Case Title: Quishenberry v. UnitedHealthcare, Inc.

Citation: 

Docket Number: S271501

State: california

Court: California Supreme Court

Date: 2023-07-13T00:00:00Z

Document:
IN THE SUPREME COURT OF 
CALIFORNIA 
 
LARRY QUISHENBERRY, 
Plaintiff and Appellant, 
v. 
UNITEDHEALTHCARE, INC., et al., 
Defendants and Respondents. 
 
S271501 
 
Second Appellate District, Division Seven 
B303451 
 
Los Angeles County Superior Court 
BC631077 
 
 
July 13, 2023 
 
Justice Groban authored the opinion of the Court, in which 
Chief Justice Guerrero and Justices Corrigan, Liu, Kruger, 
Jenkins, and Evans concurred. 
 
1 
QUISHENBERRY v. UNITEDHEALTHCARE, INC.  
S271501 
 
Opinion of the Court by Groban, J. 
 
This case concerns a Medicare Advantage (MA) enrollee 
who died after being discharged from a skilled nursing facility.  
The enrollee’s son, Larry Quishenberry, sued the MA health 
maintenance organization (HMO) plan and a healthcare 
services administrator that managed his father’s MA benefits.  
Quishenberry pled state-law claims for negligence, wrongful 
death, and elder abuse based on allegations that the HMO and 
healthcare services administrator breached a duty to ensure his 
father received skilled nursing benefits to which he was entitled 
under his MA plan.   
The HMO and healthcare services administrator assert 
that Quishenberry’s claims are expressly preempted by 
Medicare Part C’s preemption provision, which provides that the 
“standards established under” Part C “shall supersede any State 
law or regulation” concerning MA plans.  (42 U.S.C. § 1395w-
26(b)(3).)  Because Quishenberry’s state-law claims are based on 
allegations that his father’s HMO plan and healthcare services 
administrator breached state-law duties that incorporate and 
duplicate standards established under Part C, we agree and 
hold that the provision preempts them. 
QUISHENBERRY v. UNITEDHEALTHCARE, INC. 
Opinion of the Court by Groban, J. 
 
2  
I. Background 
A.  Medicare Part C 
The Medicare Act, part of the Social Security Act, provides 
for 
a 
federally 
subsidized 
health 
insurance 
program 
administered by the Centers for Medicaid and Medicare 
Services (CMS), a division of the Department of Health and 
Human Services.  (McCall v. PacifiCare of Cal., Inc. (2001) 
25 Cal.4th 412, 416 (McCall).)  “Under Parts A and B of the Act, 
Medicare beneficiaries requiring medical services obtain those 
services directly from providers participating in the Medicare 
program, and [Medicare] directly reimburses those providers on 
a ‘fee-for-service’ basis.”  (Roberts v. United Healthcare Services, 
Inc. (2016) 2 Cal.App.5th 132, 140 (Roberts); 42 U.S.C. 
§§ 1395c–1395i-5 [Part A] & 1395j–1395w-6 [Part B].)  “Part A 
covers ‘hospital, skilled nursing, home health, and hospice care 
benefits,’ while Part B covers ‘physician and other outpatient 
services.’ ”  (Roberts, at p. 140.)   
Part C — under which Quishenberry’s father was 
insured — permits Medicare beneficiaries to “sign up for a 
privately administered health care plan” — an MA plan — “that 
provides all of the Part A and B benefits as well as additional 
benefits.”  (Roberts, supra, 2 Cal.App.5th at p. 140.)  “If a 
beneficiary elects to participate in [an MA] plan, the government 
pays the plan’s administrator a flat, monthly fee to provide all 
Medicare benefits for that beneficiary.  Because Part C limits 
the government’s responsibility to just the monthly fee, the 
private health plan — rather than the government — ends up 
‘assum[ing] the risk associated with insuring’ the beneficiary.”  
(Ibid.)   
QUISHENBERRY v. UNITEDHEALTHCARE, INC. 
Opinion of the Court by Groban, J. 
 
3  
MA plans are governed by standards set out in Part C and 
in detailed federal regulations.  As described below, these 
standards comprehensively address MA plans’ coverage of 
skilled nursing care.  (See post, section III.C.) 
B.  Factual and Procedural History 
This case comes to us on review of a trial court order 
sustaining demurrers of the HMO plan and healthcare services 
administrator to Quishenberry’s second amended complaint.  
We take the relevant facts from that complaint.  (Yvanova v. 
New Century Mortgage Corp. (2016) 62 Cal.4th 919, 924.)   
According to the complaint, a hospital transferred 
Quishenberry’s 85-year-old father to a skilled nursing facility for 
physical therapy after treating him for a broken hip.  Due to the 
neglect of the nursing facility and his physician there, 
Quishenberry’s father developed severe pressure sores, which 
the facility and physician did not properly treat.1  After about 
24 days at the skilled nursing facility, Quishenberry’s father 
was discharged to his home, where he received inadequate care, 
experienced pain and suffering, and eventually died.  
Quishenberry alleges his father was enrolled in an MA 
HMO plan offered by UnitedHealthcare, Inc., UnitedHealth 
Group Incorporated, UnitedHealthcare Services, Inc., and UHC 
of 
California 
(collectively, 
UnitedHealthcare).  
UnitedHealthcare contracted with Healthcare Partners Medical 
Group (Healthcare Partners) to administer the MA plan with 
 
1  
Quishenberry also sued the skilled nursing facility and his 
father’s physician.  He settled with the skilled nursing facility, and 
the physician’s defenses are not at issue in this appeal.   
QUISHENBERRY v. UNITEDHEALTHCARE, INC. 
Opinion of the Court by Groban, J. 
 
4  
respect to physician services, delegating to Healthcare Partners 
its duty under the plan to provide such services.  
According to the complaint, Quishenberry’s father was 
entitled under Medicare to 100 days of medically necessary care 
at a skilled nursing facility — 76 additional days beyond the 24 
days he received.  However, his father’s skilled nursing facility 
and treating physician, acting pursuant to standard business 
practices of UnitedHealthcare and Healthcare Partners, falsely 
informed his father that he was not entitled to further inpatient 
care and prematurely discharged him to his home.  
Quishenberry further alleges that UnitedHealthcare had 
“responsibility for the custodial care and treatment” of his father 
by contract with CMS.  “By contract and federal law,” 
UnitedHealthcare and Healthcare Partners were able to control 
the skilled nursing facility, and they knew the facility was not 
providing 
Medicare-covered, 
medically 
necessary 
skilled 
nursing care to its resident-patients.  Nevertheless, they 
“acquiesced to, encouraged, directed, aided and abetted” the 
facility and physician in discharging Quishenberry’s father 
“under circumstances where acceptable medical practice and 
Medicare rules required” that his father remain at the facility 
“for more intense attention to his health care needs.”  
Quishenberry alleges they did so “to increase profit by reducing 
the cost of providing” skilled nursing facility care.  
Based on these allegations, Quishenberry pled — as 
relevant here — a state statutory claim under the Elder Abuse 
Act and common law claims of negligence and wrongful death.2  
 
2  
Quishenberry also pled a bad faith claim, but he does not 
dispute the dismissal of that claim, so it is not at issue. 
QUISHENBERRY v. UNITEDHEALTHCARE, INC. 
Opinion of the Court by Groban, J. 
 
5  
UnitedHealthcare and Healthcare Partners — the only 
defendants involved in this appeal — demurred to the second 
amended complaint, arguing that Quishenberry’s claims were 
preempted by Medicare Part C’s preemption provision.  The trial 
court sustained the demurrers without leave to amend and 
entered judgment in their favor.  
Quishenberry appealed, and the Court of Appeal affirmed, 
concluding that the Part C preemption provision preempted 
Quishenberry’s claims.  The Court of Appeal relied on Roberts, 
supra, 2 Cal.App.5th 132, which disagreed with earlier Court of 
Appeal decisions that concluded the provision does not expressly 
preempt either common law claims — such as Quishenberry’s 
negligence and wrongful death claims — or statutory claims 
that are based on generally applicable law, such as 
Quishenberry’s claim under the Elder Abuse Act.  (See Yarick v. 
PacifiCare of California (2009) 179 Cal.App.4th 1158, 1165–
1166 (Yarick) [observing that language like that of the Part C 
preemption provision “usually is interpreted to preempt only 
‘positive state enactments,’ that is, laws and administrative 
regulations, but not the common law”]; Cotton v. StarCare 
Medical Group, Inc. (2010) 183 Cal.App.4th 437, 450–452 
(Cotton) [holding Part C preemption provision reaches only state 
statutes and regulations relating to MA plans].)  We granted 
review to address whether the Part C preemption provision 
reaches Quishenberry’s claims. 
II. Discussion 
 
The question before us is whether the state-law duties 
Quishenberry seeks to enforce via his statutory claim of elder 
abuse and common law claims of negligence and wrongful death 
are superseded by “standards established under” Medicare Part 
QUISHENBERRY v. UNITEDHEALTHCARE, INC. 
Opinion of the Court by Groban, J. 
 
6  
C, and thus expressly preempted by the Part C preemption 
provision.  (42 U.S.C. § 1395w-26(b)(3).)  Because deciding this 
question requires us to interpret the preemption provision and 
apply it to the claims Quishenberry alleges in his complaint, our 
review is de novo.  (Farm Raised Salmon Cases (2008) 
42 Cal.4th 1077, 1089, fn. 10; see also McCall, supra, 25 Cal.4th 
at p. 415.)  
A. Preemption Principles 
The United States Supreme Court has explained the basic 
operation of federal preemption as follows:  “Congress enacts a 
law that imposes restrictions or confers rights on private actors; 
a state law confers rights or imposes restrictions that conflict 
with the federal law; and therefore the federal law takes 
precedence and the state law is preempted.”  (Murphy v. NCAA 
(2018) 138 S.Ct. 1461, 1480.)  Preemption can be “express” or 
“implied.”  The term express preemption refers to Congress’s use 
of “express language in a statute” to supersede state law.  
(Oneok, Inc. v. Learjet, Inc. (2015) 575 U.S. 373, 376.)  Whether 
Congress has expressly preempted a state-law claim is 
primarily a question of statutory construction.  (Medtronic, Inc. 
v. Lohr (1996) 518 U.S. 470, 484 (Medtronic).)   
When addressing such questions, we look first to the 
language of the preemption provision in its statutory context, 
“ ‘which necessarily contains the best evidence of Congress’ pre-
emptive intent.’ ”  (Sprietsma v. Mercury Marine (2002) 537 U.S. 
51, 62–63 (Sprietsma).)  If we determine Congress intended a 
provision “to pre-empt at least some state law,” our task 
becomes to identify “ ‘the domain expressly pre-empted.’ ”  
(Medtronic, supra, 518 U.S. at p. 484; see also Quesada v. Herb 
Thyme Farms, Inc. (2015) 62 Cal.4th 298, 308 (Quesada).)  
QUISHENBERRY v. UNITEDHEALTHCARE, INC. 
Opinion of the Court by Groban, J. 
 
7  
Congress’s objectives in enacting the statute may serve as a 
“guide” for discerning “the scope of the state law that Congress 
understood would survive” preemption and for determining 
whether a particular state-law duty is within that scope.  
(Rutledge v. Pharm. Care Mgmt. Ass’n (2020) 141 S.Ct. 474, 480 
[___ U.S. ___, ___].)3  
B. The Scope of the Medicare Part C Preemption 
Provision 
In accordance with the principles outlined above, we begin 
our analysis with the plain language of Medicare Part C’s 
preemption provision.  (Quesada, supra, 62 Cal.4th at p. 308.)  
The provision reads in full:  “The standards established under 
this part shall supersede any State law or regulation (other than 
State licensing laws or State laws relating to plan solvency) with 
respect to MA plans which are offered by MA organizations 
under this part.”  (42 U.S.C. § 1395w-26(b)(3).)  Although the 
term “standards” is not defined in the Medicare Act, we 
understand the phrase “[t]he standards established under this 
part” to refer to the provisions of Part C and federal regulations 
promulgated pursuant to Part C.  (42 U.S.C. § 1395w-26(b)(3); 
see 42 C.F.R. § 422.402; Do Sung Uhm v. Humana, Inc. (9th Cir. 
2010) 620 F.3d 1134, 1148, fn. 20 (Uhm).)  We read the words 
“shall supersede” as commanding that these federal statutory 
 
3  
Quishenberry urges us to apply a presumption against 
preemption.  We decline to do so.  (See Puerto Rico v. Franklin Cal. 
Tax-Free Trust (2016) 579 U.S. 115, 125 [“[B]ecause the statute 
‘contains an express preemption clause,’ we do not invoke any 
presumption against preemption but instead ‘focus on the plain 
wording of the clause, which necessarily contains the best evidence 
of Congress’ pre-emptive intent’ ”].) 
 
QUISHENBERRY v. UNITEDHEALTHCARE, INC. 
Opinion of the Court by Groban, J. 
 
8  
provisions and regulations be given preemptive effect.  (Cf. 
Betancourt v. Storke Housing Investors (2003) 31 Cal.4th 1157, 
1163 [“shall supersede” language in the Employee Retirement 
Income Security Act of 1974 (ERISA) creates preemption]; Rush 
Prudential HMO, Inc. v. Moran (2002) 536 U.S. 355, 364 
[same].)  We accordingly interpret the phrase “[t]he standards 
established under this part shall supersede” as reflecting 
Congress’s intent that the provisions of Part C and federal 
regulations established under Part C preempt at least some 
state-law duties.  (42 U.S.C. § 1395w-26(b)(3).)  This much the 
parties do not dispute. 
The balance of the preemption provision identifies what is 
preempted by the standards established under Part C — “any 
State law or regulation . . . with respect to MA plans which are 
offered by MA organizations under this part” — and also what 
Congress has exempted from preemption — “State licensing 
laws or State laws relating to plan solvency.”  (42 U.S.C. § 
1395w-26(b)(3).)  Quishenberry does not contend that his claims 
implicate licensing laws or solvency-related laws.  Our task 
therefore is to determine whether the standards established 
under Part C preempt the state-law duty on which 
Quishenberry’s claims concerning his father’s MA plan is based.  
(Ibid.)   
We start by considering Quishenberry’s arguments 
concerning the domain preempted.  (See Medtronic, supra, 
518 U.S. at p. 484.)  He contends this domain does not 
encompass state-law duties that duplicate federal duties, 
common-law claims such as his negligence and wrongful death 
claims, or claims based on generally applicable state statutory 
law such as his claim under the Elder Abuse Act.  We discuss 
each of these arguments in turn. 
QUISHENBERRY v. UNITEDHEALTHCARE, INC. 
Opinion of the Court by Groban, J. 
 
9  
1. The Provision Expressly Preempts Duplicative 
State-Law Duties  
Quishenberry argues that there is no express preemption 
of a state-law duty that is “based on federal standards” 
established under Part C.  For a claim rooted in duties 
established under federal law to be actionable under state law, 
there must be a state-law duty to comply with federal law; state 
law must incorporate federal law such that the federal duties 
are enforceable via a state-law claim.  (See Riegel v. Medtronic, 
Inc. (2008) 552 U.S. 312, 324 (Riegel) [“[C]ommon-law liability is 
‘premised on the existence of a legal duty,’ and a tort judgment 
therefore establishes that the defendant has violated a state-law 
obligation”].)  Quishenberry would have us read the Part C 
preemption provision as not extending to state-law duties that, 
in this way, are based on and duplicate federal standards 
established under Part C.   
The provision’s plain language does not support 
Quishenberry’s proposed reading.  By using the expansive word 
“any” to describe the domain of state standards preempted, 
Congress indicated its intent that standards established under 
Part C preempt “any” state-law duty “with respect to MA plans,” 
even when the duty is based on and duplicative of a federal 
standard.  (42 U.S.C. § 1395w-26(b)(3).)  The intent to preempt 
duplicative state-law duties is apparent when we contrast the 
Part C preemption provision’s language — superseding “any 
State law or regulation . . . with respect to MA plans” (ibid.) — 
with the language of the Federal Food, Drug, and Cosmetic Act’s 
preemption provision related to medical devices.  That provision 
specifies that state-law duties that are “different from, or in 
addition to” federal requirements are preempted.  (21 U.S.C. § 
360k(a)(1).)  In Medtronic, the United States Supreme Court 
QUISHENBERRY v. UNITEDHEALTHCARE, INC. 
Opinion of the Court by Groban, J. 
 
10  
held this provision’s preemptive domain did not extend to “state 
rules that merely duplicate some or all of [the] federal 
requirements.”  (Medtronic, supra, 518 U.S. at p. 495.)  By 
contrast, the phrase “any state law or regulation” in the Part C 
preemption provision suggests that Congress did not intend to 
narrowly preempt only those state-law standards that are 
inconsistent with the federal standards.  (42 U.S.C. § 1395w-
26(b)(3).)  Instead, it intended the standards established under 
Part C to supersede “any” state standards “with respect to MA 
plans,” including those that are based on and duplicative of 
standards established under Part C.  (Ibid.) 
The legislative history of the Part C preemption provision 
confirms this reading.  When first enacted in 1997, Medicare 
Part C included a differently worded express preemption clause 
(see Pub.L. No. 105-33, § 1856(b)(3) (Aug. 5, 1997) 111 Stat. 
251).  The 1997 version of the clause specified that federal 
standards superseded a state law or regulation “to the extent 
such law or regulation is inconsistent with such standards.”  
(Ibid.)  Congress enacted the current version of the provision in 
a section of the Medicare Prescription Drug Improvement and 
Modernization Act of 2003 titled “Avoiding duplicative State 
regulation.”  (Pub.L. No. 108-173 (Dec. 8, 2003) 117 Stat. 2066, 
§ 232.)  The 2003 amendment removed the requirement that a 
state law be “inconsistent with” federal standards.  (Ibid.)  By 
removing that requirement, Congress made clear its intent not 
to limit preemption to state-law claims that are inconsistent 
with federal standards.  (Medicaid & Medicare Advantage 
Prods. Ass’n of P.R., Inc. v. Hernandez (1st Cir. 2023) 58 F.4th 
5, 12 (Hernandez); Uhm, supra, 620 F.3d at pp. 1149–1150.)  
The current version of the provision thus extends preemption to 
QUISHENBERRY v. UNITEDHEALTHCARE, INC. 
Opinion of the Court by Groban, J. 
 
11  
state-law standards that are based on and duplicative of 
standards established under Part C. 
2.  The Provision’s Scope Extends to Common-Law 
Claims 
Quishenberry next contends that the Part C preemption 
provision does not preempt common-law claims and instead 
preempts only claims brought under state statutes and 
regulations.  The provision’s plain language contradicts 
Quishenberry’s interpretation.  The phrase “any State law or 
regulation” is most naturally read to encompass common law.  
(42 U.S.C. § 1395w-26(b)(3), italics added.)  The narrow nature 
of the provision’s savings clause confirms that Congress 
intended standards established under Part C to supersede state-
law duties regardless of whether they are rooted in statutory or 
common law.  The savings clause designates two specific areas 
of state law to be preserved from preemption — “State licensing 
laws” and “State laws relating to plan solvency” — and no 
others.  (42 U.S.C. § 1395w-26(b)(3).)  Preemption provisions in 
other federal statutes, by contrast, contain exemptions for much 
broader categories of state-law duties.  For example, the Federal 
Boat Safety Act of 1971 (FBSA) contains a savings clause that 
preserves “liability at common law or under State law.”  
(46 U.S.C. § 4311(h); see Sprietsma, supra, 537 U.S. at p. 63.)  
Similarly, the savings clause of the Occupational Safety and 
Health Act of 1970 preserves, among other rights, any “common 
law or statutory rights, duties, or liabilities of employers and 
employees under any law with respect to injuries, diseases, or 
death of employees arising out of, or in the course of, 
employment.”  (29 U.S.C. § 653(b)(4).)  The fact that Congress 
chose to identify only two categories of state statutory law as 
preserved from preemption — and chose not to specify that 
QUISHENBERRY v. UNITEDHEALTHCARE, INC. 
Opinion of the Court by Groban, J. 
 
12  
common law duties are exempt — suggests it did not intend to 
categorically exempt common law duties.4   
The preemption provision’s legislative history also 
suggests that Congress did not intend to preserve common law 
duties from preemption.  Prior to the 2003 amendment, Health 
and Human Services had interpreted the original preemption 
provision as foreclosing common law claims that are, in effect, 
claims that certain services are covered under an MA plan.  
(65 Fed.Reg. 40170, 40261 (June 29, 2000); see Uhm, supra, 
620 F.3d at p. 1155.)  We presume that Congress was aware of 
the Secretary’s interpretation when it amended the preemption 
clause in 2003.  (Uhm, at p. 1155.)  Because Congress did not act 
to correct Health and Human Services’ understanding when 
making this amendment, it appears “that Congress intended the 
Part C preemption provision . . . to preempt at least some 
common law claims.”  (Ibid.)     
CMS’s position on the meaning of the amended version of 
the Part C preemption provision also accords with our 
understanding.  When issuing a proposed rule implementing the 
2003 amendment, CMS stated that:  “[G]enerally applicable 
 
4  
This conclusion is consistent with the great weight of federal 
and sister state authority on the preemptive effect of the Part C 
preemption provision and the identical preemption provision in 
Part D of the Medicare Act (42 U.S.C. § 1395w-112(g)).  (See, e.g., 
Hernandez, supra, 58 F.4th at pp. 11–13; Aylward v. SelectHealth, 
Inc. (9th Cir. 2022) 35 F.4th 673, 681 (Aylward); Pharm. Care 
Mgmt. Ass’n v. Wehbi (8th Cir. 2021) 18 F.4th 956, 971–972; Uhm, 
supra, 620 F.3d at pp. 1153–1156; Haaland v. Presbyterian Health 
Plan, 
Inc. 
(D.N.M. 
2018) 
292 F.Supp.3d 
1222, 
1230–
1231; Morrison v. Health Plan of Nev. Inc. (Nev. 2014) 328 P.3d 
1165, 1171–1172; Snyder v. Prompt Med. Transp., Inc. 
(Ind.Ct.App. 2019) 131 N.E.3d 640, 652–653.)   
QUISHENBERRY v. UNITEDHEALTHCARE, INC. 
Opinion of the Court by Groban, J. 
 
13  
State tort, contract, or consumer protection law would not be 
preempted” because the preemption provision “was intended to 
preempt state standards governing health plans, not generally 
applicable State laws” or “contract laws and tort laws.”  
(69 Fed.Reg. 46866, 46913 (Aug. 3, 2004).)  However, CMS 
clarified this position when it promulgated the final rule, 
concluding that “all State standards, including those established 
through case law, are preempted to the extent they specifically 
would regulate MA plans, with exceptions of State licensing and 
solvency laws.  Other State health and safety standards, or 
generally applicable standards, that do not involve regulation of 
an MA plan are not pree[mp]ted.”  (70 Fed.Reg. 4588, 4665 (Jan. 
28, 2005), italics added; see Uhm, supra, 620 F.3d at p. 1156.)  
The final rule thus clarified CMS’s view that, as to the 
regulation of MA plans, federal standards established under 
Part C supersede duties established under common law.   
In support of his argument that the Part C preemption 
provision does not reach common law duties, Quishenberry 
relies on the Court of Appeal’s decisions in Yarick and Cotton, 
which read the portion of the provision identifying what is 
preempted — “ ‘any State law or regulation’ ” — to exclude 
common law.  (Yarick, supra, 179 Cal.App.4th at p. 1165; see 
also Cotton, supra, 183 Cal.App.4th at pp. 449–451.)  Yarick’s 
discussion of the scope of express preemption under Part C is 
notably brief:  The court observed that language like that found 
in Part C “usually is interpreted to preempt only ‘positive state 
enactments,’ that is, laws and administrative regulations, but 
not the common law.”  (Yarick, at pp. 1165–1166.)  In support of 
this observation, the Yarick court cited, without discussion, the 
United States Supreme Court’s decision in Sprietsma, supra, 
537 U.S. 51, which interpreted a differently worded express 
QUISHENBERRY v. UNITEDHEALTHCARE, INC. 
Opinion of the Court by Groban, J. 
 
14  
preemption provision in the FBSA as not reaching common-law 
tort claims.  (Id. at p. 64.)  In Cotton, the Court of Appeal relied 
on Yarick and Sprietsma to conclude that the Part C preemption 
provision was inapplicable to common-law claims.  (Cotton, 
supra, 183 Cal.App.4th at p. 450.)  The Court of Appeal in 
Roberts, supra, 2 Cal.App.5th at pp. 144–145 disagreed, 
rejecting Sprietsma’s reasoning as largely irrelevant to the 
interpretation of the Part C preemption provision.  We conclude 
the Roberts panel has the better view:  The U.S. Supreme 
Court’s reasoning in Sprietsma, which is based on the distinct 
language and statutory context of the FBSA preemption 
provision, does not control our analysis. 
The preemption provision at issue in Sprietsma reads:  
“ ‘[A] State . . . may not establish, continue in effect, or enforce a 
law or regulation establishing a recreational vessel or associated 
equipment performance or other safety standard . . . that is not 
identical to a regulation’ ” prescribed under the FBSA.  
(Sprietsma, supra, 537 U.S. at pp. 58–59, quoting 46 U.S.C. § 
4306.)  In support of its holding that this provision did not reach 
common-law duties, the U.S. Supreme Court observed that “the 
article ‘a’ before ‘law or regulation’ implies a discreteness — 
which is embodied in statutes and regulations — that is not 
present in the common law.”  (Sprietsma, at p. 63.)  The Part C 
preemption provision, by contrast, applies to “any State law or 
regulation” concerning MA plans, suggesting a broader 
preemptive effect.  (42 U.S.C. § 1395w-26(b)(3), italics added; 
see Uhm, supra, 620 F.3d at p. 1153 [“The [Part C preemption 
provision’s] use of ‘any’ negates the ‘discreteness’ that the Court 
identified in Sprietsma”].)  As noted above, the FBSA also 
contains a savings clause specifying that FBSA compliance 
“does not relieve a person from liability at common law or under 
QUISHENBERRY v. UNITEDHEALTHCARE, INC. 
Opinion of the Court by Groban, J. 
 
15  
State law.”  (46 U.S.C. § 4311(h).)  The U.S. Supreme Court 
considered this clause evidence that the language of the FBSA 
preemption provision “ ‘permits a narrow reading that excludes 
common-law actions.’ ”  (Sprietsma, at p. 63.)  The Medicare Act 
contains no equivalent savings clause or any other affirmative 
indication that Congress intended to preserve common-law 
duties.  (See Uhm, at p. 1153.)  For these reasons, we agree with 
the Roberts panel that Sprietsma is distinguishable.  (Roberts, 
supra, 2 Cal.App.5th at pp. 144–145.)  We accordingly conclude 
that the scope of the Part C preemption provision extends to 
common-law duties. 
3.  The 
Provision’s 
Scope 
Extends 
to 
Duties 
Established by State Laws Not Specifically 
Targeted at MA Plans 
 
Quishenberry also argues, relying on Cotton, that the 
phrase “with respect to MA plans” in the Part C preemption 
provision indicates that the provision does not expressly 
preempt 
claims 
based 
on 
state 
“statutes 
of 
general 
applicability,” such as his claim under the Elder Abuse Act.  (See 
Cotton, supra, 183 Cal.App.4th at p. 450 [Part C preemption 
provision “extends only to positive state laws or regulations 
‘with respect to MA plans.’ ”].)  Quishenberry would have us 
construe the provision as reaching only those state statutes and 
regulations that specifically refer to and target MA plans.  By 
contrast, UnitedHealthcare and Healthcare Partners argue that 
standards established under Part C preempt even those state 
standards that are set out in generally applicable laws.  They 
understand the phrase “with respect to MA plans” to indicate 
that the preemptive effect is limited to state-law standards 
concerning MA plans offered by MA organizations; standards 
governing other types of health plans are not preempted.  
QUISHENBERRY v. UNITEDHEALTHCARE, INC. 
Opinion of the Court by Groban, J. 
 
16  
(42 U.S.C. 
§ 
1395w-26(b)(3).) 
 
We 
conclude 
that 
UnitedHealthcare and Healthcare Partners offer the better 
reading.   
The U.S. Supreme Court addressed a similar question in 
Riegel, in which it interpreted the phrase “ ‘with respect to’ ” in 
the preemption clause of the 1976 Medical Device Amendments 
to the Federal Food, Drug, and Cosmetic Act.  (Riegel, supra 
552 U.S at p. 316.)  The relevant statutory language read:  
“ ‘[N]o State or political subdivision of a State may establish or 
continue in effect with respect to a device intended for human 
use any requirement. . . .’ ”  (Ibid., italics added.)  The court 
rejected the argument that state tort duties were not preempted 
because they were “not requirements maintained ‘ “with respect 
to devices.” ’ ”  (Id. at p. 327, italics added.)  It concluded that 
“[n]othing in the statutory text suggests that the pre-empted 
state requirement must apply only to the relevant device, or only 
to medical devices and not to all products and all actions in 
general.”  (Id. at p. 328; cf. Pilot Life Ins. Co. v. Dedeaux (1987) 
481 U.S. 41, 47–48 [interpreting the phrase “relate to” in 
ERISA’s preemption provision as “not limited to ‘state laws 
specifically designed to affect employee benefit plans’ ”].)   
Similar reasoning applies to the Part C preemption 
provision:  The phrase “with respect to” does not indicate that 
only those state laws and regulations that specifically refer to 
MA plans are preempted.  The standards established under Part 
C preempt even those duties set out in generally applicable state 
statutes, but only as they apply to “MA plans which are offered 
by MA organizations.”  (42 U.S.C. § 1395w-26(b)(3); see Uhm, 
supra, 620 F.3d at p. 1150, fn. 25; Roberts, supra, 2 Cal.App. at 
p. 47; cf. Rutledge, supra, 141 S.Ct. at pp. 479-481 [describing 
the scope of the requirement that state laws, to be preempted by 
QUISHENBERRY v. UNITEDHEALTHCARE, INC. 
Opinion of the Court by Groban, J. 
 
17  
ERISA, must “relate to any employee benefit plan”].)5  As CMS 
explained in the final rule implementing the 2003 amendment, 
discussed above, federal standards established under Part C 
supersede “all State standards . . . to the extent they specifically 
would regulate MA plans,” other than “State licensing and 
solvency laws.”  (70 Fed.Reg., supra, at p. 4665, italics added).  
These include state statutory or regulatory provisions that 
specifically reference MA plans and duties established under 
generally applicable state law when invoked to regulate MA 
plans.  (Id.) 
In sum, contrary to Quishenberry’s contentions, Congress 
did not categorically carve out and save from preemption state-
law claims based on duties that duplicate federal standards, 
common law actions, or statutes of general applicability.  
Instead, it intended the standards established under Part C to 
supersede any state-law duty with respect to MA plans, 
regardless of whether that duty is grounded in statutory or 
common law, and even when the state-law duty is not 
inconsistent with and instead is based on and duplicates 
standards established under Part C. 
C. Quishenberry’s Claims Are Expressly Preempted 
We next consider whether Quishenberry’s claims fall 
within the domain preempted by Part C’s preemption provision.  
(See Medtronic, supra, 518 U.S. at p. 484; Aylward, supra, 
 
5  
We disapprove Yarick v. PacfiCare of California, supra, 
179 Cal.App.4th 1158, and Cotton v. StarCare Medical Group, 
Inc., supra, 183 Cal.App.4th 437 to the extent they conclude that 
the scope of Part C’s preemption provision is limited to positive 
state enactments.  We also disapprove Cotton to the extent it 
concludes that the Part C preemption provision only reaches state 
laws and regulations specifically targeting MA plans. 
QUISHENBERRY v. UNITEDHEALTHCARE, INC. 
Opinion of the Court by Groban, J. 
 
18  
35 F.4th at p. 680.)  The touchstone of this inquiry is whether 
there is a federal standard under Part C that supersedes the 
duty alleged under state law or regulation.  To make this 
determination, we compare the state-law duties Quishenberry 
seeks to enforce to standards established under Part C.  (See 
Aylward, at p. 680.)   
Quishenberry’s operative second amended complaint sets 
out claims under the state Elder Abuse Act and the common law.  
He 
supports 
these 
claims 
with 
allegations 
that 
UnitedHealthcare — his father’s HMO MA plan — and 
Healthcare Partners — a healthcare services administrator — 
failed to ensure that his father’s physician and skilled nursing 
facility provided the benefits to which he was entitled under 
Part C, resulting in his discharge from the skilled nursing 
facility under circumstances in which Medicare rules required 
that he remain there for an additional 76 days.  As pled against 
these entities, therefore, Quishenberry’s claims are ultimately 
premised on a single alleged duty:  The duty to ensure his father 
received the services to which he was entitled under Part C and 
the terms of his MA plan, specifically, 100 days of skilled 
nursing facility care.6    
To determine the truth of Quishenberry’s allegations, a 
state factfinder would have to decide whether Quishenberry’s 
father was entitled to the skilled nursing care benefits 
Quishenberry claims his father should have received.  This 
would involve applying standards established under Part C.  MA 
 
6  
Quishenberry does not dispute the Court of Appeal’s 
determination that the same federal duties apply to Healthcare 
Partners and UnitedHealthcare; our analysis assumes that 
determination is correct. 
QUISHENBERRY v. UNITEDHEALTHCARE, INC. 
Opinion of the Court by Groban, J. 
 
19  
regulations require organizations to provide MA enrollees the 
benefits to which they are entitled under Parts A and B.  (See 
42 U.S.C. § 1395w-22(a)(1)(A) [MA plan “shall provide to” 
enrollees “through providers and other persons . . . benefits 
under the original medicare fee-for-service program option”]; 
42 C.F.R. § 422.101(a) [MA organizations must “[p]rovide 
coverage of, by furnishing, arranging for, or making payment 
for, all services that are covered by Part A and Part B”].)  
Quishenberry’s claims are based on Part A’s provision of 
coverage for “post-hospital extended care services for up to 100 
days during any spell of illness.”  (42 U.S.C. § 1395d(a)(2)(A).)  
To determine whether Quishenberry’s father was entitled to the 
full 100 days of skilled nursing facility care under this provision, 
a state factfinder would need to apply criteria detailed in 
Medicare regulations, for example:  “[T]he beneficiary must 
require skilled nursing or skilled rehabilitation services, or both, 
on a daily basis” and “[t]he daily skilled services must be ones 
that, as a practical matter, can only be provided in a [skilled 
nursing facility], on an inpatient basis.”  (42 C.F.R. § 
409.31(b)(1) & (b)(3).)  To determine whether UnitedHealthcare 
and Healthcare Partners had a duty to ensure the provision of 
these services, state courts would look to standards established 
under Part C governing the duties of Medicare Advantage 
organizations.  (See, e.g., 42 C.F.R. § 422.504(a)(3)(i) [requiring 
MA organizations, as part of their contracts with the Centers for 
Medicare and Medicaid Services, to agree to provide “[t]he basic 
benefits as required under [42 C.F.R.] § 422.101”]; 42 C.F.R. 
§ 422.752(a)(1) [authorizing the imposition of sanctions against 
MA organizations that “[f]ail[] substantially to provide 
medically necessary items and services” required by law or 
contract].)  UnitedHealthcare and HealthCare Partners’ 
QUISHENBERRY v. UNITEDHEALTHCARE, INC. 
Opinion of the Court by Groban, J. 
 
20  
liability therefore hinges on a determination of noncompliance 
with a duty rooted in federal standards established under Part 
C.  (See Riegel, supra, 552 U.S. at p. 324 [explaining how federal 
standard may be enforceable under state law].)  Because the 
state-law duty Quishenberry alleges is ultimately based 
on these standards, his claims are preempted.  (42 U.S.C. § 
1395w-26(b)(3).)    
 
Attempting to save his claims from preemption, 
Quishenberry characterizes them as “based on treatment 
decisions, not benefits determinations.”  He points to his 
allegations that UnitedHealthcare and Healthcare Partners 
“acquiesced to, encouraged, directed, aided and abetted” the 
decision of the skilled nursing facility and doctor not to provide 
covered services to his father to reduce costs and increase 
profits.  Quishenberry’s complaint makes clear, however, that  
the resolution of his claims against UnitedHealthcare and 
Healthcare 
Partners 
would 
ultimately 
turn 
on 
the 
determination whether his father qualified for additional skilled 
nursing facility care under Part C and related regulations.  In 
support of his claims against these entities, Quishenberry 
alleges “Medicare rules required that” his father remain at the 
skilled nursing facility “for more intense attention to his health 
care needs,” “Medicare rules make provision for longer periods 
for participation in physical therapy given the presence of [his 
father’s] pressure sores,” and specifically, he alleges that his 
father was “entitled under Medicare to another period of 76 days 
of care at [the skilled nursing facility] with daily care of his 
pressure sores and daily physical therapy.”  To find 
UnitedHealthcare or Healthcare Partners liable for breach of 
the alleged duty to ensure he received these services, a 
factfinder would have to apply the standards established under 
QUISHENBERRY v. UNITEDHEALTHCARE, INC. 
Opinion of the Court by Groban, J. 
 
21  
Part C to determine whether his father was entitled to them.  
Quishenberry’s claims, therefore, are based on state-law duties 
that are duplicative of standards established under Part C. 
For these reasons, we conclude that Part C’s preemption 
provision expressly preempts Quishenberry’s claims against 
UnitedHealthcare and Healthcare Partners.7  In so concluding, 
we note again that Quishenberry’s claims against his father’s 
skilled nursing facility and treating physician are not before us; 
this appeal is concerned with the liability of the provider and 
the administrator of an MA plan.  Quishenberry’s allegations 
against 
these 
entities 
are 
not 
based 
on 
treatment 
decisions (which they did not make) or provision of care (which 
they did not undertake) but instead on their duties under Part 
C and related regulations to ensure Quishenberry’s father 
received the benefits to which he was entitled under his MA 
plan.  Because Quishenberry’s state-law claims against 
UnitedHealthcare and Healthcare Partners are based on duties 
arising under Part C, they are preempted.8  
 
7  
Because we conclude that Quishenberry’s claims are 
expressly preempted, we do not address the alternative implied 
preemption arguments made by UnitedHealthcare and 
Healthcare Partners.  
8  
The Attorney General submitted an amicus curiae brief 
cautioning against an overly broad reading of the Part C 
preemption provision that would impinge on the State’s ability to 
protect California’s millions of Medicare beneficiaries though 
various state-law enforcement actions.  He argues that “Congress 
did not intend to provide MA plans with blanket immunity from 
basic health and safety obligations grounded in state law that 
apply to all persons and entities statewide, or other generally 
applicable laws that do not undermine the administration of the 
 
QUISHENBERRY v. UNITEDHEALTHCARE, INC. 
Opinion of the Court by Groban, J. 
 
22  
III. Conclusion 
For the reasons discussed above, Quishenberry’s claims 
are expressly preempted by Medicare Part C’s preemption 
provision.  Accordingly, we affirm the Court of Appeal’s 
judgment. 
 
 
 
 
 
 
 
 
GROBAN, J. 
 
 
We Concur: 
GUERRERO, C. J. 
CORRIGAN, J. 
LIU, J. 
KRUGER, J. 
JENKINS, J. 
EVANS, J. 
 
 
 
federal MA program.”  We agree.  This case does not directly 
implicate the Attorney General’s enforcement powers and nothing 
we say here would provide MA plans with blanket immunity from 
basic health and safety obligations grounded in state-law 
standards or in other state laws and regulations that are not 
superseded by standards established under Part C.  
 
 
See next page for addresses and telephone numbers for counsel who 
argued in Supreme Court. 
 
Name of Opinion  Quishenberry v. UnitedHealthcare, Inc. 
__________________________________________________________  
 
Procedural Posture (see XX below) 
Original Appeal  
Original Proceeding 
Review Granted (published)  
Review Granted (unpublished) XX NP opn. filed 9/21/21 – 2d Dist., 
Div. 7 
Rehearing Granted 
__________________________________________________________  
 
Opinion No. S271501 
Date Filed:  July 13, 2023 
__________________________________________________________  
 
Court:  Superior  
County:  Los Angeles 
Judge:  Ralph C. Hofer 
__________________________________________________________   
 
Counsel: 
 
Balisok & Associates and Russell S. Balisok for Plaintiff and 
Appellant. 
 
Gibson, Dunn & Crutcher, Kahn A. Scolnick, Heather L. Richardson, 
Jennafer M. Tryck, Patrick J. Fuster; Walraven & Westerfeld, Bryan 
S. Westerfeld, Jessica B. Hardy; Carroll, Kelly, Trotter & Franzen, 
Michael J. Trotter, Brenda M. Ligorsky and David P. Pruett for 
Defendants and Respondents. 
 
Cole Pedroza, Curtis A. Cole and Cassidy C. Davenport for California 
Medical Association, California Dental Association and California 
Hospital Association as Amici Curiae on behalf of Defendants and 
Respondents. 
 
King & Spalding, Ethan P. Davis and Matthew V.H. Noller for 
Chamber of Commerce of the United States of America as Amicus 
Curiae on behalf of Defendants and Respondents. 
 
 
Fred J. Hiestand for Civil Justice Association of California as Amicus 
Curiae on behalf of Defendants and Respondents. 
 
Rob Bonta, Attorney General, Renu R. George, Assistant Attorney 
General, Kathleen Boergers, Bryan Kao and Anna Rich, Deputy 
Attorneys General, for the Attorney General of California as Amicus 
Curiae.
 
 
Counsel who argued in Supreme Court (not intended for 
publication with opinion): 
 
Russell S. Balisok 
Balisok & Associates, Inc. 
37592 Zeolite Hills Road 
Corvallis, OR 97330 
(818) 389-7890 
 
Kahn A. Scolnick 
Gibson, Dunn & Crutcher LLP 
333 South Grand Avenue 
Los Angeles, CA 90071-3197 
(213) 229-7656