UNITED STAT ES DIS TRICT COURT F OR THE D ISTRIC T OF CO LU M BIA

) BRIAN HALL, et al., ) ) P laintif fs, )

) v. ) Civil Action No. 08-1715 (RMC) ) CH ARLES E. JOH NSO N, Ac ti ng Secre tary, Depart m ent of Health & Human Servs., et al ., ) ) ) ) ) Defendan ts. ) ) M EM OR

AN DU M OP IN ION Br ian Hall, a r etiree from the f eder al Depa

rtme n t o f H o u s in g and Ur

ban De velopment (“ HU D” ), su e s th e De partme nt o f H e a lthand Hu man Se rv ic e s ( “ HH S” ) t o avo id b e ingfo rc e d to
a c c e pt M e dic are Part

A, and fo re go the p ri va

te he a lthins ur anc e that he no w e njo y s. Mo st immediately , Mr. Hall moves for a temporary restra ining order to pre vent HHS and its constituent ag ency , the Social Secur ity Administration (“SSA”), fr om enrolling him in Medicare Part A n o w that he has turne d ag e 65. Mr. Ha ll complains that if he re fuses to ac cept Medica re Part A, he will not
on ly los e a ll of his futur e , mont hly Soc ia l Sec ur ity be ne fi ts, a c c or din g to HH S po lic ie s, but he wi ll be re qu ir e d to re pa

y to t he Soc ia l Sec ur ity Ad

min ist ra tio n all of the monthl y

Soc ia l Se c ur ity

be ne fi ts he has r ece ived over

the past three y ear s (since he retire d at ag e 62).

I. F AC TS B ri a n H a ll w a s f

or me rl y an e mpl oy e e of

, a nd is n owre tir e d f

ro m, HU D. Am . Co mpl
. ¶ 1 3. He re tir e d at a g e 62
. Pur su ant to the F e de ra l Empl oy e e He a lth B e ne fi ts pr og ra m, he c ho se to participate in the Mail Handle rs B enef it Pl an - C o nsumer Option upon re tirement, a pla n thatSeeProg ram Ope rations Manua l Sy stem/Hospital I nsuranc e (“ POMS HI ”) 00801.002, 1 Waiver of HI

Entitlement by

Monthly Be nefic iary ; POMS HI

00801.034, Wit hdraw al Considerations; and POMS GN 00206.020, Wi thdrawa l Considerations When Hospital I nsuranc e is I nvolved. -2- includes a H ealth Saving s Acc ount (“HSA” ) and a high- deductib l e health insuranc e policy . Pl.’s Mem. in Support of Mot. for TRO (Pl.’s Mem.), Attac h. 1 (De cl. of Br ian Hall (“ Hall Dec l.”) ¶ 3)
. Mr. Hall alleg es that this insura nce policy

will be available for the ba lance of his life and w ill cover his future he alth car e expenses unless he is c ompelled to enroll in Medica re Par t A. Id. ¶¶ 3- 8. Mr. Hall applied f

or re tirement bene fits under Title I Iof the S ocial S ecur ity Act on Octobe r 20, 2005. Defs.’ Opp’ n to Pl.’s Mot . for TRO, Ex. B (D ecl. of CraigA. Street (“ Street D e c l
. ” ) ¶ 4 )
. T h a ta

p p l i c a t i o ns t a t e d

o nth e f i r s tp a g e , i na l l c ap i t a l l e t t e r s , “ I A P P LY F O R A LL I NSURANCE BEN EFI TS FOR WHI CH IAM EL I GI BL E UNDER TI TL E I I(F EDERAL OL DA G E , S U RV IV O R S , A

N D D IS A B ILIT Y IN S U R AN C E ) A N D P A R T A O F T IT LE X V III (HE AL TH I

NSURANCE FOR THE A GED AN D DI SABL ED) OF THE SOCI AL SECURI TY ACT, AS PRESENTL Y AMENDED .” Id. ¶ 5. Mr. Ha ll beg an to re ceive Social Security retire ment benef its in Februa

ry 2006. Id. ¶ 6. Acc ording to cer

tain policies of HHS, M r. Ha l l complains that he will be 1 automatically

enrolled in Medic are Part A in J anuar y 2009 beca

use he turne d 65 y ear s of ag e on Janu ar y 3 , 2 0 0 9
. B e li e v in g th a t t h e me d ic a l c a

r e av a il a b le to M e d ic ar e p a ti e n ts is in f e r io r to th at pr ov ide d und e r p ri vate he a lth ins ur anc e , Mr
. Ha ll ha s no tif ie d HH S that he is unw ill ingto e nr oll in Medica re Par t B, which provides c overa g e for phy sician ca

re, but he cannot similarly decline Me dic are Part

A, wh ic h p ro vid e s c ov e ra g e fo r h os pit a l c os ts. As a re su lt, he wi ll be for c e d to discontinue his F EHB benef its, 5 U.S.C. § 891 et seq. , as he wi ll no l on g e r b e a ble to c on tr ibute to-3-

his HSA, and his insurance car rier w ill cease co v er ing his he alth car e costs and e x penses a s the pr ima ry ins ur e r. 26 U. S.C. § 2 23 (b )( 7) ; I RS Pu bli c a tio n 9 69 a t www.irs.g ov ; A m. C omp l. ¶ 13 ; H a ll Dec l. ¶ 21. Mr. Hall conte nds that upon rea chingag e 65, he a utom ati cally

beca me “. . . a

n ind ivi du a l w ho is e nti tle d to be ne fi ts und e r Part A of thi s su bc ha pte r or e nr oll e d un de r Part B of thi s subchapte r;” 42 U.S.C. § 1395a(5), a nd there by

beca me a “ Medica

re be nefic iary .” Id. An d, wh ile Medica re be nefic iaries c an ente r in private c ontrac ts with phy sicians for me dical ca re, 42 U .S.C. § 139 5 a( b)(2) (B ), Mr. Ha ll believes that a c ontrac ting phy sician would there by be bar red f rom
s u b m i tt i n g anyclaim to Medica re f or a pe riod of two y ear s, even f or other pati en ts. 42 U.S.C. § 13 95 a (b )( 3) (B )( ii) (t

wo -ye ar b ar) ; U

n i t e d S e n i o r s A s s ’ n v . Sh ala la , 182 F.3d 965, 968 ( D.C. Cir. 19 99 ) ( “ Th is m e ans that a do c tor wh o e nte rs int o a

pr ivate c on tr a ct wi th e ve n a sin g le patie nt i s barr ed fr om submit ting a claim t o Medica re on behalf of any patient for a two-y ear period.” ). Mr. Ha ll f e ar s t h a t h i s p h y s i c i an s an d p r o v i d e r s w i l l n o t p r o v i d e h e a l th c ar e s e r v i c e s andbe pa id privately by him so long as he is a “Medic are benef iciary .” F ur the r, a s a “ Me dic are e lig ibl e ind ivi du a l,” Mr . H a ll w ill no lon g e r b e a ble to contribute to his HSA and use pr e- t ax d o l l ar s for his health care costs. Acc ording to 26 U.S.C. § 223(b)( 7): Me dic ar e e lig ible ind iv idu als The limitation under t his subsection for any month with respe ct to an individual shall be zero for the f irst month such indivi dual is entitled to benef its under Title XVI I I of t he Social Secur ity Act and f or ea ch month therea fter. Se e als o I RS P ublication 969 at www.ir s.g ov.The same standard a pplies to both temporary

restra ining or ders a

nd to preliminary 2 injunctions. Expe rienceW orks, Inc . v. Chao , 267 F. Supp. 2d 93, 96 (D.D .C. 2003).

-4- Mr. Hall alleg es t hat t he poli cies reflec ted in the POMS cited above a re not re flec ted in any statutory lang uag e. T h es e p o l icies would re quire him to withdraw f rom rec eiving Social Security benef its and repa

y all such bene fits alrea dy

rec eived in orde r t o avoid M edica re Part A. He
c omp la ins tha

t th e e ff e c t of th e chal le ng e d PO MS is to f or c e him and a ll c iti zen s to e nr oll in Me dic are Part

A whe the r t

he y wa nt to or no t. He wi sh e s to re c e ive monthl y Soc ia l Se c ur ity

be ne fi ts without any

Medica re c overa g e. SeePl. ’s Me m. at 38 (“ [A]s state d a bo ve , B RI ANHA L L[sic ] is entitled to Social Security and Medic are alre ady , but he does not wa nt any Medica re be nefits.”)
. II. STA ND AR

D O F RE VI EW A co u rt m u st co n sid er f o u r f act o rs in d ecid ing w h eth er t o issu e a tem p o rary restrainin g o rde r: 2

1. whe t he r t he mova nt ha s s hown a s ubs t a nt i a l l i ke l i hood of s uc c e s s on t he m er i t s; 2. whe t he r t he mova nt woul d su f f e r i r r e pa r a bl e i nj ur y i f

t he i nj unc t i on i s no t g r a nt e d; 3. w hether t he i ssuan c e o f a p re lim in a ry in

ju n c tio n w ou l d cause s ubs t a nt i a l ha r m t o o t he r i nt e r e s t e d p a r t i e s ; a nd 4. w heth e r th e p u b li c i nter est w ou l d b e ser ved by t he iss uan ce of an i nj unc t i on. Mo va Ph a rm . C o rp . v. S h a lala , 1 4 0 F
. 3 d 1 0 6 0 , 1 0 6 6 ( D
. C
. C ir
. 1 9 9 8 ). Th e f o reg o ing f

acto rs sh o u ld be bal anced on a “sl i ding scal e, ” i
. e. , a l esser sho w i ng on on e f act or ca n b e surmo un t ed b y a g r eat er
s h o w in g o n a n o th e r fac to r. CSX T r an s p. , I nc . v . Wi l l i ams , 40 6 F
. 3d 667 ( D. C. Ci r . 20 05)
. E ve n s o, i n o r de r t o j us t i f

y i nt r udi ng i nt o t he or di na r y l i t i g a t i on pr oc e s s by i s s ui ng a pr e l i mi na r y i nj unc t i on,-5-

it is c ritic a l th a t a m o v a n t 1 ) m a k e a s u b s ta n tia l s h o w in g o f lik e lih o o d o f s u c c e s s o n th e m e rits , A m. Ban k e r s As s ’ n v . Nat ’ l Cr e di t Uni on Admi n. , 38 F. Supp. 2d 114 , 14 0 ( D. D. C. 19 99) , a nd 2) ma ke

a sh o w in g o f

at le a s t so m e in

ju ry . Ci t y Fe d F i n. Cor

p. v . Of f i c e of Th r i f t Su pe r v i s i on , 58 F. 3d 738, 74 6 (D
. C
. C i r . 19 95 )
. A prel i m i nary i njun ct i on i s “an extr aordinar y r em edy that sho uld b e g r anted

on l y w hen t he p ar t y seeki ng t he re l i ef , by a cl ear sho w i ng, car r i es t he b urden of persuasi on . ” C o b ell

v . Nor t on , 3 9 1 F.3 d 2 5 1 , 2 5 8 ( D
. C
. C ir
. 2 0 0 4 ). III. AP P LICABLE LAW The Medic are Act, which is Titl e XVI I I of t he Social Secur ity Act, 42 U.S.C. § 1395 et seq. , established a p ro gra m o f health insurance for the e lderly and disabled. Me dicar e Part A,
c a lle d H os pit a l I ns ur anc e , c ov e rs se rv ic e s f ur nis he d b y ho sp ita ls a

nd oth e r i ns tit

uti on a l pr ov ide rs . 4 2 U
. S. C. § § 1 3 9 5 c - 1 3 9 5 i- 4
. E n ti tl e me n t t o M e d ic ar e Pa rt Ab e n e f

it s o c c ur s a

u to mati c a ll y

f or individuals who turn 65 and ar e rec eiving monthly Social Security benef its unde r 42 U.S.C. § 402. See42 U. S.C. § 4 26 (a ) ( “ Ev e ry ind ivi du a l w ho
. . . h a s atta ine d th e a g e of 65 , and is ent itl e d to monthly insurance benef

its under sec tion 402 of this ti tle . . . shall be entitled to hospital insurance benef its un d er p art A of

this chapter. . . .” ). B y contra st, Medicar e Part B , which provide s
su pp le me nta l me dic a l in sura nc e be ne fi ts fo r c e rt a in me dic a l and he a lthc are se rv ic e s n ot o the rw ise
cover ed under

Medica re Par t A, including phy sician ser vices, is an optio n al prog ram to which individuals are not automatica lly entitled. Individuals entitled to P art A must pay for Par t B a nd may cho os e to op t o utof P artB. 42 U.S .C . § § 1 39 5j -13 95 w-4 . “T hi s o pt io nal cov erage [ un der P artB]

. . . sup ple me nts the mand a tor y ins tit uti on a l he a lthbe ne fi ts ( su c h a s c ov e ra g e fo r h os pit a l e xpe ns e s) p r o v id e d b y Pa rt A .” Bowen v. M

ichigan Acade my of Family Phy sicians , 476 U.S. 667, 674-75 (1986).-6- Th e g ov e rnme nt e xpla ins : There is . . . no separate statutory or cur rent re g ulatory

means of avoiding one’s “ entitlement” to Medica re Par t A benef its, at le ast for so lon g a s o ne re ta ins e nti tle me nt t o mo nth ly Soc ia l Se c ur ity

be ne fi ts. I ndeed, e ntitlement to Medi car e Part A a rises automatica lly

for persons who a

re e ntitled to mont hly

Social Security

benef its. A person c ould avoid entitlement to Me d icar e Part A by avoiding entitlemen t to monthly

social sec urity

retire ment benef

its by failing to r e qu e st the latte r. On e wa y to ac hie ve thi s re su lt is simpl y no t to file an a pplication for monthl y

Social Security

benef its. See42 U
. S. C. 4 0 2 [s ic ]. Def s.’ Opp’n at 5. I n addition, an in d i v i d u al m ay withdraw a

n application for

monthly Social Security benef its by submitt ing a

written re quest pursuant to 20 C.F.R. § 404.640. I f an individual has alre ady

beg an to re ceive Soci al S ec u ri ty retire ment benef

its, s/he can still withdraw from that prog ram but only

if, inte r a lia , th e Soc ia l Se c ur ity Ad min ist ratio n d e ter min e s th a t “ [a]ll be ne fi ts
a lr e a dy pa id b a se d on the a

pp lic a tio n be ing wi thd

ra wn are re pa id” or SSAis “ satis fi e d th a t th e y wi ll be re paid.” See20 C.F.R. § 404.640. Mr. Hall ca nnot a ffor d to r epay his Socia l Security retire ment be ne fi ts o r l ive wi tho ut t

he m. H ow e ve r, he do e s n ot c ha lle ng e the se re g ulatio ns . The foc us of Mr. Ha ll’s petition for a TRO is three pr ovisions in S SA’s POMS, which he asse rts “s er v e t o t i e monthly benef its under Social Secur ity

and Medic are , Part A, enr ollment tog e the r an d to c on fi sc a te an in div idu a l’ s So c ia l Se c ur ity monthl y be ne fi ts i f h e or

sh e a tte mpt s to op t out of Me dic are , Pa

rt A. ” Pl. ’s Me m. a

t 8. Th e POM S state , in

re le va nt p art : PO MS HI 00 80 1. 00 2, W

aiv er of HI

En tit le me nt b

yMo nth ly Be ne fic iar y A. IN TR OD UC TIO N Some individuals entit led to monthly benef its have aske d to waive HI En tit le me nt b e c a

us e of re lig iou s or ph ilo so ph ic a l r e a so ns , o r b e c a us e they pref er othe r hea lth insurance.-7- B. POLICY I ndividu al s en t i t l edt o m o n th l y b en ef i t s wh i ch co n fe r e l i gi b i l i ty for HI may not waive HI Entitlement. The only way to a void H IEntitlement is th r o u gh w it h d r awa l of the monthly

benef it application. Wit hdraw al re qu ir e s r e pa

y me nt o f a ll RS DI

and HI be ne fi t pa

y me nts
. POMS HI 00801.34, W

ithdrawal Considerations A. P OLICY To wi thd ra w fro m th e HI

pr og ra m, a n in div idu a l mu st s ub mit a wr itt e n r e qu e st f

or wi thd ra wa l and mus t re fu

nd any HI be ne fi ts p a id on his/her beha lf as explained in GN00206.095B .I .c. An individual w h o f i l e d ana p p l i c a t i o nf

o r b o thm o n th l y b e n e f

i t s an d H I m ay:
! Wi th d

r a w th e c la im f or monthly

benef its without jeopar dizi ng HI entitlement; or
! W i t h dr aw t h e c l a i mf o r b o thm o n th l y

b e n e f i t s an d H I. Th e ind ivi du a l ma

y no t e le c t to wi thd

ra w o nly the HI c la im. POMS GN 00206.020, W ithdrawal Considerations W

hen Hospital Insuranceis Involve d B. POLICY The c laimant can w ithdraw a n application for :
! R S I [ R e t i r e m e n to r S ur v i v o r s In s ur an c e , i
. e . , S o c i a l S e c ur i ty] c a s hb e n e f

i t s o n l y;
! RSI cash be nefits and HI insurance cover ag e . . ., or
! Me dic are [Par

t B ] onl y Howeve r, a claimant who is entitled to monthly RSI benef its cannot withdraw H I[Medicare , Part A] covera g e only since e ntitlement to HI [Medicare , Part A] is based on entitlement to montly RSIbenef

its. .The for eg oing policie s may be found on the web at 3 htt ps :// se c ur e .s sa .g ov/a

pp s1 0/p oms .n st/ lnx02 00 20 60 20 op e n d oc ume nt.

-8- . . 3 IV . A NA LY SIS Mr. Hall seeks a

n order to enjoin Defe ndants Charles E. Johnson, Acting Sec reta ry of HHS, and Micha el J . As t ru e, SSA C ommissi oner, f rom enfor cingthe POMS by “enr olling Pla int if f, B RI ANHA L L , in

Me dic are , Pa

rt A, ” and fr om d e nying him Soc ia l Sec ur ity be ne fi ts whil e t h i s ca s e i s l itigate d. Pl.’s Mem. at 47. I t is passing stra ng e that SSA insist s that all persons
re c e ivi ngSoc ia l Se c ur ity

re tir e me nt b e ne fi ts, a

fe de ra l pr og ra

m th a t is r

unnin g out of

mon e y , a lso
mu s t b e p art of Me dicar e, Part A, a nother fe dera l prog ram that ove rruns budg ets. Howe ver, that conundrum is for a

nother da y when this ca se g ets to the merits of the Plaintiffs ’ complaint. The iss ue no w i s much m or e na rr ow : sh ou ld t

he Cou rt e njo in D e fe nd ants fr om e nr oll ingMr . H a ll i n Medica re Par t A and deny

ing him Social Secur ity

benef its because he is not so enrolled? The question rests on a false pre mise. Defe ndants do not, and did not, “enr oll” Mr. Hall in Medica

re Par t A. Rather, he applied for all i n s uranc e bene fits for which he was e ntitled under the Social Security

Act and, upon rea ching ag e 65, bec ame a utomatically

entitled to Medicar e Part A b e ne fi ts w ith out any

a c tio n b y De fe nd a nts . 4 2 U .S. C. § 42 6( a ) s tate s, in r e le va nt p art : Every individual who – (1) has attaine d ag e 65, and (2 )( A) is e nti tle d to monthl y ins ur anc e be ne fi ts [ i.e. , monthly Social Security

benef it s ] u n der se ction 202, would be entitled to those bene fits except that he has not filed a n application ther efor (or a pplication has not be en made for a benef it the entitlement to which for a ny individual is a condition of entitlement there for) , or would be e ntitled to such benefits but for the fa ilure of ano the r ind ivi du a l, wh o mee ts al l th e c ri te ri a of e nti tle me nt t o mo nth ly

ins ur anc e be ne fi ts, t o m e e ts u c hc r i t e r i a

t h r o u g h o u ta

m o n th , an d i n c o n f

o r m i ty w i thr e g u l a t i o n s o f

th e S e c r e t ar

y, files an a pplication for hospital insuranc e bene fits under [Medicar e, Part A]. . .

. . .-9-

shall be entitled to hospital benef its under [Medicare , Part A]. Section 426(a) never uses the wor d “enr olled,” or a

ny variation thereof. The statutory provisions r elating to Me dicar e, Part B ( insurance for phy sician’s a

nd other service s), which do predic ate be nefits on voluntary “enr ollment,” clar ify the distinction betwe en “entitlement” and “enr ollment” in the statutory scheme
. See42 U.S.C. §§ 1395i-2, 1395o. 42 U.S.C. § 1395o, which addre sses Medica re Part B, state s that “[e]very individual who . . . is entitled to hospital insurance benef its unde r [Medicare , Part A] is elig ible to enroll in the ins ur anc e pr og ra

m e sta bli sh e d b y

thi s p art .” Thus , on ly up on “ e nr oll me nt” do e lig ibl e ind ivi du a ls become entitled to Me dicar e, Part B benef its. Entitlement to Medic are , Part A, on the other hand, is a status that Mr. Hall ac hieved a utomatically

upon attaining ag e 65. No “ enr o l l m ent” or other action wa s or is require d to confe r entitlement upon Mr. Ha ll. A tempo ra ry re straining order presuppose s that an ac tion has occur red or will occur that must be immediately enjoined to pre vent irrepa rable harm to the moving party . There is no action for the Cou rt t o en j o i n here ; hence , the Court has no authority

to issue a tempora

ry restra ining or der.

Date : Jan ua ry 28 , 2 00 9 /s/ ROSEMARY M. COL L YER Un i t edS t at es Di s tri ct J u d ge