Opinion ID: 613077
Heading Depth: 2
Heading Rank: 1

Heading: Observations Regarding the History of the Private Cause of Action.

Text: When first enacted, the private-cause-of-action provision read: There is hereby created a private cause of action for damages (which shall be in an amount double the amount otherwise provided) in the case of a workmen's compensation law or plan, automobile or liability insurance policy or plan or no fault insurance plan, group health plan, or large group health plan which is made a primary payer under paragraph (1), (2), (3) or (4), respectively, and which fails to provide for primary payment (or appropriate reimbursement) in accordance with such respective paragraphs. Omnibus Budget Reconciliation Act of 1986, Pub.L. No. 99-509, § 9319(b), 100 Stat. 1874. At that time, paragraphs (1)-(4) set forth the circumstances in which Medicare was only secondarily responsible and was permitted to make conditional payments subject to reimbursement. See 42 U.S.C. § 1395y(a)(1)-(4). These circumstances have been steadily expanded over the history of the Act. At first only workers' compensation and other government benefits were primary to Medicare, see Social Security Amendments of 1965, Pub.L. No. 89-97, § 1862(a), 79 Stat. 286; then automobile and liability insurance policies and plans, including no-fault auto insurance, were made primary, see Omnibus Reconciliation Act of 1980, Pub.L. No. 96-499, § 953, 94 Stat. 2599; then plans covering end-stage renal decease were made primary, see Omnibus Budget Reconciliation Act of 1981, Pub.L. No. 97-35, § 2146(a), 95 Stat. 357; then active employees covered by group health plans were excluded from primary Medicare coverage, see Tax Equity and Fiscal Responsibility Act of 1982, Pub.L. No. 97-248, § 116(b), 96 Stat. 324; then large group health plans were made primary, see Omnibus Budget Reconciliation Act of 1986, supra, § 9319(a). Paragraphs (1)-(4), referred to in the original private-cause-of-action provision, Pub.L. No. 99-509, § 9319(b), each included language very similar to the language now found in 42 U.S.C. § 1395y(b)(2)(A), regarding when conditional payment may be made by Medicare and the obligation to reimburse the appropriate Trust Fund for such payments. [1] Thus, the private cause of action has always been based on a primary plan's failure to make payments as required by the provisions that make the plan primary and permit Medicare to make conditional payments. For this reason, I conclude that the private-cause-of-action provision's reference to a fail[ure] to provide for primary payment (or appropriate reimbursement) in accordance with paragraphs (1) and (2)(A) is simply the current, short-handed iteration of the original provision. The structure of the provision bears this out. The current version, § 1395y(b)(3)(A), provides: There is established a private cause of action for damages (which shall be in an amount double the amount otherwise provided) in the case of a primary plan which fails to provide for primary payment (or appropriate reimbursement) in accordance with paragraphs (1) and (2)(A). Viewing the original and current private-cause-of-action provisions together, it is apparent that the current provision follows the same structure as the original, but omits the listing of the primary payers, referring to them only as primary plans, and then refers to paragraphs (1) and (2)(A) rather than paragraphs (1)-(4). Paragraphs (1)-(4), referred to in the original private-cause-of action provision, contained the same conditional payment and reimbursement provisions now found in paragraph (2)(A) of the current Act, referred to in the current private-cause-of-action provision. Thus, I find no special significance in the use of the conjunctive in § 1395y(b)(3)(A)(referring to a failure to pay or reimburse in compliance with paragraphs (1) and (2)(A)) and agree that § 1395y(b)(3)(A) simply provides for a private cause of action when a primary plan fails to provide payment due under paragraph (1), leaving Medicare next in line to pay.