Opinion ID: 2772181
Heading Depth: 2
Heading Rank: 1

Heading: Medicare Act Claims

Text: As to the District Court’s dismissal of plaintiffs’ Medicare Act claims, we affirm substantially for the reasons articulated in the District Court’s thorough opinion. First, plaintiffs lack standing to challenge the adequacy of the notices they received. Second, nothing in the statute entitles plaintiffs to the process changes they seek—i.e., expedited notice of their placement into observation status, and an expedited hearing to challenge this placement. As the District Court explained, the Medicare Act only requires that beneficiaries receive written notice of the receipt of a claim for benefits, which must state whether the beneficiary is entitled to Medicare coverage, and whether such coverage will be provided under Part A or Part B.32 This written notice is called a 30 Carpenters Pension Trust Fund of St. Louis v. Barclays PLC, 750 F.3d 227, 232 (2d Cir. 2014). 31 Bell Atl. Corp. v. Twombly, 550 U.S. 544, 570 (2007). 32 See 42 U.S.C. § 1395ff(a)(1) (stating in relevant part that “[t]he Secretary shall . . . make initial determinations with respect to benefits under part A of this subchapter or part B of this subchapter in accordance with those regulations for the following: (A) [t]he initial determination of whether an individual is entitled to benefits under such parts[;] (B) [t]he initial determination of the amount of 15 Medicare Summary Notice (“MSN”), and it summarizes the patient’s Medicare activity for the most recent three‐month period. If an MSN states that benefits have been denied, then it must state: (1) the reasons for the denial; (2) the procedures for obtaining additional information concerning the denial; and (3) notification of the right to seek a redetermination or to otherwise appeal the determination.33 The MSN also informs beneficiaries of their right to challenge the determination that they received observation services covered under Part B. It is undisputed that the Secretary has complied with these and other requirements. Plaintiffs’ sole argument on the merits is that 42 U.S.C. § 1395ff(b)(1)(F) entitles a beneficiary who is placed on “observation status” to expedited notice or administrative review. This provision, however, only applies when a hospital seeks “to terminate services” or “to discharge the individual from the provider of services.”34 It is clear from both the statute and our precedent that a beneficiary who is in “observation status” has not yet been formally admitted to the hospital. He or she has therefore not experienced a termination of services or a discharge.35 Accordingly, § 1395ff(b)(1)(F) does not benefits available to the individual under such parts[; and] (C) [a]ny other initial determination with respect to a claim for benefits under such parts . . . .”). 33 See id. § 1395ff(a)(4)(A). 34 See id. § 1395ff(b)(1)(F) (providing expedited proceedings to individuals who have received notice that their provider of services plans “to terminate services” or “to discharge” them). 16 entitle beneficiaries who are immediately or initially placed into “observation status” to any form of expedited process or administrative review.36 Because plaintiffs have failed to allege a plausible statutory violation, we affirm the District Court’s dismissal of claims six and seven, to the extent that these claims assert violations of the Medicare Act.