Not a Lexis Advance subscriber? Try it out for free.

Me. Cmty. Health Options v. United States

Supreme Court of the United States

December 10, 2019, Argued; April 27, 2020, Decided 1

Nos. 18-1023, 18-1028 and 18-1038.

Opinion

Justice Sotomayor delivered the opinion of the Court. 2

The Patient Protection and Affordable Care Act expanded healthcare coverage to many who did not have or could not afford it. The Affordable Care Act did this by, among other things, providing tax credits to help people buy insurance and establishing online marketplaces where insurers could sell plans. To encourage insurers to enter those marketplaces, the Act created several programs to defray the carriers’ costs and cabin their risks.

Among these initiatives was the “Risk Corridors” program, a temporary framework meant to compensate insurers for unexpectedly unprofitable plans during the marketplaces’ first three years. The since-expired Risk Corridors statute, §1342, set a formula for calculating payments under the program: If an insurance plan loses a certain amount of money, the Federal Government “shall pay” the plan; if the plan makes a certain amount of money, the plan “shall pay” [*8]  the Government. See §1342, 124 Stat. 211-212 (codified at 42 U. S. C. §18062). Some plans made money and paid the Government. Many suffered losses and sought reimbursement. The Government, however, did not pay.

] These cases are about whether petitioners—insurers who claim losses under the Risk Corridors program—have a right to payment under §1342 and a damages remedy for the unpaid amounts. We hold that they do. We conclude that §1342 of the Affordable Care Act established a money-mandating obligation, that Congress did not repeal this obligation, and that petitioners may sue the Government for damages in the Court of Federal Claims.

In 2010, Congress passed the Patient Protection and Affordable Care Act, 124 Stat. 119, seeking to improve national health-insurance markets and extend coverage to millions of people without adequate (or any) health insurance. To that end, the Affordable Care Act called for the creation of virtual health-insurance markets, or “Health Benefit Exchanges,” in each State. 42 U. S. C. §18031(b)(1). Individuals may buy health-insurance plans directly on an exchange and, depending on their household income, receive tax credits for doing so. 26 U. S. C. §36B; 42 U. S. C. §§18081, 18082. Once an insurer puts a plan on an exchange, it must “accept every employer and individual in the State [*9]  that applies for such coverage,” 42 U. S. C. §300gg-1(a), and may not tether premiums to a particular applicant’s health, §300gg(a). In other words, the Act “ensure[s] that anyone can buy insurance.” King v. Burwell, 576 U. S. 473, 493, 135 S. Ct. 2480, 192 L. Ed. 2d 483 (2015).

Read The Full CaseNot a Lexis Advance subscriber? Try it out for free.

Full case includes Shepard's, Headnotes, Legal Analytics from Lex Machina, and more.

2020 U.S. LEXIS 2530 *

MAINE COMMUNITY HEALTH OPTIONS, PETITIONER v. UNITED STATES; MODA HEALTH PLAN, INC., PETITIONER v. UNITED STATES BLUE CROSS AND BLUE SHIELD OF NORTH CAROLINA, PETITIONER v. UNITED STATES LAND OF LINCOLN MUTUAL HEALTH INSURANCE COMPANY, AN ILLINOIS NONPROFIT MUTUAL INSURANCE CORPORATION, PETITIONER v. UNITED STATES

Notice: The LEXIS pagination of this document is subject to change pending release of the final published version.

Prior History:  [*1] ON WRITS OF CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR THE FEDERAL CIRCUIT

Me. Cmty. Health Options v. United States, 729 Fed. Appx. 939, 2018 U.S. App. LEXIS 18852 (Fed. Cir., July 9, 2018)Moda Health Plan, Inc. v. United States, 892 F.3d 1311, 2018 U.S. App. LEXIS 16028 (Fed. Cir., June 14, 2018)Land of Lincoln Mut. Health Ins. Co. v. United States, 892 F.3d 1184, 2018 U.S. App. LEXIS 16026 (Fed. Cir., June 14, 2018)

Disposition: No. 18-1023 and No. 18-1028 (second judgment), 729 Fed. Appx. 939; No. 18-1028 (first judgment), 892 F. 3d 1311; No. 18-1038, 892 F. 3d 1184, reversed and remanded.

CORE TERMS

appropriations, Corridors, funds, Tucker Act, repeal, riders, Affordable Care Act, budget, plans, damages, cases, obligations, insurers, unprofitable, money-mandating, losses, fiscal year, inferring, billion, formula, incur, federal government, right of action, collections, obligation to pay, calculated, provisions, suspended, private right of action, full payment

Healthcare Law, Insurance Coverage, Health Insurance, Reimbursement, Governments, Federal Government, Claims By & Against, Legislation, Interpretation, Constitutional Law, Congressional Duties & Powers, Raising Revenue, Expiration, Repeal & Suspension, Courts, Courts of Claims