Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caDC-06-05295/USCOURTS-caDC-06-05295-0/pdf.json

Parties Involved:
Action Alliance of Senior Citizens
Appellee
American Association of Retired Persons
Amicus Curiae for Appellee
Gray Panthers
Appellee
Michael O. Leavitt
Appellant
Lucy Carolyn Loveall
Appellee

Document Text:

United States Court of Appeals 

FOR THE DISTRICT OF COLUMBIA CIRCUIT

Argued January 18, 2007 Decided April 17, 2007 

No. 06-5295 

ACTION ALLIANCE OF SENIOR CITIZENS, ET AL., 

APPELLEES

v. 

MICHAEL O. LEAVITT, SECRETARY OF DEPARTMENT OF 

HEALTH AND HUMAN SERVICES, 

APPELLANT

Appeal from the United States District Court 

for the District of Columbia 

(No. 06cv01607) 

Alisa B. Klein, Attorney, U.S. Department of Justice, 

argued the cause for appellant. With her on the briefs were 

Peter D. Keisler, Assistant Attorney General, Jeffrey A. 

Taylor, U.S. Attorney, Jeffrey S. Bucholtz, Principal Deputy 

Assistant Attorney General, Jonathan F. Cohn, Deputy 

Assistant Attorney General, Mark B. Stern, Attorney, Daniel 

Meron, General Counsel, U.S. Department of Health and 

Human Services, Kathleen H. McGuan, Associate General 

Counsel, and Marcus H. Christ and Lawrence J. Harder, 

Counsel. 

USCA Case #06-5295 Document #1034862 Filed: 04/17/2007 Page 1 of 17
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Gill Deford argued the cause for appellees. With him on 

the brief were Vicki Gottlich and Patricia B. Nemore. 

Bruce B. Vignery, Sarah Lenz Lock, and Michael 

Schuster were on the brief for amicus curiae American 

Association of Retired Persons in support of appellees. 

Before: GINSBURG, Chief Judge, and TATEL, Circuit 

Judge, and WILLIAMS, Senior Circuit Judge. 

Opinion for the Court filed by Senior Circuit Judge

WILLIAMS. 

WILLIAMS, Senior Circuit Judge: This case involves an 

effort on behalf of some 230,000 participants in the Medicare 

Part D prescription drug program to resist—indeed to 

reverse—the government’s efforts to recover payments 

mistakenly made to those participants. The district court 

issued an injunction ordering the Secretary of Health and 

Human Services (the “Secretary”) (1) to refund monies to 

those participants who had, at the Secretary’s request, 

returned the errant payments and (2) to notify all recipients of 

a right to request waiver of repayment. This court stayed the 

injunction. The plaintiffs have over the course of the 

litigation invoked two statutory bases for relief. (Plaintiffs 

also brought constitutional claims, which the district court did 

not reach.) As to the claim under 42 U.S.C. § 404(b), we find 

that the district court lacked jurisdiction; and the second 

claim, under 42 U.S.C. § 1395gg, clearly lacks merit. Thus, 

we vacate the injunction and remand. 

* * * 

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Medicare Part D, established by the Medicare 

Prescription Drug, Improvement, and Modernization Act of 

2003, Pub. L. No. 108-173, 117 Stat. 2066, offers subsidized 

prescription drug insurance coverage. 42 U.S.C. § 1395w101(a)(1). Whereas under Medicare Parts A and B the 

government pays providers on participants’ behalf for goods 

or services received, under Part D the government contracts 

for and subsidizes insurance plans offered by private, thirdparty insurers. Id. § 1395w-115. 

Part D participants pay monthly premiums to their 

insurers. See id. § 1395w-113(a). Most make these payments 

directly, but about 20% have opted to have the Social Security 

Administration (“SSA”) deduct the amount of their Part D 

premium from their monthly benefits under Title II of the 

Social Security Act and transmit that sum, on the participant’s 

behalf, to the insurer. Id. §§ 1395w-116(b)(3) & 1395w24(d)(2)(A); see also 42 C.F.R. §§ 423.293(a) & 422.262(f) 

(2006). The SSA, which plaintiffs have not sued, administers 

Old-Age, Survivor, and Disability Insurance benefits under 

Title II of the Social Security Act; Health and Human 

Services (“HHS”) administers the various Medicare programs 

found under Title XVIII of that Act. Since 1994 the SSA, 

directed by the Commissioner of Social Security (the 

“Commissioner”), has been independent of HHS. See Social 

Security Independence and Program Improvements Act of 

1994, Pub. L. No. 103-296, 108 Stat. 1464; 42 U.S.C. §§ 401-

434 (Title II); id. §§ 1395-1395hhh (Title XVIII). 

In a monumental gaffe in early August 2006, the SSA 

wrote to some 230,000 participants, stating “[w]e will no 

longer deduct money for your health plan premium(s) from 

your monthly benefits.” Amended Compl., Ex. B, Joint 

Appendix (“J.A.”) 61. The letter also said, without further 

explanation, that the addressee would be receiving a check in 

USCA Case #06-5295 Document #1034862 Filed: 04/17/2007 Page 3 of 17
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a specified amount, coinciding with the recipient’s premium 

for the just-past month. The average payment was $215, for a 

total of some $47 million. The parties agree these payments 

were all made in error. In early September, the Secretary 

requested repayment of the funds by the end of that month, 

but indicated that “[i]f returning the amount in full presents 

you with a hardship, you may request to make monthly 

installment payments for as many as seven months.” See id.

Ex. A, J.A. 58-59. The Secretary’s letter also stated 

(accurately) that despite the mistaken payment to the insured, 

“prescription drug coverage will continue uninterrupted.” Id.

On September 15, Action Alliance and the Gray Panthers 

(collectively “the Alliance”), advocacy organizations whose 

membership includes many Part D participants, filed suit in 

district court seeking injunctive, declaratory, and mandamus 

relief on statutory and constitutional grounds. (The plaintiffs 

later amended their complaint to add Lucy Carolyn Loveall, a 

Part D participant who received a check for $161.70, a sum 

which she spent and states she is now unable to repay.) The 

complaint rested in part on 42 U.S.C. § 1395gg, which allows 

the government to recover funds where “more than the correct 

amount is paid under th[e] [Medicare] subchapter . . . for 

items or services furnished an individual,” § 1395gg(b), but 

provides for government waiver of this recovery: 

There shall be no adjustment as provided in subsection 

(b) of this section (nor shall there be recovery) in any 

case where the incorrect payment has been made . . . with 

respect to an individual who is without fault . . . if such 

adjustment (or recovery) would defeat the purposes of 

subchapter II [Old-Age, Survivors, and Disability 

Insurance] or subchapter XVIII [Medicare] of this chapter 

or would be against equity and good conscience. 

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42 U.S.C. § 1395gg(c). 

The Alliance asserted that Part D participants who 

received erroneous payments were entitled, under § 1395gg, 

to “written notice . . . of their right to seek waiver of 

repayment” and an oral hearing prior to recovery of such 

payments. Amended Compl. at 14, J.A. 52. The district court 

rejected this claim, noting that § 1395gg applies only to 

payments for “items or services” (such as under Medicare 

Parts A and B), and thus that its waiver provision did not 

encompass erroneous premium refunds. Action Alliance of 

Senior Citizens v. Leavitt, 456 F. Supp. 2d 11, 18 (D.D.C. 

2006). 

But the court observed that Medicare Part A and B 

participants who authorize SSA to withhold their premiums 

under those parts do enjoy a waiver right for erroneous 

premium refunds. Internal SSA policy guidelines, in the form 

of its Program Operations Manual System (“POMS”), create 

such a right on the basis of Title II’s general waiver provision, 

42 U.S.C. § 404(b). Action Alliance, 456 F. Supp. 2d at 18-

20; see also Social Security Administration, Program 

Operations Manual System § HI 01001.330.A. 

Section 404 addresses adjustment or recovery of incorrect 

payments to Title II (Social Security) beneficiaries 

“[w]henever the Commissioner of Social Security finds that 

more or less than the correct amount of payment has been 

made to any person under this [Title II] subchapter.” 42 

U.S.C. § 404(a). Section 404(b) goes on to say: 

In any case in which more than the correct amount of 

payment has been made, there shall be no adjustment of 

payments to, or recovery by the United States from, any 

person who is without fault if such adjustment or 

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recovery would defeat the purpose of this subchapter or 

would be against equity and good conscience. 

Id. § 404(b). 

Although the POMS was silent as to waiver for erroneous 

refunds of Part D premiums, the district court believed that the 

“statutory scheme” required that Part D beneficiaries receive 

the same treatment as those under Parts A and B. Action 

Alliance, 456 F. Supp. 2d at 20. It ordered the Secretary to rereturn the erroneous payments to Part D participants who had 

repaid them and to notify all recipients of a right to request a 

hardship waiver. 

* * * 

The Secretary challenges the injunction on a number of 

grounds, most pertinently that the district court erred as a 

matter of law in concluding that the statutes and regulations 

governing overpayment of benefits and premiums under 

Medicare Parts A and B apply to premium refunds under 

Medicare Part D. The district court relied primarily on two 

statutes in support of the asserted waiver right (also invoked 

by the Alliance on appeal): § 404(b), which is the source of 

the waiver right provided in POMS for Part A and B 

beneficiaries, and § 1395gg(c), which, though applicable only 

to provision of “items and services,” also indicated a general 

embrace of waiver on grounds of “equity and good 

conscience.” Before reaching either ground, however, we 

consider the court’s jurisdiction (despite the government’s 

failure to assert its lack until we called for briefing on the 

subject). See Midwest Independent Transmission System 

Operator, Inc. v. FERC, 388 F.3d 903, 908 (D.C. Cir. 2004) 

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(describing court’s “independent obligation to be certain” of 

its jurisdiction). 

Jurisdiction of § 404(b) claim. The Alliance asserts that 

the district court had jurisdiction over its § 404(b) claim under 

the federal question and mandamus statutes, 28 U.S.C. 

§§ 1331 and 1361, as well as Title II’s separate judicial 

review provision, 42 U.S.C. § 405(g). But the Alliance (and 

the individual plaintiff) failed to present a § 404(b) claim to 

the Commissioner of Social Security before seeking review; 

the omission deprives the federal courts of jurisdiction to 

consider the claim under § 405(g), and, because that route was 

fully available to the Alliance, precludes jurisdiction under the 

other provisions. 

The starting point for analysis is 42 U.S.C. § 405(h), 

which provides: 

No findings of fact or decision of the Commissioner of 

Social Security shall be reviewed by any person, tribunal, 

or governmental agency except as herein provided. No 

action against the United States, the Commissioner of 

Social Security, or any officer or employee thereof shall 

be brought under section 1331 or 1346 of Title 28 to 

recover on any claim arising under this [Title II] 

subchapter. 

By its plain terms, then, § 405(h) bars Title II claims against 

any officer of the United States (thus including the Secretary) 

and applies to any claims “arising under this subchapter”—

i.e., 42 U.S.C. §§ 401-434. 

The Alliance makes clear (as it must, given § 404(a)’s 

requirement of a “payment . . . under this subchapter”) that its 

§ 404 claim depends on a classification of the premium 

USCA Case #06-5295 Document #1034862 Filed: 04/17/2007 Page 7 of 17
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refunds as a payment by the Commissioner under Title II. See 

Appellee’s Br. at 22 (“[T]he payments at issue and the entity 

responsible for making them are Social Security benefits and 

the SSA.”). Thus the claim is unavoidably one “arising under 

this subchapter” for the purposes of § 405(h). 

Section 405(h) operates in conjunction with Title II’s 

judicial review provision, § 405(g): 

Any individual, after any final decision of the 

Commissioner of Social Security made after a hearing to 

which he was a party, irrespective of the amount in 

controversy, may obtain a review of such decision [in a 

district court] by a civil action . . . . 

42 U.S.C. § 405(g). 

In Weinberger v. Salfi, 422 U.S. 749 (1975), the Supreme 

Court ruled that the district court had lacked jurisdiction 

where the complaint “contain[ed] no allegations that [the 

plaintiffs in question] have even filed an application with the 

[Commissioner], much less that he has rendered any decision, 

final or otherwise, review of which is sought.” Id. at 764. 

And the Court noted that § 405(h) “[o]n its face” bars federalquestion jurisdiction over such claims. Id. at 756. The Court 

soon qualified Salfi’s jurisdictional treatment of § 405(g)’s 

requirement of “a final decision . . . made after a hearing,” see 

id. at 763-64, distinguishing in Mathews v. Eldridge, 424 U.S. 

319, 328 (1976), between the “final decision” element of 

Salfi’s exhaustion requirement (from which a court could 

relieve a plaintiff) and the “nonwaivable element [of § 405(g) 

which] is the requirement that a claim for benefits shall have 

been presented to the [Commissioner].” Id. (emphasis added). 

The Court held that a plaintiff had satisfied presentment by 

responding to a questionnaire from a state agency, where the 

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SSA later adopted (pursuant to the statutory scheme then in 

effect) the state agency’s conclusion that Eldridge was no 

longer disabled as a ground for terminating his federal 

disability benefits. Id. at 329; see also Amendments to Title II 

of the Social Security Act, Pub. L. 83-761, ch. 1206, tit. I, 

§ 221(a), 68 Stat. 1052, 1081 (1954) (current version at 42 

U.S.C. § 421(a)). 

We have described Salfi’s presentment requirement as an 

“absolute prerequisite” to review, finding a lack of jurisdiction 

where a plaintiff “proceeded directly to district court, seeking 

a preliminary injunction barring HHS . . . from implementing 

[a] new rate reduction.” Nat’l Kidney Patients Ass’n v. 

Sullivan, 958 F.2d 1127, 1129-30 (D.C. Cir. 1992); cf. Ryan v. 

Bentsen, 12 F.3d 245, 247 n.3 (D.C. Cir. 1993) (presentment 

satisfied where plaintiff requested reconsideration from a 

regional SSA office of a decision to terminate his retirement 

benefits). 

The Alliance points first to the fact that Lucy Loveall’s 

social worker contacted “Medicare and Social Security” on 

her behalf after Loveall received the erroneous check. See 

Amended Compl. at 12, J.A. 50. But, as described by the 

Alliance, that communication made no mention of any claim 

to a waiver right. 

Alternatively, the Alliance relies on an August 30 e-mail 

to the Administrator of the Centers for Medicare & Medicaid 

Services (“CMS”) “inform[ing] him that the letter that CMS 

was sending out to the affected beneficiaries did not alert 

them to their right to waiver and request[ing] that [the letter] 

be revised to include that information.” Amended Compl. at 

8, J.A. 46; see also Appellees’ Supp. Br. at 6. We need not 

decide whether an e-mail to CMS (which administers federal 

health care financing programs under Titles XI, XVIII, and 

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XIX of the Social Security Act and is a division of the 

Department of Health and Human Services) would qualify as 

presentment of a claim under § 404(b) (a provision so far as 

appears administered by the Commissioner of Social 

Security), as the Alliance has failed to show that it ever 

invoked § 404(b) before either agency. Neither in its original 

or amended complaint, nor in any papers that it has called to 

our attention, nor in its supplemental briefing on jurisdiction, 

has it suggested that the e-mail mentioned § 404(b). 

The Alliance’s various other arguments attempting to 

avoid presentment are also unavailing. The Alliance contends 

that the “Secretary knows, without receiving a specific 

demand, that beneficiaries want the right to seek waiver.” 

Appellees’ Supp. Br. at 6. But, putting aside that presentment 

to the Commissioner is in question, a notion that imputed 

official intuition of people’s probable desires could qualify as 

a presentment would strip the requirement of all content. See 

Eldridge, 424 U.S. at 328; see also Nat’l Kidney Patients 

Ass’n, 958 F.2d at 1130. Similarly, the Alliance’s assertion 

that Loveall’s non-response to the Secretary’s demand for 

repayment amounted to presentment is simply another label 

for a proposal to erase the requirement. 

The Alliance also cites Linquist v. Bowen, 813 F.2d 884, 

887-88 & nn.11-12 (8th Cir. 1987), a case involving SSA’s 

misreading of a provision reducing benefits on account of 

beneficiaries’ outside income. The decision treated as 

presentment the unnamed class members’ filing of their initial

claims and their later earnings reports. Id. at 887 n.11. But it 

also rested on the continued availability of mandamus—a 

proposition with which we agree but which is subject to 

mandamus’s invariable condition, the absence of an 

alternative remedy, which the court did not address. 

Moreover, the decision’s explicit reliance on categorizing the 

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claim as “collateral,” see id. at 887-88 n.12, has been rendered 

obsolete by Shalala v. Illinois Council on Long Term Care, 

Inc., 529 U.S. 1, 13-14 (2000). (Briggs v. Sullivan, 886 F.2d 

1132, 1139 (9th Cir. 1989), which the Alliance also cites, was 

grounded on the same distinction.) Finally, insofar as Linquist

dispenses with the presentment requirement for nonentitlement claims, as it appears to do, see 813 F.2d at 887-88 

n.12, we respectfully disagree. 

The Alliance alternatively asserts that the district court 

had mandamus jurisdiction over the § 404(b) claim. But the 

existence of an administrative remedy under Subchapter II—

i.e., the Alliance could present the § 404(b) claim directly to 

the Commissioner and then, if it were denied, seek judicial 

review pursuant to § 405(g)—precludes the exercise of 

mandamus, which is available only if “no other adequate 

remedy [is] available to plaintiff.” Fornaro v. James, 416 

F.3d 63, 69 (D.C. Cir. 2005). 

We note that our prior observations that § 405(h)’s 

jurisdiction-stripping provision (which explicitly mentions 

only §§ 1331 and 1346) does not in theory bar a court from 

exercising mandamus jurisdiction with respect to a Social 

Security claim, see Ganem v. Heckler, 746 F.2d 844, 850 

(D.C. Cir. 1984) (“[M]andamus jurisdiction is not precluded 

by [§ 405(h) of] the [Social Security] Act.”), are obviously 

subject to the standard rule that the existence of an alternative 

remedy precludes mandamus. See also Heckler v. Ringer, 466 

U.S. 602, 620-21 (1984) (mandamus jurisdiction “not 

available” where plaintiff had administrative remedy under 

Medicare Act). 

Thus, we conclude that the district court lacked 

jurisdiction to consider a claim for waiver under § 404(b). 

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* * * 

We now turn to the Alliance’s second ground for relief, 

42 U.S.C. § 1395gg. Adopting a position in some tension 

with its earlier characterization of the erroneous payment as 

having been made under Title II, the Alliance asserts that the 

monies were “improper payments made in the Medicare 

program,” Appellees’ Br. at 29-30, and thus subject to waiver 

under § 1395gg(c). Compare Oral Arg. at 21:30 (“The only 

place this money could have come from was the Title II trust 

fund.”). Accepting this view arguendo, we hold that although 

the district court had jurisdiction, the § 1395gg claim clearly 

lacks merit. 

Jurisdiction of § 1395gg claim. The general bar on 

federal question jurisdiction originating in the Social Security 

domain, § 405(h), is integrated into the Medicare subchapter 

by 42 U.S.C. § 1395ii, which provides: 

The provisions of . . . subsections (a), (d), (e), (h), (i), (j), 

(k), and (l) of section 405 of this title [42 U.S.C. § 405], 

shall also apply with respect to this subchapter [XVIII] to 

the same extent as they are applicable with respect to 

subchapter II of this chapter, except that, in applying such 

provisions with respect to this subchapter, any reference 

therein to the Commissioner of Social Security or the 

Social Security Administration shall be considered a 

reference to the Secretary or the Department of Health 

and Human Services, respectively. 

42 U.S.C. § 1395ii (emphasis added). Thus, general federal 

question jurisdiction is generally unavailable for “any claim 

arising under” the Medicare Act—i.e., any claim that has its 

“standing and . . . substantive basis” in that Act. Illinois 

Council, 529 U.S. at 11. 

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But the Supreme Court has recognized an exception to 

this rule where application of § 1395ii “would not lead to a 

channeling of review through the agency, but would mean no 

review at all.” Illinois Council, 529 U.S. at 17 (Medicare Part 

A claim); see also Bowen v. Michigan Academy of Family 

Physicians, 476 U.S. 667, 669-70 (1986) (applying, in the 

absence of any statutory grant of judicial review in the Part B 

statute then in effect, a “strong presumption that Congress 

intends judicial review of administrative action” and finding 

jurisdiction over a statutory and constitutional challenge to a 

Medicare Part B regulation); American Chiropractic Ass’n, 

Inc. v. Leavitt, 431 F.3d 812, 816 (D.C. Cir. 2005) (“[I]f the 

claimant can obtain judicial review [of his Medicare Part C 

claim] only in a federal question suit, § 1395ii will not bar the 

suit.”). 

In Illinois Council the Court recently reaffirmed the 

principle that federal question jurisdiction is available where 

application of §§ 1395ii and 405(h) would mean “no review at 

all” of a plaintiff’s claim, 529 U.S. at 19, but found that the 

plaintiffs there had failed to show that they could obtain “no 

review at all” (absent § 1331 jurisdiction) of their statutory 

and constitutional challenges to certain Part A regulations, id.

at 20. Thus the Court appears to have left open a door to 

§ 1331 to fill jurisdictional gaps it presumes Congress did not 

intend. Although the plaintiffs in Illinois Council and 

Michigan Academy backed their statutory claims with 

constitutional ones, the same appears to be true here. 

Moreover, Illinois Council did not explicitly restrict its rule to 

constitutional claims. And Michigan Academy formulated its 

broad presumption against “prohibit[ing] all judicial review of 

executive action,” 476 U.S. at 681 (internal quotation marks 

omitted), by relying in part on Dunlop v. Bachowski, 421 U.S. 

560, 567 (1975), a case involving only a statutory challenge to 

agency action. 

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Under Illinois Council and Michigan Academy, then, we

must consider whether the Alliance could have obtained 

judicial review of its § 1395gg claim through the “special 

review channel[s]” of the Medicare Act. The problem is that 

no statute appears to make any affirmative grant of 

(channeled) jurisdiction over Medicare Part D claims of the 

type pressed by the Alliance. First, § 405(g) is conspicuously 

absent from the list of Title II provisions incorporated into 

Medicare by § 1395ii. Second, while 42 U.S.C. 

§ 1395ff(b)(1)(A) provides for judicial review of benefit 

claims under § 1395ff(a)(1), incorporating § 405(g) by 

reference, subsection (a)(1) in turn covers only claims under 

Medicare Parts A and B. In Ringer, the Court held that 

§ 405(g) provided the sole jurisdictional basis for a claim for 

benefits under Medicare Part A. 466 U.S. at 620-21. Under 

Salfi and Eldridge, the incorporation of § 405(h) into 

Medicare rendered § 1331 “not available” as a source of 

jurisdiction. Id.

Medicare Part D contains its own, more narrowly-tailored 

provision for judicial review, 42 U.S.C. § 1395w-104(h)(1), 

on which the Alliance relied here as a basis for jurisdiction. 

That section operates by imposing on Part D insurers certain 

provisions already applicable to providers under Part C: 

[A] PDP sponsor [i.e., the private insurer providing the 

Part D drug coverage] shall meet the requirements of 

paragraphs (4) and (5) of section 1395w-22(g) of this title 

with respect to benefits . . . in a manner similar (as 

determined by the Secretary) to the manner such 

requirements apply to a[] M[edicare] A[dvantage] 

organization . . . under part C [of this subchapter]. 

42 U.S.C. § 1395w-104(h)(1). 

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The cross-referenced § 1395w-22(g) (the judicial review 

provision for Medicare Part C) deals with coverage 

determinations by a Part C private insurer. Section 1395w22(g)(1)(A) requires insurers (known as “Medicare 

Advantage” (“MA”) organizations) to have a procedure for 

making benefit determinations for enrolled individuals, and 

subsection (g)(2)(A) requires MA organizations to provide for 

reconsiderations of such decisions. Sections 1395w-22(g)(4) 

and (5), mentioned explicitly in § 1395w-104(h)(1), provide: 

(4) The Secretary shall contract with an independent, 

outside entity to review and resolve in a timely manner 

reconsiderations [by MA organizations] that affirm denial 

of coverage, in whole or in part. . . . 

(5) An enrollee with a[n MA organization] . . . under this 

part who is dissatisfied by reason of the enrollee’s failure 

to receive any health service to which the enrollee 

believes the enrollee is entitled . . . if the amount in 

controversy is $100 or more, [is entitled] to a hearing 

before the Secretary to the same extent as is provided in 

section 405(b) of this title [42 U.S.C. § 405(b)], and in 

any such hearing the Secretary shall make the 

organization a party. If the amount in controversy is 

$1,000 or more, the individual or organization shall . . . 

be entitled to judicial review of the Secretary’s final 

decision as provided in section 405(g) of this title . . . . 

Id. § 1395w-22(g)(4) & (5). 

Thus the Part D provisions, in the context of stating 

prerequisites for PDP sponsors, weave in provisions for 

judicial review derived from Part C. But these sections do not 

appear to provide for judicial review of the kind of claim 

asserted here. The Alliance did not bring a claim against a 

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“PDP sponsor,” see 42 U.S.C. § 1395w-104(h)(1), or for the 

“failure to receive any health service to which the enrollee 

believes the enrollee is entitled,” see § 1395w-22(g)(5). 

Rather, the claim was directed against the Secretary for the 

way in which he has collected premium payments. 

As the Medicare statute appears to provide no avenue for 

judicial review of the Alliance’s § 1395gg waiver claim, we 

apply the rule of Michigan Academy and Illinois Council and 

hold that the district court had jurisdiction over that claim 

under 28 U.S.C. § 1331. 

Merits of § 1395gg claim. At last we reach the merits of 

the Alliance’s claim to a waiver right under § 1395gg. This 

proves the easy part of the case. Subsection (a) makes 

individuals responsible for “payment[s] under this subchapter 

to any provider of services . . . with respect to any items or 

services furnished any individual,” 42 U.S.C. § 1395gg(a) 

(emphasis added), and subsection (b) gives the Secretary 

authority to recoup from an individual where “more than the 

correct amount is paid under this subchapter to a provider of 

services . . . for items or services furnished an individual,” id.

§ 1395gg(b) (emphasis added). Finally, subsection (c) 

provides for a waiver, saying that, under certain hardship 

conditions there shall be “no adjustment as provided in 

subsection (b) . . . where [an] incorrect payment has been 

made . . . with respect to an individual.” Id. § 1395gg(c). 

Thus, by its plain terms, 1395gg applies to overpayments to a 

“provider of services” for “items or services furnished an 

individual.” It has nothing to do with erroneous refunds of 

Medicare premiums. 

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* * * 

Having found that the district court lacked jurisdiction to 

consider a waiver claim under 42 U.S.C. § 404(b), and that the 

parallel claim under 42 U.S.C. § 1395gg clearly lacks merit, 

we vacate the district court’s injunction and remand the case 

for proceedings not inconsistent with this judgment. 

So ordered.

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