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TEXAS GRAY PANTHERS v. THOMPSON

March 28, 2001

TEXAS GRAY PANTHERS, ET AL., PLAINTIFF,
V.
TOMMY G. THOMPSON, SECRETARY OF HEALTH AND HUMAN SERVICES; AND, WILLIAM A. HALTER, ACTING COMMISSIONER OF THE SOCIAL SECURITY ADMINISTRATION, DEFENDANTS.



The opinion of the court was delivered by: Roberts, District Judge.

  MEMORANDUM OPINION

BACKGROUND

Medicare is a federally funded and administered health insurance program available to all Americans over the age of 65. 42 U.S.C. ¶¶ 1395-1395gg. It is not free. Beneficiaries must share costs with the government in the form of deductibles, coinsurance, and premiums. Most beneficiaries are automatically eligible for Medicare Part A, which provides for hospital coverage, and do not pay a premium for these benefits. (Compl. at ¶ 17.) In 1999, the Part A premium for those not automatically enrolled was $309 per month. (Compl. at ¶ 22.) Those beneficiaries who choose to enroll in the optional Medicare Part B, which provides for outpatient and physician coverage, must pay a monthly premium. In 1999, the part B premium was $45.50 per month. (Compl. at ¶ 17.) Monthly Medicare premiums are automatically deducted from the Social Security, Railroad Retirement, or Civil Service Retirement checks of beneficiaries. 42 U.S.C. § 1395s.

To relieve the financial hardships wrought by cost-sharing upon low-income Medicare beneficiaries, Congress enacted several "buy-in" programs linked to the Medical Assistance program ("Medicaid"). Medicaid is jointly funded and administered by the federal and state governments and is available to those whose income and assets fall within specified guidelines. 42 U.S.C. § 1396a et seq. There are five major buy-in programs.

The first program is the Qualified Medicare Beneficiary program ("QMB"), which became effective in 1989. QMB pays the Part B premium, all Medicare coinsurance and deductibles, and sometimes the Part A premium, for those who are enrolled. (Compl. at ¶ 19; Defs.' Mem. Supp. Mot. Dismiss ("Defs.' Mot.") at 2-3.) To qualify, a beneficiary's income must fall below the poverty level*fn2 and his resources must not exceed $4,000 for an individual or $6,000 for a couple. 42 U.S.C. § 1396a(a)(10)(E)(i), 1396d(p)(1), 1396d(p)(3). (Compl. at ¶ 19; Defs.' Mot. at 2-3.)

The second program is the Specified Low-Income Medicare Beneficiary program ("SLMB"), which became effective in 1990. SLMB pays the Part B premium, but not deductibles or coinsurance, for those who are enrolled. (Compl. at ¶ 20; Defs.' Mot. at 3.) To qualify, a beneficiary's income must be within 100% to 120% of the poverty level*fn3 and his resources must meet the same requirements as under QMB. 42 U.S.C. § 1396a(a)(10)(E)(iii), 1396d(p)(3)(A)(ii). (Compl. at ¶ 20; Defs.' Mot. at 3.)

The third program is the Qualified Disabled and Working Individuals program ("QDWI"), which also became effective in 1990. QDWI pays the Part A premium for those who are enrolled. To qualify, an individual must be below age 65, disabled, not automatically eligible for Part A, and have an income below 200% of the poverty level.*fn4 42 U.S.C. § 1396a(a)(10)(E)(ii), 1396d(p)(A)(I). (Compl. at 1122; Defs.' Mot. at 3.)

The fourth and fifth programs are the Qualified Individual-1 (QI-1) and Qualified Individual-2 (QI-2) programs, both of which became effective in 1998. QI-1 pays the entire Part B premium for those who are enrolled. (Compl. at ¶ 21; Defs.' Mot. at 3-4.) To qualify, a beneficiary's income must be below 135% of the poverty level.*fn5 42 U.S.C. § 1396a(a)(10)(E)(iv)(I), 1396d(p)(3)(A)(ii). (Compl. at ¶ 21; Defs.' Mot. at 3-4.) QI-2 pays only a portion of the Part B premium for those who are enrolled. To qualify for QI-2, a beneficiary's income must be below 175% of the poverty level.*fn6 42 U.S.C. § 1396a(a)(10)(E)(iv)(II), 1396d(p)(3)(A)(ii). (Compl. at 121; Defs.' Mot. at 3-4.) Unlike the other buy-in programs, QI-1 and QI-2 are block grants, awarded on a first-come, first-served basis and funded only through 2002. (Compl. at 1121; Defs.' Mot. at 3-4.) They are not permanent entitlements.

Participation in a buy-in program is not automatic. A qualified beneficiary must enroll through one of a number of methods, most usually by filing an application at a local public assistance office. (Compl. at 1 24; Defs.' Mot. at 4). As of 1996, over 45% of all beneficiaries eligible for QMB, and almost 85% of all beneficiaries eligible for SLMB, were not enrolled. (Compl. at ¶ 24.)

In 1990, Congress enacted 42 U.S.C. § 1395b-3. Section 1395b-3(a) provides that:

The Secretary of Health and Human Services shall establish a health insurance advisory service program (in this section referred to as the `beneficiary assistance program') to assist medicareeligible individuals with the receipt of services under the medicare and medicaid programs and other health insurance programs.

Section 1395b-3 describes elements of this beneficiary assistance program (the "Program"), including methods of providing outreach, types of assistance to be provided, development of educational materials, notice to medicare-eligible beneficiaries and the general public, and annual reports to Congress. Section 1395b-3(c)(2)(B) states that the Program "shall provide for information, counseling, and assistance for medicare-eligible individuals with respect to . . . linkages between the [M]edicare and [M]edicaid programs. . . ."

In 1994, Congress amended section 1395b-3. The amendment requires the Secretary to establish a method of gathering and transmitting to the States information regarding the eligibility of new Medicare beneficiaries (the "Method"). The statute provides that:

[The Secretary] shall establish and implement a method for obtaining information from newly eligible medicare beneficiaries that may be used to determine whether such beneficiaries may be eligible for medical assistance for medicare cost-sharing under State medicaid plans as qualified medicare beneficiaries, and for transmitting such information to the State in which such a beneficiary resides.

Pub.L. 103-432, § 154, 108 Stat. 4437 (1994) ("Section 154"), published at 42 U.S.C. § 1395b-3 (note).

Plaintiffs, who advocate for the interests of senior citizens, include numerous low-income Medicare beneficiaries in their memberships. (Compl. at ¶¶ 3-6.) They allege that, under section 1395b-3, defendants are responsible for establishing "a comprehensive plan of information, counseling and assistance to assure that low income Medicare beneficiaries learn about the buy-in program[s] and how to participate in [them,]" and that defendants have breached this responsibility. (Compl. at 1.) The primary relief they seek is an injunction ordering defendants to aggressively provide information and aid to those Medicare beneficiaries qualified for the buy-in programs.

Defendants have moved to dismiss, or, in the alternative, for summary judgment. They argue that (1) plaintiffs lack standing to bring the complaint; (2) the efforts of the Secretary of Health and Human Services ("the Secretary") pursuant to section 1395b-3 and section 154 are not subject to judicial review; and (3) if subject to judicial review, these efforts constitute a reasonable interpretation of his statutory responsibilities.*fn7

DISCUSSION

I. Motion to ...


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