Parra v. Pacificare of Arizona, No. 11-16069 (9th Cir. 2013)
Annotate this CasePlaintiffs claimed that PacifiCare was not entitled to any reimbursement payments out of the wrongful death benefits paid by an insurance policy to them. PacifiCare counterclaimed, arguing that it was entitled to reimbursement under both the terms of its contract with the deceased (Count I) and directly under the Medicare Act (Count 11), 42 U.S.C. 1395. At issue was whether a private Medicare Advantage Organization (MAO) plan could sue a plan participant's survivors, seeking reimbursement for advanced medical expenses out of the proceeds of an automobile insurance policy. Because interpretation of the federal Medicare Act presented a federal question, the district court had subject matter jurisdiction to determine whether that act created a cause of action in favor of PacifiCare against plaintiffs. The district court properly dismissed the causes of action arising under the Medicare Act for failure to state a claim where section 1395y(b)(2) did not create a federal cause of action in favor of a MAO and where, under section 1395y(b)(3)(A), the Private Cause of Action applied in the case of a primary plan which failed to provide for primary payment, which was not applicable in this instance. The court affirmed the district court's dismissal of Count II for failure to state a claim as well as its decision to decline to exercise supplemental jurisdiction over Count 1.
Court Description: Medicare Act. Affirming the district court’s judgment, the panel held that a private Medicare Advantage Organization plan cannot sue a plan participant’s survivors for reimbursement for advanced medical expenses out of the proceeds of an automobile insurance policy. The panel held that the district court had subject matter jurisdiction to determine whether the Medicare Act created a cause of action in favor of the MAO plan. The panel held that even though the MAO Statute, Medicare Part C, allows an MAO to charge a primary plan for conditional payments made on behalf of a plan participant, it does not grant an MAO a private right of action to recover those payments. The panel held that 42 U.S.C. § 1395y(b)(3)(A), which provides for a private cause of action for Medicare beneficiaries and healthcare providers to recover medical expenses from primary plans, did not apply. Concurring in the panel’s decision, Judge Callahan wrote that although prior opinions have been “less than consistent” on this issue, a district court has subject matter jurisdiction to determine whether a private right of action exists under federal law.
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