ACS Primary v. UnitedHealthcare
26 F.4th 716
| 5th Cir. | 2022Background
- Plaintiffs are Texas non‑network emergency‑care physician groups who treated UHC plan enrollees and claim UHC paid rates below the “usual and customary” amounts required by Texas law.
- Relevant Texas Insurance Code provisions: §§1271.155(a), 1301.0053(a), and 1301.155(b) require issuers to reimburse out‑of‑network emergency providers at the usual and customary rate (or an agreed rate).
- Plaintiffs sued in state court for violations of those emergency‑care statutes (and some contract/quantum meruit claims); UHC removed to federal court.
- The district court dismissed certain PPO claims for a pre‑2019 period but allowed other statutory claims to proceed; UHC sought interlocutory review on (1) whether the statutes create an implied private right of action, and (2) whether ERISA §514 preempts the claims.
- The Fifth Circuit granted review and, because the state‑law question was close and important, certified to the Texas Supreme Court whether the statutes authorize a private cause of action; the court did not decide ERISA preemption.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether §§1271.155(a), 1301.0053(a), 1301.155(b) create an implied private cause of action | Statutory text specifies who pays, who is paid, and what is payable, supporting an implied private right to enforce usual‑and‑customary reimbursement | Texas law requires strict construction; detailed regulatory scheme and other express causes suggest no implication of a private right | Question certified to the Texas Supreme Court for resolution; Fifth Circuit did not decide on the merits |
| Whether ERISA §514 preempts the state‑law claims | State statutes regulate reimbursement and are not preempted by ERISA | ERISA §514 preempts conflicting state‑law causes of action | Not addressed by the Fifth Circuit; reserved pending Texas Court’s answer |
Key Cases Cited
- McMillan v. Amazon.com, Inc., 983 F.3d 194 (5th Cir. 2020) (articulates factors favoring certification to state supreme court)
- Silguero v. CSL Plasma, Inc., 907 F.3d 323 (5th Cir. 2018) (discusses certification considerations)
- Brown v. De La Cruz, 156 S.W.3d 560 (Tex. 2004) (sets Texas standard for implying private rights of action; strict construction)
- City of Beaumont v. Bouillion, 896 S.W.2d 143 (Tex. 1995) (example of Texas Supreme Court finding an implied right of action)
- Tex. Med. Res., LLP v. Molina Healthcare of Tex., Inc., 620 S.W.3d 458 (Tex. App.—Dallas 2021) (state appellate court held emergency‑care statutes do not create an implied private right of action)