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Common Ground Healthcare Coop. v. United States

United States Court of Federal Claims

February 15, 2019, Filed

No. 17-877C

Opinion

 [*39]  OPINION AND ORDER

SWEENEY, Chief Judge

Plaintiff Common Ground Healthcare Cooperative contends, for itself and on behalf of those similarly situated, that the federal government ceased making the cost-sharing reduction payments to which it and other insurers are entitled under the Patient Protection and Affordable Care Act ("Affordable Care Act"), Pub. L. No. 111-148, 124 Stat. 119 (2010), and its implementing regulations. Currently before the court are plaintiff's motion for summary judgment and defendant's cross-motion to dismiss for failure to state a claim upon which relief can be granted. For the reasons set forth below, the court finds that plaintiff is entitled to recover the unpaid cost-sharing reduction reimbursements. Therefore, it grants plaintiff's motion and denies defendant's motion.

I. BACKGROUND

A. The Affordable Care Act

Congress enacted the Affordable Care Act as part of a comprehensive scheme of health insurance reform.1 See generally King v.  [*40]  Burwell, 135 S. Ct. 2480, 192 L. Ed. 2d 483 (2015). Specifically, the Act includes "a series of interlocking reforms designed to expand coverage [**2]  in the individual health insurance market." Id. at 2485. In conjunction with these reforms, the Act provided for the establishment of an American Health Benefit Exchange ("exchange") in each state by January 1, 2014, to facilitate the purchase of "qualified health plans" by individuals and small businesses. 42 U.S.C. §§ 18031, 18041 (2012); accord King, 135 S. Ct. at 2485 (describing an exchange as "a marketplace that allows people to compare and purchase insurance plans"). Qualified health plans can be offered at four levels (bronze, silver, gold, and platinum) that differ based on how much of a plan's benefits an insurer must cover under the plan.2 42 U.S.C. § 18022(d)(1).

Among the reforms included in the Affordable Care Act were two aimed at ensuring that individuals have access to affordable insurance coverage and health care: the premium tax credit enacted in section 1401 of the Act, 26 U.S.C. § 36B (2012), and the cost-sharing reduction program enacted in section 1402 of the Act, 42 U.S.C. § 18071. "The premium tax credits and the cost-sharing reductions work together: the tax credits help people obtain insurance, and the cost-sharing reductions help people get treatment once they have insurance." California v. Trump, 267 F. Supp. 3d 1119, 1123 (N.D. Cal. 2017).

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142 Fed. Cl. 38 *; 2019 U.S. Claims LEXIS 83 **

COMMON GROUND HEALTHCARE COOPERATIVE, Plaintiff, v. THE UNITED STATES, Defendant.

Prior History: Common Ground Healthcare Coop. v. United States, 137 Fed. Cl. 630, 2018 U.S. Claims LEXIS 317 (Apr. 17, 2018)

CORE TERMS

cost-sharing, reduction, insurers, appropriation, premium, tax credit, Affordable Care Act, health plan, reimbursements, silver-level, funds, permanent, plans, advance payment, Tucker Act, intent of congress, payment obligation, appropriate fund, money-mandating, parties, silver, summary judgment, obligations, district court, Termination, regulations, provisions, corridors, eligible, offering