only those patients who were not affected by the Repeal Act because they had satisfied the post-hospital requirement, and who therefore were covered on January 1, 1990, would qualify for transition benefits. This is clearly not what Congress intended, and the Secretary's policy literally makes no sense.
Because the Secretary's interpretation of the Repeal Act's transition provisions is inconsistent with what this Court deems to be Congress' express statutory mandate, this Court need not defer to the agency. I.N.S. v. Cardoza-Fonseca, 480 U.S. 421, 107 S. Ct. 1207, 94 L. Ed. 2d 434 (1987); N.L.R.B. Union v. FLRA, 266 U.S. App. D.C. 165, 834 F.2d 191, 198 (1987); Waterman S.S. Corp. v. Burnley, 691 F. Supp. 1524, 1533 (D.D.C. 1988). The statutory provision at issue in this case is unambiguous and allows for only one reasonable construction. Even if there were some ambiguity, a court need not defer to an agency's views on a "pure question of statutory interpretation." Union of Concerned Scientists v. United States Nuclear Regulatory Commission, 262 U.S. App. D.C. 381, 824 F.2d 108, 113 (1987).
Remedial statutes should be broadly construed so as to effectuate their remedial purposes and serve the interests of the individuals they were designed to protect. Rodriguez v. Compass Shipping Co., Ltd., 451 U.S. 596, 101 S. Ct. 1945, 68 L. Ed. 2d 472 (1981); Bell v. Brown, 181 U.S. App. D.C. 226, 557 F.2d 849 (1977). The Medicare laws should be construed so as "not to disentitle old, chronically ill and basically helpless, bewildered, confused people." Gartmann v. Department of Health and Human Services, 633 F. Supp. 671, 679 (E.D.N.Y. 1986). There is therefore no justification, given the clear language of the statute and the legislative history, to defer to the Secretary's overly restrictive interpretation of § 101 (b)(1)(C). Accordingly, this Court finds as a matter of law that the Secretary's interpretation is invalid.
Class Certification :
Plaintiffs have moved for certification of a class consisting of all individuals who have been or will be denied Medicare SNF coverage pursuant to the Secretary's policy of requiring that patients who received extended care services on December 31, 1989, and January 1, 1990, must also have actually received Medicare coverage on those days in order to be eligible for 100 days of coverage in 1990 without having to satisfy the post-hospital requirement. This class consists of thousands of individuals all over the United States who were receiving extended care services on December 31, 1989, and January 1, 1990, but have been or will be denied coverage for skilled nursing facility benefits in 1990 under the Repeal Act due to the Secretary's flawed interpretation of that statute.
All of these individuals are commonly affected by the Secretary's interpretation of the Repeal Act. Whether the Secretary has correctly construed that Act so as to deny these individuals SNF benefits in 1990 is a question of law common to all these individuals.
The named plaintiffs in this action are elderly individuals who were receiving extended care services at an SNF for a continuous period including December 31, 1989, and January 1, 1990. They received 150 days of SNF benefits under the Catastrophic Act in 1989.
Plaintiffs have either had their claims for 1990 Repeal Act coverage denied by an insurance intermediary, have had their benefits for 1990 recouped, or have submitted initial determination/reconsideration requests. See Plaintiffs' Memorandum Regarding Status of Plaintiff's Claims.
Under plaintiffs' interpretation of the Repeal Act, they should automatically qualify for 100 days of SNF benefits in 1990. The Secretary, however, has denied plaintiffs that coverage unless the care they received on the days of December 31 and January 1 was actually covered by Medicare.
The plaintiffs have clearly satisfied the three requirements for class certification pursuant to Fed. R. Civ. P. 23 (b)(2). First, the members of the class are so numerous that joinder would be impracticable. Second, the questions of law and fact are common to all members of the class and the claims of the representative parties are typical of the entire class. All members of the class and all the named plaintiffs have the same interest -- obtaining a reversal of the Secretary's policy in order to obtain 100 days of SNF benefits in 1990 under the Repeal Act. There is no requirement that a factual record be developed, as the issue raised is discrete and narrow and is thus particularly well-suited for determination as a class action. Moreover, the representative parties will fairly and adequately protect the interest of the class as a whole. The Center for Medicare Advocacy has wide experience in Medicare-related litigation and has demonstrated admirable commitment to furthering the interests of the elderly.
Defendant's objection to class certification centers on his view that each plaintiff requires an individualized administrative review before he or she can obtain a reversal of a denial of benefits. However, defendants miss the focus of plaintiffs' claims. Plaintiffs are attacking the legitimacy of the Secretary's interpretation of a Congressional enactment. Thus, plaintiffs satisfy the third requirement for class certification as well: the Secretary has acted on grounds generally applicable to the class, thereby making appropriate relief with respect to the class as a whole:
Plaintiffs . . . [do] not request an adjudication of individual class members' entitlement to benefits. Rather [they] seek only a determination of the validity of certain administrative regulations and policies which themselves determine eligibility when applied to specific cases.
Pratt v. Heckler, 629 F. Supp. 1496, 1503, reconsideration denied sub nom. Pratt v. Bowen, 642 F. Supp. 883, 885-87 (D.D.C. 1986).
Defendant argues that these individuals cannot comprise a class because their claims are premature and inchoate, as the class is not restricted to those individuals who have actually been denied benefits after presenting a claim. To begin with, this Court takes note of plaintiffs' argument that many putative class members were notified by their SNF that they were ineligible for transitional benefits without being informed of their right to appeal this decision or with instructions drafted by the Secretary which implied that review was available only of the beneficiary's claim, and not of the Secretary's interpretation of the Repeal Act. Plaintiffs' Memorandum of Points and Authorities in Opposition to Defendant's Motion to Dismiss at 5-12. Therefore, a failure by a putative class member to present a claim after being informed by the SNF that benefits were not available given the Secretary's transition policy is attributable to misinformation on the part of the Secretary, rather than a desire to avoid the administrative process.
The class appropriately includes those individuals who have been denied or who will be denied benefits because of the Secretary's interpretation of the Repeal Act. Hence, all members of the class either have or will meet the jurisdictional "presentment" requirements before becoming a member of the class. This is not unlike the class certified by the district court in Bowen v. City of New York, 476 U.S. 467, 106 S. Ct. 2022, 2027 n. 6, 90 L. Ed. 2d 462 (1986), where the class included all individuals whose "applications for benefits have been denied or whose benefits have been or will be terminated on the basis of defendants' determination that such people are capable of substantial gainful activity." (Emphasis added).
This case presents compelling reasons for class certification. The plaintiffs are elderly and sick Medicare patients. They are dependent on the receipt of Medicare benefits for their care; whether or not they receive 100 days of coverage in 1990 could influence their economic ability to arrange for future health care. Moreover, because of their age and infirmity, plaintiffs are particularly vulnerable to the time process and errors of the administrative process. One of the original named plaintiffs in this case has already passed away without having her Medicare benefits claim adjudicated.
For the foregoing reasons, this Court certifies a nationwide class consisting of all persons who have been or will be denied SNF Medicare benefits due to the Secretary's construction of § 101(b)(1)(C) of the Repeal Act.
Plaintiffs argue that this Court has jurisdiction pursuant to 42 U.S.C. § 405 (g) as incorporated by 42 U.S.C. § 1395ff. Section 405 (g) provides:
Any individual, after any final decision of the Secretary made after a hearing to which he was a party . . . . may obtain a review of such decision by a civil action commenced within sixty days after the mailing to him of notice of such decision or within such further time as the Secretary may allow.
Defendant's primary contention is that this Court lacks jurisdiction to hear plaintiffs' action because the plaintiffs have failed to exhaust their administrative remedies. According to defendants, "this case involves a simple failure to exhaust administrative remedies." Defendant's Reply to Plaintiffs' Opposition to Defendant's Motion to Dismiss at 1. Defendant argues that the Court cannot review the Secretary's instructions in the SNF manual. According to defendant, this Court can only review each individual plaintiff's eligibility if plaintiff has been denied benefits after compliance with the defendant's 4-step administrative review process.
The first step in this process consists of presenting a formal claim to a fiscal intermediary within one year of the date health care services are provided.
The fiscal intermediary, with whom the Secretary contracts, makes the initial determination of the claim's merit on behalf of the Secretary. If the claim is denied, the claimant has a right to reconsideration by the Health Care Financing Administration ("HCFA"), which reviews the intermediary's determination, the administrative record, and any additional information provided by the claimant. If the claim is still denied, the claimant has a right to an administrative appeal before an Administrative Law Judge ("ALJ").
If the ALJ denies the claim, review may be obtained from HHS' Appeals Council.
Defendant argues that the Secretary is not deemed to have rendered a "final decision" until all four steps in the administrative process have been completed. Defendant contends that the Supreme Court in Heckler v. Ringer, 466 U.S. 602, 104 S. Ct. 2013, 80 L. Ed. 2d 622 (1984), provided that a court may not review a claim arising under the Medicare Act unless all four steps in the administrative process have been pursued. However, Ringer does not stand for the proposition that a court may never intervene before the administrative process has been exhausted. The Ringer Court noted that while plaintiffs must meet the requirement of initially presenting a claim before federal court jurisdiction attaches, the requirement that the claimant fully pursue the prescribed administrative remedy is "waivable." Ringer, 104 S. Ct. at 2023.
Among the elements to be considered by the court in its application of the exhaustion requirement is whether the plaintiffs' claim is wholly "collateral" to their claim for benefits and whether they have a colorable claim that an erroneous denial in the early stages of the administrative process would injure them in a manner which could not be remedied by later payment of benefits. Id. In addition, where further exhaustion would be futile, the Supreme Court noted that "deference to the Secretary's conclusion as to the utility of pursuing the claim through administrative channels is not always appropriate." Id.
For example, the Supreme Court in Bowen held that the district court properly waived the exhaustion requirement to permit plaintiffs to challenge an internal policy of the Secretary that denied disability benefits to any claimant who did not meet the Secretary's list of specified impairments. Plaintiffs there argued that the presumption led to routine denials of eligible claimants, and the policy was therefore arbitrary and capricious in violation of the Social Security Act and applicable regulations.
The Bowen Court, in considering whether it was permissible to hear the claims of these plaintiffs notwithstanding the Secretary's exhaustion procedure, quoted the landmark case of Mathews v. Eldridge, 424 U.S. 319, 96 S. Ct. 893, 900, 47 L. Ed. 2d 18 (1976): "cases may arise where a claimant's interest in having a particular issue resolved promptly is so great that deference to the agency's judgment is inappropriate." Bowen, 106 S. Ct. at 2031.
Applying the Ringer analysis, the Supreme Court held that the plaintiffs in Bowen were entitled to immediate relief without exhausting their administrative remedies on the basis that, first, their claims were collateral to the claims for benefits because "the class members neither sought nor were awarded benefits in the District Court, but rather challenged the Secretary's failure to follow the applicable regulations." Id. at 2032. Second, the Court held that "the claimants . . . would be irreparably injured were the exhaustion requirement . . . enforced against them." Id. The Court considered the severe medical conditions of the plaintiffs and noted that a court "should be especially sensitive to this kind of harm where the Government seeks to require claimants to exhaust administrative remedies merely to enable them to receive [what] they should have been afforded in the first place." Id.
In sum, the Bowen Court held that, notwithstanding its holding in Ringer, where a claimant alleges more than deviation from applicable regulations and instead asserts a "systemwide . . . policy that [is] inconsistent in critically important ways with established regulations" and which does not depend on the particular facts of the claimant's case, the exhaustion requirement may be excused. Bowen, at 2032-33.
The case currently before this Court is squarely governed by the holding in Bowen. Plaintiffs in this case do not seek an award of benefits to individual claimants but rather a court determination that the Secretary's policy violates the Repeal Act. The interpretative issue raised by plaintiffs is clearly collateral to their individual claims for benefits.
Plaintiffs in this case are all sick and elderly persons. It would be unreasonable to force each of them to pursue an administrative process with respect to which they were absolutely assured a denial of their claim based upon an impermissible interpretation. Because the intermediary insurance companies work on contract with the Secretary, they are required to follow his interpretations. This means that each and every claim for 1990 SNF transition benefits presented to an intermediary by plaintiffs will be summarily denied. Moreover, these plaintiffs are often stymied even earlier in the process, because the SNF is put on notice that the intermediary will deny the claim and therefore will not file a claim on behalf of the patient until the patient submits a "demand bill," thereby lengthening the process further.
Defendant contends that because only the intermediary is governed by the Secretary's interpretations, there is no basis for an assertion that exhaustion would be futile as it is conceivable that a claimant would be granted benefits, notwithstanding the Secretary's policy, further along in the administrative process. However, it is clear that the plaintiffs will face certain denial at the administrative stage as well as at the intermediary stage, because HCFA follows the Secretary's interpretation. Indeed, it is HCFA that is responsible for crafting the interpretation in the first place.
Whether or not ALJ's and the Appeals Council have certain independence in rendering decisions, they must give great deference to the Secretary's interpretation as it constitutes the applicable law to be enforced. Even in the unlikely event of a reversal by an ALJ or the Appeals Council, there would be no precedential effect outside of the specific claimant's case, and intermediaries would still be bound to treat all other claimants according to the Secretary's existing policy. To force elderly and sick patients to proceed through an elaborate administrative process where an improper interpretation is being applied to deny them their benefits is an indignity that no individual should suffer. This is certainly not what is intended by the policy underlying the exhaustion requirement.
It is simply not meaningful to point to the chance that the plaintiffs might obtain a reversal later in the administrative process. Denial of benefits to these elderly plaintiffs will almost certainly cause irreparable harm which cannot be remedied by a later reversal. These plaintiffs are struggling to obtain the funds necessary to arrange for their SNF care. Denial of Medicare benefits can result in indigence, loss of crucial health care, and emotional distress. Moreover, the legal costs involved for each of the plaintiffs to exhaust their administrative remedies and then to pursue individually court contests could be astronomical.
As the court in Fox v. Bowen, 656 F. Supp. 1236, 1240-1241 (D. Conn. 1986) explained concerning coverage denials to SNF patients in their mid-80's needing daily skilled physical therapy treatments:
Patients who are denied Medicare coverage are responsible for paying for their own physical therapy through insurance, personal savings or contributions from family members. . . . In such circumstances, many patients forgo medically necessary physical therapy because they or their families believe that they cannot afford to pay for such therapy themselves. . . .
A patient's recovery may be jeopardized. . . . In some cases, . . . recovery is also inhibited by the emotional distress that may result from a denial of Medicare coverage.
The record before this Court dramatically illustrates these cogent points. Plaintiff Mary Kirwin was moved from a Medicare-certified to a non-certified bed in the nursing home when SNF benefits were denied.
Elouise Munoz, another member of the plaintiff class, was denied SNF benefits under the Secretary's interpretation. Because of this, her right to supplemental insurance was not triggered, and her 1990 bill remained unpaid. The SNF would not readmit her, and she was forced to transfer to a different nursing home, in a county far from the home of her son who was looking after her.
The administrative process is rife with delays. According to information compiled from the Social Security Administration Office of Hearings and Appeals and the Center for Medicare Advocacy, the four-step administrative process would involve an average total of 632 days. Id. at 3. While the delay involved in the administrative process is not enough to excuse exhausting that process, in the case of the ill and elderly, mechanical application of that process causes intolerable hardship. Any relief afforded by this Court would not be "inconsistent with the policies underlying exhaustion" because by simply ordering that "the claims be reopened at the administrative level, this District Court [would show] proper respect for the administrative process . . . . [doing] no more than the agency would have been called upon to do had it, instead of the District Court, been alerted to the charge than an undisclosed procedure was illegal and had improperly resolved innumerable claims." Bowen, 106 S. Ct. at 2033.
Plaintiffs are not using this lawsuit to bypass the administrative process but rather to make that process meaningful. What plaintiffs seek in this action is collateral to their claims for benefits, and requiring exhaustion of the administrative process would be futile and would lead to irreparable harm. Accordingly, this Court finds that the class members have standing to bring this suit and that it has jurisdiction to adjudicate their claims.
Defendant's motion to dismiss will be denied because this Court finds that it has jurisdiction to adjudicate plaintiffs' claims. Furthermore, because this case presents compelling reasons for class certification, this Court will grant plaintiffs' motion to certify a nationwide class. Lastly, this Court will grant summary judgment for plaintiff class. The issue before this Court is solely a question of law involving statutory construction; there is no need for further discovery or the establishment of a factual record, as explained above in the certification of the class of plaintiffs. Accordingly, this Court finds that the plaintiffs, as a class, are entitled to summary judgment as a matter of law.
ORDER - December 21, 1990, Filed
Having considered plaintiffs' motion for class certification, defendant's motion to dismiss, plaintiff's motion for summary judgment, all opposition thereto, oral argument, and the entire record in this case, it is hereby
ORDERED, that plaintiff's motion for class certification is GRANTED; and it is further
ORDERED, that defendant's motion to dismiss is DENIED; and it is further
ORDERED, that plaintiff's motion for summary judgment is GRANTED; and it is hereby
DECLARED, that the Medicare Catastrophic Coverage Repeal Act of 1989, Pub. L. No. 101-234 § 101(b), requires defendant Secretary to grant Medicare skilled nursing facility benefits in 1990 to all individuals who would have been eligible for such benefits under the Medicare Catastrophic Act of 1989, Pub. L. No. 100-360, and who were receiving extended care services in a Medicare-certified skilled nursing facility for a continuous period including December 31, 1989 and January 1, 1990, regardless of whether such individuals first entered the facility or began their current spells of illness within thirty days of a three-day hospitalization or were receiving Medicare coverage for those services during that period, and that defendant's contrary policy is not in accordance with the law; and it is further
ORDERED, that defendant Secretary and his agents are permanently enjoined from enforcing defendant's policy of requiring that individuals have actually received Medicare coverage for services received on December 31, 1989 and January 1, 1990 in order to qualify for transition benefits under the Repeal Act; and it is further
ORDERED, that defendant Secretary must apply the correct interpretation of the transition provisions of the Repeal Act to all eligible beneficiaries including these plaintiffs and all others similarly situated.