Opinion ID: 4576558
Heading Depth: 2
Heading Rank: 1

Heading: Medicare Secondary Payer Act

Text: In 1972, Congress provided Medicare benefits to individuals with end stage renal disease. See 42 U.S.C. § 426-1. Many of these individuals also had coverage under private health plans. The question thus arose: Who should pay healthcare providers—a private plan or Medicare? Private parties enacted plan terms that made them secondary payers behind Medicare or that denied coverage to Medicare-eligible individuals. See S. Rep. 97-139, at 469 (1981). To save money, Congress responded by amending the “Medicare Secondary Payer Act.” The change required private plans covering individuals with end stage renal disease to be the primary payers for a defined period (originally 12 months, now 30). Pub. L. No. 97-35, § 2146(a), 95 Stat. 357, 800 (1981). To stop plans from avoiding their primary-payer obligations by ending coverage for these individuals, this law eliminated a tax deduction for plans that differentiated in their benefits between individuals with end stage renal disease and others. Id. § 2146(b), 95 Stat. at 801. In 1989, Congress restructured the Medicare Secondary Payer Act into the format found today at 42 U.S.C. § 1395y(b). Pub. L. No. 101-239, § 6202(b), 103 Stat. 2106, 2229–32 (1989). Two clauses (which I will call the “take-into-account clause” and the “differentiate clause”) continue to limit a plan’s ability to target individuals with end stage renal disease. They provide: No. 19-4039 DaVita, Inc. et al. v. Marietta Mem. Hosp. et al. Page 41 A group health plan (as defined in subparagraph (A)(v))— (i) may not take into account that an individual is entitled to or eligible for benefits under this subchapter under section 426-1 of this title during the [30]-month period which begins with the first month in which the individual becomes entitled to benefits under part A under the provisions of section 426-1 of this title, or, if earlier, the first month in which the individual would have been entitled to benefits under such part under the provisions of section 426-1 of this title if the individual had filed an application for such benefits; and (ii) may not differentiate in the benefits it provides between individuals having end stage renal disease and other individuals covered by such plan on the basis of the existence of end stage renal disease, the need for renal dialysis, or in any other manner[.] 42 U.S.C. § 1395y(b)(1)(C). My colleagues hold that DaVita may enforce these clauses under the Act’s private right of action. Id. § 1395y(b)(3)(A). I would not answer that difficult question. I would instead hold that the two clauses quoted above do not prohibit the Marietta Plan’s terms.
The differentiate clause states that a “group health plan” “may not differentiate in the benefits it provides between individuals having end stage renal disease and other individuals covered by such plan on the basis of the existence of end stage renal disease, the need for renal dialysis, or in any other manner[.]” Id. § 1395y(b)(1)(C)(ii). DaVita argues that the Marietta Plan violates this clause because it treats dialysis services differently from all other covered services. The plan has no preferred dialysis provider and offers low reimbursement rates for dialysis services. Yet DaVita does not allege that the plan differentiates between participants who have end stage renal disease and other individuals. All participants receive the same benefits. So this case asks: Does this clause prohibit a plan that treats all participants the same, but provides worse coverage for services commonly used by those with end stage renal disease? My answer: No. The clause prohibits plans that offer participants with end stage renal disease different benefits from others. A plan cannot, for example, cover dialysis services for all participants except those with end stage renal disease. Yet a plan that uniformly offers the same benefits to all groups does not violate this clause. That is so even if this neutral plan has a disparate No. 19-4039 DaVita, Inc. et al. v. Marietta Mem. Hosp. et al. Page 42 impact on those with end stage renal disease because it provides lower reimbursement for services that they use. This reading follows from the relevant text, context, regulations, and precedent.
The clause says that a “group health plan” may not “differentiate . . . between” groups of “individuals” “in the benefits it provides” “on the basis of the existence of end stage renal disease, the need for renal dialysis, or in any other manner.” Id. This text’s component parts show that the clause prohibits plans that expressly engage in disparate treatment of individuals with end stage renal disease. It does not bar neutral plans that may have a disparate impact on those individuals. Group Health Plan. Start with the subject. The clause identifies a “group health plan” as the thing that cannot engage in the differentiation. The act uses the definition of “group health plan” from the Internal Revenue Code. Id. § 1395y(b)(1)(A)(v). The code, in turn, defines group health plan as “a plan . . . of, or contributed to by, an employer . . . to provide health care” to, among others, its employees. 26 U.S.C. § 5000(b)(1). A “plan” is “a formal program for specified benefits.” Random House Dictionary of the English Language 1480 (2d ed. 1987); 42 C.F.R. § 411.21 (defining “plan” as “arrangement”). The clause thus regulates the program, not the entity that picks its terms. That choice suggests that it is the plan terms (the arrangement) that may not engage in the forbidden “differentiation.” Cf. 42 C.F.R. § 411.21 (defining “payer” separately from “plan”). Differentiate Between. Congress’s verb choice indicates what those plan terms may not do: They may not “differentiate . . . between” two categories. The phrase “differentiate between” means “to establish or create the difference between people or things.” McGraw-Hill’s Dictionary of American Idioms and Phrasal Verbs 151 (2005); Random House, supra, at 552. To fall within this clause, therefore, the terms must create differences between the listed categories. Individuals. The clause next identifies the categories that the plan terms may not create differences between: “individuals having end stage renal disease” and “other individuals covered by such plan.” The clause thus bars terms that establish differences between two groups of individuals; it does not bar terms that establish differences between services. A plan might create No. 19-4039 DaVita, Inc. et al. v. Marietta Mem. Hosp. et al. Page 43 service differences if it covers outpatient chemotherapy but not outpatient dialysis. Or it might do so if it requires a $20 copayment for cancer drugs, but a $50 copayment for similarly priced dialysis drugs. If, however, the plan applies these coverage choices to all participants, the plan has not established differences between “individuals.” It has treated all individuals equally. Benefits. The clause also suggests that it might not bar all differentiation between the two groups, but only a subset of distinctions: those that are “in the benefits it provides” to participants. It thus prohibits a plan from giving individuals with end stage renal disease a different “entitlement to have payment made” for a healthcare service as compared to the entitlement offered to other participants for the same service. 42 U.S.C. § 1395d(a); see Webster’s Third New International Dictionary of the English Language 204 (3d ed. 1986). In Any Manner. Congress lastly added a phrase to ensure that plan terms would not avoid this prohibited differentiation by drawing clever distinctions. The clause notes that a plan may not differentiate between the two groups of individuals “on the basis of the existence of end stage renal disease, the need for renal dialysis, or in any other manner.” (This list likely contains a typo because it makes no sense to say “on the basis of . . . in any other manner.” A regulation parroting the statute thus adds an extra “or,” noting that a plan may not differentiate between individuals “on the basis of the existence of [end stage renal disease], or the need for renal dialysis, or in any other manner.” 42 C.F.R. § 411.161(b)(1).) The first item in this series shows that a plan may not divide participants into one group of individuals who have “end stage renal disease” and another group who do not, and provide different benefits to the two groups. The second item shows that a plan may not avoid that illegal differentiation by changing the label of the first group from individuals with “end stage renal disease” to individuals who “need renal dialysis.” The third item (“in any other manner”) bars other “ways” or “methods” that plans might establish differences between individuals who have end stage renal disease and others. See 9 Oxford English Dictionary 324 (2d ed. 1989). The “expansive” use of the word “any” bars any similar differentiation between the two groups. Freeman v. Quicken Loans, Inc., 566 U.S. 624, 635 (2012) (citation omitted). Yet this catchall cannot change the nature of the prohibited action. Just as a ban on “running in any manner” would not prohibit walking, so too the use of “any other No. 19-4039 DaVita, Inc. et al. v. Marietta Mem. Hosp. et al. Page 44 manner” cannot transform a ban on differentiating between individuals into a ban on differentiating between services. As the Supreme Court has noted when describing the word “any”: “Expansive, yes; transformative, no. It can broaden to the maximum, but never change in the least, the clear meaning of the phrase selected by Congress here.” Id. Putting these phrases together, I read the clause as barring plan terms that give different benefits to individuals with end stage renal disease, either by name or by definitions that impliedly target that group. The text requires courts to ask: Do a plan’s terms offer different benefits to individuals with end stage renal disease? Or, to put it differently, would an end-stage-renal-disease diagnosis change the benefits that a participant receives? If the answer is “no,” the plan is facially neutral and has not differentiated between individuals in a way that the clause prohibits. In this case, moreover, DaVita makes no claim that the Marietta Plan would flunk this neutrality test.
The Medicare Secondary Payer Act’s context confirms that we should interpret the differentiate clause to prohibit plans that engage in express disparate treatment of those with end stage renal disease, not neutral plans that have disparate impacts on them. The Act is not a substantive healthcare law like the Affordable Care Act designed to regulate health-plan benefits. Nor is it an antidiscrimination law like Title VII designed to protect against discrimination. Rather, it is a coordination-of-benefits law designed to dictate “the order of payment” when two programs cover the same service. Blue Cross & Blue Shield of Tex., Inc. v. Shalala, 995 F.2d 70, 73 (5th Cir. 1993); S. Rep. 97-139, at 469–70. A broad reading of the differentiate clause—one that bars even neutral plans with disparate impacts—would transform the Act well beyond this coordination-of-benefits domain. Cf. Epic Sys. Corp. v. Lewis, 138 S. Ct. 1612, 1626–27 (2018). But the clause’s text shows that it lacks the same structure as these other broader laws. Is the Act a substantive healthcare law? No. A comparison of the Act to other healthcare laws shows that it lacks the provisions that Congress uses when regulating the benefits that health plans must offer. Take the Affordable Care Act. It requires certain health plans to cover a minimum “essential health benefits package.” 42 U.S.C. § 300gg-6(a); id. § 18022(b). Or consider ERISA. It, too, requires group health plans to cover various healthcare services. See, No. 19-4039 DaVita, Inc. et al. v. Marietta Mem. Hosp. et al. Page 45 e.g., 29 U.S.C. § 1185. It also requires plans to provide a level of “parity” between medical benefits and mental-health benefits. Id. § 1185a. But Congress did not write the differentiate clause in either of these ways. The clause imposes neither a substantive mandate that a plan cover services associated with end stage renal disease nor an equality mandate that the plan treat those services like any other. Indeed, the Act’s allowance for Medicare to make secondary payments if a primary plan does not cover a provider’s full charge signals that it does not compel any minimum reimbursement rates. 42 U.S.C. § 1395y(b)(4). If, however, we read this clause to regulate a plan’s neutral benefits decisions, we would effectively impose the requirement that all plans cover services associated with end stage renal disease on the same terms as other services. Is the Act an antidiscrimination law? No again. The Act lacks the defining features of the specific antidiscrimination laws that the Supreme Court has read to impose disparate-impact liability. See Tex. Dep’t of Hous. and Cmty. Affairs v. Inclusive Cmtys. Project, Inc., 576 U.S. 519, 530–40 (2015) (Fair Housing Act); Griggs v. Duke Power Co., 401 U.S. 424, 429–32 (1971) (Title VII). To begin with, when interpreting these laws to prohibit neutral practices with disparate impacts, the Supreme Court reasoned that their text tied the legality of a defendant’s action “to the consequences of [the] action[.]” Doe v. BlueCross BlueShield of Tenn., Inc., 926 F.3d 235, 242 (6th Cir. 2019). Title VII, for example, contains two catchall clauses, one of which makes it unlawful for employers “otherwise to discriminate” against an employee and the other of which makes it unlawful for employers to “otherwise adversely affect” the employee. Tex. Dep’t of Hous., 576 U.S. at 531 (quoting 42 U.S.C. § 2000e-2(a)). The Court relied only on the latter clause to find disparate-impact liability. Id. It reasoned that the clause’s “operative text looks to results” by requiring courts to consider how a neutral practice affected an employee. Id. at 534. The Court thus found it proper to rely on the practice’s outcome when deciding on its legality. Id. This rationale is missing here. See Doe, 926 F.3d at 242. The differentiate clause contains no similar “results-oriented” verb. Tex. Dep’t of Hous., 576 U.S. at 535. Its catchall phrase (“in any other manner”) refers to ways in which plan terms might differentiate between the two groups of individuals. I do not read it as considering the effects of non-differentiating plan terms that treat all individuals equally. Oxford English Dictionary, supra, at 324. At most, this clause is analogous No. 19-4039 DaVita, Inc. et al. v. Marietta Mem. Hosp. et al. Page 46 to Title VII’s first clause (“otherwise to discriminate”). But the Court has not read that clause as creating disparate-impact liability. See Tex. Dep’t of Hous., 576 U.S. at 530–35. Next, when finding that the antidiscrimination laws impose disparate-impact liability, the Court relied on their “central purpose”: to “eradicate discriminatory practices within a sector of our Nation’s economy.” Id. at 539. That rationale is also missing here. The Act serves a different function: to protect taxpayers. As many courts have recognized, Congress passed the Act “[t]o ‘curb the rising costs of Medicare[.]’” MSPA Claims 1, LLC v. Kingsway Amigo Ins. Co., 950 F.3d 764, 767 (11th Cir. 2020) (citation omitted); Bio-Med. Applications of Tenn., Inc. v. Cent. States Se. & Sw. Areas Health and Welfare Fund, 656 F.3d 277, 282 (6th Cir. 2011). “The oddity of applying disparate-impact discrimination in this area points in the same direction.” Doe, 926 F.3d at 242. A disparate-impact framework would require a “wholly unwieldy” analysis. Id. (quoting Alexander v. Choate, 469 U.S. 287, 298 (1985)). A health plan covers services for many different health conditions at varied rates. How should courts decide whether a benefits package uniformly offered to all participants has an illegal disparate impact on individuals with end stage renal disease? Suppose the services associated with that disease are reimbursed at the “median” rate—such that many conditions have better coverage and many have worse. What conditions should we compare end stage renal disease to? Or must end stage renal disease have the absolute worst coverage, such that all other conceivable conditions fare better? Consider, too, that an administrator’s coverage choices might depend on factors outside its control. Here, for example, DaVita challenges Marietta’s failure to enter into a preferred-provider contract with a dialysis provider. Should it matter whether Marietta made good-faith efforts to do so? Should it matter whether a region’s dialysis market is highly concentrated, such that the rates for dialysis are much higher than the rates for other services? What if a preferred dialysis provider dramatically increases its prices? Would a plan be required to retain the provider on threat of a disparate-impact suit? At day’s end, I see no “objective and workable standard for choosing a reasonable benchmark by which to” decide whether a neutral plan has an illegal disparate impact on those with end stage renal disease. Holder v. Hall, 512 U.S. 874, 881 (1994) (plurality op.). No. 19-4039 DaVita, Inc. et al. v. Marietta Mem. Hosp. et al. Page 47 And the subjectivity of this exercise will inevitably give providers leverage to threaten suit (and double damages, 42 U.S.C. § 1395y(b)(3)(A)) whenever they do not like a neutral plan. Lastly, apart from disparate-impact claims, the antidiscrimination laws typically otherwise bar a neutral practice only if adopted with an invidious intent to harm a protected group. Ricci v. DeStefano, 557 U.S. 557, 577–78 (2009). And a practice’s disparate impact on that group can be evidence of the intent to harm. Tex. Dep’t of Hous., 576 U.S. at 588 (Alito, J., dissenting). That is what the Supreme Court means when it says that a “tax on wearing yarmulkes is a tax on Jews”: A tax on a practice associated with a group can be evidence of “an intent to disfavor” it. Bray v. Alexandria Women’s Health Clinic, 506 U.S. 263, 270 (1993). Here, though, I do not read the differentiate clause to make intent relevant. It regulates a “group health plan,” not the employer who adopts the plan, and so focuses on the express terms rather than the hidden motives. The catchall “in any other manner” confirms that the clause bars any act that qualifies as the forbidden “differentiation”—whether taken with an invidious or innocuous intent. This fact, too, suggests that the clause does not cover neutral plans. If it did, the clause might not allow the standard antidiscrimination defense that an employer adopted the plan for a legitimate reason unrelated to an intent to harm those with end stage renal disease. And even disparate-impact claims come with the standard “business necessity” defense—another defense that this clause’s text might not include. Tex. Dep’t of Hous., 576 U.S. at 541–42. In sum, any reading that would reach neutral group health plans would depart from the Act’s context and prove unworkable. So even if I found some ambiguity in the clause’s plain text, I would stick with the reading I have chosen: The clause bars differentiation between individuals, not services. See Util. Air Regulatory Grp. v. EPA, 573 U.S. 302, 321–24 (2014).
Because “Congress has supplied a clear and unambiguous answer to the interpretive question at hand,” I would not defer to how the relevant administrative agency (the Department of Health and Human Services) approached this question if its view differed from my own. Pereira v. Sessions, 138 S. Ct. 2105, 2113 (2018). Still, the regulation implementing this clause largely comports with my view that it prohibits differentiation between individuals. 42 C.F.R. § 411.161. No. 19-4039 DaVita, Inc. et al. v. Marietta Mem. Hosp. et al. Page 48 A subsection entitled “Uniform Limitations on particular services permissible” states: “A plan is not prohibited from limiting covered utilization of a particular service as long as the limitation applies uniformly to all plan enrollees.” Id. § 411.161(c) (emphasis added). This subsection nowhere suggests that courts must consider whether this limit disparately affects those with end stage renal disease. A hypothetical confirms the point: “For instance, if a plan limits its coverage of renal dialysis sessions to 30 per year for all plan enrollees, the plan would not be differentiating in the benefits it provides between plan enrollees who have [end stage renal disease] and those who do not.” Id. Even though this hypothetical limit will have a disparate impact on end-stage-renal-disease patients, the limit does not violate the differentiate clause because it applies to all plan participants equally. The regulation also identifies four examples of improper “differentiation” that support my reading that the clause prohibits differentiation between individuals, not services. It notes that a plan engages in improper “differentiation” if it: ends coverage for “individuals” who have end stage renal disease; imposes limits on those “persons” “but not on others enrolled in the plan”; charges the “individuals” higher premiums; or reimburses healthcare providers less for services furnished “to individuals who have” end stage renal disease as compared to the reimbursement for the “same services” furnished to others. 42 C.F.R. § 411.161(b)(i)–(iv) (emphases added). The last example would suggest that it is acceptable to pay different rates for different services, so long as the different providers received those different rates for all participants in the plan. That said, I agree that this regulation includes one outlier example that seems servicebased, not individual-based. The regulation suggests that a plan would violate this clause if it failed “to cover routine maintenance dialysis or kidney transplants, when [it also] cover[ed] other dialysis services or other organ transplants.” Id. § 411.161(b)(v). This service-based example cannot be reconciled with the regulation’s allowance for uniform coverage limits. Id. § 411.161(c). It also departs from the other four individual-based examples of improper differentiation. Id. § 411.161(b)(i)–(iv). All told, then, the regulation generally supports my reading and, to the extent it does not, it would lose any right to deference given its internally contradictory nature. No. 19-4039 DaVita, Inc. et al. v. Marietta Mem. Hosp. et al. Page 49
As far as I am aware, every district court to consider this question has interpreted this clause as I do. See DaVita, Inc. v. Marietta Mem’l Hosp. Emp. Health Benefit Plan, 2019 WL 4574500, at  (S.D. Ohio Sept. 20, 2019); Dialysis of Des Moines, LLC v. Smithfield Foods Healthcare Plan, 2019 WL 8892581, at  (E.D. Va. Aug. 5, 2019); DaVita, Inc. v. Amy’s Kitchen, Inc., 379 F. Supp. 3d 960, 973 (N.D. Cal. 2019); Nat’l Renal All., LLC v. Blue Cross & Blue Shield of Ga., Inc., 598 F. Supp. 2d 1344, 1354 (N.D. Ga. 2009). These courts hold that the clause does not bar a plan that offers the same benefits “to all enrollees equally,” even if it offers worse coverage for end-stage-renal-disease services. Marietta, 2019 WL 4574500, at . So, for example, a plan that uniformly provides lower reimbursement rates for dialysis services does not differentiate between individuals with end stage renal disease and others. See Amy’s Kitchen, 379 F. Supp. 3d at 973; Nat’l Renal All., 598 F. Supp. 2d at 1354. Likewise, a nine-month cap on dialysis coverage does not violate the clause as “long as it is uniform, meaning that it applies to all plan enrollees regardless of” an end-stage-renal-disease diagnosis. Dialysis of Des Moines, 2019 WL 8892581, at . This precedent supports my conclusion: Because the Marietta Plan applies the same uniform benefits to everyone, it does not violate this differentiate clause.
The take-into-account clause states that a “group health plan” “may not take into account that an individual is entitled to or eligible for benefits under” 42 U.S.C. § 426-1 for a discrete period of time. 42 U.S.C. § 1395y(b)(1)(C)(i). DaVita again asserts that this clause does not permit group health plans to offer a neutral benefits package that has a disparate impact on those who are Medicare eligible. At the least, DaVita suggests, the neutral plan could violate this provision if an entity adopted its terms with an intent to target Medicare-eligible individuals. Yet, for the same reasons that I have already discussed, I read this clause to bar only group health plans that contain terms expressly targeting Medicare-eligible individuals who are eligible because of their end stage renal disease. The clause, for example, prohibits a plan from disqualifying an individual from coverage if the individual becomes Medicare eligible. See Bio-Med., 656 F.3d at No. 19-4039 DaVita, Inc. et al. v. Marietta Mem. Hosp. et al. Page 50 282–83. The clause does not, by contrast, prohibit neutral plans that treat Medicare-eligible individuals the same as everyone else—regardless of any disparate impact or plan-sponsor intent. First, the text compels this reading. Like the differentiate clause, this clause applies to a “group health plan,” not the employer or payer. So it regulates the “formal program” or “arrangement,” not the motives of the “entities” that adopted it. 42 C.F.R. § 411.21; Random House, supra, at 1480. The phrase “take into account” next shows that the clause bars that arrangement from giving “consideration” to, or making “allowance” for, something. 1 Oxford English Dictionary 86 (2d ed. 1989) (defining “account”); Longman Dictionary of Phrasal Verbs 649 (1983); see Bio-Med., 656 F.3d at 282. The something? Unlike the differentiate clause, this clause shifts the focus from all individuals with end stage renal disease to certain individuals with that disease. It says that, for 30 months, the plan may not consider the fact “that an individual is entitled to or eligible for” Medicare benefits under 42 U.S.C. § 426-1. The clause thus has a narrower scope because Medicare does not cover all individuals with end stage renal disease. It instead starts covering individuals only after they have received dialysis treatment for three months (or have had a kidney transplant). Id. § 426-1(b)(1)–(2); see also 42 C.F.R. § 406.13(e)(2). Thus, this clause prohibits plan terms that consider an individual’s Medicare eligibility under § 426-1, not terms that consider an end-stage-renal-disease diagnosis. When the clause is read in this way, the Marietta Plan does not violate it. DaVita concedes that the plan terms do not facially target Medicare-eligible individuals. Consider this point from a participant’s perspective. A patient with end stage renal disease must seek dialysis treatments under the Marietta Plan’s rates for the first three months. See 42 U.S.C. § 426-1(b)(1). After that period, the patient will become Medicare eligible. Does that change in status affect this Medicareeligible participant in any way? No, it will not have any effect on the benefits that a participant receives or the reimbursement rate offered to dialysis providers. I thus do not see how the Marietta Plan itself could be said to take into account a participant’s Medicare eligibility. That participant is treated the same as a participant with end stage renal disease who is not Medicare eligible. Second, the contextual factors I discussed earlier caution against finding liability for neutral plan terms. If anything, these contextual clues apply with even more force here. To begin with, No. 19-4039 DaVita, Inc. et al. v. Marietta Mem. Hosp. et al. Page 51 nowhere does the take-into-account clause contain the type of “results-oriented” language that the Supreme Court has required for disparate-impact liability. Tex. Dep’t of Hous., 576 U.S. at 535; see Doe, 926 F.3d at 242. In addition, the Medicare Secondary Payer Act uses the same “take into account” phrase in nearby provisions. The Act indicates that a group health plan may not “take into account” that a plan participant is entitled to participate in the general Medicare program because of age or disability. 42 U.S.C. § 1395y(b)(1)(A)(i)(I), (B)(i). A disparate-impact theory thus would not be cabined to this end-stage-renal-disease provision. It would prohibit group health plans from enacting any neutral term that caused a disparate impact on, for example, individuals over 65 who are Medicare eligible. Many diseases and conditions uniquely impact the elderly, and disparate-impact liability would leave plans with no guidance concerning plan terms for these elder-focused services. Additionally, this disparate-impact theory would render superfluous a nearby provision that bars plans from providing inferior benefits to those over 65 as are available to those under that age. Id. § 1395y(b)(1)(A)(i)(II). That illegal age-based differential treatment would also have an obvious disparate impact on Medicare-eligible individuals over 65. It confirms that the take-into-account clause should not be broadly read to impose disparate-impact liability. Third, while I again find the language clear, regulations confirm my reading that the clause bars discriminatory plan terms that target Medicare-eligible individuals, not neutral plan terms that apply to all participants. See 42 C.F.R. §§ 411.108, 411.161(a)(1). All of the regulatory examples of improper “taking into account” involve plan terms that target Medicare-eligible individuals. A plan may not terminate “coverage because the individual has become entitled to Medicare,” id. § 411.108(a)(3), impose “limitations on benefits for a Medicare entitled individual that do not apply to others enrolled in the plan,” id. § 411.108(a)(5), or pay “providers and suppliers less for services furnished to a Medicare beneficiary than for the same services furnished to an enrollee who is not entitled to Medicare,” id. § 411.108(a)(8). The examples, by contrast, nowhere suggest that a plan could improperly “take into account” Medicare eligibility by providing the same reimbursement for Medicare-eligible and non-eligible individuals if those neutral rates disparately affected the former group. If anything, the examples suggest that a group health plan may apply neutral rules to all individuals. They note that a plan could neutrally extend to Medicare-eligible No. 19-4039 DaVita, Inc. et al. v. Marietta Mem. Hosp. et al. Page 52 individuals the requirement that an employee must have worked for a year as long as that requirement applied to all other participants. Id. § 411.108(b)(1). Fourth, precedent again supports my view. The same district courts discussed above agree that a plan only violates this provision when it “treats those eligible for Medicare differently than those who are not.” Marietta, 2019 WL 4574500, at ; Dialysis of Des Moines, 2019 WL 8892581, at ; Amy’s Kitchen, 379 F. Supp. 3d at 972–733; Nat’l Renal All., 598 F. Supp. 2d at 1354. To date, moreover, our court has found a violation of the take-into-account clause only when a health plan expressly eliminated coverage for participants who were eligible for Medicare. Bio-Med., 656 F.3d at 282–83. Yet the Marietta Plan falls on the right side of this divide because, unlike the plan in Bio-Medical, it does not target Medicare-eligible individuals for unique treatment. It thus does not violate this take-into-account clause.