Court Opinion

ID: 9378927
Source: CourtListenerOpinion
Date Created: 2023-03-14 00:00:34.086365+00
Date Added: 2024-06-11T17:16:24.211809
License: Public Domain

Case: 22-10062        Document: 00516674855          Page: 1    Date Filed: 03/13/2023

             United States Court of Appeals
                  for the Fifth Circuit
                                                                             United States Court of Appeals
                                                                                      Fifth Circuit

                                                                                    FILED
                                                                              March 13, 2023
                                      No. 22-10062                             Lyle W. Cayce
                                                                                    Clerk

   Roslyn Gonzalez, individually and on behalf of all others similarly
   situated,

                                                               Plaintiff—Appellant,

                                         versus

   Blue Cross Blue Shield Association; Health Care
   Services Corporation, doing business as Blue Cross Blue
   Shield of Texas; United States Office of Personnel
   Management,

                                                           Defendants—Appellees.

                     Appeal from the United States District Court
                         for the Northern District of Texas
                              USDC No. 3:20-CV-2149

   Before Graves, Willett, and Engelhardt, Circuit Judges.
   Don R. Willett, Circuit Judge:
         Roslyn Gonzalez is a former federal employee and participant in a
   health-insurance plan (“Plan”) that is governed by the Federal Employees
   Health Benefits Act (“FEHBA”).1 The Plan stems from a contract between

         1
             5 U.S.C. §§ 8901–8914.
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   the federal Office of Personnel Management (“OPM”) and Blue Cross Blue
   Shield Association and certain of its affiliates (together, “Blue Cross”). Blue
   Cross administers the Plan under OPM’s supervision.
           Gonzalez suffered from cancer, and she asked Blue Cross whether the
   Plan would cover the proton therapy that her physicians recommended. Blue
   Cross told her the Plan did not cover that treatment. So Gonzalez chose to
   receive a different type of radiation treatment, one that the Plan did cover.
           The second-choice treatment eliminated the cancer, but it also caused
   devastating side effects. Gonzalez then sued OPM and Blue Cross, claiming
   that the Plan actually does cover proton therapy. As against OPM, she seeks
   the “benefits” that she wanted but did not receive, as well as an injunction
   directing OPM to compel Blue Cross to reform its internal processes by,
   among other things, covering proton therapy in the Plan going forward. As
   against Blue Cross, she seeks monetary damages under Texas common law.
           The district court dismissed Gonzalez’s suit. It concluded that
   sovereign immunity bars Gonzalez’s monetary claims against OPM, that
   Gonzalez lacks standing for injunctive relief, and that FEHBA expressly
   preempts Gonzalez’s state-law claims against Blue Cross. Our reasoning
   follows a different path, but we AFFIRM the district court’s judgment.
                                              I
                                              A
           “The Federal Employees Health Benefits Act of 1959[] establishes a
   comprehensive program of health insurance for federal employees.”2
   “FEHBA assigns to OPM responsibility for negotiating and regulating

           2
            Empire Healthchoice Assur., Inc. v. McVeigh, 547 U.S. 677, 682 (2006) (citations
   omitted) (internal abbreviations omitted).

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   health-benefits plans for federal employees.”3 OPM carries out that duty by
   agreeing to contracts with private insurers like Blue Cross, who then act as
   “carriers”4 to “provide health benefits to federal employees.”5 As a carrier,
   “Blue Cross never takes on the risks of an insurer in its relationship with
   OPM. It operates instead as a claims processor, rather than an insurer.”6
           OPM has the first and last word on the health benefits that an
   employee may receive under the Plan. First, OPM’s contract with Blue
   Cross describes the benefits that employees are eligible for, and on what
   terms. That contract requires Blue Cross to furnish each enrolled employee
   with a detailed Statement of Benefits (the contract also incorporates that
   document).7 Blue Cross must provide the benefits that OPM requires, and it
   cannot modify or misrepresent those benefits. OPM has the last word, too,
   because Blue Cross must honor any case-by-case determinations that OPM
   makes for an individual employee.8
           “In the event of a dispute between a patient and Blue Cross over
   coverage, OPM resolves the issue.”9 Here’s how. The patient begins the
   process by submitting a claim to Blue Cross.10 If Blue Cross denies the claim,

           3
               Id. at 684; see 5 U.S.C. § 8902.
           4
               5 U.S.C. § 8901(7).
           5
             St. Charles Surgical Hosp., LLC v. La. Health Serv. & Indem. Co., 935 F.3d 352,
   356 (5th Cir. 2019) (citations omitted).
           6
               Id.
           7
               5 U.S.C. § 8902(d).
           8
               5 U.S.C. § 8902(j).
           9
               St. Charles, 935 F.3d at 356; see 5 C.F.R. § 890.105(a)(1).
           10
                5 C.F.R. § 890.105(a)(1).

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   the patient can ask Blue Cross to reconsider.11 If Blue Cross affirms the
   denial, then the patient can ask for OPM’s review.12 If OPM also denies the
   claim, then the patient can then seek judicial review of OPM’s denial.13
           OPM’s regulations require a patient to “exhaust both the carrier and
   OPM review processes . . . before seeking judicial review.”14 The regulations
   also say that a patient who wishes to challenge a denial may sue only OPM,
   not Blue Cross.15 “The recovery in such a suit shall be limited to a court order
   directing OPM to require the carrier to pay the amount of benefits in
   dispute.”16 The Plan documents describe all of these procedures.
                                                   B
           Roslyn Gonzalez is a former federal employee and participant in the
   Plan.17 In 2019, she was diagnosed with a malignant tumor in her lower
   abdomen. Her healthcare provider, the MD Anderson Cancer Center,
   determined that radiation treatment was necessary. Given the tumor’s
   location and severity, as well as Gonzalez’s medical history, MD Anderson
   recommended a special, more expensive type of radiation therapy called
   proton beam therapy.
           Blue Cross allows providers and claimants to ask about coverage using
   a process that it calls “advance benefit determination.” This process lets

           11
                Id.
           12
                Id.
           13
                Id. § 890.107(c).
           14
                Id. § 890.105(a)(1); id. § 890.107(d)(1).
           15
                Id. § 890.107(c).
           16
                Id.
           17
             In this appeal from a motion to dismiss, we draw the facts from Gonzalez’s
   operative complaint. See Sewell v. Monroe City Sch. Bd., 974 F.3d 577, 582 (5th Cir. 2020).

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   patients and providers seek Blue Cross’s pre-treatment approval for a
   procedure that the Plan will cover (if at all) only after the patient submits a
   post-treatment claim to Blue Cross. This process is not part of Blue Cross’s
   contract with OPM, and it does not appear in the Plan, the Statement of
   Benefits, or in any other Plan materials that Gonzalez received.
          MD Anderson submitted an advance request explaining that proton
   therapy treatment was medically necessary to treat Gonzalez’s cancer. Blue
   Cross responded with a letter titled “Advance Benefit Determination –
   DENIAL.” That letter contained a “review of benefit coverage” and told
   Gonzalez that “we are unable to approve your request.” It also “denied” the
   specific proton therapy that MD Anderson’s request described. The Plan
   covered “chemotherapy and radiation therapy,” and it did not specifically
   exclude proton therapy from coverage, but it also contained an exception for
   “[e]xperimental or investigational” treatments. The letter explained that
   Blue Cross classified proton therapy as an investigational procedure. That
   classification relied on an internal Blue Cross document that was also not part
   of the Plan.
          MD Anderson appealed the decision, but Blue Cross doubled-down.
   Two days after its “initial denial of coverage,” Blue Cross sent a letter that
   stated flatly: “[y]our claim is denied.” And about a month later, Blue Cross
   tripled-down, again sending a letter telling Gonzalez it had “reviewed our
   initial denial of coverage” but would “uphold the previous denial.” Blue
   Cross also told Gonzalez that she had “exhausted” her claim. Blue Cross’s
   first denial letter explained that the denial “is not covered by the
   reconsideration and appeals process outlined in [the Plan documents]” and
   that “[o]ur decision is not subject to [OPM] appeal rights.” The second
   letter reiterated that “[t]his advance benefit decision is not subject to the
   disputed claims process. [OPM] appeal rights do not apply.” The third letter

                                         5
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   summed up in plain English: “Additional appeal rights have been
   exhausted.”
          At no point did Blue Cross explain that the advance process was only
   preliminary, or that Gonzalez could undergo proton therapy at her own
   expense and then submit a claim for reimbursement, or that Blue Cross’s
   decision did not bind OPM. Instead, Blue Cross told Gonzalez that her
   “claim” was “denied” and that her “remedies” were “exhausted.”
          Because she needed radiation treatment but could not afford proton
   therapy, Gonzalez had “no choice” but to undergo a different type of
   treatment called intensity-modulated radiation therapy (which her Plan
   unquestionably covered). Gonzalez is now cancer-free, but she also suffers
   from severe side effects. And on top of all that, Gonzalez says, it turns out
   that proton therapy is neither experimental nor investigational. Rather,
   Gonzalez argues that the medical community has long recognized proton
   therapy as an appropriate treatment for cancer.
                                               C
          Gonzalez sued OPM and Blue Cross on her own behalf and on behalf
   of a putative class of federal employees to whom Blue Cross denied proton
   therapy. Her operative complaint asserts eight theories of liability against the
   two defendants, all arising from (1) Blue Cross’s denial of coverage and (2)
   Blue Cross’s reliance on the “advance benefit determination” process that
   purported to bar OPM review.
          Count 1 is a FEHBA benefits claim that seeks an order compelling
   OPM to direct Blue Cross to pay Gonzalez “the amount of benefits due for
   the wrongful denial of covered [proton therapy].”18 Count 2, under the

          18
               See 5 C.F.R. § 890.107 (authorizing a cause of action “against OPM”).

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   Administrative Procedure Act, seeks an injunction requiring OPM to
   compel Blue Cross to: end the “advance benefit determination” process;
   stop classifying proton therapy as experimental; identify benefit funds
   belonging to employees who should have received proton therapy; ensure
   that those funds are not wrongfully directed to another purpose; and re-
   adjudicate all prior proton-therapy denials under the Plan.
          Counts 3–8 are Texas common-law claims against Blue Cross. They
   focus on Blue Cross’s “advance benefit determination” process and on Blue
   Cross’s decision to deny coverage for proton therapy. These six claims are
   for third-party breach of contract, breach of contract, tortious interference
   with an employment contract, intentional infliction of emotional distress,
   fraud, and negligent misrepresentation.
          The district court granted each defendant’s motion to dismiss. Citing
   Rule 12(b)(1), that court held that sovereign immunity bars Gonzalez’s
   benefits claim (Count 1), and that Gonzalez lacks standing for injunctive
   relief (Count 2). And citing Rule 12(b)(6), it held that FEHBA expressly
   preempts Gonzalez’s claims against Blue Cross (Counts 3–8). Because the
   district court dismissed the complaint, it did not address class certification.19
          Gonzalez timely appealed both dismissals.
                                          II
          We review the district court’s dismissals under Rules 12(b)(1) and
   12(b)(6) de novo, taking all well-pleaded factual allegations in the complaint

          19
            Gonzalez v. Blue Cross & Blue Shield Ass’n, No. 3:20-CV-2149-B, 2021 WL
   5882825 (N.D. Tex. Dec. 13, 2021).

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   as true, and viewing them in the light most favorable to the plaintiff.20 We
   may affirm the district court’s dismissal on any ground the record supports.21
                                                 III
          We begin with Gonzalez’s benefits and injunctive claims against
   OPM. We affirm dismissal as to Count 1 because FEHBA does not
   recognize the “benefits” that Gonzalez seeks to recover, and we affirm as to
   Count 2 because Gonzalez lacks Article III standing to seek injunctive relief.
                                                 A
          Count 1 seeks monetary relief from OPM, under FEHBA, in the
   amount of the “benefits” Gonzalez argues that the Plan entitles her to. The
   district court dismissed this claim on grounds of federal sovereign immunity.
   We conclude that sovereign immunity does not bar Gonzalez’s suit, but we
   affirm dismissal on the alternative ground that Gonzalez has failed to state a
   claim under Rule 12(b)(6).
                                                  1
          “[T]he United States may not be sued except to the extent that it has
   consented to suit by statute. Further, where the United States has not
   consented to suit or the plaintiff has not met the terms of the statute the court
   lacks jurisdiction and the action must be dismissed.”22 As relevant here,
   “[t]he district courts of the United States have original jurisdiction . . . of a
   civil action or claim against the United States founded on [5 U.S.C. §§ 8901–

          20
               Lane v. Halliburton, 529 F.3d 548, 557 (5th Cir. 2008).
          21
               Walmart Inc. v. U.S. Dep’t of Just., 21 F.4th 300, 307 (5th Cir. 2021).
          22
              Alabama-Coushatta Tribe of Tex. v. United States, 757 F.3d 484, 488 (5th Cir.
   2014) (internal quotation marks and citations omitted).

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   14, that is, FEHBA].”23 The government has thus “consented to suits to
   vindicate rights or enforce obligations created by [FEHBA].”24
           In contrast to that broad waiver, OPM has promulgated a regulation
   that says:
           A covered individual may seek judicial review of OPM’s final
           action on the denial of a health benefits claim. A legal action to
           review final action by OPM involving such denial of health
           benefits must be brought against OPM and not against the
           carrier or carrier’s subcontractors. The recovery in such a suit
           shall be limited to a court order directing OPM to require the
           carrier to pay the amount of benefits in dispute.25
   OPM argues that this regulation states the full extent of Congress’s waiver
   of sovereign immunity. So, OPM says, immunity bars Gonzalez from seeking
   anything beyond a court order directing OPM to require Blue Cross to pay
   the “amount of benefits in dispute.”
           OPM erroneously assumes that it can use a regulation to narrow or
   retract a statutory waiver of immunity. On the contrary, just as “only
   Congress can waive an agency’s sovereign immunity,”26 so too only
   Congress can withdraw or modify a waiver of immunity.27 This is because

           23
                5 U.S.C. § 8912.
           24
             Nat’l Treas. Emps. Union v. Campbell, 589 F.2d 669, 674 (D.C. Cir. 1978); see also
   Empire Healthchoice, 547 U.S. at 696 (“FEHBA’s jurisdictional provision, 5 U.S.C. § 8912,
   opens the federal district-court door to civil actions ‘against the United States.’”).
           25
                5 C.F.R. § 890.107(c) (emphases added).
           26
                Wagstaff v. U.S. Dep’t of Educ., 509 F.3d 661, 664 (5th Cir. 2007).
           27
              See Lynch v. United States, 292 U.S. 571, 581 (1934) (“Although consent to sue
   was thus given when the policy issued, Congress retained power to withdraw the consent at
   any time.” (emphasis added)); Becker Steel Co. of Am. v. Cummings, 296 U.S. 74, 80 (1935)
   (“Only compelling language in the congressional enactment will be construed as withdrawing
   or curtailing the privilege of suit against the government granted in recognition of an

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   “[a] waiver of the Federal Government’s sovereign immunity must be
   unequivocally expressed in statutory text and will not be implied.”28 An
   agency cannot waive the federal government’s immunity when Congress
   hasn’t.29 For the same reason, an agency’s regulation cannot narrow, rescind,
   withdraw, retract, or otherwise modify Congress’s statutory waiver. Section
   8912 waives federal sovereign immunity in federal court for “a civil action or
   claim against the United States founded on [FEHBA].”30 Sovereign
   immunity, therefore, does not bar Gonzalez’s FEHBA claim.
           Although the Tenth Circuit reached the opposite conclusion in Bryan
   v. OPM, our sister circuit did so based on a mistaken premise.31 In Bryan, the
   court relied on OPM’s regulations to conclude that “Congress clearly
   intended a limited waiver of sovereign immunity in [FEHBA] disputes.”32
   Congress, however, enacted § 8912—not § 890.107(c). An agency’s
   regulation, just like “[a] statute’s legislative history[,] cannot supply a waiver
   that does not appear clearly in any statutory text.”33 As one district court
   aptly put it, “[OPM’s] regulatory scheme reflects OPM’s choices, not

   obligation imposed by the Constitution.” (emphasis added)); Juda v. United States, 13 Cl.
   Ct. 667, 689 (1987) (“An unbroken line of decisions holds that Congress may withdraw its
   consent to sue the Government at any time.” (emphasis added) (collecting cases)).
           28
             Lane v. Pena, 518 U.S. 187, 192 (1996) (emphasis added); see also F.A.A. v. Cooper,
   566 U.S. 284, 290 (2012) (same).
           29
               See United States v. Mitchell, 463 U.S. 206, 215–16 (1983) (“[N]o contracting
   officer or other official is empowered to consent to suit against the United States. The same
   is true for claims founded upon executive regulations.” (footnote omitted)); see also, e.g.,
   Charles v. McHugh, 613 F. App’x 330, 335 (5th Cir. 2015) (“EEOC does not have the
   authority to waive sovereign immunity through its regulations.”).
           30
                5 U.S.C. § 8912.
           31
                165 F.3d 1315, 1318 (10th Cir. 1999).
           32
                Id. (citing 5 C.F.R. § 890.107(c)).
           33
                Lane, 518 U.S. at 192.

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   necessarily a manifestation of congressional intent.”34 We therefore disagree
   with Bryan, and we do not follow it here.
           In sum, because § 8912 waives immunity, the district court erred by
   concluding that sovereign immunity bars Gonzalez’s FEHBA claim.
                                                 2
           OPM next argues that Gonzalez failed to exhaust her remedies, and
   that this failure is an alternative ground for affirming. Blue Cross’s repeated
   assurances that Gonzalez’s claims were both denied and exhausted leave us
   skeptical that OPM can rely on exhaustion here.35 But because regulatory
   exhaustion requirements are not jurisdictional, we need not decide this issue.
           There are two types of exhaustion requirements: jurisdictional and
   jurisprudential.36 When “Congress statutorily mandates that a claimant
   exhaust        administrative      remedies,        the   exhaustion      requirement    is
   jurisdictional.”37 But when an exhaustion requirement appears only in a
   regulation, “the jurisprudential doctrine of exhaustion controls.”38 The
   jurisprudential doctrine involves discretion, not jurisdiction.39 Here, OPM

           34
                Smith v. OPM, 80 F. Supp. 3d 575, 586 (E.D. Pa. 2014).
           35
              See, e.g., United States v. Henderson, 707 F.2d 853, 856 (5th Cir. 1983) (“While
   we agree that the United States was under no obligation to provide appellant with its
   interpretation of the applicable statutory provisions, the government nonetheless may not
   affirmatively misrepresent the obligations of a debtor.” (emphasis added)).
           36
                Williams v. J.B. Hunt Transp., Inc., 826 F.3d 806, 810 (5th Cir. 2016).
           37
                Taylor v. U.S. Treasury Dep’t, 127 F.3d 470, 475 (5th Cir. 1997).
           38
             Williams, 826 F.3d at 810 (quoting Taylor, 127 F.3d at 475); see Kobleur v. Group
   Hospitalization & Med. Services, Inc., 954 F.2d 705, 711 (11th Cir. 1992) (“But when, as in
   this [FEHBA] case, the exhaustion requirement is created by agency regulations, the
   decision whether to require exhaustion is a matter for district court discretion.”).
           39
                See Dawson Farms, LLC v. Farm Serv. Agency, 504 F.3d 592, 602 (5th Cir. 2007).

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   relies on a regulatory exhaustion requirement.40 Because that requirement is
   not jurisdictional, we have discretion to decide this appeal on another basis.
   In the next section, we do just that.
                                                3
          With our jurisdiction secure, and with Gonzalez’s Count 1 claim for
   benefits properly before us on the merits, we “may affirm dismissal for any
   reason supported by the record.”41 OPM argues that we should affirm
   dismissal because Gonzalez “fail[ed] to state a claim upon which relief can
   be granted.”42 We agree that Rule 12(b)(6) supports dismissal.
          OPM has statutory authority to “prescribe regulations necessary to
   carry out [FEHBA].”43 OPM’s regulations allow a patient to “seek judicial
   review of OPM’s final action on the denial of a health benefits claim.”44 The
   regulations also say that “recovery in such a suit shall be limited to a court
   order directing OPM to require the carrier to pay the amount of benefits in
   dispute.”45 Gonzalez’s Count 1 thus cannot survive unless she has identified
   a benefits claim for which there is some “amount of benefits in dispute.”46
          The statutory and regulatory definitions do not have any entry for
   “benefits in dispute,”47 but that term’s meaning is still plain as relevant here.

          40
               See 5 C.F.R. § 890.107(d)(1).
          41
               Walmart, 21 F.4th at 307.
          42
               Fed. R. Civ. P. 12(b)(6).
          43
               5 U.S.C. § 8913.
          44
               5 C.F.R. § 890.107(c) (emphasis added).
          45
              Id. (emphasis added). Because Gonzalez and OPM seemingly agree that the
   regulation itself is lawful, we express no view on that issue.
          46
               Id.
          47
               See 5 U.S.C. § 8901; 5 C.F.R. § 890.101.

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   Benefits cannot be “in dispute” during judicial review unless they are part of
   the “health benefits claim” that opens the door to judicial review.48 OPM’s
   regulations define “claim” as “a request for (i) payment of a health-related
   bill[] or (ii) provision of a health-related service or supply.”49 Gonzalez has
   not identified any “bill” that Blue Cross denied—not for the proton therapy
   that she wanted, and not for the intensity-modulated radiation therapy that
   she received. And because Gonzalez is presently “cancer-free,” she also is
   not seeking to undergo proton therapy or any other radiation treatment as a
   “service.”50
          Gonzalez thus has not identified any “payment of a . . . bill” or any
   “provision of a . . . service” that is “in dispute” in this case.51 Instead, she
   seeks to blend those categories by seeking payment for a service that she never
   received. No matter how she describes the service—whether proton therapy
   itself, access to coverage, or access to administrative process—OPM’s
   regulations do not authorize judicial review for such a hybrid “benefit.” We
   therefore affirm dismissal as to Count 1 for failure to state a claim.
                                                  B
          Gonzalez’s second count seeks injunctive relief under the
   Administrative Procedure Act. The APA waives sovereign immunity for
   suits that seek non-monetary relief against federal agencies such as OPM.52
   Gonzalez asks for an order compelling OPM to direct Blue Cross to stop
   using the “advance benefit determination” process and to amend its internal

          48
               5 C.F.R. § 890.107(c) (emphasis added).
          49
               5 C.F.R. § 890.101.
          50
               See id.
          51
               Id.; 5 C.F.R. § 890.107(c).
          52
               Cambranis v. Blinken, 994 F.3d 457, 462 (5th Cir. 2021) (citing 5 U.S.C. § 702).

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   policies to cover proton therapy going forward.53 We conclude that the
   district court correctly dismissed Gonzalez’s injunctive request for lack of
   Article III standing.
           “To have standing to sue for injunctive relief, a party must: (1) have
   suffered an injury-in-fact; (2) establish a causal connection between the
   injury-in-fact and a complained-against defendant’s conduct; (3) show that it
   is likely, not merely speculative, that a favorable decision will redress the
   injury-in-fact; and (4) demonstrate either continuing harm or a real and
   immediate threat of repeated injury in the future.”54 As the party invoking
   federal jurisdiction, Gonzalez “bears the burden of establishing these
   elements” of standing.55
           Because the fourth element is lacking here, so is jurisdiction.56
           Gonzalez does not allege that she is currently involved in the advance
   process, so that process is not responsible for a “continuing harm.”57 And
   because Gonzalez does not allege that Blue Cross will require her to use the
   advance process again, she has not shown how that process creates a threat
   of “repeated injury.”58 On the contrary, OPM and Blue Cross have

           53
               Gonzalez also seeks injunctive relief that appears targeted to assist her in
   recovering the monetary amounts that she seeks for herself and the putative class as part of
   Count 1. We have concluded that the district court properly dismissed Count 1, see supra
   Part III.A, so we need not address Gonzalez’s requests for injunctive relief related to that
   count.
           54
              Funeral Consumers All., Inc. v. Serv. Corp. Int’l, 695 F.3d 330, 342 (5th Cir. 2012)
   (internal quotation marks omitted).
           55
                Lujan v. Defenders. of Wildlife, 504 U.S. 555, 561 (1992).
           56
                See Attala Cnty. NAACP v. Evans, 37 F.4th 1038, 1042 (5th Cir. 2022).
           57
                Funeral Consumers All., 695 F.3d at 342; Attala Cnty. NAACP, 37 F.4th at 1042.
           58
                Id.

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   confirmed that an advance determination is a “voluntary” process that an
   employee “can choose to request.” So, while Gonzalez may choose to use the
   process again, “standing cannot be conferred by a self-inflicted injury.”59
   Because Gonzalez is free to ignore the advance process, she does not face any
   continuing or threatened harm sufficient to create standing for injunctive
   relief.
             Nor does Blue Cross’s internal proton-therapy guideline pose an
   immediate threat of injury. This is because OPM has the final word regarding
   proton therapy—not Blue Cross.60 At worst, then, Blue Cross’s internal
   guideline threatens Gonzalez only to the extent that it might require her to
   seek OPM’s review if her cancer goes into remission and if Blue Cross again
   denies coverage. But even if Gonzalez does end up seeking OPM’s review
   for some future claim, she would not thereby suffer an injury under Article
   III. Nor would an injunction that eliminates Blue Cross’s proton-therapy
   guideline prevent OPM from denying coverage for treatment. And to top it
   off, Gonzalez has not even alleged that OPM would deny coverage.
             Neither the advance process nor the proton-therapy guideline poses
   an immediate threat of injury, so injunctive relief is therefore unavailable.
                                                   IV
             We now turn to Gonzalez’s state-law monetary claims against Blue
   Cross (that is, Counts 3–8). FEHBA contains a preemption clause that
   “displac[es] state law on issues relating to ‘coverage or benefits.’”61 The

             59
                  Zimmerman v. City of Austin, 881 F.3d 378, 389 (5th Cir. 2018).
             60
              See, e.g., 5 C.F.R. § 890.105(e)(2)(iv) (providing that, in reviewing a carrier’s
   decision, OPM may “[m]ake its decision based solely on the information the covered
   individual provided with his or her request for review.”).
             61
                  Empire Healthchoice, 547 U.S. at 683 (citing 5 U.S.C. § 8902(m)(1)).

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   district court correctly determined that this clause preempts Gonzalez’s
   Texas common-law claims against Blue Cross. The preemption clause says:
                  The terms of any contract under this chapter which relate
                  to the nature, provision, or extent of coverage or benefits
                  (including payments with respect to benefits) shall
                  supersede and preempt any State or local law, or any
                  regulation issued thereunder, which relates to health
                  insurance or plans.62
           The clause helps “[t]o ensure uniform coverage and benefits under
   plans OPM negotiates for federal employees.”63 The clause’s language is
   “expansive,” and the Supreme Court has “‘repeatedly recognized’ that the
   phrase ‘relate to’ in a preemption clause ‘expresses a broad pre-emptive
   purpose.’ Congress characteristically employs the phrase to reach any
   subject that has ‘a connection with, or reference to,’ the topics the statute
   enumerates.”64 Thus, “state law—whether consistent or inconsistent with
   federal plan provisions—is displaced on matters of ‘coverage or benefits.’”65
            “[P]reemption occurs under FEHBA when (1) the FEHBA
   contract terms at issue relate to the nature, provision, or extent of coverage
   or benefits, and (2) the state law relates to health insurance or plans.”66
   Gonzalez’s claims against Blue Cross meet both prongs of this test.

           62
                5 U.S.C. § 8902(m)(1).
           63
                Empire Healthchoice, 547 U.S. at 686.
           64
               Coventry Health Care of Missouri, Inc. v. Nevils, 581 U.S. 87, 95–96 (2017)
   (citations omitted).
           65
                Empire Healthchoice, 547 U.S. at 686.
           66
             Health Care Serv. Corp. v. Methodist Hosps. of Dallas, 814 F.3d 242, 253 (5th Cir.
   2016) (internal quotation marks omitted); see 5 U.S.C. § 8902(m)(1).

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                                       No. 22-10062

                                            A
         Each of Gonzalez’s claims against Blue Cross arises either from Blue
   Cross’s refusal to cover proton therapy under the Plan or from Blue Cross’s
   reliance on the advance process that the Plan does not mention. Each claim
   thus places “at issue” Plan terms that “relate to the nature, provision, or
   extent of coverage or benefits (including payments with respect to
   benefits).”67 To see why, consider each claim individually—

          Count 3, for third-party breach of contract, alleges that Blue
           Cross denied coverage for proton therapy even though the
           Plan’s terms cover radiation therapy.
          Count 4, for breach of contract, alleges that Blue Cross
           imposed the advance process that the Plan’s terms do not
           mention.
          Count 5, for tortious interference, alleges that Blue Cross
           interfered with Gonzalez’s (alleged) employment contract
           by denying her the rights that the Plan’s terms guarantee.
          Count 6, for intentional infliction of emotion distress,
           alleges that the Plan’s terms did not give Blue Cross any
           basis to deny proton therapy.
          Counts 7, for fraud, alleges that Blue Cross made false
           representations about the Plan’s terms.
          Count 8, for negligent misrepresentation, alleges that Blue
           Cross misrepresented the Plan’s terms.
         The claims alleging that the Plan covers proton therapy “relate to”
   the Plan terms that address the “nature” and “extent” of coverage.68 And

         67
              5 U.S.C. § 8902(m)(1).
         68
              Id.

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   the claims about the advance process “relate to” the Plan terms that address
   “payments with respect to benefits.”69 The claims involving the advance
   process also fail because “[t]ort claims arising out of the manner in which a
   benefit claim is handled are not separable from the terms of the contract that
   governs benefits.”70 Prong one, therefore, is satisfied.
                                                 B
          We next address preemption’s second prong—whether the state laws
   that Gonzalez relies on “relate[] to health insurance or plans.”71 She invokes
   Texas common law for her tort and contract claims against Blue Cross. These
   causes of action do not specifically relate to health insurance, but preemption
   reaches even a state’s general laws when their application relates to the scope
   or administration of federal healthcare plans.
          “[T]he key phrase, obviously, is ‘relat[es] to.’ The ordinary meaning
   of these words is a broad one.”72 The phrase means “to stand in some
   relation; to have bearing or concern; to pertain; refer; to bring into
   association with or connection with.”73 It is thus no surprise that the phrase
   “express[es] a broad pre-emptive purpose.”74 “[A] state law may ‘relate to’
   a benefit plan, and thereby be pre-empted, even if the law is not specifically
   designed to affect such plans, or the effect is only indirect.”75

          69
               Id.
          70
               Burkey v. Gov’t Emps. Hosp. Ass’n, 983 F.2d 656, 660 (5th Cir. 1993).
          71
               5 U.S.C. § 8902(m)(1); see Health Care Serv. Corp., 814 F.3d at 253.
          72
               Morales v. Trans World Airlines, Inc., 504 U.S. 374, 383 (1992).
          73
             Id. (quoting Black’s Law Dictionary 1158 (5th ed. 1979) (internal
   quotation marks omitted).
          74
               Id.
          75
               Id. at 386 (quoting Ingersoll-Rand Co. v. McClendon, 498 U.S. 133, 139 (1990)).

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           In an analogous context, the Supreme Court held that ERISA’s
   preemption clause bars common-law tort and breach-of-contract actions that
   seek “[d]amages for failure to provide benefits.”76 ERISA, like FEHBA,
   preempts state laws that “relate to” benefit plans. Citing the phrase’s
   “expansive sweep,” the Court reasoned that “[t]he common law causes of
   action raised in [the] complaint, each based on alleged improper processing
   of a claim for benefits under an employment benefit plan, undoubtedly meet
   the criteria for pre-emption.”77 The Court has squarely rejected the notion
   that “laws of general applicability” escape the broad “sweep of the ‘relating
   to’ language.”78 FEHBA’s preemption clause uses exactly the same
   language, so the high Court’s interpretation compels ours.79
           Gonzalez’s common-law claims seek to hold Blue Cross liable for
   denying proton therapy and for imposing the advance process. But as just
   discussed, Blue Cross’s actions relate to the Plan’s terms.80 As a result,
   Gonzalez’s common-law claims based on these actions “relate[] to”81 the
   Plan as well, and her claims thus “meet the criteria for pre-emption.”82

           76
                Pilot Life Ins. Co. v. Dedeaux, 481 U.S. 41, 43, 47–48 (1987).
           77
                Id. at 48.
           78
                Morales, 504 U.S. at 386.
           79
              See id. at 384 (applying ERISA preemption precedents to other preemption
   statutes containing substantively identical language because the Supreme Court’s ERISA
   precedents “clearly and unmistakably rely on . . . a construction of the phrase ‘relates
   to.’”).
           80
                See supra Part IV.A.
           81
                5 U.S.C. § 8902(m)(1).
           82
                Pilot Life Ins., 481 U.S. at 48.

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           Gonzalez argues that our decision in Corporate Health Insurance v.
   Texas Department of Insurance compels a different result, but we disagree.83
   According to Gonzalez, that case means that preemption does not bar state
   laws that impose duties that are completely separate from and additional to
   the duties that arise under a healthcare plan. That argument misunderstands
   the case’s holding. In Corporate Health Insurance, the defendants wore two
   “hats”—one as insurer, and one as medical-care provider.84 True, we held
   that FEHBA did not preempt a state law that regulated the defendants in
   their capacity as healthcare providers (rather than insurers).85 But we also
   held that FEHBA did preempt the state law insofar as that law purported to
   regulate the defendants in their capacity as insurance-plan administrators.86
   Because Gonzalez seeks to use state law to regulate the way that Blue Cross
   administers benefits and resolves claims-related disputes, Corporate Health
   Insurance reinforces our conclusion.
           FEHBA preempts Gonzalez’s common-law claims against Blue
   Cross, and we therefore affirm the district court’s dismissal of those claims.
                                                V
           Health insurance is too often maddening. Policy terms can be vague
   and confusing, insurers might have hidden guidelines that conflict with
   prevailing medical norms, and procedural hurdles can be byzantine. Here, a
   confluence of these and other all-too-common complications conspired to

           83
              Corp. Health Ins., Inc. v. Texas Dep’t of Ins., 215 F.3d 526, 539 (5th Cir.
   2000), cert. granted, judgment vacated sub nom. Montemayor v. Corp. Health Ins., 536 U.S. 935
   (2002), opinion modified and reinstated in relevant part, 314 F.3d 784 (5th Cir. 2002),
   abrogated on other grounds by Rush Prudential HMO, Inc. v. Moran, 536 U.S. 355 (2002).
           84
                Id. at 534.
           85
                Id. at 539.
           86
                Id.

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                                  No. 22-10062

   prevent Gonzalez from making an informed choice about treatment. We
   sympathize. But under the statutory and regulatory regime that we are bound
   to apply, no relief is available. We AFFIRM the district court’s judgment.

                                       21