Opinion for the Court filed by Circuit Judge GINSBURG. *
The Ohio Hospital Care Assurance Program (HCAP) ensures that indigent Ohioans who “are not recipients of the medical assistance program,” ie., the Ohio Medicaid plan, nonetheless receive “basic, medicаlly necessary hospital-level services” at no charge. Ohio Rev.Code § 5112.17(B); see Title XIX [Medicaid] of the Social Security Act, 42 U.S.C. § 1396 et seq. The state of Ohio does not reimburse hospitals for the cost of providing such mandatory charity care.
Seeking indirectly to cover some of their HCAP expenses, the 25 plaintiff-appellee hospitals took the position that the Secretary of Health and Human Services should include bеneficiaries of the HCAP in calculating the monies the Hospitals are due under the Medicare program for the elderly and the disabled.
See
Title XVIII [Medicare] of the Act, 42 U.S.C. § 1395
et seq.
The Secretary disagreed but the Hospitals successfully challenged his decision in the district court.
I. Background
Under the Medicare statute, the Secretary generally pays hospitals a sum for each covered inpatient service without regard to the hospital’s actual cost.
See
42 U.S.C. § 1395ww(d). In 1983, howеver, the Congress determined any hospital that serves a disproportionately large percent
*178
age of low-income patients — known as a disproportionate share hospital (DSH)— should be reimbursеd at a higher rate, apparently because the more low-income patients a hospital treats, the more it costs on average to care for Medicare patients. See
Cabell Huntington Hosp., Inc. v. Shalala,
II. Analysis
The question before us is whether HCAP patients are “eligible for medical assistance under a State plan approved under [Medicaid].” If so, then the Secretary miscalculated the DSH adjustments the Hospitals should have received under Mediсare. We conclude for two reasons that the Secretary was correct, and accordingly was entitled to summary judgment: First, the HCAP provision that requires hospitals to care for indigent patients, § 5112.17(B), is not part of the Ohio “State plan approved under [Medicaid]” and, second, HCAP patients are not “eligible for medical assistance” within the meaning of that term in the Medicare DSH provision. We reach these conclusions based not upon any deference to the Secretary’s interpretation but upon our own reading of the Social Security Act.
See Chevron U.S.A. Inc. v. Natural Res. Def. Council, Inc.,
A. HCAP Provision Is Not Part of Medicaid Approved Plan
Contrary to the Hospitals’ argument, § 5112.17(B) is clearly not part of a “State plan approved under [Medicaid]” because an approved state Medicaid plan — as thе Hospitals acknowledge in their brief— must pay providers for the care of eligible patients. See 42 U.S.C. §§ 1396a-1396b; see also § 1396d(a), (b). Section 5112.17(B) of the HCAP, however, requires the Hospitals to care for indigent patients without payment. See also Ohio Admin. Codе 5101:3-2-07.17. By its terms, moreover, § 5112.17(B) requires hospitals to care for patients only if they “are not recipients of the medical assistance program,” that is, Medicaid. See Ohio Rev. Code § 5112.01 (defining “medical assistance program” as “the program of medical assistance established under section 5111.01 of the Revised Code and Title XIX [Medicaid] of the ‘Social Security Act’ ”); see also § 5112.17(C) (hospital may “require] an individual to apply for eligibility under the medical assistance program [Medicaid] before ... process [ing] an application under” § 5112.17). It is clear, therefore, that under Ohio law HCAP patients do not receive care pursuant to the Medicaid plan and, consequently, that HCAP patients are not eligible for care “under a State plan approved under sub-chapter XIX [Medicaid]” within the meaning of the Medicare statute, 42 U.S.C. § 1395ww(d)(5)(F)(vi)(II).
The Hospitals point оut that the Secretary approved certain modifications to the Ohio regulation implementing § 5112.17(B) *179 as an amendment to Ohio’s Medicaid plan. True enough; see Ohio Admin. Code 5101:3-2-07.17, approved by the Secretary April 6, 2001. Accordingly, the Hospitals maintain, the regulation must be pаrt of the Ohio Medicaid plan: Why else would the Secretary have approved the regulation as an amendment to that plan?
The answer is not far to seek. The federal Medicaid statute contains its own DSH provision, which requires each state “specifically [to] define[]” eligibility for DSH adjustments in the state Medicaid plan and to “provide! ] ... for an appropriate increase in the rate or amount of payment” eligible hospitals receive. See 42 U.S.C. § 1396r-4(a)(1). * Ohio acted pursuant to that provision to determine DSH adjustments in its Medicaid program by reference to a hospital’s compliance with the requirement, set out in Rulе 5101:3-2-07.17, that a hospital provide charity care under the HCAP. See, e.g., Ohio Admin. Code 5101:3—2—09(K)(5)(c) (hospitals are not eligible for Medicaid DSH adjustments if they do not provide charity care under the HCAP). Thus the regulation, which determines the eligibility of patients for such charity care, indirectly also determines the Hospitals’ eligibility for and amount of DSH adjustments under the Ohio Medicaid plan. Federal law obliged Ohio to submit the regulation to the Secretary for аpproval because the mechanism for providing a DSH adjustment under Medicaid is part of Ohio’s Medicaid plan, and the Secretary must approve that plan, see 42 U.S.C. § 1396r-4(a) (state plan does not satisfy requiremеnt of § 1396a(a)(13)(A) unless state has submitted to Secretary methodology for making DSH adjustments); § 1396a(b) (“The Secretary shall approve any plan which fulfills the conditions specified in § 1396a(a)”); see also § 1396r-4(a)(3) (governing approval by Seсretary of amendments made under § 1396r-4). The Secretary’s approval of Rule 5101:3-2-07.17 does not suggest in any way that HCAP patients receive care pursuant to the Ohio Medicaid plan. **
B. HCAP Patients Are Not Eligible for “Medical Assistance”
As we noted at the outset, in order to prevail the Hospitals must demonstrate that patients who obtain charity care under the HCAP are “eligible for medical assistance under a State plan approved under [Medicaid]” within the meaning оf that phrase in the Medicare statute, 42 U.S.C. § 1395ww(d)(5)(F)(vi)(II). As explained below, we conclude that the term “medical assistance,” which is not defined in Title XVIII of the Act, has the same meaning in the Medicare DSH provision of Title XVIII as it has in the federal Medicaid statute, Title XIX of the Act; as a result, the Hospitals’ case would fail even *180 if HCAP patients did obtain care under the Ohio Medicaid plan for, as the Government points out, the federаl Medicaid statute defines “medical assistance” as “payment of part or all of the cost” of medical “care and services” for a defined set of individuals, § 1396d(a), whereas the HCAP does not entail any рayment.
First, we note the Medicare DSH provision in Title XVIII of the Act expressly refers to the Medicaid statute (as Title XIX of the Act), § 1395ww(d)(5)(F)(vi)(II), and the same phrase — “medical assistance under a State plan approved under [Medicaid]” — appears throughout the Act.
*
As the Supreme Court has instructed on countless occasions, we are to presume “identical words used in different parts of the same act are intеnded to have the same meaning.”
Atl. Cleaners & Dyers, Inc. v. United States,
Second, and perhaps mоre probative, the Medicaid DSH provision permits the states to adjust DSH payments “under a methodology that” considers either “patients eligible for medical assistance under a State plan apprоved under [Medicaid] or ... low-income patients,” 42 U.S.C. § 1396r-4(c)(3)(B), such as those served under the HCAP. The Medicaid and Medicare DSH provisions serve the same purpose — to adjust payments to hospitals that serve a disрroportionate share of poor patients— and in doing so each refers to patients “eligible for medical assistance under a State plan approved under” the Medicaid title of the Aсt. Id.; § 1395ww(d)(5)(F)(vi)(II). It stands to reason the Congress intended the quoted phrase to have the same meaning in the two provisions.
We thus conclude HCAP patients do not obtain, and are not eligible for, “medical assistance” within the mеaning of the Medicare DSH provision, wherefore the Hospitals’ case must fail. As the Fourth Circuit has noted, “[i]f Congress had wanted ‘medical assistance’ to take on a completely different meaning” in the Medicare DSH provision in Title XVIII than it has in the Medicaid statute, Title XIX, then the “Congress could easily have so indicated.”
Cabell Huntington Hosp., Inc.,
III. Conclusion
In sum, we conclude the HCAP provision requiring the Hospitals to care for indigent patients is not part of the Ohio “State plan approved under [Medicaid]” and the indigent patients covered by the HCAP provision are not “eligible for medical assistance” within the meaning of the Medicare statute, 42 U.S.C. § 1395ww(d)(5)(F)(vi)(II). * Therefore, the judgment of the district court is
Reversed.
Notes
Circuit Judge BROWN concurs in the оpinion of the Court except as to Part II.A.
The Medicare DSH provision, in contrast, does not defer to the states on those questions. See § 1395ww(d)(5)(F).
At oral argument the hospitals suggested § 5112.17(B) of the Ohio Code is part of the Mеdicaid plan because “their [Medicaid DSH] payments will increase if they’re treating more HCAP patients and ... will decrease if they’re treating less [sic] HCAP patients.” The suggestion reflects a misunderstanding of the rationаle for DSH adjustments. Hospitals in Ohio receive more DSH funds under the Medicaid plan the more HCAP patients they treat not because those patients receive care under the Medicaid plan, but because Ohio law treats such patients as a proxy for low-income patients, just as the Medicare provision treats Medicaid patients as a proxy for low-income patients. Thus, the Ohio Medicaid plаn provides a hospital more money for Medicaid patients the more HCAP patients it treats, just as the federal Medicare statute provides a hospital more money for Medicare patients the more Medicaid patients it treats,
Cabell Huntington Hosp., Inc.,
See, e.g., 42 U.S.C. §§ 1320a-7b(a)(6), 1382h(b)(3), 1396a(a)(10)(E), 1396n(i)(1).
The Hospitals’ other arguments are sufficiently lacking in merit as not to warrant consideration in a published opinion.