiving cash SSI benefits?

The Disproportionate Share Hospital adjustment (“DSH”) is a statutory provision administered by the Centers for Medicare & Medicaid Services (“CMS”) within the Department of Health and Human Services (“HHS”) that increases payments to hospitals serving high percentages of low-income patients to account for their increased treatment costs. At issue here is how eligibility for Supplemental Security Income (“SSI”) affects these DSH payments. Advocate Christ Medical Center argues that the phrase “entitled to [SSI] benefits” in the DSH provision should include all patients enrolled in the SSI program, even if they do not receive monthly cash payments. HHS counters that only patients receiving cash benefits during hospitalization should count. This case has important ramifications on agency interpretation, administrative workability, and hospitals’ ability to accept low-income patients.

Questions as Framed for the Court by the Parties

Whether the phrase “entitled ... to benefits,” used twice in the same sentence of the Medicare Act, means the same thing for Medicare part A and Supplemental Social Security benefits, such that it includes all who meet basic program eligibility criteria, whether or not benefits are actually received.

Administered by the Centers for Medicare & Medicaid Services (“CMS”) within the Department of Health and Human Services (“HHS”), the Medicare program aims to provide health insurance to elderly or disabled individuals. Advocate Christ Med. Ctr. v. Becerra at 349, 351. Hospitals receive a fixed payment for treating a Medicare patient. Id. At 349.

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American Hospital Association v. Becerra

Issues

Is the Department of Health and Human Services entitled to deference in its interpretation of a statute that enabled it to reduce drug reimbursement rates for hospitals; alternatively, is the Department of Health and Human Services’ action unreviewable because of 42 U.S.C. § 1395l(t)(12)?

This case asks the Supreme Court to determine the scope of authority granted to the Department of Health and Human Services (“HHS”) in setting hospital Medicare reimbursement rates for outpatient drugs. The Medicare Modernization Act (“MMA”) prescribes two alternative reimbursement rate methodologies for outpatient drugs—hospital acquisition cost or average drug price—and conditions HHS’s choice on whether HHS collects hospital drug cost-acquisition data. American Hospital Association et al. argue that MMA prevents HHS from tailoring rates to hospital acquisition costs and varying rates by group unless HHS has the requisite data. Xavier Becerra responds that MMA gives HHS the authority to “adjust” reimbursement rates as necessary, and therefore deference under Chevron permits HHS discretion to set reasonable rates. The outcome of this case has significant implications for the financial health of 340B hospitals, and the Medicare system more broadly, as well as the scope of the administrative state and judicial deference under Chevron.

Questions as Framed for the Court by the Parties

(1) Whether deference under Chevron U.S.A. v. Natural Resources Defense Council permits the Department of Health and Human Services to set reimbursement rates based on acquisition cost and very such rates by hospital group if it has not collected adequate hospital acquisition cost survey data; and (2) whether petitioners’ suit challenging HHS’s adjustments is precluded by 42 U.S.C. § 1395l(t)(12).

The Medicare program consists of Part A and Part B. Am. Hosp. Ass’n v. Azar at 820. Under Medicare Part B, which provides coverage for certain hospital-administered drugs, the Department of Health and Human Services (“HHS”) sets hospital reimbursement rates. Id. The “Outpatient Prospective Payment System” (“OPPS”) regulates the establishment of these rates.

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Azar v. Allina Health Services

Issues

Under either Sections 1395hh(a)(2) or 1395hh(a)(4) of the Medicare Act, did the Department of Health and Human Services err in not providing notice and an opportunity for comment before interpreting Medicare Part C enrollees to be “entitled to benefits under Part A” of Medicare, which thereby altered one of the calculations used to determine hospitals’ Medicare reimbursement payments?

The Supreme Court will decide whether Sections 1395hh(a)(2) or 1395hh(a)(4) of the Medicare Act requires the Department of Health and Human Services to provide notice and an opportunity for comment when issuing an interpretation of the Medicare Act that affects calculations involving Medicare Part C patients and Medicare payments. Petitioner Alex M. Azar II, the Secretary of Health and Human Services, argues that the agency’s issuance of a legally nonbinding interpretation of the Medicare Act that affected Medicare payment could not substantively affect legal standards and therefore did not trigger the notice-and-comment requirements of Sections 1395hh(a)(2) or 1395hh(a)(4). Respondents Allina Health Services et al. contend that this issuance was legally significant because hospitals and contractors were required to follow it, therefore triggering the notice-and-comment requirements of both Subsections (a)(2) and (a)(4). The Court’s decision could affect the administration of the Medicare Program, including the Department of Health and Human Services’ ability to respond swiftly to frequent Medicare changes and its ability to accurately anticipate the financial impacts of its issuances.

Questions as Framed for the Court by the Parties

Whether 42 U.S.C. § 1395hh(a)(2) or § 1395hh(a)(4) required the Department of Health and Human Services to conduct notice-and-comment rulemaking before providing the challenged instructions to a Medicare administrative contractor making initial determinations of payments due under Medicare.

The federal government, through the Department of Health and Human Services (“HHS”), provides Americans who are at least 65 years old or disabled with health insurance through the multi-part Medicare program. Allina Health Servs. v.

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Becerra v. Empire Health Foundation

Issues

Did the Secretary of the Health and Human Services permissibly include in a hospital’s Medicare reimbursement calculation all the days that a hospital treated patients who satisfied the requirements to be entitled to Medicare Part A benefits, regardless of whether Medicare paid the hospital for those particular days?

This case asks the Supreme Court to determine whether an agency had the authority to interpret the Medicare statute and change the calculation of payments distributed to hospitals that serve low-income patients who receive Medicare benefits. Petitioner Xavier Becerra, the Secretary of Health and Human Services, argues that the Department of Health and Human Services properly followed the procedural and substantive requirements of the Administrative Procedure Act when implementing its interpretation of the meaning of “entitled to” Medicare benefits in effecting a new calculation for determining two different pools of low-income patients. Respondent Empire Health Foundation counters that the agency’s rule causes a severe undercount of the low-income patient pool, causing those hospitals that serve indigent patients to receive a significantly lower reimbursement amount. The outcome of this case has important implications for the distribution of Medicaid funding and the extension of deference to government agencies’ reasonable interpretations of legislation.

Questions as Framed for the Court by the Parties

Whether, for purposes of calculating additional payment for hospitals that serve a “significantly disproportionate number of low-income patients,” the secretary of health and human services has permissibly included in a hospital’s Medicare fraction all of the hospital’s patient days of individuals who satisfy the requirements to be entitled to Medicare Part A benefits, regardless of whether Medicare paid the hospital for those particular days.

The Medicare program currently provides additional payments, known as the disproportionate-share-hospital (“DSH”) adjustment, to hospitals that treat a significantly higher number of low-in

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Biden v. Missouri

Issues

Can the Centers for Medicare and Medicaid Services continue to temporarily enforce a mandate requiring health care workers at Medicare- and Medicaid-certified facilities to be fully vaccinated against COVID-19 notwithstanding a district court injunction prohibiting the rule’s enforcement?

This case asks the Supreme Court to grant a stay of a district court injunction that currently blocks the Biden Administration from enforcing a mandate requiring certain healthcare workers to be fully vaccinated against COVID-19. The Biden Administration argues that the Supreme Court should issue a stay because the mandate is statutorily authorized, and its enforcement is in the public interest. The State of Missouri and nine other states (collectively “Missouri”) counter that the Supreme Court should reject the Biden Administration’s application for a stay and maintain enjoinment of the mandate throughout the pending litigation. The outcome of this case has significant implications for the Biden Administration’s pandemic-related authority and the role that the Supreme Court will play in either upholding or invalidating such authority.

Questions as Framed for the Court by the Parties

Whether the Supreme Court should issue a stay of the injunction issued by the United States District Court for the Eastern District of Missouri blocking a federal rule that requires all health care workers at facilities that participate in Medicare and Medicaid programs to be fully vaccinated against COVID-19 unless they are eligible for a medical or religious exemption.  

On November 5, 2021, the Centers for Medicare and Medicaid Services’ (“CMS”), an agency within the Department of Health and Human Services (“HHS”), promulgated 86 Fed. Reg.

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Marietta Memorial Hospital Employee Health Benefit Plan v. DaVita, Inc.

Issues

Does a health insurance plan’s uniform classification of all dialysis providers as “out-of-network” violate the Medicare Secondary Payer Act by “tak[ing] into account” Medicare-eligibility of end-stage renal disease patients or “differentiat[ing]” in benefits eligible to Medicare-eligible end-stage renal disease patients?


This case asks the Supreme Court to decide what type of dialysis-reimbursement schemes are acceptable for group health plans considering that end-stage renal disease (“ESRD”) patients are eligible for Medicare. The Medicare Secondary Payer Act (“MSPA”) prohibits health plans from “tak[ing] into account” Medicare eligibility of ESRD patients and “differentiat[ing]” in benefits provided to Medicare-eligible ESRD patients. Marietta contends that its plan did not violate the “take into account” or “differentiation” provisions of the MSPA because the dialysis reimbursement applies equally to dialysis patients with and without ESRD and because the purpose of the MSPA is coordination-of-benefits for ESRD patients rather than anti-discrimination. DaVita counters that the design of Marietta’s plan is intended to induce ESRD-patient members to drop the Plan in favor of Medicare, and that the plan design differentiates based on the disparate impact that ESRD patients face when seeking dialysis reimbursement. The outcome of this case has heavy implications for ESRD access to care, dialysis-treatment reimbursement, and health insurance plan structuring.

Questions as Framed for the Court by the Parties

(1) Whether a group health plan that provides uniform reimbursement of all dialysis treatments observe the prohibition provided by the Medicare Secondary Payer Act that group health plans may not “take into account” the fact that a plan participant with end stage renal disease is eligible for Medicare benefits; (2) whether a plan that provides the same dialysis benefits to all plan participants, and reimburses dialysis providers uniformly regardless of whether the patient has end stage renal disease, observe the prohibition under the Medicare Secondary Payer Act that a group health plan also may not “differentiate” between individuals with end stage renal disease and others “in the benefits it provides”; and (3) whether the Medicare Secondary Payer Act is a coordination-of-benefits measure designed to protect Medicare, not an antidiscrimination law designed to protect certain providers from alleged disparate impact of uniform treatment.

DaVita and its subsidiary DVA Renal Healthcare (collectively “DaVita”) are well-known healthcare providers specializing in kidney care. DaVita, Inc. v. Marietta Mem. Hosp. at 2.

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Sebelius, Secretary of Health and Human Services v. Auburn Regional Medical Center

Since 1983, hospitals have received reimbursement for treating Medicare patients with the option of receiving additional compensation for treating low-income individuals. It was recently discovered that the Center for Medicare and Medicaid Services (CMS) miscalculated rates in the 1990s, causing certain hospitals to receive less than they were entitled to receive. Several hospitals challenged these underpayments under 42 U.S.C. 1395oo(a)(3), arguing that the 180-day deadline for challenging payments should be "equitably tolled," or extended for reasons of fairness. Although the agency that receives these challenges, the Provider Reimbursement Review Board (PRRB), concluded that the decision to extend the filing deadline was beyond its authority, the United States Circuit Court of Appeals for the D.C. Circuit held that this deadline may be extended due to a presumption for equitable tolling. Here, Petitioner Sebelius of the Department of Health and Human Services contends that Congress intended to give her the authority to decide when to toll a statute and that this is not one of those cases. In contrast, Respondents Auburn Regional Medical Center, et al., argue that a court may extend this filing deadline. If hospitals are able to challenge underpayments beyond the 180-day deadline, the caseload of PRRB may drastically increase and so slow the process of compensating hospitals. However, allowing this extension may ensure that hospitals are properly compensated. 

Questions as Framed for the Court by the Parties

Whether the 180-day statutory time limit for filing an appeal with the Provider Reimbursement Review Board from a final Medicare payment determination made by a fiscal intermediary, 42 U.S.C. 1395oo(a)(3), is subject to equitable tolling.

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Issue

May a hospital challenge a reimbursement payment outside of the legal filing deadline because of fairness concerns? 

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U.S. ex rel. Schutte v. SuperValu Inc.

Issues

Is a defendant’s subjective believe about the lawfulness of its conduct relevant to whether it “knowingly” violated the False Claims Act?

This case asks the Court to determine whether the False Claims Act (FCA), 31 U.S.C. § 3729, which punishes individuals who “knowingly present[], or cause[] to be presented, a false or fraudulent claim for payment or approval,” applies if, regardless of their subjective belief about the lawfulness of their conduct, defendants’ conduct is consistent with an objectively reasonable reading of an ambiguous statute. The United States argues that, under common law and the FCA’s text, when individuals make arguments that they believe are false, they can be liable even if they did not definitively know they were lying. The United States further argues that individuals receiving government funds have a duty to ask for clarification and determine the proper law, and thus are liable for advancing false claims against the government. In opposition, SuperValu argues that an individual’s subjective belief is irrelevant under the FCA because interpretations of ambiguous statutes cannot be objectively verified; thus, an individual is not liable if the statute is ambiguous, and the individual’s interpretation is objectively reasonable. SuperValu also states that, because the FCA is a punitive statute, the burden is on the government to clarify the statute and give individuals notice. This case touches on issues of efficient government fraud prosecution, separation of powers, and Medicare and Medicaid reimbursement.

Questions as Framed for the Court by the Parties

Whether and when a defendant’s contemporaneous subjective understanding or beliefs about the lawfulness of its conduct are relevant to whether it “knowingly” violated the False Claims Act.

This case arises from the consolidation of two cases, United States ex rel. Schutte v. SuperValu Inc. and United States ex rel. Proctor v. Safeway, Inc, which are factually similar and present an identical question of law. Both cases stem from the same question regarding the False Claims Act (FCA) as it relates to reimbursements under Medicare and Medicaid.

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United States v. Quality Stores Inc.

Issues

Are supplemental unemployment benefits paid to laid-off employees considered “wages” under the Federal Insurance Contributions Act (FICA), and therefore taxable as income?

In 2001, Quality Stores made severance payments to employees who were involuntarily terminated after Quality Stores filed for Chapter 11 bankruptcy. Quality Stores later argued that the payments should not have been taxed as wages under the Federal Insurance Contributions Act (FICA). When the IRS did not respond to Quality Stores’ claim seeking a $1 million refund in FICA taxes, Quality Stores commenced an adversary action in bankruptcy court. The bankruptcy court ruled for Quality Stores, concluding that the severance payments were non-taxable supplemental unemployment benefits (SUBs). The district court and Sixth Circuit affirmed. The Supreme Court will determine whether severance payments to involuntarily terminated employees are taxable wages under FICA. The Court will resolve a circuit split between the Sixth and Federal Circuits in a decision that will affect all employers who provide severance pay. At stake are billions of dollars in FICA tax refunds to employers and their former employees.

Questions as Framed for the Court by the Parties

Whether severance payments made to employees whose employment was involuntarily terminated are taxable under the Federal Insurance Contributions Act (“FICA”), 26 U.S.C. 3101 et seq.

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Facts

In October 2001, involuntary Chapter 11 bankruptcy proceedings commenced against Quality Stores, the largest agriculture-specialty retailer in the United States at the time. See In re Quality Stores, Inc., et al., 693 F.3d 605, 608 (6th Cir. 2012).

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