Advocate Christ Medical Center v. Becerra

TEXTUAL INTERPRETATION OF THE DSH PROVISION

Advocate Christ Medical Center argues for a consistent interpretation of the phrase “entitled to” with regard to Medicare and Supplemental Security Income in the Disproportionate Share Hospitals program. Brief for Petitioners, Advocate Christ Medical Center et al. (“Advocate Christ”) at 19. Advocate Christ asserts that by treating the phrase the same way in both programs, “entitled to” should include patients eligible to receive benefits, regardless of whether they received a payment for those benefits in that month. Id. Advocate Christ cites Becerra v. Empire Health, arguing that only two years ago the Supreme Court defined “entitled to [Medicare benefits]” as referring to patients eligible for the Medicare program even where that program had not paid for the patient’s care. Id.at 18. Under Empire Health, Advocate Christ claims patients entitled to SSI should include any patients eligible for SSI regardless of payment in a particular month. Id. Advocate Christ maintains that under the principles of statutory construction, identical phrases used in the same sentence should adopt the same meaning, furthering their understanding of entitlement to SSI. Id. at 19.

Additionally, Advocate Christ argues that “entitled to benefits” inherently refers to more than just the receipt of cash payments. Id. at 22. Advocate Christ points out that using the phrase “entitled to” typically means “eligible” for a larger program, as the terms are often interchangeable. Id. at 21–22. Further, Advocate Christ notes SSI benefits include Medicaid continuation and vocational-rehabilitation services, which show that patients can be eligible for SSI even when not receiving cash payments. Id. at 22–23. Advocate Christ thus contends that entitlements extend beyond HHS’s definition. Id. Furthermore, Advocate Christ points out that the application and eligibility process for SSI supports this argument because when a beneficiary’s cash payment eligibility is suspended for a month, their overall eligibility nonetheless remains for a 12-month period. Id. at 25–26. Advocate Christ contends that the broad benefits included in the SSI program contradict HHS’s purported distinctions between eligibility for the Medicaid program and for SSI benefits. Id. at 26–27.

Health and Human Services counters that the phrase “entitled to SSI benefits” only refers to when a person is owed a cash payment for the month of their hospitalization. Brief for Respondent, Becerra at 15. HHS relies on the text of the DSH provision specifically referring to the language of benefits “under Title XVI.” Id. HHS argues that in interpreting “entitled to Medicare” in Empire, the Court looked to the statutory provisions that governed Medicare for guidance. Id. at 34. Under a similar reasoning, HHS asserts that the Court should look to the language of Title XVI, which refers only to a cash payment benefit, to define “entitled to [SSI] benefits.” Id. at 34–35. HHS contends that even when the same phrase appears twice in the same sentence, its meaning may nonetheless be different when referring to distinct statutory objectives. Id. at 35.

HHS argues that Advocate Christ’s interpretation of SSI eligibility is premised on terms that do not exist under the statute. Id. at 21. For example, HHS points out that Title XVI refers only to persons “entitled to [SSI] benefits” and not “eligible for the SSI program” as Advocate Christ claims in its brief. Id. at 22. HHS contends that it may make sense to describe Medicare as a “program” because it consists of long-term inpatient hospital insurance coverage and physician and nursing services, and not just payments for a medical service. Id. at 23–24. By contrast, HHS argues that SSI contains no broader “program” beyond cash payments—it’s not an insurance program as Advocate Christ asserts. Id. at 24. HHS furthers this point by referencing other sections of the Social Security Act which refer to eligibility as being eligible for payment. Id. at 28–29. HHS also asserts that benefits referenced by Advocate Christ such as vocational-rehabilitation and Medicare continuation are all either other forms of cash payments that are not mentioned in the text of Title XVI, or in the case of Medicare continuation, not SSI benefits at all. Id. at 27–34.

WORKABILITY OF A CASH PAYMENT-BASED ELIGIBILITY

Advocate Christ contends that the current rules lack the ability to define entitlement based on when a patient is due a cash benefit payment. Brief for Petitioners at 45. Advocate Christ posits that the actual-receipt and payment-due rules will cause significant numbers of low-income individuals to be omitted from the DSH formula entirely. Id. For instance, Advocate Christ contends that SSI payments are reduced to $0 if an SSI-eligible patient receives income over $30, which almost always happens because such patients receive Social Security retirement or disability benefits. Id. Furthermore, Advocate Christ indicates that SSI determines payment for any given month based on income for the prior month, which could unintentionally exclude patients from DSH determinations based on their income from a month in which they were not even hospitalized. Id. at 46. Similarly, Advocate Christ asserts that SSI may exclude patients due to clerical or administrative issues such as slow processing or errors within the Social Security system. Id. at 47. Advocate Christ points out that HHS does not defend its actual-receipt rule and concedes its payment-due rule is imperfect. Id.

HHS counters that it has never used an actual payment rule. Brief for Respondent at 46. HHS argues that Advocate Christ bases its alleged actual payment rule only on short-hand descriptions from previous cases and non-binding comments to regulations. Id. at 47. HHS furthers that the payment due definition mirrors a longstanding definition used by HHS to determine entitlement to SSI. Id. at 45. HHS argues that under Loper Bright Enterprises v. Raimondo, an agency’s interpretation of a statute implemented by that agency, such as HHS, should guide the courts and litigants, as the agency typically has the requisite expertise and experience. Id. at 44–45. Because a complex understanding of interrelated statutes informs the DHS provision, HHS contends that its interpretation should be given due respect. Id. at 45–46. HHS also indicates that, contrary to Advocate Christ’s unworkability claims, the payment due method accounts for clerical and administrative issues with payments. Id. 46–47. According to HHS, the payment due method retroactively counts patients who have been inaccurately denied payments and even continues to update SSI eligibility up to 15 months after a payment’s suspension. Id. at 48.

CONGRESSIONAL PURPOSE OF THE DSH PROVISION

Advocate Christ argues that including only entitlement to cash payments fails to administer Congress’s purpose for the DSH provision. Brief for Petitioners at 44. Advocate Christ asserts that the DSH provision intends to account for a hospital’s treatment of low-income patients because those patients are typically in worse health and are more expensive to treat. Id. at 48. Therefore, Advocate Christ maintains that removing patients who lose their entitlement to SSI payments for a singular month fails to account for all low-income patients. Id. at 48. Specifically, Advocate Christ asserts that the adverse effects of poverty considered in the DSH provision cannot be remedied in a single month. Id. Additionally, Advocate Christ contends that while some fluctuations in income occur, a patient’s income skyrocketing at any given time is unlikely. Id. at 49. Advocate Christ indicates this results in little risk for the DSH program accidentally counting high-income patients while certainly neglecting some low-income patients. Id.

HHS maintains that its definition of entitlement to SSI benefits promotes the DSH provision’s purpose of accounting for low-income patients. Brief for Respondent at 37. HHS believes that a determination made on a monthly basis better tailors the calculations to accommodate for fluctuations in income, and therefore creates a more accurate reflection of a patient’s low-income status. Id. at 38. For instance, HHS points out that an unemployed individual receiving payments in January who became employed in February but hospitalized in December has certainly moved beyond low-income status. Id. at 39. HHS argues however that Advocate Christ’s regime would still count this patient, therefore overinflating low-income status patient numbers. Id. at 39. HHS maintains that increases in income remain the most common reason for SSI cash payment ineligibility and that in any given year, hundreds of thousands of patients become ineligible due to increased income. Id. at 39–40. HHS contends that sensitivity to income status remains a virtue of the DSH program in maintaining accurate payments to DSH hospitals. Id. at 40.