Opinion ID: 4576558
Heading Depth: 4
Heading Rank: 2

Heading: The Take-Into-Account Provision

Text: Similar reasoning extends to DaVita’s claim that the Plan violates the take-into-account provision of the MSPA. As a reminder, this provision states that a group health plan “may not take into account that an individual is entitled to or eligible for [Medicare benefits due to ESRD]” during the thirty-month period when the plan is primary to Medicare. 42 U.S.C. § 1395y(b)(1)(C)(i). The statute itself does not define what “take into account” means. DaVita argues that to take something into account means to consider or think of it, which means that plans are prohibited from adopting policies that are motivated by a desire to treat Medicareentitled individuals differently. See Appellant Br. at 51–52. In DaVita’s view, discovery may reveal evidence of the defendants’ illicit motive. Id. at 52. The defendants do not directly address why DaVita’s motive-based definition of “take into account” is incorrect. Instead, they argue that “take into account” speaks to a plan’s terms, which, in their view, were nondiscriminatory. See MedBen Br. at 39 (“Because all plan beneficiaries who use outpatient dialysis services, regardless of their diagnosis or condition and including those ESRD patients No. 19-4039 DaVita, Inc. et al. v. Marietta Mem. Hosp. et al. Page 32 who are eligible for Medicare, are subject to out-of-network reimbursement rates, the Plan does not violate the MSPA’s ‘take into account’ prohibition.”). Because “take into account” appears susceptible to these conflicting meanings, it is ambiguous. See Brilliance Audio, Inc. v. Haights Cross Commc’ns, Inc., 474 F.3d 365, 372 (6th Cir. 2007) (“As both parties have laid out plausible readings of the statutory language, we find that the language of § 109(b)(1)(A) is not unambiguous.”). We thus consider whether the agency has construed this term, and if so, whether its construction is permissible. See Chevron U.S.A. Inc. v. Nat. Res. Def. Council, Inc., 467 U.S. 837, 843 (1984); Bio-Med, 656 F.3d at 282 (deferring to 42 C.F.R. § 411.108’s “reasonable interpretation” of the “take into account” clause). Section 411.108 of the Code of Federal Regulations sets forth a nonexclusive list of “[e]xamples of actions that constitute ‘taking into account’” that a person is entitled to Medicare on the basis of ESRD, age, or disability. 42 C.F.R. § 411.108(a). At least two of § 411.108’s illustrations buoy DaVita’s motive-based interpretation of the ambiguous statutory phrase: “taking into account” includes “denying or terminating coverage because an individual is entitled to Medicare on the basis of disability without denying or terminating coverage for similarly situated individuals who are not entitled to Medicare on the basis of disability[,]” id. § 411.108(a)(4) or “[i]mposing limitations on benefits for a Medicare entitled individual that do not apply to others enrolled in the plan, such as providing less comprehensive health care coverage, excluding benefits, reducing benefits, charging higher deductibles or coinsurance, providing for lower annual or lifetime benefit limits, or more restrictive pre-existing illness limitations[,]” id. § 411.108(a)(5). These two examples support DaVita’s theory of discrimination for the same reasons discussed above in Part III.C.1.19 DaVita’s central allegation in this case is that ESRD patients, who are, by law, “Medicare[-]entitled individuals,” id., are singled out for differential treatment because their costs are expensive and could be shifted to Medicare. If DaVita shows, through discovery, a “near-perfect overlap” between Medicare-entitled patients (via ESRD diagnosis) and dialysis patients, Reply Br. at 14, then it may show that, compared to other Plan enrollees, Medicare-entitled individuals are subject to 19Our holding does not preclude a disparate impact view of the take-into-account clause. No. 19-4039 DaVita, Inc. et al. v. Marietta Mem. Hosp. et al. Page 33 reduced benefits. For these reasons, DaVita has plausibly alleged a violation of the “take into account” provision of the MSPA for purposes of its ERISA claims.