Document: 456 U.S. 201 102 S.Ct. 1650 72 L.Ed.2d 12 UNITED STATES, Petitioner,v.ERIKA, INC. No. 80-1594. Argued March 1, 1982. Decided April 20, Syllabus Part B of the Medicare program, federally subsidized, voluntary health insurance system for persons 65 or older who are disabled, supplements A, which covers institutional costs such as hospital expenses, by insuring against a portion medical expenses excluded from A. Under statute, private carriers assigned task paying claims. If carrier determines that claim meets coverage criteria, is paid out federal funds. Disputed determinations subject to review in hearing if disputed amount $100 more. The statute also provides Secretary Health and Human Services whether an individual entitled benefits under A B, determination Persons dissatisfied with Secretary's decision granted right additional administrative review, together option judicial when dispute relates their eligibility participate either concerns benefits. When respondent distributor kidney dialysis supplies made sales covered purchasers claims respondent. Respondent turn billed carrier, was required contract reimburse 80% what it determined were "reasonable charges" supplies. interpreted relevant regulations define be catalog price July 1 preceding calendar year. refused respondent's request make adjustments this method reimbursement order reflect interim increases, sought before one carrier's officers, upheld decision. then brought action United States Court Claims, seeking on basis its current charges. After ruling suit within jurisdiction Tucker Act, Claims held calculation allowable charges erred several respects, remanded redetermination Held : has no payable program. Pp. 206-211. (a) In context statute's precisely drawn provisions, omission authorize awards persuasive evidence Congress deliberately intended foreclose further 206-208. (b) legislative history confirms limit awards, generally smaller than awards. 208-211 634 F.2d 580, 225 Ct.Cl. 252, 647 129, 273, reversed. Edwin S. Kneedler, Washington, D. C., petitioner. Stephen H. Oleskey, Boston, Mass., Justice POWELL delivered opinion Court. question statute. 2 * 79 Stat. 301, amended, 42 U.S.C. § 1395j et seq. (1976 ed. Supp.IV), disabled. companion program expenses. A's some certain physician services X-rays, Eligible individuals pay monthly premiums they choose enroll B. These premiums, contributions Federal Government, deposited Supplementary Medical Insurance Trust Fund finances See §§ 1395j, 1395r, 1395s, 1395t, 1395w Supp.IV). 3 administers "In provide administration . maximum efficiency convenience benefits," authorized assign experienced matters.1 1395u. H.R.Rep. 213, 89th Cong., 1st Sess., 46 (1965); S.Rep. 404, 53 (1965), U.S.Code Cong. & Admin.News 1965, p. 1943. enrollees receive care, (or, after assignment, providers) bill carrier. 4 all criteria necessity reasonable cost, pays 1395u; Schweiker v. McClure, 188, 1665, 1. decides full not warranted, designate appeal procedure available claimants. All may "review determination," de novo written employee different initially decided claim. Claimants remain whose involves more petition oral officer designated 1395u(b)(3)(C); CFR 405.820 (1980). Unless reopen proceeding, officer's "final binding upon parties hearing. ." 405.835. Neither nor provision decisions. II 5 Respondent, major supplies, sold products institutions individuals. About half purchasing 426(e), 426-1 ed., Supp.IV) (establishing renal disease). Prudential Company America, New Jersey area based. According Secretary, charg[e]" these 1395l 6 year.2 For example, reimbursed invoices 1975, June 30, 1976, prices contained 1974, catalog. 7 began reimbursing 1974. Early 1976 learned about grounds Prudential's partial invoices. At time requested adjust past future reimbursements increases effective agreed prospectively payment drug heparin, apparently had increased sharply. Cf. Dept. HEW, Carriers Manual 5010.2 (1980) (permitting customary "highly unusual situations where equity clearly indicates warranted"). But retroactive heparin any at other products.3 8 refusal officers pursuant 1395u(b)(3)(C). affirmed instant charges, asserting set contravened Fifth Amendment well Social Security Act applicable regulations. ruled jurisdictional grant 28 1491, permits hear "any founded Constitution, Congress, regulation executive department." 584-588, 256-262 (en banc), clarified, 273 (1981).4 On merits, court charge respects. Id., 588-590, Ct.Cl., 262-268. case matters.5 We certiorari determine over suits kind. 451 982, 101 2312, 68 838 (1981). now reverse. III 9 argues enacting specifically precluded adverse payments. agree.6 10 Our lodestar language specified "a fair controversy 1395u(b)(3)(C) (emphasis added).7 provided explicitly "determination[s] part [of] 1395ff(a) added). Individuals matters review,8 review,9 two instances only: 1395ff(b).10 11 Section 1395ff thus distinguishes between types decisions: (that decide "disabled" meaning program) particular claim). Conspicuously, fails See, e.g., Lehman Nakshian, 453 156, 162-163, 2698, 2702-2703, 69 548 (1981); Fedorenko States, 449 490, 512-513, 737, 750, 66 686 IV view explains logic. Committee Reports accompanying original enactment stated supplemental payments expected those primary Apparently, reason proposed did concerning [P]art 55 pp. 1943, 1995.11 13 This intent reiterated amended 1395ff(b) 1972.12 introducing amendment, Senator Bennett clarify existing law, "greatly restricted" appealability decisions "in avoid overloading courts quite minor matters." 118 Cong.Rec. 33992 (1972). explained amendment would assure questions "eligibility medicare but [as] given service."13 Ibid. 14 Conference advanced identical explanation amendment: 15 "CLARIFICATION OF MEDICARE APPEAL PROCEDURES 16 "Amendment 561: Senate added new section House clear there authorization solely involving amounts insofar concerned, only $1,000 17 "The recedes." H.R.Conf.Rep. 92-1605, 61 (1972), 1972, 4989, 5394. 18 expressions unambiguously support our reading statutory language. advances contrary congressional will. circumstances, end.14 19 judgment 20 So ordered. involved America. Claimants' reimbursable charge" cannot exceed "prevailing calculated "the locality." 1395u(b)(3) effort control extent contributes inflation costs, formula based typical local rates 405.504(a)(2)(i) (defining fee "would cover 75 percent similar same locality during year start 12-month period (beginning each year) submitted made") defined own because virtually provider locality. claimed substantial printing error product. been settled longer issue. added: plaintiff asserts we have 10(b) Administrative Procedure 703. holding find unnecessary consider jurisdiction. cf. Califano Sanders, 430 99, 97 980, 51 192 (1977)." F.2d, 585, n. 5, 256, 5. Respondent's arguments directed large measure actions Prudential. Prudential, however, party litigation. specify Administrator Care Financing Administration "is real interest litigation [Medicare] program." 421.5(b) found constitutional "insubstantial," citing Aznavorian, 439 170, 99 471, 58 435 (1978); Mathews Eldridge, 424 319, 96 893, 47 (1976); Dandridge Williams, 397 90 1153, 25 491 (1970). 591, 268. One judge wrote separately express regret regarding "short shrift" majority gave 593, 272. He reasoned "Erika have, probably has, allegations mostly aid jurisdiction, should spurn aid." 594, 272 (Nichols, J., concurring). does press us. As dispositive, do reach Government's alternative contentions 405(h) controls failed show unequivocally waived sovereign immunity. Although terms affords "individual enrolled [Part B]," 1395u(b)(3)(C), extends suppliers whom beneficiaries 405.801(a) 405(b); subpart J 405(g). "§ 1395ff. Determinations "(a) Entitlement shall accordance prescribed him. "(b) Appeal "(1) Any subsection to— "(A) he conditions 426 426a title [which forth requirements satisfied permitted program], "(B) eligible provisions [the program] ., or, "(C) (including zero) thereon 405(b) final 405(g) title." With respect "Appeals" Report stated: committee's determinations, both plan A] supplementary B], B] hearings determination. Hearings (Under carriers, beneficiary complaints benefits, will substantially A.) Hospitals, extended care facilities, home agencies It remedies procedures exclusive." 54-55 1995 (1965). Congressional limitation claimants must understood light magnitude 1980, instance, 158 million processed. U.S., 190, S.Ct., 1667. originally enacted, provided: "Any entitlement matter more, title, and, 330, (1970 ed.) 1972 replaced emphasized language, including first word "entitlement," create wording quoted 10, supra. Bennett's entire opening statement follows: ". Mr. President, purpose sure gives person go welfare, mean can take court. never end it. reconfirm intention law eligibility. appealable greatly restricted matters. refers 'entitlement' being issue service. "If denied, held, resources unduly taxed little value derived enrollees. merely prevent trivial considered unclear." without discussion. addition substantive money assertedly arising derives implied-in-fact third-party States. fail contracts necessarily include preclusion officers' response questioning argument, counsel answered Tr. Oral Arg. 39. neither argued ground included among presented brief opposition devoted briefing consequently address Court's Rules 34.2 22.1; Neely Martin K. Eby Construction Co., Inc., 386 317, 87 1072, 1080, (1967).

Category: 8