The HonorableLoui s F. Oberdorfer, District Judge, United State s District C ourtfor * the District of C olu mbia , who was ori ginallya member of the panel , recused himself after oral argument and had no roleinthe preparationof this deci sion . Bec ausethe re maining members of the P anel are in agreement, we decide this case in accordance with Secon d C ircuit Interim Loc al Rule§ 0 .1 4 (b). 06-4 921 -cv Estate of Lan ders v. Leavitt 1 UN I TED STATES COU RT OF APPEA LS 2 F O R T H E S E C O N D C IR C U IT 3 4 A ugustTer m 2007 5 6 7 (A r gued: M ay 7, 2008 D ec i ded: O c t obe r1, 2008 8 R evi se d: January15, 2009) 9 10 D ocket N o. 06-4921-c v 11 12

_____________________________________ 13 14 E S T A T E O F M A R IO N LA N D E R S , as r epresented byi t s executor , 15 RI CHARD LA NDERS, M ARI ON A. DI XON, a n dM URI EL GRI GLEY , 16 o n b e hal f o f t he m s e lve s a nd a l lo t he r s s i m i l ar l y s i t uat e d, 17 P laint if f s-A pp el lan t s- C ross -A

pp el lees , 18 19 -v .- 20 21 M I CH AEL O. LEAVI TT, 22 S ecret ary of t h e D epa rt m en tof

H eal t h an d H u m an Servi ces, 23 D ef e ndant -Appe l le e - Cro s s -Appe l lant . 24

_____________________________________ 25 26 B e fo r e : H A L L a n dL IV IN G S T O N , C i rcui tJu dges . * 27 28 M edic ar e part i c i pant s br oughtthi s put at ive c l as s ac ti on ch a l l en gin g de ni al 29 of

coverage f

or post - h ospi t al i zati on care i n ski l l ed nu rsi n g faci l i t i es. T h e U n i t ed 30 S t ates D i st ri ctC ou rtforthe D i st ri ctof C on n ect i cut (Jan etC . H al l , J. ) , cer t i f i ed2

1 th e class, 2 3 2 F . R . D . 42 , an dthe n gra n ted su m m a ryju d gm en t to th e d efen d a n t, 2 200 6 W L 256 029 7, hol di n g t h at t h e pl ai n t i f fs w ere not en t i t l ed to M edi care 3 c o ve r ag e b e c aus e t he durati o ns o f t he i rho s pi t al i z at i o n di d no tm e e tt he 4 s t at ut o r y qua l i f yi ng s t ayr e qui r e m e nt . W e ho l d t hatt he i nt e r pr e t at i o n o f t he 5 q u a lify in gs ta yre q u ir e m e n t s e t fo r th in th e g o v e r n m e n t’s M e d ic a r e B e n e fit 6 P ol i cy M an u alis n oten t i t l ed t o deference un der Chev r o n U. S. A. I nc . v . Nat ur al 7 R esource s D ef

ense Cou n ci l, I

n c. , 4 67 U . S. 8 37 ( 19 84), b u t w e ne ve r t he l e s s f i nd 8 th e g ov ern m en t’ s i n terp reta ti on of th e sta tu te p ersu a sive a n dad op t i t. 9 Af

f i r m e d. 10 G I LL D EF O RD , W i l l i m ant i c , Conn. (Jud i t h A. St e i n, Br adS. 11 P l eb a n i , W ey -W eyK w ok , W i l l i m a n ti c, C on n . , S a l l y H a rt, 12 T u c s o n , A r iz ., T o b yE d e lm a n , W a s h in g to n , D .C ., on t h e bri ef ), 13 C e n te rfo rM e d ic a r e A d v o c a c y , f or Plai n t if

f s-A pp el lan t s- C ross 14 A pp el lees . 15 16 LE W I S S. YE LI N , At t o r ne y, Appe l l at e St af f, Ci vi lD ivi s i o n, 17 U. S . De p a r t m e n to f J u s t i c e , W a s h i n g t o n , D . C. ( S c o t tR. 18 M cI n t o sh , A t t orney, A pp el l ate Staf f, P et er D . K ei sl er, 19 Ass i s t antAt t o r ne y G e ne r al , Ci vi lD ivi s i o n, U . S. D e pa r t m e nt 20 of Ju st i ce, W ash i n gton, D . C . , K evi n J. O ’ C on n or, U n it ed 21 S ta te s A tt o r n e yfo rt h e D is tr ic t o f C o n n e c tic u t, on t h e bri ef ), 22 f or D efe n d a n t-A

pp ellee -C ro ss -A

pp ella n t. 23 24 C a r o l C . L o e p e r e (E liz a b e t h A . R a n s o m , on t h e bri ef ) , R eed 25 S m ith L L P , W a s h in g to n , D .C ., f or Am i c iCur i ae Am er i c an 26 Heal t h Care A ssoc i ati on , A l l i a n c e f o r Q u a l i ty Nu rs i ngHo me 27 Care , Am e r i c an A ssoc i at i o n of Ho m e s andSe r v i c e s f o rt he 28 Agi ng , Nati on al A ssocia ti on of Prof ess i on al G eri atr i c Care 29 Man ag ers , Cathol i c Heal t h A ssoc i a t i on of t h e Un i t ed S t ate s , 30 Nati on al A ssoc i ati on f or t h e Supp ortof

L ong T erm Care , and 31 Nati on al A ssoc i ati on of Heal t h Care A ssi st an ces i n S u pp ortof3

1 P laint if f s-A pp el lan t s- C ross -A

pp el lees . 2 3 S t u artR . C oh en , AA R P F ou n da t i on L i t i gati on ( B ruce 4 V i gn ery, Stacy C an an , AA R P F ou n da t i on L i t i gati on , M i cha el 5 S c h u s te r , AA R P , on t h e bri ef ), W a s h in g t o n , D C , f or A m i ci 6 Curi ae AARP , Al l i anc ef o rRet i r e d Am e r i c ans , Ca lifo r n ia 7 A d vocat es f or Nu rs ing Hom e R ef orm , G r e at e rBos t o n Lega l 8 S ervi ces , L ong- T erm Care Com m u n i ty Co a lit i on , Me di c i ne 9 R igh t s Cente r , Mi c higa n Campaign f o r Q ual i ty C are , 10 NC CNHR , an dNati on al S eniorC i t izens La w Cente r in 11 S u pp ortof P laint if

f s-A pp el lan t s- C ross -A

pp el lees . 12 13 L IV IN G S T O N , C i r c ui tJudge : 14 In t h i s c ase — a di spu t e abou thow t o coun t t o th re e — t h e pl ai n t i f fs15 ap pel l an t s are M edi care benefi ci ari es w h o app ealf rom a gran tof

sum m a ry 16 j udg m e nto f

t he U ni t e d St at e s D i s t r i c tCour tf o rt he D i s t r i c to f

Con n ect i cut 17 ( H a l l , J . ) . Eac h o f t he m s p e nt a t l e a s t t hr e e d a y s i n t he ho s p i t a l b utw as 18 di scharged l ess t h an t h ree days af t er hav i n g been f

orm al l y ad m i t t ed, an d each 19 soug h tcoverage u n der P artAof t h e M edi care program f or a post - h ospi t al i zati on 20 n u rsi n g h o m e stay. A f t er t h ei r c l ai m s f

or c overage w ere i n i t i al l y den i ed, t h ey 21 brou gh tt h i s l aw sui tchal l en gi n g t h e den i al . Th e di s t ri c tcourtgran t ed su m m ary 22 j u d gm en t f

or th e g ov ern m en t, h o ld i n g th a t t h e p l a i n ti ffs w ere n ot en ti tl ed to 23 M edi care r ei m bu rsem en tbecau se t h ey h ad not sp e n tt h e requi si t e am ou n tof 24 t i me a s h o s p i t a li n p a t i e n t s . We a g r e e a n dt h e r e f o r e a f f i r m. 25 26 BA CK GRO UND4

1 “M e di c ar e i s t he fe de r alg o ve r nm e nt ’ s he al t h- i n sur anc e pr o gr am f o rt he 2 elde rl y.” Co n n . D ep ’ t of S o c. S er v s. v. L ea v itt , 4 2 8 F .3d 1 3 8 , 1 4 1 (2 d C ir. 2 0 0 5 ). 3 Itcontain s fou r di st i n ctprogram s, t h e f i rstof w h i ch, kn ow n as “ P artA , ” i s a 4 h o s p ita l in s u r a n c e p r o g r a m . S ee42 U . S . C . §§ 1395 c t o 1 395 i - 5. P artA“ provi des 5 b a sic p rotection ag a i n st th e costs of h osp i tal, related p ost-h osp i tal, h om e h ea l th 6 servi ces, an d hospi ce care” f or, am on g ot h ers, el i gibl e peop l e over 65 years of age. 7 I d. § 1 3 9 5 c ; seealso i d. § 4 2 6 (e sta b li sh in gth e e n titlem e n t t o P a rt Ab e n e fits). 8 “ U nde rPar tA, s e r vi c e pr o vi de r s s uc h as h ospi t al s a r e pa i d t he l e s s e ro f t he 9 ‘ r e as o nab l e c o s t ’o f c o ve r e d s e r vi c e s pr o vi de d t o pr o gr am ben ef i c i ar i e s o r‘ t he 10 c ust om ar y c harge s w i t h r es pec t t o suc h se r vi c es , ’ and agr ee n ot to c harge 11 b en efi ci a ri es for th ese serv i ces.” Y a le-New Ha v en Ho sp . v . L ea v itt , 470 F. 3d 71, 12 7 3 (2 dC ir . 2 0 0 6 ) (c ita t i o n s o m i tt e d ) (q u o tin g4 2 U .S .C . § 1 3 9 5 f(b )(1 )); seealso 13 Kraem er v. Heckler , 7 3 7 F .2 d 2 1 4 , 2 1 5 -1 6 (2 dC ir . 1 9 8 4 ) (d e s c r ib in gth e b a s ic 14 ca te g o rie s o f se rv ice s c o v e re db yP a rt A). 15 T h e enti t l em en t s un der P artAi n cl u de an ext en ded care ben ef i t , w h i ch 16 pro vi des c ove r age f or“ pos t - hos pi t alex t en d ed c ar e s ervi c es f orup t o 1 00 days 17 d u r in ga n ys p e ll o f illn e s s .” 4 2 U .S .C . § 1 3 9 5 d (a )(2 ). P a r t Ad o e s n o t c o v e ra ll 18 ex ten d ed care serv i ces th a t f oll ow h osp i tal st a ys , h ow ev er. R a th er, P a rt A 19 r e qui r e s t hatt he ho s pi t als t ayb e a “ qua l i f yi ng” ho s pi t al s t ay be f o r e i tc o ve r s t he 20 sub s e q ue nte x t e nd e dc a r e . S p e c i f i c a l l y , t he s t a t ut e d e f i ne s “ p o s t - ho s pi t al5

1 ext ended c ar e s ervi c es ” t o m ean “ ext ended c ar e s ervi c es f urni she d an i ndi vi dual 2 af t e rt r ans fe rf

r o m a ho s pi t ali n whi c h he w as a n i npa t i e ntf o rno tl e s s t han 3 3 consecutive da ys bef ore hi s di scharge f

rom t h e hosp i t al i n conn ect i on w i t h such 4 tran sfer. ” I

d. § 1395x(i) . I n t urn, i tdef i nes “ ext ended ca re serv i c es ” t o m ean 5 “serv i ces fu rn i sh ed to an i n p a ti en t of a sk i l l ed n u rsingfa ci l i ty. ” I d. § 1 3 9 5 x (h ). 6 Th es e s ervi c es i ncl ude nurs i ng c ar e, be d and boar d, physi c aland oc c upat i onal 7 th e r a p y , a n dd r u g s . I d. I f post - h ospi t alext en ded care servi ces are n otcovered 8 b yP a r tA , t h e ys t i l lma yb e c o v e r e db yP a r tB . P a r tB i s a v o l u n t a r yp r o g r a m, 9 h o w e v e r , a n du n lik e P a r t Ab e n e fic ia r ie s , P a r t B e n r o lle e s m u s t p a ya m o n th ly 10 p r e m iu m . Ma tth ew s v . L ea v itt , 4 5 2 F .3 d1 4 5 , 1 4 6 n .1 (2 dC ir . 2 0 0 6 ); Co n n . D e p ’t 11 of

S oc. S ervs . , 4 2 8 F .3 da t 1 4 1 n .2 ; Fu rlo ngv. S h a la la , 238 F . 3d 227 , 229 ( 2d C i r. 12 2 0 0 1 ). 13 M a r io n L a n d e r s , M a r io n D ix o n , a n dM u r ie l G r ig le y , th e fir s t o f w h o m is 14 n ow deceased an d i s represented h ere byher est ate, w ere M edi care benefi ci ari es 15 w ho e ac h r e c e ive d i npa t i e ntho s pi t alc ar e f o l l o w e d b y c ar e ata s ki l l e d nu r s i ng 16 fa c ility , o r“S N F ” — e s s e n tia lly , an u r s in gh o m e . S ee42 U . S. C . § 1395i - 3( a) 17 ( defi n i n g S N F ) . E ach of t h em spen tt h ree c on secutive da ys i n t h e h ospi t albef ore 18 m ovi n g t o t h e SN F . Y ett h e C en t ers for M e d ic are an d M edi cai d S ervi ces 19 ( “ CM S” ) — t he fe de r ala ge nc y s i t uat e d wi t hi n t he D epa rt m ento f H e al t h a nd 20 H u m an Servi ces (“H H S ”) tha tadm i n i st ers t h e M edi care program on beh al f ofI n 197 7, HHS — thencalle d the Department of Health, Education, and We lfar e — 1 es tab li sh edth e HealthC areFin ancin gAdminis tr ation(the “HC FA ”) , seeReorgani zation O r d er , 4 2 Fed. Reg . 13 ,262(Mar. 9, 1 977), an d vested in it the Secretary’s full rul emakin g powers un der the Me dicare sta tute s, seeStatement of Organiz ation, Function s, an d Delegations of Authority , 49Fed. Reg . 35 ,247 , 35 ,248(Sept . 6, 198 4). The HC FA was rena med the C entersf

orMedic arean d Me dicaidServic esin20 0 1 . SeeC enters for Medicare &Medicaid Services; State ment of Organi zation , Function s an d Delegations of Authority ; Reorgani zation Order , 6 6Fed . Reg . 3 5 ,4 3 7(July5 , 2 0 0 1 ). 6 1 th e S e c r e ta r yo f H H S — d e n ie dt h e ircla im s fo rco v e r a g e w ith re s p e c t t o th e ir 1 2 post- h ospi t al i zati on S N F stays. C M S di d so i n accor da n ce w i t h i t s ow n rul es f or 3 determ i ni ng w he t he ra pa t i e nti s e l i gibl e f o rpo s t - ho s pi t alSN F c o ve r age. 4 A c c o r d in gto o n e s u c h ru le , k n o w n a s th e “t h r e e -m id n ig h t r u le ,” a p a tie n t is 5 el i gibl e f

or SN F coverage onl y i f he or she ha s been “hospit al i zed . . . f or 6 m edi cally n ecess ary i n p a tien t h o sp ita l or in p a tien t [critica l ac ce ss h o sp ita l] care, 7 f oratl eas t3 c ons ec ut ive c al endardays , n otcount i ng t he date of di sc harge . ” 42 8 C . F. R . § 409. 30( a) ( 1) . An d ac c or di ng t o a not herr ul e, “ a pat i enti s c ons i der ed an 9 i n pa t i en ti f

[h e or she i s] for m a ll y ad m i t t ed as [ an ] i n pa t i en t . ” C t rs. f or 10 M e d i c a r e & M e d i c a i dS e r v s ., P u b l ’n N o . 1 0 0 -0 2 , M e d i c a reBe nef

i tPo l i cy Manua l , 11 ch. 1, § 10 ( 45th rev. 200 6) [h erei n af t er Me di c ar eBe nef

i tPo l i cy Manua l], 12 ava i la b le a t h t t p: //w w w . c m s . hhs . go v/M anua l s /I O M /li s t . as p. La nde r s , D ixo n, a nd 13 G r ig le ya ll s p e n t th r e e — b u t o n lyth r e e — co n s e c u tiv e m id n ig h ts in h o s p ita ls 14 an d then m oved t o n u rsi n g h om es, w h ere t h ey received extend ed c are servi ces. 15 Butw hi l e i n t he hos pi t al , e ac h o f t he m s pe nta tl e as to ne m i dni ghte i t he ri n t he 16 em ergenc y r o o m o ro n o bs e r va t i o n s t at us b e f o r e b e i ng f

o r m al l y ad m i t t e d.7

1 A c c or di ngly, C M S d eterm i n ed tha t, be ca u se th eyh a dn ot sp en tthre e c ons ec ut ive 2 m i dn i gh t s hospi t al i zed aft er hav i n g been f orm ally ad m it t ed, P artAdi d n otcover 3 t h ei r SN F st ays. 4 Lande r s , D i xo n, a nd Gr i gl e y c hal l e n ged CM S’ s i nt e r pr e t at i o n o f t he 5 q u a l i fyi n g h osp i tal st a y re q u i rem en t i n a p u tative cl a ss a cti on . T h eysou gh t a 6 perm an en ti nj u n ct i on an d a w ri t of m an da m u s prohibi t i n g t h e Secret ary f rom 7 exc l udi ng M edi c ar e b enef i c i ar i es ’t i m e i n t he e m er genc y r oo m and on o bs erva8 t i on st atus f

rom cou n t i n g t ow ard t h e q u al i f yi n g st ay requ i rem en t . T h e di st ri ct 9 court gran t e d cl ass c ert i f i cat i on , L a n d er s v . L ea v itt(L an d ersI ) , 232 F. R . D . 42 10 ( D . C on n . 200 5) , an d on cr oss- m ot i on s f or sum m ary j u dg m en t , rul ed i n favor of 11 th e S e c r e ta r y , L a n d er s v. L ea v itt(L a n d ers II ) , N o. 3: 04- c v- 1988 (JC H ) , 2006 W L 12 2 5 6 0 2 9 7 (D . C o n n . S e p t. 1 , 2 0 0 6 ). T h e p la in tiffs n o w a p p e a l. 13 14 DI S CU S S I ON 15 T h e p l a i n ti ffs ch a l l en ge the distri ct cou rt’ s ru l i n g on th ree gro u n d s. F i rst, 16 th eyarg u e th a t t h e M ed i ca re sta tu te e n ti tl es th em to cov era ge f or th eir po st17 h ospi t al i zati on SN F st ays. Secon d, t h ey contend th a t C M S ’ s i n t erpret ati on of 18 t h e s t a t u t e v i o l a t e s t h e e q u a lp r o t e c t i o n g u a r a n t e e o f t h e U. S . Co n s t i t u t i o n. 19 T h ir d , th e ya r g u e th a t th e d is tr ic t co u r t er r e d b y b a s in g its d e c is io n e x c lu s iv e ly 20 o n t he a dm i ni s t r at ive r e c o r d.8

1 I. 2 T h e Me d i c a r e s t a t u t e p r o v i d e s c o v e r a g e f o ra p o s t - h o s p i t a l i z a t i o n S NF 3 s t ayf

o ra be ne f

i c i ar y w ho r e c e ive s e xt e nde d c ar e s e r vi c e s i n a n SN F af t e rha vi ng 4 b e e n “ a n i n p a t i e n tf o rn o tl e s s t h a n 3 c o n s e c u t iv e d a y s ” i n a h o s p i t a l . 4 2 U. S . C. 5 § 1 3 9 5 x (i). N e ith e rt h e s ta tu te n o ra n ya p p lic a b le re g u la tio n d e fin e s “in p a tie n t.” 6 C M S ’ s p o l i c y m a n u a l d e fin e s a n in p a tie n t a s a p e r s o n w h o h a s b e e n fo r m a lly 7 ad m i t t ed to a h ospi t al . Th e governm en turges us to credi tt h e i n t erpret ati on of 8 t h e st atute t h at i tha s s etfor t h in t h e pol i cy m an u al . W e onl y consi der w h et h er 9 w e shou l d d efer t o t h e agen cy’ s i n t erpret ati on of t h e st atute, how ever, up on 10 fin d in gth e s ta tu te a m b ig u o u s . G e n. Dy nam i c s Land Sys . v . Cl i ne , 540 U . S. 581, 11 600 ( 200 4) ( “ [ D ] eference t o [ an agen cy’ s] st atutor y in te rpret ati on i s c al l ed f or 12 o n lyw h e n th e d e v ic e s o f ju d ic ia l c o n s tr u c tio n h a v e b e e n t r ie da n dfo u n dt o y ie ld 13 no c l ears ens e o f c ongr es si onali nt ent . ” (c i t i ng INSv. Card oza- F on sec a , 4 80 U . S. 14 4 2 1 , 4 4 6 (1 9 8 7 ))); Kruse v. W el ls Fa rgo Hom e M

ortg. , I n c. , 383 F . 3 d 49 , 55 ( 2d 15 C i r. 200 4) ( “ If

the provi si on s of

the st atute are u n cl ear or am bi gu ou s . . . w e m u st 16 dec i de w het hert o de fert o [t he age ncy’ s] readi ng of them . . . . If

w e de c i de t hat 17 w e a r e to d e fe r , w e m u s t t h e n d e c id e th e a p p r o p r ia te le v e l o f d e fe r e n c e .” ) . W e 18 h ave l i t t l e di f

f i cul t y f i n di n g am bi gu i t y h ere. Th e st atute provi des n o def i n i t i on 19 of

“ i n pa t i en t , ” an d both the p la in tiffs and t h e agen cy can ci t e t o di ct i on ary 20 d e fin itio n s s u p p o r tin gth e irco m p e tin gd e fin itio n s . S eeW ebster ’ s Th i rd N ew9

1 I nt e r na t i o n a l Di c t i o n a r y 1 1 6 7 ( 1 9 7 6 ) ( d e f i n i n g “ i n p a t i e n t” a s “ a p a t i e n t i n a 2 h o sp ita l or in firm a ryw h o re ce ive s lo d g in ga n dfoo da s w e lla s tr e a t m e n t ”); 3 A m erican H er i t age D i c t i onar y o f t he E ngl i sh Language 932 ( 3d ed. 1992) 4 ( defi n i n g “ i n pa t i en t” as “ [ a] pati en tw h o i s adm i t t ed to a h o sp it alor cl i n i c f or 5 tr e a tm e n t t h a t r e q u ir e s a t le a s t o n e o v e r n ig h t s ta y”); seealso O xf ord E n gl i sh 6 D i c t i o nar y ( 2de d. 1 98 9) ( de f i ni ng “ i npa t i e nt” a s “ a pa t i en tw ho r e m ai ns i n a 7 h ospi t alw h i l e un der m edi calt reat m en t” ) . T h eref ore, w e agree w i t h t h e agen cy 8 th a t t h e s ta tu te is a m b ig u o u s a s to w h e th e rp r e -a d m is s io n tim e s p e n t in 9 o b serv a ti on an di n the em erg en cyroom sh ou l dbe con sider ed “i n p a ti en t” tim e 10 upo n t he pa t i e nt ’ s l at e ra dm i s s i o n. 11 T he ne xt que s t i o n f o r us i s w he t he r t he ag e nc y’ s i nt e r pr e t at i on of 12 “ i n pa t i en t” i s of t h e t yp e t h at i s el i gibl e f or deference un der C h evron U. S . A . I n c. 13 v. Natural R esource s D ef ense Cou n ci l, I

n c. , 4 6 7 U. S . 8 3 7 ( 1 9 8 4 ) . I f i ti s , t h e n we 14 pro c ee d w i t h a C h evron a n a l ys i s. McNam ee v. D ep’ tof t h e Treasu ry , 488 F. 3d 15 1 0 0 , 1 0 5 (2 dC ir . 2 0 0 7 ); L evi n e v. A pk er , 4 5 5 F . 3 d 7 1 , 8 0 (2d C i r. 2 0 0 6 ). If n ot, 16 t h e n w e c o n s t r u e th e s t a t u t e in th e fi r s tin s t a n c e , g iv in ge ffe c tto C M S ’s 17 no nl e gi s l at ive i nt e r pr e t at i o n t o t he e xt e ntw e f i nd i tpe r s uas ive i n a c c ordan ce 18 wi t h S k id m o re v. S w if t& Co. , 323 U . S . 134 ( 194 4) . W e revi ew de n ovo t h ese 19 qu est i on s of l aw t h at t h e di st ri ctcourtadd ress ed on cr oss- m ot i on s f or s u m m ary 20 ju d g m e n t. Krau ss v. Oxf ord Heal t h P lan s, I

n c. , 517 F . 3d 614 , 6 21-22 ( 2d C i r.10

1 2 0 0 8 ); Pr o t . & A d vo c acy f o rPe rs o ns w i t h Di s ab i l i t i e s v . Me nt alHe al t h & 2 A d d i ct i on S ervs . , 4 4 8 F .3 d1 1 9 , 1 2 3 (2 dC ir . 2 0 0 6 ); B u t t s v. B arn h art , 388 F. 3d 3 3 7 7 , 3 8 4 (2 dC ir . 2 0 0 4 ), am end ed on re h ’ g i n pa rt , 4 1 6 F .3d 1 0 1 (2d C ir. 2 0 0 5 ). 4 A. 5 “ [A ] n ‘ ad m i n i st rat ive i m pl em en t ati on of a . . . st atutor y provi si on qu al i f i es 6 f or C h evron de fe r e nc e w he n i ta ppe ar s t hatCong r e s s de l e ga t e d a ut ho r i t y t o t he 7 agen cy generally t o m ak e rul es c arryi n g t h e f orce of l aw , an d that t h e agen cy 8 i nt er pre t at i on c l ai m i ng def er enc e w as pr om ul gat ed i n t h e e xer c i se of t hat 9 a u th ority. ’” R ot i m iv. G on zales , 4 7 3 F . 3 d5 5 , 5 7 ( 2 dC i r . 2 0 0 7 ) (p e rc u r i a m) 10 ( quot i ng Uni t e d St at e s v . Me ad Co r p. , 533 U . S . 218 , 2 2 6 -2 7 ( 200 1) ) . Th e f i rst 11 hal f

o f t hi s t e s ti s c l e ar l y s at i s f i e d: Cong r e s s ha s de l e ga t e d g e ne r alr ul e m ak i ng 12 aut hor i t y w i t h re spe c tt o M edi c a re to th e S ec r et ar y o f H H S, w ho i n t urn has 13 d e le g a te dth a t a u th o r ityto C M S . See , e . g. , 4 2 U . S. C. § 1 39 5f f( a) ( 1) ( “ The 14 S ecre tarysh a l lpr om u l ga te reg u l a ti on s an dm a k e initi a lde term i n a ti on s w i th 15 resp ect to be n efi ts u n d er p a rt A or pa rt B of th i s su b ch a p ter i n acco rd a n ce w i th 16 th o s e r e g u la tio n s . . . .”); i d. § 1395 h h ( a) ( 1) ( “ T h e Secret ary sha l lprescr ibe such 17 regulat i on s as m ay be n ecess ary t o carry ou t t h e adm i n i st rat i on of t h e i n suran ce 18 p r o g r a m s u n d e r t h is s u b c h a p te r .”); seealso Shalala v . G ue r ns ey Me m ’lHo s p. , 19 514 U . S . 87, 96 ( 199 5) (recogni zi n g “ t h e M edi care st atute’ s broad delegat i on of 20 a u th o r ity ”); New Y ork ex rel . S t ei n v. S ec’ y of Heal t h & H u m an S ervs . , 924 F. 2d11

1 431 , 433 ( 2d C i r. 199 1) ( “ R esol u t i on of M edi care rei m bu rsem en ti ssues requi res 2 an un derst an di n g of com p li ca te da n dtec h n ica l fa cts , a n dC o n g re ss h as del egated 3 t he s e dif

f i c ul tde c i s i o ns t o t he a ge nc y t hatha s s peci al i z e d k no w l e dg e i n t he 4 a r e a . ” ) . T h u s , we mo v e t o t h e s e c o n dh a l f o f t h e t e s ta n dc o n s i d e rwh e t h e rCM S 5 has pr om ul gat ed i t s i nt er pre t at i on i n t he e xer c i se of i t s aut hor i t y. 6 M ostagen cy i n t erpret ati on s t h at have qu al i f i ed f or C h evron deference are 7 r ul e s t hatha ve b e e n pr o m ul ga t e d i n “ r e gul at i o ns i s s ue d t hr o ugh no t i c e a nd 8 c o m m e nto ra dj udi c at i o n, o ri n a no t he rf o r m ata ut ho r i z e d b y Cong r e s s f o ruse 9 i n issu i n g ‘ l eg i slative ’ru l es.” C m ty. Heal t h C t r. v. Wi lson-Coker , 311 F. 3d 132, 10 1 3 8 (2 dC ir . 2 0 0 2 ) (c ita tio n s o m itt e d ); seealso Me ad , 5 33 U . S. a t2 30 ( “ [ T] he 11 ove r w hel m i ng num berof ourc as es appl yi ng C h evron d eference ha ve revi ew ed 12 t he f

r ui t s o f no t i c e - and - c o m m e ntr ul e m ak i ng o rf o r m ala dj udi c at i o n. ” ) . The 13 po l i c y m anua lpr o vi s i o n a t i s s ue he r e , o f c o ur s e , i s no tt he pr o duc to f no t i c e - and 14 c o m m e n t r u le m a k in go rfo r m a l a dju d ic a tio n . N e v e r t h e le s s , le s s fo r m a l, 15 n on l egi sl ativ e inter pretat i on s are n otf or t h at r eason al on e di squ al i f i ed f rom 16 r ec eivi ng C h evron d e fe r e n c e . S ee B arn h artv. W alt on , 535 U . S. 212, 221- 22 17 (2 0 0 2 ); Me ad , 5 3 3 U .S . a t 2 3 0 -3 1 ; C m ty. Heal t h C t r. , 3 1 1 F .3 d a t 1 3 8 ; seealso 18 G on zales v. O regon , 54 6 U . S . 24 3 , 25 8 -69 ( 2 0 0 6 ) (con sider i n g a t grea t l en gth 19 w h et h er an inter pretive rul e w as eli gibl e f or C h evron d e fe r e n c e b u t u ltim a te ly 20 a n sw e rin ginth e n e g a tiv e ).Arguing to the contrary , the governme nt pointsu sto the Ninth Circuit’s recent 2 decision in County of Los Ange les v. Leav itt , 521 F.3d 10 73 (9thCir. 200 8), which cited Chevron indis cu ssin ga definitionsetforthinCMS ’sMe dicareProviderRei mb urs em ent Manu al. Id. at 107 8. The NinthC ircuit has clearlystated, however, that Medicare p olicy manu als are interpretiverules and thereforedo not receive Chevrondef erence . See Errin

ger v. Thompson , 3 7 1 F .3 d 6 2 5 , 6 2 9 -3 3( 9 thC ir . 2 0 0 4); Cmt y. Hosp. v. Thompson , 323 F.3 d 782 , 78 8, 7 91 (9th C ir . 2 0 0 3); see a lso Omohundro v. Unit e d States , 30 0 F .3d 1 065 , 10 68 (9thC ir. 2 002) (per curi am) (“[A

]n a dm in is t r at ive a ge ncy’s interpretation of astatute cont ained in an informal rul emakin g must be accorded the level of defere nce set forthin Sk idmore. . . .”). More over, although the court in LosAngelescited Chevron , it appeared elsewhere in the opinion to treat the manu al provisionas an interpretiverule to b e considered in accordance with Sk idmore . LosAngeles , 5 2 1 F .3 d at 1 0 7 7n .5 ; id. at10 79 n.8. 12 1 A l t h ou gh non l egi sl ative rul es are n o tper se i n el i gibl e f or C h evron 2 def

er enc e a s a ge ner alm at t er , w e a r e a w ar e o f f ew , i f any, i nst ance s i n w hi c h an 3 ag e nc y m anua l , i n pa r t i c ul ar , ha s b e e n a c c o r de d C h evron d e fe r e n c e . I n d e e d , we 2 4 h a ve rem a rk ed tha t C h ris ten se n v . Ha rr is Co u n ty , 5 29 U . S. 5 76 ( 20 00 ) , “ m ad e 5 c l e art hat‘ i nt e r pr e t at i o ns c o nt ai ne d i n po l i c y s t at e m e nt s , a ge nc y m anua l s a nd 6 en forcem en t gu i d eli n es . . . do n ot w a rra n t C h evron st yl e def eren ce.’” De La 7 Mot a v. U. S . D ep’ tof E d u c. , 412 F. 3d 71, 79 ( 2d C i r . 2005) ( quot i ng C h ri st ensen , 8 529 U . S. a t5 87 ) . Al t ho ugh b o t h B arn h arta nd Me adr e c o g n i z e dt h a ts o me 9 sub setof

i n f orm ali n t erpret ati on s c an rec eive C h evron d e fe r e n c e , th e s o le 10 e x a m p le th a t b o th ca s e s cit e , Nat i o ns Bank v . Var i ab leAnnui ty Lif eI ns uran ce 11 Co. , 5 1 3 U .S . 2 5 1 (1 9 9 5 ), co n c e r n e da n a g e n c yo p in io n le tt e r , i d. at 255 , w h i ch 12 i s qua l i t ativel y di f ferent f rom an agen cy m an u al . N ei t h er B arn h artnor Me ad 13 cast s dou bt on pri or pronou n cem e n ts t h at agency m an u al s, as a cl ass, are 14 gen eral ly i ne li gibl e f or C h evron d e fe r e n c e . S ee Me ad , 5 33 U . S. a t2 34 ( de s c r ibi ng13

1 po l i c y s t at e m e nt s , ag e nc y m anua l s , a nd e nf o r c e m e ntg ui de l i ne s a s “be yo nd t he 2 C h evron p a le ”); G ue r ns ey Me m ’lHosp. , 5 1 4 U .S . a t9 9 (d e fi n it io n in H H S ’s 3 M edi c ar e Pr ovi derR ei m burs em entM anual“ i s a pr ot oty p i ca lex am pl e o f an 4 i nt e r pr e t ive rul e ” and t he r e f o r e “ do [ e s ] no tha ve t he f o r c e a nd e f

fe c to f l aw and 5 [is] n o t a cc o rd e dth a t w e igh t in th e a dju d ica to ryp ro ce ss ”); Pu b. C i t ize n, I nc. v. 6 U. S . D ep’

tof Heal t h & Hu m an S ervs . , 3 3 2 F .3d 6 5 4 , 6 6 0 (D .C . C ir. 2 0 0 3 ) (Me ad 7 and C h ri st ensen “ c i t e d ‘ ag e nc y m anua l s ’a s an ar c he t yp e o f t he ki nd o f do c um e nt 8 t h at i s not en t i t l ed to [ C h evron ] deference”) . W e t h eref ore decl i n e t o accor d 9 C h evron d e fe r e n c e to th e in te r p r e ta tio n o f “in p a tie n t” in C M S ’ s p o lic ym a n u a l. 10 B. 11 A n agen cy i n t erpret ati on t h at does not qu al i f y f or C h evron d e fe r e n c e is 12 sti l l en ti tl ed to “resp ect a ccord i n g t o it s p ersu a siven ess , ” Me ad , 533 U . S. at221, 13 as e vi de nc e d b y “ t he t ho r o ugh ne s s e vi de nti n [t he agen cy’ s] c o ns i de r at i o n, t he 14 vali di t y of

it s reason i n g, it s con si st en cy w i t h earl i er and l aterpronou n cem en t s, 15 a n dalltho se factors w h i ch give itpo w er to p ersu a d e,” i d. at 228 ( quot i ng 16 S ki d m ore , 32 3 U . S. at 14 0) . As w e c o nduc tt hi s i nqui r y, w e a r e m i ndf ulo f t he 17 S u prem e C ou rt ’ s r epea t ed su ggesti on t h at H H S i n t erpret ati on s, i n parti cul ar, 18 s h o u ldre c e iv e m o r e re s p e c t t h a n th e m in e -r u n o f a g e n c yin te r p r e ta tio n s . S ee, 19 e . g. , T

h o m a s J

effer so n Un iv. v. S h a la la , 5 1 2 U .S . 5 0 4 , 5 1 2 (1 9 9 4 ); Schw e i ke rv. 20 G ray Pan t h ers , 45 3 U . S . 34 , 43 & n . 1 4 ( 1 9 8 1 ). Ind ee d , w e h a ve ob serv ed tha t,14

1 in ca s e s s u c h a s th o s e in v o lv in gM e d ic a r e o rM e d ic a id , in w h ic h C M S , “a h ig h ly 2 exp ertagen cy[ , ] adm i n i st ers a l arge com pl ex regulat ory schem e i n cooperat i on 3 w i t h m an y ot h er i n st i t u tiona lact ors, t h e vari ou s possibl e st an da rds f or 4 d e fe r e n c e ” — n a m e ly , C h ev ron a nd S ki d m ore— “beg i n to con ve rg e.” C m ty. 5 Heal t h C t r. , 311 F. 3d at138. 6 1. 7 O u r ana l ysi s of t h e S ki d m orefac t or s i n t hi s c as e l eads u s t o co ncl ude t hat 8 C M S ’ s i n terp reta ti on i s en ti tl ed to a g rea t de a lof p ersu a sive w eigh t. F i rst, 9 C M S ’ s in te r p r e ta tio n is lo n g s ta n d in g . S ee N. Ha v en B d . of E d u c. v. B ell , 456 10 U . S. 5 12 , 5 22 n. 12 ( 19 82 ) ( “ I n c o ns t r ui ng a s t at ut e , t hi s Cour tno r m al l y ac c o r ds 11 gr e at de fe r e nc e t o t he i nt e r pr e t at i o n, pa r t i c ul ar l y w he n i t i s l o ngs t and i ng, o f t he 12 a ge n cych a rg ed w i th the statu te’ s ad m i n i stration .”). M ed i ca re ca m e into 13 e x is te n c e in 1 9 6 5 . S ee H ea l th In su ra n ce f or t h e A ge d A ct, P u b . L . N o. 8 9 -97 , ti t. 14 I, 79 S t at. 290 ( 196 5) . Anea rl y contem poran eou s H H S regul ati on est abli shed 15 a rul e t h at, li ke C M S ’ s cu rrent rul e, b egan cou n t i n g i n pa t i en tday s f or purp oses 16 o f

t he qual i f

yi ng s t ayr e qui r e m e nto n t he da y t he pa t i e ntw as f o r m al l y ad m i t t e d: 17 The3c o ns e c ut i v eday s asa ho s pi t al i npa t i e nt;def

i ne d. 18 The 3- c o ns e c ut ive - da y ho s pi t ali npa t i e n t r e quir e m e nt 19 i s a pe r i o d o f 3 c o ns e c ut ive c al e nda rda ys b e gi nni ng 20 w i t h t he c al e nda rda y o f a dm i s s i o n e ve n i f

l e s s t han a 21 24 - ho urda y, a nd e ndi ng w i t h t he da y be f o r e t he 22 c al e nda rda y o f di s c har ge . Thus , i n de t e r m i ni ng 23 w he t he rt he 3 - c o ns e c ut ive - da y r e qui r e m e nt i s m e t , t he 24 day o f a dm i s s i o n i s c o unt e d a s o ne da y; t he da y ofThis regulation , althou gh codified, was not subj ect to the Administrative Procedure 3 Act’ s notice- and- com me nt proce ssbecaus e M edicar e regulationswer e not subjectto 5 U.S. C. § 5 5 3 (b)’ s re quirem ents until 1 9 7 1 . Nat’ l Med. En te rs., I

nc. v. Sullivan , 95 7F. 2 d 66 4 , 67 0n .8 (9thC ir . 1 9 9 2); see a lsoPublic Participation in Rule Making , 36 Fed. Reg . 2532(Feb. 5, 1 971 ) ( s t at e m e ntof

th eS e cr et aryof

H e alth , E duc atio n , an dWelf ar eop tin gintoth ep ro c e dur es sp ecified by § 5 5 3). Eventhou ghnota dopt edp urs u ant torel ativelyf ormal proc edure s, how ever , the re gulationstill evidence s th e lon gst an din gn atureof the a gency’sview. 15 1 di s c har ge i s no tc o unt e d a s a da y; a nd e ac h i nt e r ve ni ng 2 day i s c ount ed as a s i ngl e day . 3 20 C. F. R . § 405. 120(c ) ( 1966) . CM S’ s i nt er pre t at i on t hus r ef l ec t s a pos i t i on t hat 3 4 H H S f

i rstadop t ed m ore t h an 40 yea rs ago. 5 S eco nd, C M S i s c ons i st enti n i t s i nt er pre t at i on, em pl oyi ng t he s am e 6 de f

i ni t i o n e l s e w he r e i n it s g ui da nc e m anua la nd e xp r e s s l y de c l i ni ng t o c o unt 7 t i m e o n obs ervat i on st at us or i n t he e m er genc y r oo m t ow ar d t he qual i f yi ng s t ay 8 r e q u ir e m e n t. S ee Me di c ar eBe nef i tPo l i cy Manua l , sup ra , ch . 8 , § 2 0 .1 . T h is 9 sect i on of

t h e pol i cy m a n u a lal so r eferences t h e 196 6 F ederalR egi st er 10 pub l i c at i o n i n w hi c h H H S pr o m ul ga t e d § 40 5. 12 0(c ) , w hi c h f ur t he r bo l s t e r s t he 11 c o nc l us i o n t hatCM S de s i r e s t o m ai nt ai n i t s c o ns i s t e nta nd l o ng- he l d p o s i t i o n. 12 T h e pl ai n t i f fs urge us to f

i n d the govern m en t ’ s posi t i on i n consi st en tbased 13 o n t he w ayi n whi c h CM S r e i m bur s e s b e ne f i c i ar i e s f

o rt he i rho s pi t als t ay s . The 14 p l a i n ti ffs in this case sou gh t M ed i ca re re i m b u rsem en t no t on l y for th eir po st15 h ospi t al i zati on SN F st ays, bu tal so f or t h e t i m e t h e y s p e n t in hosp i t al s bef ore 16 t h ei r SN F st ays. Th e sam e sec t i on of t h e M edi care s t atute t h at provi des 17 c ove r age f

orpost - hos pi t al i zat i on S N F st ays al so provi des c ove r age f orhos pi t al16

1 st ays , i n t he l at t erc as e f or“ i npat i enthos pi t als ervi c es . . . for u p to 150 days 2 du ri n g an y spel lof i l l n ess. ” 42 U . S . C . § 13 9 5 d (a )(1). Y ett h e pl ai n t i f fs w ere 3 r e i m bur s e d b o th f or t h e servi ces t h ey received af t er they w ere f

orm al l y ad m i t t ed 4 — i n t h e govern m en t ’ s vi ew , t h e on l y t i m e du ri n g w h i ch they w ere i n pa t i en t s — 5 and f

o r t he s e r vi c e s t he y r e c e ive d w hi l e i n t he e m e r ge nc y r o o m and on 6 obs ervat i on s t at us be f or e b ei ng f

or m al l y adm i t t ed. Th i s r ei m burs em entpol i c y, 7 t h e p l a i nt i f

fs c o n t e n d , ma k e s t h e g o v e r n me n t ’ s p o s i t i o n wi t h r e s p e c tt o S NF 8 r e i m bur s e m e ntunr e as o nab l e a nd inc o ns i s t e nt : if pr e - ad m i s s i on em ergency room 9 a n do b s e r v a tio n s ta tu s s e r v ic e s a r e “in p a tie n t h o s p ita l s e r v ic e s ,” w h ys h o u ld 10 t i m e spe nt i n t he em er genc y r oo m or on obs ervat i on st at us not cou n t as 11 “ i npat i ent” hos pi t alt i m e f ort he purpo se of

m ee t i ng t he qual i f yi ng s t ay 12 req u i rem en t? 13 The d i f

f i c ul t y wi t h t hi s a r g um e nt i s t ha t t he s t a t ut e m a nd a t e s — o r at 14 l e as t st r o ngly c o uns e l s i n fav o ro f m ak i ng — pr e c i s e l y t he di s t i nc t i o n t hatt he 15 govern m en th as d raw n . Pa rtA ’ s r ei m bu rsem en t s f or i n pa t i en thosp i t alservi ces 16 ar e de t e r m i ne d b y r e fe r e nc e t o t he s t at ut o r y t e r m “ o pe r at i ng c o s t s of i npa t i e nt 17 h osp i tal services.” A s th e sta tu te d efi n es th a t t erm , i t m ea n s op e r a tin g co sts 18 “w ith re s p e c t t o in p a tie n t h o s p ita l s e r v i c e s . . . , a n din clu d es th e c o sts of a ll 19 ser vi cesf

or w h i ch pa ym e n t m ay be m ad e un der t h i s s u bch ap t er t h at are 20 p r o v id e db yth e h o s p ita l . . . t o t h e pati ent d u ri ng t h e 3 days . . . im m ed ia tely17

1 prece d i ng t h e date of t h e pati ent’

s adm i ssi on i f su ch serv i ces a re . . . related to 2 t h e adm i ssi on . ” 42 U . S . C . § 1395 w w ( a) ( 4) ( em ph as e s add ed). Th u s, 3 § 1 395w w ( a) ( 4) di r ec t s C M S t o pr ovi de c ove r age f oran in p a ti en thos pi t als t ay 4 andup t o t hr e e day s of re l at e d i n- ho s pi t als e r vi c e s r e nde r e d b e f o r e t he pa t i e nt 5 w as adm i t t ed to t h e hosp i t al . T h e st atute does not, how ever, requi re oreven 6 sug gestt h at t h e pre- ad m i ssi on day s t h em selves be t reat ed as i n pa t i en tday s. 7 I nde e d, C M S ha s r e l i e d o n t hi s a s pe c to f t he s t at ut e t o e xp l ai n i t s pr e s e nt 8 p o s itio n . S eeM edi care Program ; P rospect ive P aym en tSy st em an d C on sol i da t ed 9 B i l l i ng f

orSki l l ed N urs i ng Faci l i t i es f orFY2006, 70 Fed . R eg. 29, 070, 29, 100 10 (M ay 19 , 200 5) [h erei n af t er 2005 P roposed R u l es] . A ccor di n gl y, regardl ess of 11 w h et h er w e t h i n k i tsen sib le as a poli cy m att er f or C M S t o rei m bu rse pre12 ad m i ssi on hosp i t alservi ces as i f t h ey w e re i n pa t i en tservi ces bu tnot c on si der 13 t h at t i m e t o be part of a pre- S N F i n pa t i en tst ay, t h e st atut oryr equi r em entt hat 14 pre- ad m i ssi on servi ces be rei m bu rsed l ead s us t o fi n d n o regul ator y i n consi s15 t e nc y i n C M S’ s dec i s i o n nott o co untpr e - ad m i s s i o n hos pi t alt i m e i n de t e r m i ni ng 16 w het hera pat i enthas had an SN F qual i f yi ng s t ay. 17 T h i rd , C M S h a s rece n tl y re con sider ed i ts po sit i on on the pu b l i c reco rd . In 18 2 0 0 5 , C M S “inv i te[d] co m m en ts o n w h eth er [i t] s h ou l dco n siderthe po ssibil i ty 19 o f

c o u n t i n g t h e t i me s p e n t i n o b s e r v a t i o n s t a t u s t o w a r d me e t i n g t h e S NF 20 b en efi t’ s q u a l i fyi n g 3 -da y h osp i tal st a y re q u i rem en t. ” I d. at 29 , 09 9. I n i nvi t i ng18

1 t hes e c om m ent s, C M S obs erved t hatt he t hre e- day s t ay r equi r em entw as 2 desi g n e d “t o t arget t h e SN F ben ef i tm ore ef

fect ivel y at t h e l i m i t ed segm en tof 3 t h e nu rsi n g h om e pop u l a tion t h at t h e ben ef i tw as act u al l y desi gn ed to cover 4 (t h a ti s , t h o s e b e n e f i c i a r i e s r e q u i r i n g a s h o r t - t e r m, fa i r l y i n t e n s iv e s t a y i n a S NF 5 a s a co n ti n u a ti on of a n acu te h osp i tal st a y o f sev era lda ys ). ” I d. I tobserved, 6 f ur t he r , t hatt h e m e di c alpr ac t i c e o f pl ac i ng pa t i e nt s o n o bs e r va t i o n s t at us 7 bef

ore f orm al l y ad m i t t i n g t h em ha s grow n in prevalence s i n ce C on gress en act ed 8 t he M edi c ar e s t at ute i n 1965, t hats om e c om m ent at or s have s ugges t ed t hat 9 pat i ent s on o bs ervat i on s t at us r ec eive qual i t at ivel y t he s am e typ e of c ar e a s 10 ad m i t t e d pa t i e nt s , andt hats o m e v i e w i ta s unfai rf o rM e di c ar e r e i m bur s e m e nt 11 de c i s i o ns t o t ur n o n a di s t i nc t i o n t hat t he y be l i e ve t o b e “ a m e r e r e c o r dke e pi ng 12 c o nve nt i o n o n t he pa r to f t he ho s pi t alr at he rt han a s ubs t ant ive c hang e i n t he 13 a ctu a lcare tha t t h e b en efi ci a ryrece ive s th ere . ” I d. 14 F ol l ow i n g t h i s i n vi t ati on , C M S rec eived com m en t s on th is preci se i ssue. 15 M anyo f

t he s e c o m m e nt s “ e x p r e s s e d s upp o r tf o rt he i de a t hatho s pi t alt i m e s pe nt 16 i n ob s e r va t i o n s t at us i m m e di at e l y pr e c e di ng a f o r m ali npa t i e nta dm i s si on 17 sho ul d c ountt ow ar d s at i sf yi ng t he SN F benef

i t ’ s st at ut or y qual i f

yi ng t hre e- day 18 h ospi t alst ay requ i rem en t . ” M edi care P rogram ; P rospect ive P aym en tSy st em 19 and C ons ol i dat ed Bi l l i ng f or Ski l l ed N urs i ng Faci l i t i es f orFY2006, 70 Fed. R eg. 20 45, 026 , 45, 050 (A u g. 4, 200 5) . “ [ S ] om e ot h ers sup ported c o u n tin g t h e obser-19

1 va ti on ti m e,” bu t no t “ti m e sp en t i n the em erg en cyroom . ” I d. 2 U l ti m a tel y, ho w ev er, C M S de cl i n ed to ch a n ge i ts i n terp reta ti on . W i th 3 r e ga r d t o t he sug ge s t i o n t hatem e r ge nc y r o o m t i m e co untt o w ar d t he q ual i f yi ng 4 s t ayr e qui r e m e nt , CM S “ d[i d] no ts har e t he b e l i e f . . . tha t ti m e sp e nti n t he 5 em erg en cyroom i s esse n ti a l l y c o m p a r a b l e to ob serv a ti on ti m e in th i s con tex t” 6 bec ause “ t he m er e pr es enc e o f ti m e spe nti n t he em er genc y ro om pri ort o f or m al 7 a d m iss io n w o u ld n o t, in itse lf, se rv e to id e n tify th e d e g re e of se v e rityof a 8 p a rti cu la r p a ti en t' s con d i ti on du ri n g th a t t i m e.” I d. W i t h r e ga r d t o t he 9 s u g g e s t i o n t h a tt i m e o n o b s e r v a t i o n s t a t u s c o u n tt o wa r dt h e r e q u i r e m e n t , CM S 10 stated th a t i tw as “ c ont i nui ng t o r evi ew t hi s i ss ue, but[w as ] notye tr eady to 11 m a k e a f

i n a lde term i n a ti on . ” I d. CM S w as w ar y o f

c hang i ng i t s i nt e r pr e t at i o n, 12 i ts ai d, be c ause i tdi d notw antt o a dopta r ei m burs em entgui del i ne t hat 13 c o nf

l i c t e d wi t h w h at i tv i e w e d a s Cong r e s s ’ s “ i nt e nti n e s t ab l i s hi ng t he 14 qu al i f

yi n g h ospi t alst ay requ i rem en t” — na m el y, t h at t h e S N F ben ef i t“ serv[ e] 15 as a l ess exp en sive al t erna t ive t o w h at w ou l d otherw i se be t h e f i n al , conva l es16 c e n t p o r tio n o f a n a c u te ca r e s ta yo f s e v e r a l d a y s a s a n in p a tie n t a t a h o s p ita l.” 17 I d. at45, 051. 18 T h e p r e c e d i n ge x c h a n g e s h o w s th a t C M S o p e n e dits p o lic ie s to p u b lic 19 com m en t , rec eived com m en t s c h al l en gi n g t he i nt e r pr e t ati o n a ti ssue i n t h i s c ase, 20 a n dd e c li n e dto c h a n g e it s p o s it io n in lig h to f w h a tit p e r c e iv e s a s C o n g r e s s ’s20

1 i n ten t i n i m p osin g th e q u a l i fyi n g sta y re q u i rem en t. C M S ’ s statem en t w i th 2 respectt o observati on st atus m ay be l ess t h an w h ol l y sati sf yi n g, bu ti ti s not so 3 defi ci en tt h at i tl acks persu a sive f orce. To be su re, w e m ay rej ectan agen cy 4 i nt e r pr e t at i o n t hat m e r e l y “ m i r r o r s t he c o m m o n und e r s t and i ng” a tt he t i m e t he 5 ag e nc y ad o pt e d i t s i nt e r pr e t at i o n b utha s no t be e n r e vi s e d t o r e f l e c t“ c hang i ng 6 c i r c um st ance s, par t i c ul ar l y i n ar eas c haracteriz ed byr api d t ec hnol ogi c al 7 d ev elop m en t. ” D e t s e lv . Sul l i v an , 895 F . 2d 5 8 , 6 3 -6 4 (2d C i r. 199 0) . H ere, 8 how eve r , CM S d o e s n o ta t t e m p tt o j us t i f yi t s p o s i t i o n b ya r g ui ngt ha ti twas 9 r e as o nab l e w he n f i r s tado pt e d. Rat he r , CM S a ppe ar s t o b e a c ut e l y awar e o f t he 10 cha n ges i n m edi calp ract i ce s i n ce t h e 196 0s an d h as decl i n ed to i n cl u de ti m e on 11 observati on sta tu s t ow ard the t h ree- da y coun tbecau se, i n i t s vi ew , doi n g so 12 w o ul d r i s k und e r m i ni ng c o ngr e s s i o nali nt e nt . W e a r e t hus una bl e t o c o nc l ude 13 t h at C M S “ en t i rel y fai l ed to consi der an i m portant aspectof t h e probl em ” or 14 “ of

fered an expl an ati on f or i t s d eci si on tha trun s c ou n t er t o t h e evi den ce” bef ore 15 it. Mot or V

ehic le M

f rs. A ss’ n v. S t ateF

arm Mu t . A u t o. I

n s. Co. , 463 U . S. 29, 43 16 (1 9 8 3 ). 17 T h e p la in t if fs u r g e u s to v ie w t h is p u b li c c o m m e n to p p o r t u n it ya n dC M S ’s 18 reconsi derati on of i t s i n t erpret ati on as a farce or as ot h erw i se t ai n t ed becau se 19 i tw as cond u ct ed d u ri n g t h e p en den cy of t h i s l i t i gati on . W e decl i n e t o do so. 20 A l t hough w e do notdefer to age ncy c ons t r uct i ons of s t at ut es as se r t ed as21

1 litig a tin gp o s itio n s , see R h od es- B radf ord v. K

ei sler , 507 F .3d 7 7 , 80 (2d C i r. 2 2007) (c i t i ng Bow e n v . G e o rge t o w n Uni v . Ho s p. , 4 8 8 U .S . 2 0 4 , 2 1 2 -1 3 (19 8 8 )), 3 C M S presented i t s constr u ct i on t o t h e pu bl i c at l arge an d c on si dered i t s posi t i on 4 as a g ener al l y appl i c abl e m at t err at hert han f ora s i ngl e l i t i gat i on. The l aw 5 g e n e r a llys e e k s t o e n c o u r a g e p u b lic p a r tic ip a tio n in a g e n c yd e c is io n m a k in g , see 6 A m . Pos t alW

orke rs Uni on v. U. S. Pos t alSer v. , 707 F . 2 d 5 4 8 , 5 6 5 ( D . C . C i r. 7 1 9 8 3 ); G uar di an Fe d. Sav . & Lo an As s ’ n v . Fe d. Sav . & Lo an I ns . Cor p. , 589 F. 2d 8 658, 662 ( D . C . C i r . 1978) , and w e w oul d f r ust r at e r at her t han f urt hert hatgo al 9 if w e w e r e t o s tr ip a n a g e n c yo f d e fe r e n c e it w o u ldo th e r w is e b e d u e m e r e ly 10 be c aus e t hatpub l i c par t i c i pa t i o n w as sp ur r e d byl i t i ga t i o n ra t he rt han ar i s i ng 11 fr o m th e a g e n c y ’ s s e lf-g e n e r a te dd e s ir e o rb e n e fic e n c e . B yw a y o f a n a lo g y , a d u ly 12 p ro m u lga te da g e n cyr e g u la tion e njoy s th e fu llex te n t of C h evron deference even 13 w he n t he r e gul at i o n was pr o m pt e d b y pe ndi ng l i t i ga t i o n t hatl ur ke d i n t he b ac k14 g r o u n d . Smi ley v . Ci t i ba nk ( S. D. ), N. A. , 5 17 U . S. 7 35 , 7 40 - 41 ( 19 96 ) . The 15 pl ai n t i f

fs prof fer no persua sive reason w h y w e shou l d qu est i on t h e i n t egri t y of 16 CM S’ s de l ibe r at i ve pr o c e s s he r e g ive n t hatw e w o ul d d e c l i ne t o do s o i n t he 17 C h evron con tex t. 18 F o u r th , C M S ’ s r u l e i s th e p r o d u c t o f a n in te r p r e ta tio n th a t is re la tiv e ly 19 form a lw i th i n the u n ive rse o f i n form a l i n terp reta ti on s. “[T ]he d eferen ce d u e” to 20 an agen cy i n t erpret ati on “ i s at the h i gh en d of the spect rum of

deference” w h en22

1 “t h e in te r p r e ta tio n in q u e s tio n is n o t m e r e lya dh o c b u t . . . i s a p p l i c a b l e to a ll 2 ca ses . ” C hauf

f e r ’ s Trai ni ng Sch. , I

nc. v. Spel l i ngs , 478 F . 3d 117 , 129 ( 2d C i r. 3 200 7) . C M S ’ s i n t erpret atio n , setf ort h i n a pol i cy m an u alrat h er t h an , f or 4 exam pl e, a nonpr ec ede nt i all et t err ul i ng, i s gener al l y appl i c abl e and i s notan ad 5 hoc pos i t i on. I n t he M edi c ai d c ont ext, w e have r egar ded a C M S m anualas 6 m eri t i n g an “ i n te rm e di ate l evel” of deference t h at l i es “betw een a pu bl i shed 7 reco m m en d a ti on an dan i n terp reta ti on ad va n ced on l y in l i ti ga ti on , ” R abi n v. 8 Wi lson-Coker , 362 F . 3d 190 , 198 ( 2d C i r. 200 4) , an d w e do t h e sam e here. 9 * * * 10 In sum , t h e S ki d m orefact ors l ead us t o r e ga r d the st atutor y i n t erpret ati on 11 setf

ort h i n C M S ’ s pol i cy m an u alas persuasi ve. 12 2. 13 In vi ew of our S ki d m ore an al ysi s, w e concl u de that a M edi care benefi ci ary 14 i s no t an i npa t i e nt w i t hi n t he m e ani ng o f § 13 95 x(i) unl e s s he o r s he ha s been 15 f o r m al l y ad m i t t e d t o a ho s pi t al . W e r e ac h t hi s c o nc l us i o n no to nl y be c aus e o ur 16 deci si on i s i n f

orm ed byC M S ’ s hi gh l y persua sive i n t erpret ati on , bu tal so because 17 i taccor ds w i t h t h e st atutor y t ext an d ou r governi n g preceden t s. 18 T h e st atutor y defi n i t i on of i n pa t i en thosp i t alservi ces en u m erat es s u ch 19 serv i ces a s “be dan dbo a rd , ” 42 U .S .C . § 13 9 5 x(b )( 1 ), “nu rsingserv i ces,” i d. 20 § 1 3 9 5 x(b )( 2 ), an d“othe r d i a gn ostic or th era p eu ti c i tem s or se rv i ces,” i d.23

1 § 1 39 5x (b) ( 3) . The pl ai nt i f fs ur ge us t o c r e di tt he i ra r gum e ntt hata nyo ne w ho 2 r e c e ive s t he s e s e r vi c e s i n t he ho s pi t ali s r e c e ivi ng i n p a t i e n tho s pi t als e r vi c e s a nd 3 i s t he r e f

o r e a n i npa t i e nt . I n l i ght o f t he s t at ut o r y t e xt , ho w e ve r , t hi s a r gum e nt 4 i s ul t i m atel y qu est i on - begg i n g. T h e st atute defi n es i n pa t i en t h ospi t alservi ces 5 t o i nc l ude t he af o r e m e nt i o ne d i t e m s and s e r vi c e s w he n t he y ar e “ f ur ni s he d t o an 6 i npa t i e ntof

a ho s pi t ala n d. . . b y th e h osp i tal. ” I d. § 1 3 9 5 x (b ) ( e m p h a sis a d d e d ). 7 T h u s, servi ces can n otbe i n pa t i en thosp i t alservi ces u n les s t h ey are f u rni shed 8 to a n in p a tie n t. T h e co n s tr u c tio n o f th e s ta tu te th a t t h e p la in tiffs p r o p o s e w o u ld 9 rea dthe w ord s “t o a n i n p a ti en t of a h osp i tal” ou t of

the statu torytext. T h e facts 10 o f

t h i s c ase dem on st rat e, at m ost , t h at t h e servi ces rend ered t o t h e pl ai n t i f fs 11 w o u ld h ave been i n pa t i en thosp i t alservi ces if the pl ai n t i f

fs had been i n pa t i en t s. 12 U nf

o r t unat e l y, t hati s no te no ugh t o e nt i t l e t h e p l ai nt i f fs t o r e i m bur s e m e nt 13 b eca u se itsti l ll ea ve s u n a n sw ere dthe esse n ti a li ssu e of de fi n i n g a n i n p a ti en t. 14 T h e concl u si on here — t h at one i s an i n pa t i en tf or th e p u rp o se of 15 § 1 3 9 5 x (i) o n lyif o n e h a s b e e n fo r m a llya d m itt e dto a h o s p ita l

— is a ls o n o t in 16 t e ns i o n wi t h o urde c i s i o n i n L evi v. Hec k ler , 736 F . 2d 848 ( 2d C i r. 198 4) (per 17 c u r i a m) , o rt h o s e o f t h e o t h e rC o u r t s o f A p p e a l s t h a th a v e a d o p t e dt h e s a me 18 r e a s o n i n g , see Mayb u rg v. S ec’ y of Heal t h & Hu m an S ervs . , 740 F . 2d 100 ( 1st 19 C ir . 1 9 8 4 ) (B r e y e r , J .); K a ufm a n v . Ha r r is , 731 F . 2d 370 ( 6th C i r. 198 4) (per 20 c u r ia m ); Fri edb erg v. S chw ei ker , 721 F . 2d 4 45 ( 3d C i r. 198 3) (per curi am ) . Th ese24

1 case s c o nc e r ne d M e di c ar e ’ s c o ve r ag e o f i npa t i e ntho s pi t als e r vi c e s , f o rw hi ch 2 M e di c ar e pa r t i c i pa nt s a r e e nt i t l e d t o r e i m bur s e m e nt “ f o r up t o 15 0 da ys dur i ng 3 an y spel lof

il l n ess. ” 42 U . S . C . § 139 5d ( a) ( 1) . U n der t h e stat u t e, a sp el lof i l l n ess 4 be gi ns o n t he f

i r s t da y a pa t i e nti s f

ur ni s he d i npa t i e ntho s pi t als e r vi c e s a nd e nds 5 whe n he o r s he i s ne i t he r a n i np a t i e nt o f a ho s p i t a ln o ra n i np a t i e nto f a n SNF. 6 I d. § 1 39 5x ( a) . I n Levi , w e de f i ne d a n i npa t i e nto f

a n SN F to m e an a pa t i e nt 7 “ w ho bo t h r es i des i n a ski l l ed nurs i ng fac i l i t y andr e c e ive s t he ‘ s ki l l e d nu r s i ng 8 ca re’t her e a vai l abl e, ” 736 F. 2d at849 ( quot i ng L eviv. Heckler , 5 7 5 F . S u pp. 9 1 3 8 1 , 1 3 8 4 (S .D .N .Y . 1 9 8 3 )) (in te r n a l q u o ta tio n m a r k o m itt e d ), a n dth u s h e ld 10 th a t a p a tie n t’s s p e ll o f illn e s s e n d e dif h e re s id e din a n S N F b u t r e c e iv e do n ly 11 c us t o di alca r e , notnur s i ng c ar e . Buti n Levi , w e c ons i der ed onl y w het herf or m al 12 resi den ce i n an SN F w as s uf f i c i e ntto re n d e ro n e a n in p a tie n t o f th a t fa c ility . W e 13 h ad no occasi on t o a dd ress the an al ogu e of t h e qu est i on t h at i s presented here: 14 w h et h er f

o rm a l a d m i ssi on or f orm alres i den ce i s n ece ssaryt o r enderone an 15 in p a tie n t. Levit h eref ore does not shed l i gh ton the qu est i on at i ssue. 16 A ccor di n gl y, w e concl u de thi s port i on of ou r op i n i on b y rei t erat i n g ou r c ore 17 ho l di ng i n t hi s c as e : i n de t e r m i ni ng w he t he ra M e di c ar e b e ne f i c i ar y has m e tt he 18 statu torythr e e -d a y h osp i tal st a y re q u i rem en t ne ed ed to qu a l i fy f or p ost19 h o s p ita liz a tio n S N F b e n e fits u n d e r P a r t A , th e tim e th a t t h e p a tie n t s p e n d s in 20 th e em erg en cyro om o r o n o b serv a ti on s tatu s b efore b ein g form a l l y a d m i tted to25

1 th e h o sp ita l do e s n o t co u n t. In so h o ld in g , w e ex p re ss ly r ejec t th e ru le o f Jenk el 2 v . S h a la la , 8 4 5 F. Su p p . 6 9 ( D. Co nn . 1 9 9 4 ) , whi c h he l d t ha t “ l a t e r‘ for m al 3 ad m i ssi on ’” of

a pati en tf

ol l ow i n g h er t reat m en ti n t h e em ergency room operates 4 as “ a n u n c pro t u n c r ati f i cat i on of

her de fact o adm i ssi on at t h e t i m e of her 5 a rriva li n the em erg en cyroom . ” I d. a t7 1 ( e m pha s i s om i t t e d) . As a po s t s c r i pt 6 t o t h i s port ion of our holdi n g, w e note t h at t h e M edi care s t atute does not 7 u n a m b i gu ou sly req u i re t h e con stru cti on w e h a ve ad op ted . If C M S w ere to 8 p rom u l ga te a d i ff ere n t d efi n i ti on o f i n p a ti en t in th e ex ercise of it s au th ority to 9 m ak e rul es c arryi n g t h e f orce of l aw , t h at def

i n i t i on w ou l d be el i gibl e f or 10 C h evron d e fe r e n c e n o tw ith s ta n d in go u rh o ld in gto d a y . S ee Nat’ lCab le & 11 T

elecom m s. A ss’

n v. B ran dX

I n t ernetS ervs . , 5 4 5 U .S . 9 6 7 , 9 8 2 -8 6 (20 0 5 ). 12 II. 13 The pl ai nt i f fs al s o c hal l e nge t he c o ns t i t ut i o nal i t y o f CM S’ s r ul e , a r gui ng 14 th a t itv io la te s th e irrig h ts to e q u a l p r o te c tio n u n d e r th e F ifth A m e n d m e n t. S ee 15 Ni cholas v. Tu cker , 11 4 F . 3 d17 , 19 ( 2 dC i r. 19 9 7 ) (“A l th ou gh . . . the F i ft h 16 [A m e n d m e n t ] d o e s n o t c o n ta in a n e q u a l p r o te c tio n cla u s e , ‘ it d o e s fo rb id 17 di s c r i m i nat i o n t hati s “ s o unj us t i f i able as to b e v i o l at ive o f due pr o c e s s . ” ’The 18 s t and ar ds f

o r an al yz i ng e qua lpr o t e c t i o n c l ai m s und e re i t he r[t he Fi f t h o rt he 19 Fourt ee nt h A ] m endm entar e i dent i c al . ” (ci t at i on o m i t t ed) ( quot i ng S chn ei d er 20 v. R u sk , 3 7 7 U .S . 1 6 3 , 1 6 8 (1 9 6 4 ))). S p e c ific a lly , th e y c o n te n d t h a t t h e ru le26

1 unl awf

ul l y di scr i m i nat e s a ga i ns tM e di c ar e pa t i e nt s w ho s pe nd t i m e i n t he 2 em er genc y r oo m oron o bs ervat i on s t at us byt r eat i ng t hem l es s favor abl y t han 3 t h o se w h o are f orm al l y ad m i t t ed i m m edi atel y u pon arrivi n g or very s oon 4 t h ereaf

t er. 5 The p l a i n t i f fs c o n c e d e t h a t CM S ’ s i n t e r p r e t a t i o n d o e s n o t i m p l i c a t e a ny 6 s u s p e c t c la s s ific a tio n s a n dth a t, th e r e fo r e , w e s h o u lda p p lyra tio n a l b a s is 7 s c r u tin y . S ee Fu rlo ngv. S h a la la , 156 F. 3d 384, 392 ( 2d C i r . 1998) . A c c or di ngl y, 8 w e shou l d f

i n d t h e i n t erpret ati on consti t u t i on al l y vali d i f i ti s “ rat i on al l y rel ated 9 to a legiti m a te go ve rn m en t i n teres t, ” Kr aha m v . Li ppm an , 478 F. 3d 502, 506 ( 2d 10 C ir. 2 0 0 7 ), a n dstr ik e it d o w n a s u n co n stitu tion a l on ly if th e p la in tiffs 11 “ dem on st rat e t h at t h e govern m en t regulat i on i s arbi t rary an d/or un reasona bl e, 12 a n dn ot ration a l l y re l a ted to a l eg i ti m a te go ve rn m en t i n teres t, ” T a n o v v . I

NS , 13 4 4 3 F .3d 1 9 5 , 2 0 1 (2d C ir. 2 0 0 6 ). 14 W e c o n c lu d e th a tth e r u le d o e s n o t v io la t e th e C o n s t it u t io n ’s 15 gu a ra n tee of eq u a lpr otection . A s C M S h a s n oted , C on gr ess i n ten d ed to crea te 16 a n e x te n d e dca r e b e n e fit t o s e r v e “a s a le s s e x p e n s iv e a lte r n a tiv e t o . . . th e fin a l, 17 c o n v a l e s c e n tp o r t i o n o f a n a c u t e c a r e s t a y. . . a ta h o s p i t a l . ” Me d i c a r e P r o g r a m; 18 Pr o s pe c t ive Pay m e ntSys t e m a nd Co ns o l i da t e d Bi l l i ng f o rSki l l e d Nurs i ng 19 Fa c i l i t i e s f

o rF Y 2 0 0 6 , 7 0 F e d . Re g . 2 9 , 0 7 0 , 2 9 , 0 9 9 (M ay19, 200 5 ) . CMS 20 r a t i o n a l l yc o u l dh a v e c o n c l u d e dt h a ta b r i g h tl i n e r u l e me a s u r i n gi n p a t i e n tt i me27

1 bas e d o n f

o r m ala dm i s s i o n woul d s i m pl i f y c l ai m s pr o c e s s i ng andr edu ce 2 ad m in istrati on cos t s, w h i l e t argeti n g t h e program at t h e group C on gress 3 in te n d e d t o b e n e fit. C M S ’ s le g itim a te in te r e s t in a d m in is tr a tiv e e ffic ie n c yis 4 s u f

f i c i e n t t o u p h o ldth is ru le a g a in s t a ra tio n a l b a s is ch a lle n g e . SeeE l l i s v. 5 A pfe l , 1 4 7 F .3d 1 3 9 , 1 4 6 (2d C ir. 1 9 9 8 ). 6 III . 7 P l ai n t i f

f ’ s f i n alargu m en ti s t h at t h e di st ri ct court erred w h en i tref u sed 8 t o consi d e r e v id en ce outs i de the ad m i n i st rat ive recor d. Ju di ci alrevi ew of 9 adm i ni st r at ive det er m i nat i ons w i t h r es pec tto M edi c ar e benef i t s i s gov er ned by 10 4 2 U .S .C . § 1 3 9 5 f f(b )(1 )(A), w h ic h in c o r p o r a te s th e p r o v is io n s o f 4 2 U .S .C . § 11 405 ( g) . A ccor di n g t o t h e l att er s t atute, t h e di st ri ctcourtordi n ari l y m u stbase 12 its ju d g m e n t “ u p o n th e p le a d in g s a n dtr a n s c r i p t o f t h e re c o r d .” 4 2 U .S .C . § 13 4 0 5 (g); seealso Mathew s v. W eber , 423 U . S . 261 , 263 ( 197 6) (n ot i n g t h at, un der 14 § 4 05 ( g) , “ [ t ] he c o ur t m ay c o ns i de r o nl y t he pl e ad i ngs a nd a dm i ni s t r at ive r e c o r d, 15 and m ustac c eptt he Sec r et ar y' s f i ndi ngs of

fac ts o l ong as t hey ar e s upport ed by 16 s u b s ta n tia l e v id e n c e ”); i d. a t270 ( “ [ U nde r§ 405 ( g) , ] nei t he rpar t y m ayputa ny 17 ad di t i on alevi den ce bef ore t h e di st ri ct court. ” ) . N evert h el ess, t h e di st ri ctcourt 18 h as “a d e q u ate authori t y t o res olve an y st atutor y or c on st i t u t i on alcontenti on 19 t h at t h e agen cy [ di d] n ot , or ca n n ot , deci de, ” a pow er t h at i n cl u des, “ w h ere 20 nec es sa r y, the au th ority to de ve l op an ev i d en ti a ryreco rd . ” S h a la la v . Ill . Co u n cil28

1 on L ong T

erm Care, I

n c. , 5 2 9 U .S . 1 , 2 3 -2 4 (20 0 0 ). 2 In sup port of theirm ot i on forsu m m ary j u dg m en t , t h e pl ai n t i f fs s u bm i t t ed 3 a st atem en tof

m ater i alfact s, several decl arati on s, an d i n t errogat ori es i n w h i ch 4 CM S o f

f i c i al s e xp l ai ne d t he po l i cy a ti s s ue . The di s t r i c tc o ur tg r ant e d t he 5 gov er nm ent ’ s m ot i on t o s t r i ke t hes e e xt r a- r ec or d s ubm i ss i ons , r ul i ng t hat 6 b e c a u s e th e ca s e p r e s e n ts “a p u r e lyle g a l c h a lle n g e to th e S e c r e ta r y ’ s p o lic y ,” it 7 “ doe s notr equi r e fac t ualdet er m i nati o ns wi t h r e s p e c tt oi nd iv i d ua lp l ai nt i f fs t hat 8 w ou l dreq u i re re sort to ev i d en ce ou tsi d e t h e ad m i n i strative record . ” L a n d ers II, 9 2 0 0 6 W L 2 5 6 0 2 9 7 , a t * 3 . B e c a u s e th e d is tr ic t c o u r t’s d e c is io n n o t t o a d m it 10 evi dence ou tsi d e t he r ec or d i s an exe r c i se of i t s “ aut hor i t y t o de vel op an 11 ev i d en ti a ryreco rd , ” Il l . Cou n ci lon L ong T erm Care , 529 U . S . at 23-24, w e revi ew 12 t h a t d e c is io n fo ra b u s e o f d is c r e tio n . A rlio v. L ive ly , 47 4 F. 3d 46 , 51 ( 2d C i r. 13 2007) ( “W e r evi ew ev i dent i ar y r ul i ngs f orabus e o f

di sc r et i on. ” (c i t i ng Caruo lo v . 14 Joh n C ran e, I n c. , 2 2 6 F .3d 4 6 , 5 4 (2d C ir. 2 0 0 0 ))) . 15 T h e di st ri ct court corr ect l y excl u ded t h e i n t errogat ori es. I n t h e ordi n ary 16 c as e , w e m us tuph o l d o rs e ta si de t h e a genc y’ s a c t i o n o n t he g r o unds t hatt he 17 a g e n c yh a s a r tic u la te d . S t ateF arm , 4 63 U . S. a t5 0. S u ppl e m e nt at i o n o f t he 18 a d m in is tr a tiv e re c o r dm a yb e a p p r o p r ia te if “t h e r e w a s s u c h fa ilu r e to e x p la in 19 a dm i ni str at ive action as to fru strate eff ective j u d i ci a lrev i ew , ” Ca mp v. P itts , 411 20 U . S. 138 , 14 2 - 4 3 ( 1 9 7 3 ) (p e rc u r i a m ) , b u twe f i n dn o s u c h fa i l u r e h e r e . As29

1 di sc uss ed ab ove , w e f i nd t he age ncy’ s j ust i f i c at i on of i t s dec i si on nott o c hange 2 i ts i n te r p reta ti on “discl ose [s] the fa ctors th a t w ere con sider ed , ” C itizen s to 3 Pr e s e r v eOv e r t o n Pa r k v . Vol pe , 4 0 1 U .S . 4 0 2 , 4 2 0 (1 9 7 1 ), a n da d e q u a te ly 4 e x p la i n s it s a c tio n . S e eCa mp , 4 1 1 U .S . a t 1 4 2 . T h e p la in tiffs a r g u e th a t t h is 5 pr i nc i pl e o f

j udi c i alr e vi e w c r e at e s a r i s k t hat ag e nc i e s w i l l be a bl e t o ho o dwi nk 6 c o ur t s i nt o a c c e pt i ng ag en ci es’sel f

- i n t erest ed j u st i f i cat i on s, bu tw e are un w i l l i ng 7 to a s c r ib e s u c h n e fa r io u s m o tiv e s to a g e n c y a c tio n a s a g e n e r a l m a tt e r . S ee U. S. 8 Po sta l S er v . v. G regor y , 53 4 U . S . 1, 1 0 ( 2 0 0 1 ) (“ [A] p resu m p ti on of reg u l a ri ty 9 a tt a c h e s to th e a c tio n s o f G o v e r n m e n t a g e n c ie s . . . .”); With ro w v. L a rk in , 421 10 U .S . 3 5 , 4 7 (1 9 7 5 ) (r e fe r r in gto th e “p r e s u m p tio n o f h o n e s tya n din te g r ityin 11 th o s e s e r v in ga s [a g e n c y ] a dju d ic a tors”). Iti s w e ll-e s ta b lis h e dth a t c o u r ts s h o u ld 12 fo c u s e x c lu s iv e lyo n th e fo r m a l a d m i n is tr a tiv e re c o r du n le s s th a t r e c o r d is 13 i n suff

i ci en tto sh ed l i gh ton the rat i on al e fort h e agen cy’ s deci si on . Th e rec ord 14 h ere i s s u f

f i ci en tan d w e decl i n e t o consi der ad di t i on alevi den ce. 15 The di s t r i c tc o ur ta l s o c o r r e c t l y e xc l ude d t he pl ai nt i f fs’de c l ar at i o ns a nd 16 st atem en tof

m ater i alfact s. Th e fact s se t fo rth i n t h ese s u bm i ssi on s are n ot 17 m at e r i alt o t he pl ai nt i f fs ’ e l i gibi l i t y f

o r r e i m bur s e m e nt be c aus e t he na t ur e o f t he 18 m e di c als e r vi c e s r e nde r e d t o t he pl ai nt i f fs c anno t , b y t he m s e lve s , e s t ab l i s h t he 19 p la in tiffs ’ e lig ib ility fo r S N F co v e r a g e . S ee Jo ne s v . Sul l i v an , 949 F. 2d 57, 60 ( 2d 20 C i r . 1991) ( “ Th e c onc eptof m at er i al i t y r equi r es . . . a r eas onabl e po ss ibi l i t y t hat30

1 t h e n e w e v id e n c e w o u ld h a v e i n fl u e n c e dt h e S e c r e t a r yt o d e c id e [t h e ] c la im a n t ’s 2 ap pl i cat i on di f ferentl y. ” ) . I n ref

u si n g t o con si der t h ese s u bm i ssi on s, t h eref ore, 3 t he di s t r i c tc o ur ta c t e d wi t hi n i t s s o und di s c r e t i o n. 4 5 CO NC L US I ON 6 F or th e foreg oin g re a son s, w e a ff i rm the j u d gm en t of

the distri ct cou rt. 7