950 F.3d 764
11th Cir.2020Background
- April 29, 2012: automobile accident injured a Medicare beneficiary covered by Medicare Advantage Organization (MAO) Florida Healthcare Plus; Florida Healthcare made $21,965 in conditional payments for treatment through July 26, 2012.
- March 28, 2013: beneficiary settled with the at-fault insurer, Kingsway Amigo Insurance, for $6,667; Florida Healthcare assigned its recovery rights (eventually to MSPA Claims 1).
- MSPA received notice (letters from Kingsway) and the settlement paperwork in November 2015, sent a reimbursement demand Nov. 23, 2015, and sued Kingsway Dec. 7, 2015 under the MSPA private cause of action, 42 U.S.C. § 1395y(b)(3)(A).
- Kingsway moved for judgment on the pleadings arguing MSPA’s claim was barred because MSPA (or Medicare) did not request reimbursement within three years of the dates services were furnished, as required by § 1395y(b)(2)(B)(vi).
- The district court granted judgment for Kingsway; the Eleventh Circuit reversed, holding § 1395y(b)(2)(B)(vi) is permissive and not a prerequisite to bringing a private MSPA suit, and remanded.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether compliance with §1395y(b)(2)(B)(vi) (the 3‑year claims‑filing provision) is a prerequisite to bringing a private MSPA suit under §1395y(b)(3)(A) | §1395y(b)(2)(B)(vi) is permissive (uses “may”) and merely allows Medicare to overcome employer plan deadlines; it is not a prerequisite to suit | The provision creates a mandatory 3‑year requirement: if no request was made within 3 years of treatment, plaintiff cannot later sue | Held: Not a prerequisite; provision is permissive and does not bar private suits |
| Whether the claims‑filing provision applies to MAOs | MSPA: Court need not decide applicability; even if it applies, it is permissive and not a condition precedent | Kingsway: Provision applies to the government and to MAOs and therefore limits their ability to sue | Held: Court assumed arguendo it applied to MAOs but did not decide definitively; ruled that even if it applies, it does not bar suit |
| Whether §1395y(b)(2)(B)(vi) functions as a statute of limitations that would supersede the notice‑triggered 3‑year SOL in §1395y(b)(2)(B)(iii) | Reading (vi) as permissive preserves the notice‑based limitations scheme and avoids making (iii) superfluous | Reading (vi) as mandatory would convert it into an independent limitations bar and render (iii) meaningless | Held: (vi) is not a separate limitations prerequisite; interpreting it as mandatory would create conflict and be disfavored |
| Whether the private cause of action requires that the primary payer’s responsibility be "demonstrated" before suit | MSPA: Demonstration exists here (settlement) so private cause of action is available | Kingsway: Timeliness/filing requirement should bar suit regardless | Held: Court reaffirmed that demonstrated responsibility is required (Glover) and accepted MSPA’s allegation of demonstration for pleadings; timeliness argument under (vi) rejected |
Key Cases Cited
- Humana Med. Plan, Inc. v. W. Heritage Ins. Co., 832 F.3d 1229 (11th Cir. 2016) (MAOs can sue under MSPA private cause of action)
- MSPA Claims 1, LLC v. Tenet Fla., Inc., 918 F.3d 1312 (11th Cir. 2019) (limits on private cause of action; read §1395y(b)(2)(B) into private action only to determine when responsibility is "demonstrated")
- United States v. Baxter Int’l, Inc., 345 F.3d 866 (11th Cir. 2003) (describing Medicare’s payment‑in‑the‑dark problem and MSPA context)
- MSP Recovery, LLC v. Allstate Ins. Co., 835 F.3d 1351 (11th Cir. 2016) (overview of MSPA primary/secondary payer framework)
- Glover v. Liggett Grp., 459 F.3d 1304 (11th Cir. 2006) (private suit requires that primary payer responsibility be "demonstrated")
- NLRB v. SW Gen., Inc., 137 S. Ct. 929 (2017) (ordinary meaning of "notwithstanding")
- King v. Burwell, 135 S. Ct. 2480 (2015) (statutory interpretation must account for text and statutory scheme)
- Merit Mgmt. Grp., LP v. FTI Consulting, Inc., 138 S. Ct. 883 (2018) (interpretive principles regarding "notwithstanding" clauses)
- Ela v. Destefano, 869 F.3d 1198 (11th Cir. 2017) ("may" is permissive in statutory context)
- Black Warrior Riverkeeper, Inc. v. Black Warrior Minerals, Inc., 734 F.3d 1297 (11th Cir. 2013) (avoid interpretations that render other statutory provisions superfluous)