MDPhysicians & Associates, Inc. v. State Bd. of Ins.MDPhysicians & Associates, Inc. v. State Bd. of Ins.
This case involves the definition of an “employee welfare benefit plan” found in the
I.
MDPhysicians, Inc. (“MDPhysicians,” also known as MDPhysicians of Amarillo, Inc.) is an independent physician practice association of over 130 doctors who work in the Amarillo, Texas area. MDPhysicians, a Texas corporation, contracts its professional services to health care providers. In 1988, MDPhysicians formed an entity called MDPhysicians & Associates, Inc. (“MDP“) and created the MDPhysicians and Associates, Inc. Employee Benefit Plan (“MDP Plan” or “Plan“). MDP adopted the Plan, served as Plan Administrator, and funded the Plan through a trust established by itself and three physicians. The same three doctors who control MDPhysicians, the practice association, also control the MDP entity and the MDP Plan -- not only are these three doctors officers of MDP, but they also serve as trustees of the Plan. MDP entered into a service agreement with a third-party administrator to provide administrative claims services. The Plan is self-funded, which simply means that it is not fully insured. Rather, it purchased stop-loss insurance to protect the Plan only from losses exceeding
The MDP Plan operated in the following manner. Through the broadcast and print media, MDP advertised the Plan to employers located in the Texas panhandle. Over 100 disparate employers (“Subscribing Employers“) subscribed to the MDP Plan by executing an Application and Subscription Agreement, paying a one-time fee, and paying a small, monthly, per-employee fee. MDP administered the Plan under the Trust Agreement and Summary Plan Description to provide medical and health benefits to the Subscribing Employers’ employees and the employees’ dependents (collectively, the “Employees“). An Employee who needed medical or health care could choose to obtain treatment from a network medical service provider and pay only 10% of the medical expense or seek treatment from a non-network provider and pay 20% of the charge. Under the Plan, then, the Employees had a financial incentive to pursue treatment from a network medical service provider, which included physicians in the physicians practice association that formed MDP.
MDP sued the Texas State Board of Insurance (“Board“), seeking a declaratory judgment that the Board‘s attempts to regulate MDP and the MDP Plan were inconsistent with the
The district court concluded that the MDP Plan did not constitute an “employee welfare benefit plan” under
Appellant MDP argues that the federal district court had jurisdiction over this case because the MDP Plan qualified as an “employee welfare benefit plan” within the meaning of
II.
Since a motion to dismiss for lack of subject matter jurisdiction under
A. The ERISA Map
Before we embark on our journey, we comment that our task as judicial travellers is confined to following the
The parties do not disagree that the MDP Plan is a “multiple employer welfare arrangement” as defined by
The parties disagree whether the MDP Plan, admittedly a MEWA, constitutes an EWBP under
The driving force of our journey remains whether this lawsuit belonged in federal court or whether the district court properly dismissed it for lack of subject matter jurisdiction.
We continue to traverse the lexicographic topography charted by Congress.
B. The Place Called “Employee Welfare Benefit Plans”
A court deciding whether a particular arrangement constitutes an EWBP under
As we read the definition of “employer,” MDP had to prove that it acted in one of two ways to fall within the scope of the term: Either MDP acted directly as an employer in relation to an employee benefit plan or MDP acted indirectly in the interests of an employer in relation to an employee benefit plan.
The district court considered the definitional language of
MDP argues that it constitutes an “employer” within the plain language of the statute and that the MDP Plan qualifies as an “employee welfare benefit plan.” MDP insists that the definitional language interpreted by the district court is clear and unambiguous. Thus, the argument continues, the court erred in subjecting the language to statutory construction, inserting language into the definitions that modified the plain meaning of the statute, looking to interpretive case law, and relying on DOL opinions.8 We suspect that MDP urges this position because the indications of the Congressional map-makers and the helpful legends supplied by judicial interpreters on journeys similar to ours all counsel against locating the MDP Plan within the borders of
In reaction to the broad range of “persons” claiming “employer” status to gain the protection of
H.R. Rep. No. 1785, 94th Cong., 2d Sess. 48 (1977). “While not contemporaneous legislative history,” we, like other courts, findcertain entrepreneurs have undertaken to market insurance products to employers and employees at large, claiming these products to be ERISA covered plans. For instance, persons whose primary interest is in profiting from the provision of administrative services are establishing insurance companies and related enterprises. The entrepreneur will then argue that [its] enterprise is an ERISA benefit plan which is protected, under ERISA‘s preemption provision, from state regulation. . . . [W]e are of the opinion that these programs are not ‘employee benefit plans‘. . . . [T]hese plans are established and maintained by entrepreneurs for the purpose of marketing insurance products or services to others. They are not established or maintained by the appropriate parties to confer ERISA jurisdiction . . . . They are no more ERISA plans than is any other insurance policy sold to an employee benefit plan. . . . . . . [W]e do not believe that the statute and legislative history will support the inclusion of what amounts to commercial products within the umbrella of the [‘employee benefit plan‘] definition. . . . [T]o be properly characterized as an ERISA employee benefit plan, a plan must satisfy the definitional requirement of section 3(3)[, which defines “employee welfare benefit plan“,] in both form and substance.
We glean several guiding principles from this passage, but we are not the first judicial travellers to make this same statutory journey. Other courts, examining similar terrain, provide certain descriptive attributes that characterize statutory “employers.” We do not attempt to formulate or ascertain a comprehensive, definitive test for determining whether an entity constitutes an “employer” for the purposes of
First, we know that the MDP Plan, as a MEWA, offered or provided certain medical and health benefits to the Employees of the multiple Subscribing Employers. See supra p.6 (explaining definition of MEWA). But we also understand that the Subscribing Employers did not establish the MDP Plan, nor did they “participate in the day-to-day operation or administration of the plan“; rather, MDP established and maintained the MDP Plan, at least in terms of the Plan‘s status as a “multiple employer welfare arrangement.”
We hold that MDP did not act indirectly “for the [Subscribing Employers]” in relation to the MDP Plan.
Next, we consider the relationship between the provider of
Outside the provision of medical and health benefits under the MDP Plan, MDP had no relationship with the Employees of Subscribing Employers. DOL persuasively contends that the “relationship between the plan sponsor and the participants . . . distinguishes an employee welfare benefit arrangement from other health insurance
Our final destination in the jurisdiction of
III.
Based on our excursion through the definitional topography of
Notes
If the MDP Plan qualified as an EWBP, subsection (6)(A)(ii) would apply because the MDP Plan is not fully insured. Subsection (6)(A)(i) is directed to “employee benefit plan“-MEWAs that are fully insured.[n]otwithstanding any other provision in this section--(ii) in the case of any other employee welfare benefit plan which is a multiple employer welfare arrangement, in addition to this subchapter, any law of any State which regulates insurance may apply to the extent not inconsistent with the preceding sections of this subchapter.
any plan, fund, or program which was heretofor or is hereafter established or maintained by an employer or by an employee organization, or by both, to the extent that such plan, fund, or program was established or is maintained for the purpose of providing its participants or their beneficiaries, through the purchase of insurance or otherwise, (A) medical, surgical, or hospital care or benefits, or benefits in the event of sickness, accident, disability, death or unemployment, or vacation benefits, apprenticeship or other training programs, or day care centers, scholarship funds, or prepaid legal services, or (B) any benefit described in section 186(c) of this title (other than pensions on retirement or death, and insurance to provide such pensions).