Opinion ID: 4547825
Heading Depth: 1
Heading Rank: 3

Heading: Dismissal Order Issues.

Text: Plaintiffs appeal the dismissal of claims that Wellmark violated cost-sharing and information and disclosure requirements of the ACA mandate. In reviewing dismissal order issues under Rule 12(b)(6), we take the facts alleged in the Complaint as true and draw all reasonable inferences in Plaintiffs’ favor. Meiners v. Wells Fargo & Co., 898 F.3d 820, 821 (8th Cir. 2018). To survive, the Complaint must allege “sufficient factual matter, accepted as true, to state a claim to relief that is plausible on its face.” Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009), quoting Bell Atl. Corp. v. Twombly, 550 U.S. 544, 570 (2007). -6- The parties agree that the ACA mandate provides no private right of action. Rather, the Complaint alleged that Plaintiffs may enforce provisions of the ACA governing CLS benefits “through Incorporation by Reference in [Wellmark] Plan Documents.” As York was a member of a UIChoice group health plan not governed by ERISA, her breach of contract claim is governed by and construed in accordance with the laws of the State of Iowa, as the coverage manual expressly stated. Under Iowa law, parties subject to a statute “are presumed to contract in reference to the existing law, which becomes a part of the contract.” In re Mt. Pleasant Bank & Tr. Co., 426 N.W.2d 126, 134 (Iowa 1988); see 11 Richard A. Lord, Williston on Contracts § 30:19 (4th ed. 2012). Wellmark has not raised the issue, so we assume without deciding that this principle applies to York’s state law claims.3 Plaintiffs first argue the district court erred in dismissing their claims that Wellmark violated “information and disclosure requirements” in the preventive health services mandate. The Complaint listed “administrative barriers” to accessing CLS benefits from Wellmark -- “inconsistent guidance” from customer service representatives, “inaccurate information” given to insureds, and failure to provide a list of in-network providers by mail, through customer representative phone consultation, or through Wellmark’s website. The Complaint recounted the struggles of York and Bailey to identify a lactation consultant through phone calls and Wellmark’s website. Plaintiffs argue these allegations state a facially plausible violation of the ACA’s preventive health services mandate. 3 Plaintiffs fail to address how York’s information and disclosure claims would be resolved under Iowa law, either in an administrative proceeding under the State’s insurance laws or by a state court. Plaintiffs simply present York’s claims as if they were based on a federal private right of action the ACA does not provide. This alone is reason to affirm the district court’s dismissal Order as to York. But the district court addressed the merits of that claim, so we will also. -7- In dismissing these claims, the district court accurately noted that neither the statutory mandate nor its implementing regulations requires the disclosure of information -- including a list of providers -- or prohibits “administrative barriers” or “inconsistent guidance.” Rather, the mandate provides that group health plans and health insurance issuers “shall, at a minimum provide coverage for and shall not impose any cost sharing requirements for” preventive health services. 42 U.S.C. § 300gg-13(a). The mandate addresses only “coverage” and “cost sharing,” whereas related sections and regulations implementing other health care statutes address the information plans must disclose to their participants. See 42 U.S.C. §§ 300gg-15, 300gg-15a, 18031(e)(3); 29 C.F.R. § 2590.715-2715. Likewise, the mandate’s implementing regulations do not include information and disclosure requirements. See 29 C.F.R. § 2590.715-2713. Plaintiffs’ initial brief, like the Complaint, contains lengthy assertions regarding “fundamental, immutable constructs of insurance coverage” and the objectives, purpose, and underlying policies of the ACA. But “vague notions of a statute’s basic purpose” cannot “overcome the words of its text regarding the specific issue under consideration.” Great-W. Life & Annuity Ins. Co. v. Knudson, 534 U.S. 204, 220 (2002) (quotation omitted). “[I]t frustrates rather than effectuates legislative intent simplistically to assume that whatever furthers the statute’s primary objective must be the law.” Rodriguez v. United States, 480 U.S. 522, 526 (1987). Plaintiffs argue the district court erred in dismissing their claims that Wellmark failed to provide a “separate list” of lactation counseling providers. According to Plaintiffs, that is a failure to provide “coverage.” We reject this argument because it is contrary to the plain language of the statute, which we enforce according to its terms. See King v. Burwell, 135 S. Ct. 2480, 2489 (2015). Both ERISA and the ACA define “health insurance coverage” as “benefits consisting of medical care (provided directly, through insurance or reimbursement, or otherwise and including items and services paid for as medical care) under any hospital or medical service policy or certificate, hospital or medical service plan contract, or health maintenance organization contract -8- offered by a health insurance issuer.” 29 U.S.C. § 1191b(b)(1); 42 U.S.C. § 300gg-91(b)(1). “[W]e must read the words [in a statute] in their context and with a view to their place in the overall statutory scheme” because “[o]ur duty, after all, is to construe statutes, not isolated provisions.” King, 135 S. Ct. at 2489 (quotations omitted). Thus, “coverage” under the ACA refers to “the type or amount of benefits or services covered under a plan,” not “the hassle associated with utilizing those services.” Hartford Healthcare Corp. v. Anthem Health Plans, Inc., No. 3:17-CV-1686 (JCH), 2017 WL 4955505, at -9 (D. Conn. Nov. 1, 2017); contra Briscoe v. Health Care Serv. Corp., 281 F. Supp. 3d 725, 733 (N.D. Ill. 2017). Like the district court, we do not find persuasive a 2015 Frequently Asked Question (“FAQ”) issued by the Departments of Labor, the Treasury, and Health and Human Services stating that “plans and issuers [are] required to provide a list of the lactation counseling providers within th[eir] network.”4 As the district court explained, this FAQ relied on regulations promulgated under other federal statutes regulating group health plans and issuers, including disclosure requirements under ERISA. See 29 C.F.R. § 2520.102-3(j)(3), implementing 29 U.S.C. § 1022. But these other regulations provide no authority for prescribing substantive disclosure requirements under the ACA and its implementing regulations, which contain no such requirements. To validly impose new substantive requirements under the ACA requires proceeding by full notice and comment rulemaking under the Administrative Procedure Act, 5 U.S.C. § 553. See Children’s Health Care v. Centers for Medicare & Medicaid Servs., 900 F.3d 1022, 1025-27 (8th Cir. 2018); Children’s Hosp. of the King’s Daughters, Inc. v. Azar, 896 F.3d 615, 621-23 (4th Cir. 2018). We conclude the term “coverage” in the ACA mandate did not require Wellmark to provide a separate list of its innetwork lactation counseling providers. 4 FAQs About Affordable Care Act Implementation (Part XXIX) and Mental Health Parity Implementation at 2 (Oct. 23, 2015), available at https://www.dol.gov/ sites/default/files/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-xxix.pdf. -9- Bailey seeks relief under a group health plan governed by ERISA, which preempts state law remedies. Although the ACA does not impose “information and disclosure requirements,” ERISA provides a private right of action for an alleged breach of a plan administrator’s duty “to distribute written notices that are sufficiently accurate and comprehensive to reasonably apprise plan participants and beneficiaries of their rights and obligations under the plan.” CIGNA Corp. v. Amara, 563 U.S. 421, 443 (2011) (statutory quotation omitted). But Bailey did not assert a breach of that duty, no doubt because it would be defeated by her failure to present a timely claim for relief under the Wellmark Alliance Select plan. Rather, her claim is that the ACA mandate and its implementing regulations impose a categorical fiduciary duty on the administrators of group health plans governed by ERISA to publish a “separate list” of lactation counseling providers. We agree with the district court that, under regulations implementing an ERISA fiduciary’s disclosure obligations, “the health plan need only provide a list of network providers and describe when out-of-network services are covered -- not specify which of those providers offer certain services such as lactation counseling.” York, 2017 WL 11261026 at , citing 29 C.F.R. § 2520.102-3(j)(3). Thus, Bailey’s information and disclosure claim under ERISA, like York’s claim under Iowa law, failed to state a claim on which relief may be granted. The district court’s Order dismissing these claims is affirmed.