Court Opinion

ID: 8408676
Source: CourtListenerOpinion
Date Created: 2022-11-02 16:46:13.463548+00
Date Added: 2024-06-11T16:46:43.852129
License: Public Domain

WINTER, Circuit Judge,
dissenting.
I respectfully dissent.
This is an action under the Medicare statute against the Secretary of Health and Human Services. It seeks to compel the Secretary to order HHAs to give written notice in one particular circumstance to those patients on whose behalf Medicare pays for some or all of an HHA’s services. That circumstance is when an HHA ceases some or all of its services because it has determined that Medicare no longer covers the services because the patient lacks a current physician certification. See Brief of Appellants at 2, 20, 23, 25. Appellants claim that the Secretary is required to order HHAs to give written notice in that circumstance because such a determination involves a Medicare coverage decision, and notice to Medicare recipients is necessary to enable them to use appeal procedures to *159challenge the reduction in Medicare coverage without losing the current coverage. See id. at 15-16. The Secretary argues that a physician’s certification is a non-reviewable (within the Medicare system) prerequisite to seeking Medicare payment for the pertinent services and that written notice is not required, the issue essentially being one between the patient and his or her physician and not one involving either the HHA or the Secretary. See Brief of Appellees at 18, 24-25.
My colleagues resolve a different issue. They require the Secretary to order HHAs to give their patients written notification of any change in services, whether or not there is a change in Medicare coverage. See Maj. Op. at 154,157-58. This outcome treats the problem of whether denial of a physician certification is a coverage decision — the issue at the heart of this case— as irrelevant, because the written notice requirement is not limited to Medicare coverage decisions. In short, they read 42 U.S.C. § 1395bbb(a)(l)(E) as a general “patient’s bill of rights” covering contractual relationships between HHAs and all their patients to be enforced by the Secretary.1
In my view, this is a misreading of the statute. Section 1395bbb(a)(l) concerns “[cjonditions of participation” by HHAs in the Medicare program and sets out rights of their patients to information. Among these rights are:
(A) the right to be fully informed in advance about the care and treatment to be provided by the agency, to be fully informed in advance of any changes in the care or treatment to be provided by the agency that may affect the individual’s well-being, and (except with respect to an individual adjudged incompetent) to participate in planning care and treatment or changes in care or treatment. ‡ ‡ ‡ ‡
(E) The right to be fully informed orally and in writing (in advance of coming under the care of the agency) of—
(i) all items and services furnished by (or under arrangements with) the agency for which payment may be made under this subchapter.
(ii) the coverage available for such items and services under this subchap-ter, subchapter XIX of this chapter, and any other Federal program of which the agency is reasonably aware.
(iii) any charges for items and services not covered under this subchapter and any charges the individual may have to pay with respect to items and services furnished by (or under arrangements with) the agency, and
(iv) any changes in the charges or items and services described in clause (i), (ii), or (iii).
The subject of the statute therefore is the conditions an HHA must meet for covered services to be reimbursed by Medicare. Under Subsection (A), an HHA that wants to be reimbursed for its services by Medicare must confer orally with the patient about the proposed program of care or changes in it. Before the patient agrees to the program or changes in it, Subsection (E) requires that the patient be informed in writing of what services are to *160be paid by Medicare (or may be paid after a Medicare appeal procedure), what other federal sources of funds exist for those services, and what costs will have to be borne by the patient.
Read together and in the context of a Medicare appeal procedure, Subsections (A) and (E) are a straightforward statutory scheme. They allow the patient to confer with the HHA as to the plan of care and to be informed of rights to Medicare coverage and costs to be borne individually before proceeding with the plan or changes in it. They also allow the patient to gauge the need to exercise rights under Medicare appeal procedures. If Subsection (E) was intended as a general written notice of changes in services requirement, there would have been no need to separate (A) from (E) or to make the distinctions embodied in (E)(i), (ii), and (in), all of which relate to who will make payments. Nor would Congress likely burden the Secretary with responsibility to enforce notice requirements unrelated to payment issues. In fact, another provision of the statute, Section 1395(a), expressly governs the contractual relations between HHAs and their patients seeking non-covered services and spells out the mandatory terms for such contracts.
Left to my druthers, therefore, I would agree with the district court that the statutory language and general context are unambiguous in linking Subsection (E) to Medicare coverage issues, the difficulty being in defining what are coverage decisions and what are not, the issue briefed and argued in this case.
However, my colleagues disagree, a fact that leads me to conclude that Subsection (E)’s interplay with Subsection (A) may be ambiguous. This conclusion is to me fortified by the fact that a magistrate judge, district judge, and circuit judge have now all read the statute in a way at odds with my two colleagues. See Healey v. Thompson, 186 F.Supp.2d 105 (D.Conn.2001) (report and recommendation of Magistrate Judge Smith, adopted by Judge Squatrito in an order entered Sept. 24, 2001).
Under Chevron, U.S.A., Inc. v. Natural Resources Defense Council, Inc., 467 U.S. 837, 104 S.Ct. 2778, 81 L.Ed.2d 694 (1984), issues regarding an administrative agency’s interpretation of a statute are governed by a three-step analysis. The first question is “whether Congress has directly spoken to the precise question at issue. If the intent of Congress is clear, that is the end of the matter; for the court, as well as the agency, must give effect to the unambiguously expressed intent of Congress.” Id. at 842-43, 104 S.Ct. 2778. If Congress has not directly spoken to the question at issue, then “the question for the court is whether the agency’s answer is based on a permissible construction of the statute.” Id. at 843, 104 S.Ct. 2778. Finally, the agency’s interpretation is “given controlling weight unless [it is] arbitrary, capricious, or manifestly contrary to the statute.” Id. at 844, 104 S.Ct. 2778.
I would therefore follow the Secretary’s view that Subsection (E) is linked to coverage decisions and is not a general patient’s bill of rights. With regard to whether written notice is required of an HHA’s cessation of services based on a denial of physician certification, I agree substantially with the analysis of the district court, save for my reliance on Chevron, and would affirm.
I therefore respectfully dissent.

. How far-reaching this rationale may be is hard to determine because no party has briefed what kinds of changes an expanded (beyond Medicare coverage) notice requirement might reach. For example, my colleagues' ruling expressly states that the Secretary must require HHAs to give notice before an HHA's decision to cease providing unprofitable services, Maj. Op. at 157-58, and written notice of a host of other matters that are of importance to HHA patients, such as changes in care personnel or times of arrival or departure of such personnel, may be included.