action regarding their duty to give certain notice to Medicare
beneficiaries eligible to enroll in Medicaid "buy-in" programs
as required by 42 U.S.C. § 1395b-3 and section 154 of Pub.L. No.
103-432. Defendants have moved to Dismiss or, in the
Alternative, for Summary Judgment. Because I find that (1)
plaintiffs have standing to bring their claim; and (2) judicial
review of defendants' action in this case is appropriate,
defendants Motion to Dismiss will be denied. However, because I
find that defendants' actions do not constitute an unreasonable
interpretation of their statutory responsibilities, defendants'
Motion for Summary Judgment will be granted.
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
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. . . ."