Court Opinion

ID: 9701637
Source: CourtListenerOpinion
Date Created: 2023-08-25 22:28:47.157737+00
Date Added: 2024-06-11T15:02:35.610078
License: Public Domain

CONCURRING AND DISSENTING OPINION BY
Judge SMITH-RIBNER.
I concur with the Majority’s decision to overrule the first preliminary objection of the Department of Public Welfare (DPW) and Secretary Feather O. Houstoun (hereafter Respondents) as to Petitioners’ standing to bring their action. I respectfully dissent, however, from the Majority’s decision to sustain Respondents’ remaining preliminary objections in the nature of a demurrer to the claims raised in Petitioners’ petition for review.
Petitioners have averred that the disputed language of the General Appropria*1208tion Act of 2002, Act of June 29, 2002, P.L. -, No. 7A (2002 GAA), contains substantive language which directs DPW to reimburse Petitioners at a default reimbursement rate set at DPWs fee-for-service rate for Petitioners’ provision of medical emergency services to medical assistance managed care organization (MCO) enrollees and that this default rate setting violates Article III, Section 11 of the Pennsylvania Constitution. Petitioners further aver that the legislature’s default rate setting violates their due process rights. The ultimate question before the Court is whether the 2002 GAA contains substantive language which violates the Article III, Section 11 mandate that a “general appropriation bill shall embrace nothing but appropriations for the executive, legislative and judicial departments of the Commonwealth, for the public debt and for public schools.”
The disputed language included in the 2002 GAA, which Petitioners challenge, reads as follows:
Whenever medical assistance recipients enrolled in the Department of Public Welfare’s prepaid capitation program receive medically necessary emergency services, including, but not limited to, emergency transportation services and poststabilization inpatient hospital services, provided by noncontracting service providers, such service shall be paid for by the contractor at the payment rates adopted by the department for equivalent services provided under the department’s fee-for-service program.
Petitioners assert that the default reimbursement rate established by the disputed language violates the prohibition that this Court announced in Common Cause of Pennsylvania v. Commonwealth, 668 A.2d 190 (Pa.Cmwlth.1995), aff'd, 544 Pa. 512, 677 A.2d 1206 (1996), and furthermore that without any opportunity for notice and comment the legislative “logrolling” of a default rate deprived Petitioners of their substantive rights to receive all reasonably necessary costs for their provision of necessary medical emergency services guaranteed to them under the Act commonly known as the Quality Healthcare Accountability and Protection Act,1 40 P.S. §§ 991.2101-991.2193 (Act 68).
Respondents have demurred on the basis that Petitioners failed to state a claim on which relief may be granted inasmuch as the disputed language is “within the zone of lawful legislative direction accompanying an appropriation of funds” and does not violate Article III, Section 11 and further that the disputed language does not violate Petitioners’ due process rights. The Majority agreed, holding that the disputed language is not substantive language in violation of Article III, Section 11 and, moreover, that it does not conflict with Act 68, and that when any doubts exist as to the constitutionality of a particular piece of legislation those doubts must be resolved in favor of a finding of its constitutionality. In my view, the Majority’s ruling fails to comport with the well-settled standard that must be followed when ruling on preliminary objections.
Cases have repeatedly held that when ruling on preliminary objections in the nature of a demurrer the Court must accept and consider as true all well-pleaded facts in the petition for review and all reasonable inferences which might be deduced from those facts, and the Court must then decide whether the facts pleaded are legally sufficient to permit the case to proceed further. Allegheny Sportsmen’s League v. Ridge, 790 A.2d 350 (Pa.Cmwlth.2002). *1209When the facts pleaded state a claim for relief, the Court may not sustain the demurrer, Willet v. Pennsylvania Medical Catastrophe Loss Fund, 549 Pa. 613, 702 A.2d 850 (1997), and any doubts must be resolved in favor of refusing to sustain the demurrer. Baravordeh v. Borough Council of Prospect Park, 706 A.2d 362 (Pa.Cmwlth.1998). A careful review of the averments of Petitioners’ petition for review shows unquestionably that this case is not clear and free from doubt and that the law does not state with certainty that no relief or remedy may be granted under the facts pleaded. Pennsylvania AFL-CIO ex rel. George v. Commonwealth, 563 Pa. 108, 757 A.2d 917 (2000).
Petitioners have averred, inter alia, (1) that the activities of the MCOs under contract with DPW are governed by Act 68, which delegates oversight authority to the Department of Health and to the Insurance Department (40 P.S. § 991.2181); (2) that Petitioners have not entered into contracts with a particular HealthChoices MCO and therefore are considered as out-of-network or non-plan providers; (3) that Act 68 provides that when an MCO enroll-ee receives necessary emergency services the managed care plan shall pay all reasonably necessary costs associated with the emergency services provided during the period of the emergency (40 P.S. § 991.2116; 31 Pa.Code § 154.14); and (4) that applicable regulations of the Department of Health and Insurance Department rejected the creation of a default rate for out-of-network or non-plan providers.
Petitioners further averred (1) that the default language in the 2002 GAA deprives them of reimbursement for reasonably necessary costs associated with the provided out-of-network emergency services; (2) that under the 2002 GAA those hospital providers who elected not to enter into contracts with a HealthChoices MCO will be required to accept DPW’s fee-for-service reimbursement rates rather than obtain reasonable negotiated reimbursement rates from the MCOs under Act 68; (3) that the disputed language is substantive and essential to the medical assistance program as it establishes how emergency services must be reimbursed, and therefore it exceeds legislative authority under a general appropriation act and conflicts with existing law; (4) that Act 68 controls the payment by MCOs for emergency services; (5) that the legislative attempt to set emergency services reimbursement rates for non-contracting hospitals exceeds monetary appropriation and thus violates Article III, Section 11; (6) that the 2002 GAA appropriates money to private entities (MCOs) either directly or through DPW; (7) that DPW has no authority under Act 68 to require out-of-network or non-plan providers to accept medical assistance program reimbursement rates; and (8) that state law permits out-of-network or non-plan providers to contract with the MCO for reasonable reimbursement. 40 P.S. § 991.2116; 31 Pa.Code § 154.14.
Petitioners contend that the disputed language in the 2002 GAA fails to meet the test enunciated in Biles v. Department of Public Welfare, 44 Pa.Cmwlth. 274, 403 A.2d 1341 (1979), which held, inter alia, that appropriation act language in conflict with existing law constitutes substantive language and is in violation of the Article III, Section 11 requirements.2 Petitioners further submit that because the default *1210rate conflicts with Act 68 emergency services reimbursement requirements, the default rate therefore conflicts with existing law and, as a consequence, represents substantive language in the 2002 GAA. Petitioners posit that Respondents’ argument to the contrary is based on their contention that the 2002 GAA can be read in pari materia with Act 68 and that in making this argument they have ignored the exception contained therein that the act shall not apply to DPW’s fee-for-service programs. Under principles of statutory construction, Petitioners assert, the Court cannot fairly read the 2002 GAA and Act 68 together because of this conflict. See Fumo v. Hafer, 155 Pa.Cmwlth. 520, 625 A.2d 733 (1993) (courts must consider plain and unambiguous meaning of statutes).
In Common Cause this Court cited Cedarbrook Nursing Homes v. Department of Public Welfare, 154 Pa.Cmwlth. 1, 622 A.2d 401 (1991), aff'd, 533 Pa. 307, 622 A.2d 282 (1993), for the holding that Article III, Section 11 prohibits the legislature from inserting substantive language in a general appropriation act, i.e., language which goes beyond a monetary appropriation. In Cedarbrook the Court cited Wesbury United Methodist Community v. Department of Public Welfare, 142 Pa.Cmwlth. 353, 597 A.2d 271 (1991), aff'd, 533 Pa. 85, 619 A.2d 1057 (1993), in which the Court held that when the legislature has delegated rate-establishing authority, the legislature’s attempt in a general appropriation act to create a new start date for a rate change went beyond “monetary appropriation” and consequently violated the proscription in Article III, Section 11 that a general appropriation bill shall embrace nothing but appropriations. More precisely, however, the Court in Common Cause held that the legislature may not lawfully “authorize, designate, allot or set aside monies, either directly or indirectly earmarked for specific entities not under the absolute control of the Commonwealth.” 668 A.2d at 205. It indicated that the legislative branch may not micromanage the executive’s power to administer an appropriation by earmarking nongovernmental recipients of the appropriation. Petitioners maintain here that the disputed language in the 2002 GAA falls within the Common Cause prohibition because the language establishes a reimbursement rate to be paid by private MCOs to private out-of-network hospitals for their services and that these private entities are not under the “absolute control” of the Commonwealth.
In response, the Majority merely states that the points raised in this connection are good ones but that “on balance” they do not dissuade the Majority from dismissing the action. Citing Hahnemann University v. Department of Public Welfare, 128 Pa.Cmwlth. 605, 564 A.2d 521 (1989), as support, the Majority additionally finds that DPW’s fee-for-service schedule of rates satisfies the reimbursement-of-reasonable-eosts standard, irrespective of the express exclusion of such rates from Act 68’s coverage or the fact that Hahnemann predated Act 68. Furthermore, Hahne-mann involved DPW reimbursement rates for in-patient services, a totally distinct category of health care services, which were based on concept scores of an efficient and economically operated hospital and included score factors such as the hospital’s teaching status, its medical assistance volume, its environmental characteristics and hospital costs. The issues and circumstances in Hahnemann make it completely distinguishable from the matter at hand.
If the Majority had accepted as true, as it must, Petitioners’ well-pleaded facts and all reasonable inferences deducible from those facts, it properly should have concluded that the facts pleaded are legally *1211sufficient to allow this case to go forward. Under the circumstances, the question presented in this case cannot be fairly resolved on demurrer. Additionally, a close review of the facts pleaded and current case law indicates that the disputed language is clearly susceptible to the interpretation advanced by Petitioners. See Pennsylvania AFL-CIO. Because it cannot be said with certainty that the law permits no relief or a remedy under the facts, I believe that the Majority’s dismissal of Petitioners’ petition for review is premature and improper.
Judge PELLEGRINI joins in this dissent.

. Sections 2101-2193 of The Insurance Company Law of 1921, Act of May 17, 1921, P.L. 682, as amended, added by Section 1 of the Act of June 17, 1998, P.L. 464.

. Compare Franklin County Nursing Home v. Department of Public Welfare, 126 Pa.Cmwlth. 375, 559 A.2d 1002 (1989) (court found no violation of Article III, Section 11 when language in appropriation act was germane, did not conflict with existing law or exceed life of appropriation bill, and, moreover, it did not involve reimbursement rates to private entities).