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Me. Cmty. Health Options v. United States

United States Court of Federal Claims

June 10, 2019, Filed

No. 17-2057C

Opinion

 [*385]  OPINION AND ORDER

SWEENEY, Chief Judge

Plaintiff Maine Community Health Options contends 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. In its February 15, 2019 Opinion and Order, the court determined that plaintiff was entitled to recover the cost-sharing reduction payments that the government did not make for 2017. Plaintiff subsequently amended its complaint to add claims for the payments that the government did not make for 2018 and moved for summary judgment on those claims. For the reasons set forth below, the court grants plaintiff's motion.1

I. BACKGROUND

A. The Affordable Care Act

Congress enacted the Affordable Care Act as part of a comprehensive scheme of health insurance reform.2 See generally King v. Burwell, 135 S. Ct. 2480, 192 L. Ed. 2d 483 (2015). Specifically, the Act includes "a series of interlocking reforms designed to expand coverage in the individual health [**2]  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.3 42 U.S.C. § 18022(d)(1).

Among the reforms included in the Affordable Care Act were two aimed at ensuring  [*386]  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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143 Fed. Cl. 381 *; 2019 U.S. Claims LEXIS 625 **

MAINE COMMUNITY HEALTH OPTIONS, Plaintiff, v. THE UNITED STATES, Defendant.

Subsequent History: Later proceeding at Cmty. Health Choice, Inc. v. United States, 2020 U.S. App. LEXIS 772 (Fed. Cir., Jan. 10, 2020)

Prior History: Me. Cmty. Health Options v. United States, 142 Fed. Cl. 53, 2019 U.S. Claims LEXIS 82 (Feb. 15, 2019)

CORE TERMS

cost-sharing, reduction, insurers, health plan, premium, appropriation, Affordable Care Act, tax credit, reimbursements, Issuer, obligations, advance payment, regulations, damages, parties, implied-in-fact, silver-level, contracts, corridors, offering, plans, exchanges, funds, appropriate fund, permanent, Tucker Act, intent of congress, payment obligation, summary judgment, money-mandating