Moda Health Plans Lawsuit

8/15/2019 Moda Health Plans Lawsuit

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DC: 6065887-7

IN THE UNITED STATES COURT OF FEDERAL CLAIMS

MODA HEALTH PLAN, INC. ))

Plaintiff, )) No. __________

. )))

THE !NITED "TATE" O# )AME$ICA, )

D%f%n&ant. )

COMPLAINT

I. INTRODUCTION

'. T(% Pati%nt Pot%*tion an& Affo&a+l% Ca% A*t of 0'0, P+. L. No.

'''-'8, ' "tat. ''/ 1ACA2), 3i4nifi*antl *(an4%& t(% (%alt( in3an*% a%t

nationi&%. 9 oi&in4 finan*ial a33i3tan*% fo in&ii&al3 to *(a3%

1;alifi%& H%alt( Plan32 on t(% n% 1H%alt( In3an*% Ma%tla*%3,2 an&

t(o4( a n+% of ot(% (%alt( in3an*% a%t %fo3, t(% ACA *%at%&

a**%33 to affo&a+l% (%alt( in3an*% fo illion3 of %io3l nin3%&

A%i*an3. T(%3% ot(% a%t %fo3 in*l&%& o(i+itin4 (%alt( in3%3 fo

&%nin4 *o%a4% o 3%ttin4 %i3 +a3%& on (%alt( 3tat3 o %&i*al (i3to.

. D% to t(% ACA


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H%alt( Plan3. "%*ifi*all, in3%3 la*%& infoation %4a&in4 t(% n+% an&

(%alt( %=%n3%3 of t(% n% %noll%%3 t(at ol& %noll in ;alifi%& H%alt( Plan3.

>. To %n*oa4% in3%3 to off% ;alifi%& H%alt( Plan3 &%3it% t(i3

n*%taint, "%*tion '> of t(% ACA %3ta+li3(%& a t%oa 1$i3 Coi&o3

Po4a.2 T(% $i3 Coi&o3 Po4a a3 &%3i4n%& to (%l i33%3 of ;alifi%&

H%alt( Plan3 %at(% 3(ot-t% finan*ial *(all%n4%3 *a3%& + 3%ttin4 %i

at%3 fo a olation a+ot (i*( t(% in3%3 la*%& infoation. It a3 al3o

int%n&%& to &i3*oa4% ati*iatin4 in3%3 fo +%in4 %=*%33i%l *on3%ati%

in t(%i *o3t %3tiat%3, (i*( ol& (a% in*%a3%& %i3 fo t(% ;alifi%&

H%alt( Plan3 an& in*%a3%& t(% ?o%n%nt


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a ati*iatin4 lan


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7. 9a3%& on it3 a*tal alloa+l% *o3t3, Mo&a H%alt( i3 %ntitl%& to a

i3 *oi&o3 a%nt fo t(% ?o%n%nt of 8/,6,>0 fo it3 0' ;alifi%&

H%alt( Plan3 an& '0',8,05 fo it3 0'5 ;alifi%& H%alt( Plan3.

8. Ho%%, t(% !nit%& "tat%3 +%a*(%& it3 3tatto an& *onta*tal

o+li4ation to a% fll i3 *oi&o3 a%nt3. #o t(% 0' lan3, t(% !nit%&

"tat%3 ill a ot onl '.6 %*%nt of t(% aont &% an in3%, it( t(% %3lt

t(at Mo&a i3 to %*%i% onl '',8>,708 of t(% 8/,6,>0 t(at it i3 o%&. In

a&&ition, t(% ?o%n%nt ill not a an of it3 0'5 i3 *oi&o3 o+li4ation3,

nl%33 an& ntil it %*%i%3 3ffi*i%nt i3 *oi&o3 a%nt3 fo in3%3 to

3ati3f it3 .5 +illion &%+t to all ;alifi%& H%alt( Plan3 fo t(% 0' i3 *oi&o3

o+li4ation3, an %=t%%l nli%l %%nt. T(i3 (a3 t(% %ff%*t of &%nin4 Mo&a

H%alt( t(% %nti% '0',8,05 in 0'5 i3 *oi&o3 a%nt to (i*( it i3

%ntitl%&.

/. T(i3 la3it 3%%3 t(% %*o% of t(% '7/,/85,'7 3(otfall t(%

?o%n%nt o%3 Mo&a H%alt( fo t(% 0' an& 0'5 *o%a4% %a3.

II. JURISDICTION

'0. T(i3 Cot (a3 i3&i*tion o% t(i3 a*tion 3ant to t(% T*% A*t,

8 !.".C. '/', +%*a3% "%*tion '> i3 a on%-an&atin4 3tatt% oi&in4

t(at, (%n *%tain %a3il &%t%ina+l% finan*ial *it%ia a% %t, t(% ?o%n%nt

13(all a to t(% lan an aont2 3%*ifi%& + 3tatt%. An il%%ntin4


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%4lation, 5 C.#.$. '5>.5'0, 3iilal %Bi%3 t(% ?o%n%nt to a%

a%nt3 of t(% 3a% aont3. T(% T*% A*t i3 al3o t(% i3&i*tional +a3i3 fo

Mo&a H%alt(. In 0'0, Con4%33 %na*t%& t(% ACA. T(% ACA %fo%& (%alt(

in3an*% a%t3 nationi&%, in*l&in4 + io3in4 n% %Bi%%nt3 on (%alt(

in3%3. #o %=al%, in3%3 *an no lon4% &%n *o%a4% to in&ii&al3 &% to

%-%=i3tin4 *on&ition3, an& *%tain (%alt( lan3 3t %%t oi&% n%to

5


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a&%Ba* %Bi%%nt3 an& *o% %33%ntial (%alt( +%n%fit3, aon4 an ot(% n%

%Bi%%nt3.

'. T(% ACA al3o *%at%& n% H%alt( In3an*% Ma%tla*%3 al3o *all%&

1H%alt( E=*(an4%32) an& at(oiG%& in3%3 to 3%ll ;alifi%& H%alt( Plan3 on

t(o3% Ma%tla*%3. ;alifi%& H%alt( Plan3 3t oi&% %33%ntial (%alt( +%n%fit3,

*ol it( n%to a&%Ba* 3tan&a&3, an& follo %3ta+li3(%& liit3 on *o3t-

3(ain4, aon4 ot(% t(in43. ;alifi%& H%alt( Plan3 3t +% *%tifi%& + %a*(

Ma%tla*% in (i*( t(% a% 3ol&. ACA '>0', !.".C. '80'.

'5. An in&ii&al i3 %li4i+l% to *(a3% a ;alifi%& H%alt( Plan t(o4( a

Ma%tla*% if (% o 3(%: i3 a *itiG%n o national of t(% !nit%& "tat%3, o a lafll

%3%nt non-*itiG%n i3 not in*a*%at%& an& %%t3 *%tain %3i&%n* %Bi%%nt3.

ACA '>'f), !.".C. '80>f) see also 5 C.#.$. '55.>05a). !n&%

"%*tion '0' of t(% ACA, an in&ii&al %li4i+l% to *(a3% a ;alifi%& H%alt(

Plan a +% %li4i+l% fo a ta= *%&it to off3%t t(% *o3t of t(% %i if (i3 o (%

(o3%(ol& in*o% i3 +%t%%n '00 %*%nt an& 00 %*%nt of t(% f%&%al o%t

l%%l, an& (% o 3(% i3 not ot(%i3% %li4i+l% fo ini %33%ntial (%alt( *a%

*o%a4%. See id. '55.>05f). !n&% "%*tion '0 of t(% ACA, an in&ii&al

%li4i+l% to *(a3% a ;alifi%& H%alt( Plan a +% %li4i+l% fo a *o3t 3(ain4

%&*tion if (i3 o (% (o3%(ol& in*o% i3 +%t%%n '00 %*%nt an& 50 %*%nt of

6


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t(% f%&%al o%t l%%l, an& (% o 3(% i3 not ot(%i3% %li4i+l% fo ini

%33%ntial *o%a4%. See id. '55.>054).

'6. !n&% t(% ACA, ;alifi%& H%alt( Plan i33%3 (a& to nai4at% t(% n%

(%alt( in3an*% %fo3 (il% att%tin4 to %&i*t (%alt( *a% *o3t3 fo a

olation in&ii&al3 *(a3in4 ;alifi%& H%alt( Plan3) a+ot (i*( t(% i33%3

la*%& infoation an& %=%i%n*%. A3 a %3lt, in3%3 fa*%& 3i4nifi*ant

*(all%n4%3 an& n*%tainti%3 in 3%ttin4 %i at%3 fo t(%i ;alifi%& H%alt(

Plan3.

'7. To a&&%33 t(%3% n*%tainti%3 an& to %nti*% in3%3 to off% ;alifi%&

H%alt( Plan3, t(% ACA *%at%& t(%% a%t 3ta+iliGation o4a3, *oonl

*all%& t(% 1>$32: %in3an*%, i3 a&3t%nt, an& i3 *oi&o3.

'8. T(i3 la3it %lat%3 to t(% t(i& o4a. "%*tion '> of t(% A*t

&i%*t3 t(% "%*%ta of HH" to a% a%nt3 to ;alifi%& H%alt( Plan3 n&% t(%

t%oa $i3 Coi&o3 Po4a. !n&% t(% $i3 Coi&o3 Po4a, HH" 3t

a% a%nt3 to an ;alifi%& H%alt( Plan t(at, fo t(% ali*a+l% %a, (a&

(%alt( *a% *o3t3 t(at %% o% t(an > %*%nt 4%at% t(an a ta4%t aont +a3%&

on a44%4at% %i3 *(a4%& + t(% lan in t(% ali*a+l% %a. "%*ifi*all,

"%*tion '> oi&%3 in %l%ant at:

+) PAMENT METHODOLO?. ') Pa%nt3 ot. T(% "%*%ta 3(all oi&%n&% t(% o4a %3ta+li3(%& n&% 3+3%*tion a)t(at if

7


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A) a ati*iatin4 lan


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to 3%t a**at% %i3. See Standards Related to Reinsurance, Risk Corridors

and Risk Adjustment , 77 #%&. $%4. '7,0, '7,', '7,>6J>/ Ma. >, 0').

'. 9 liitin4 i3, t(% $i3 Coi&o3 Po4a %n*oa4%& i33%3 to

ati*iat% in t(% Ma%tla*%3. @it(ot t(% o4a, in3%3 fa*%& t(% o33i+ilit

of 3i4nifi*ant lo33%3 4i%n t(% nnon &%o4a(i*3 of t(% n% %noll%%3. In

a&&ition, t(% o4a allo%& in3%3 to %% %i at%3 at affo&a+l% l%%l3

+ not a&&in4 a i3 %i to a**ont fo a*taial n*%tainti%3. CM",

Reinsurance, Risk Corridors, and Risk Adjustment Final Rule Ma. 0'),

available at (tt3:KK.*3.4oK**iioK%3o*%3Kfil%3K&onloa&3K >3-final-

l%.&f.

. T(% $i3 Coi&o3 Po4a al3o a&&%33%3 3itation3 in (i*( a

(%alt( in3% (a& *(a4%& %i3 (i4(% t(an n%*%33a in %to3%*t) to *o%

it3 *o3t3. "%*tion '>+)) oi&%3 fo a%nt3 by t(% (%alt( in3% to t(%

?o%n%nt in t(at *i*3tan*%:

) Pa%nt3 in. T(% "%*%ta 3(all oi&% n&% t(% o4a %3ta+li3(%& n&% 3+3%*tion a) t(at if

A) a ati*iatin4 lan


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%*%nt of t(% %=*%33 of / %*%nt of t(% ta4%taont o% t(% alloa+l% *o3t3.

>. In "%*tion '>a), Con4%33 in3t*t%& t(at t(% ACA $i3 Coi&o3

Po4a 13(all +% +a3%& on t(% o4a fo %4ional ati*iatin4 oi&%

o4aniGation3 n&% at D of titl% III of t(% "o*ial "%*it A*t.2 Coonl

%f%%& to a3 1M%&i*a% Pat D,2 t(at o4a oi&%3 *o%(%n3i% M%&i*a%

*o%a4% of otati%nt %3*ition &43. See M%&i*a% P%3*ition D4

Io%%nt an& Mo&%niGation A*t of 00>, P+. L. No. '08-'7>, ''7 "tat.

066, !.".C. '>/5-'0' et seq. 00>). T(% M%&i*a% Pat D o4a al3o

tiliG%3 i3 *oi&o3, n&% (i*( t(% ?o%n%nt annall a%3 i3 *oi&o3

a%nt3 to, o %*%i%3 i3 *oi&o3 a%nt3 fo, lan 3on3o3, &%%n&in4

on (%t(% a 3on3o). T(% final l%3 %Bi% ;alifi%& H%alt( Plan i33%3 to 1a&(%% to t(%

%Bi%%nt3 3%t + HH" in '5>.500J.5>0 an& in t(% annal HH" noti*% of

a%nt an& +%n%fit aa%t%3,2 an& oi&% t(at 1;alifi%& H%alt( Plan i33%3

will receive payment fo HH"2 in aont3 *on3i3t%nt it( t(% 3tatto

oi3ion3 of "%*tion '>+)'). 5 C.#.$. '5>.5'0 %(a3i3 a&&%&).

'0


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5. A %a lat%, on Ma*( '', 0'>, HH" +li3(%& anot(% final l%

t(at, aon4 ot(% t(in43, in*l&%& noti*% of +%n%fit an& a%nt aa%t%3 fo

*al%n&a %a 0', to %na+l% t(% in3%3 to %3ta+li3( t(%i at%3 fo t(% fi3t %a

of t(% Ma%tla*%3 0'). In t(% %a+l%, CM" 3tat%&: 1T(% i3 *oi&o3

o4a i3 not 3tattoil %Bi%& to +% +&4%t n%tal. $%4a&l%33 of t(% +alan*%

of a%nt3 an& %*%it3, HH" ill %it a%nt3 a3 %Bi%& n&% 3%*tion '>

of t(% Affo&a+l% Ca% A*t.2 Patient Protection and Affordable Care Act !!S

"otice of #enefit and Payment Parameters for $%&', 78 #%&. $%4. '5,'0, '5,7>

Ma. '', 0'>). In ot(% o&3, *on3i3t%nt it( t(% *l%a lan4a4% of "%*tion

'>, lan3 %ntitl%& to a%nt3 n&% t(% $i3 Coi&o3 Po4a ol& %*%i%

3*( a%nt3 in fll, %4a&l%33 of (%t(% t(% a44%4at% aont3 of 3*(

a%nt3 o%& to ;alifi%& H%alt( Plan3 %=*%%&%& t(% a44%4at% aont of

a%nt3 %*%i%& + HH" fo ;alifi%& H%alt( Plan3 (o3% %=%n&it%3 f%ll

3(ot of t(% ta4%t aont.

6. CM" al3o oi&%& t(at t(% &%a&lin% fo t(% ?o%n%nt to a% i3

*oi&o3 a%nt3 to i33%3 13(ol& +% t(% 3a%2 a3 t(% &%a&lin% + (i*(

i33%3 it( alloa+l% annal *o3t3 t(at a% l%33 t(an /7 %*%nt of t(% ta4%t

aont 3t a% i3 *oi&o3 a%nt3 to t(% ?o%n%nt. 77 #%&. $%4. at

'7,'/. CM" %n&%& io3in4 a >0-&a &%a&lin% fo ;alifi%& H%alt( Plan

i33%3 t(at o% a%nt3 n&% t(% o4a to a% t(o3% a%nt3 to t(%

''


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?o%n%nt, 5 C.#.$. '5>.5'0&), an& t(3 i33%3 t(at o%& 0' i3

*oi&o3 a%nt3 %itt%& t(o3% a%nt3 to CM" +%fo% t(% %n& of *al%n&a

%a 0'5.

C. Re$&lator) A((ro*al of Moda Health+" ,-/ 0&al!f!ed Health

Pla".

7. T(o4( t(% %na*t%nt of t(% ACA in 0'0, t(% %4lation3 an& t(%

%a+l%3 t(%%to, a3 %ll a3 l%tt%3, %oan&a, an& ot(% itt%n an& oal

*oni*ation, CM" off%%& to oi&% ta= *%&it3, *o3t 3(ain4 3+3i&i%3, i3

*oi&o3 a%nt3, an& ot(% %i+3%%nt to Balifi%& %ntiti%3, 3*( a3 Mo&a

H%alt(, t(at a4%%& to 3%ll an& oi&% ;alifi%& H%alt( Plan *o%a4% in 0'

an&Ko 0'5, n&% t(% t%3 an& *on&ition3 3%t fot( in t(% ACA, it3 il%%ntin4

%4lation3, an& CM" oli* an& 4i&an*%. See, e.(., 5 C.#.$. Pat3 ', '7,

'8, '50, '5>J'56 )*c+an(e and nsurance -arket Standards for $%& and

#eyond , 7/ #%&. $%4. >0,0, >0,60 Ma 7, 0') 78 #%&. $%4. '5,'0 77

#%&. $%4. '7,0 CM", #%&%al Ma%tla*% Po4%33 #a*t "(%%t Ma >', 0'>),

available at (tt3:KK.*3.4oKCCIIOK$%3o*%3K#a*t-"(%%t3-an&-#A;3K

ff%.(tl CM", L%tt% to I33%3 on #%&%all-#a*ilitat%& an& "tat% Patn%3(i

E=*(an4%3 A. 5, 0'>), available at (tt3:KK.*3.4oKCCIIOK$%3o*%3K

$%4lation3-an&-?i&an*%KDonloa&3K0'_l%tt%_to_i33%3_0050'>.&f.

8. Mo&a H%alt( a**%t%& CM"


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*al*latin4 %i at%3 fo t(% nnon olation t(at ol& *(a3%

;alifi%& H%alt( Plan3. T(% a*tai%3 *on3i&%%& a n+% of fa*to3 in

*al*latin4 t(% at%3, in*l&in4: *o3t t%n&3, t(% ia*t of %4in4 (i4( i3 ool3,

t(% %3tiat%& *o3t of *o%in4 %io3l nin3%& in&ii&al3 (o a (a%

a**lat%& nt%at%& %&i*al n%%&3), an& 3tat% an& f%&%al la3 an& oli*i%3.

/. $%4lato aoal fo ;alifi%& H%alt( Plan3 i3 a to-3t% o*%33:

') ;alifi%& H%alt( Plan3< at%3 an& ot(% f%at%3 3t +% ao%& + 3tat%

in3an*% %4lato3 fo *olian*% it( 3tat% an& f%&%al la an& ) ;alifi%&

H%alt( Plan3 3t +% *%tifi%& + t(% Ma%tla*% fo *olian*% it( t(% f%&%al

%Bi%%nt3 4o%nin4 ;alifi%& H%alt( Plan3 3%*ifi*all. In 3tat%3 t(at *(oo3%

to o%at% t(%i on Ma%tla*%, a3 O%4on (a& &on% fo 0', t(% 3tat% offi*ial3

nnin4 t(% Ma%tla*% *%tif t(% ;alifi%& H%alt( Plan3 fo *olian*% it( t(%

f%&%al ;alifi%& H%alt( Plan %Bi%%nt3. In 3tat%3 fo (i*( t(% f%&%al

4o%n%nt o%at%3 t(% Ma%tla*%, 3*( a3 Ala3a, CM" *%tifi%3 t(% ;alifi%&

H%alt( Plan3 fo *olian*% it( t(% f%&%al ;alifi%& H%alt( Plan %Bi%%nt3.

>0. Mo&a H%alt( 3+itt%& it3 ;alifi%& H%alt( Plan at%3 fo 0' to

Ala3a 3tat% %4lato3 fo %i% an& aoal on Ma /, 0'> 3all 4o) an&

Ma >, 0'> in&ii&al). Ala3a 3tat% %4lato3 ao%& Mo&a H%alt(


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>'. Mo&a H%alt( 3+itt%& it3 ;alifi%& H%alt( Plan at%3 fo 0' to

O%4on 3tat% %4lato3 fo %i% an& aoal on Ail /, 0'> in&ii&al) an&

Ail >0, 0'> 3all 4o). O%4on %4lato3 ao%& Mo&a H%alt(, 0'>.

>. Mo&a H%alt( 3+itt%& it3 Ala3a ;alifi%& H%alt( Plan3 to CM" fo

%i% an& *%tifi*ation on o +%fo% Ma >, 0'>. Mo&a H%alt( %*%i%& a

*%tifi*ation a4%%%nt fo it3 Ala3a ;alifi%& H%alt( Plan3 on "%t%+% /,

0'>, an& it 3i4n%& t(% *%tifi*ation on "%t%+% >, 0'>.

>>. Mo&a H%alt( 3+itt%& it3 O%4on ;alifi%& H%alt( Plan3 to t(%

1Co% O%4on2 Ma%tla*% fo %i% an& *%tifi*ation on Ail >0, 0'>.

Co% O%4on *%tifi%& Mo&a H%alt(, it( *o%a4% %ff%*ti% ana ', 0'. T(o4(ot 0', Mo&a H%alt(

oi&%& (%alt( *a% *o%a4% n&% t(%3% ;alifi%& H%alt( Plan3 to t%n3 of

t(o3an&3 of Ala3an3 an& O%4onian3, n&% t(% t%3 %Bi%& + 3tat% an&

f%&%al la an& oli*.

'


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D. Cha$e" to the 0&al!f!ed Health Pla R!"# Pool Re"&lt!$ fro%

Act!o" of the Federal Go*er%et.

>5. In t(% final ont(3 of 0'>, an (%alt( in3%3 +%4an to *an*%l

%=i3tin4 (%alt( in3an*% oli*i%3 t(at %% not *oliant it( t(% n% ACA

%fo3 t(at ol& +%*o% %ff%*ti% ana ', 0'. T(% *an*%llation of t(%3%

oli*i%3 *%at%& 3i4nifi*ant oliti*al %33% on t(% ?o%n%nt, a3 an %ol%

(a& +%li%%& t(at t(% ACA ol& not *a3% t(% to lo3% t(%i %=i3tin4 *o%a4%.

>6. On No%+% ', 0'>, CM" %3on&%& + annon*in4 a

1tan3itional oli*2 &%3i4n%& to *+ t(% *an*%llation of %=i3tin4 oli*i%3. !n&%

t(% tan3itional oli*, an *o%a4% in %ff%*t on O*to+% ', 0'> a3 not

*on3i&%%& non*oliant fo fail% to *ol it( *%tain ACA %fo3 t(at

ot(%i3% +%*a% %ff%*ti% on ana ', 0'. CM" annon*%& t(at t(i3

tan3itional oli* ol& al onl to lan %a3 +%4innin4 +%fo% O*to+% ',

0'. "tat%3 %% %n*oa4%&, +t not %Bi%&, to al a 3iila tan3itional

oli*. L%tt% fo ?a Co(%n, Di., Ct. fo Con3% Infoation an& In3.

O%3i4(t 1CCIIO2), CM", to "tat% In3an*% Coi33ion%3 No. ', 0'>),

available at (tt3:KK.*3.4oK**iioK%3o*%3Kl%tt%3K&onloa&3K*oi33ion%-

l%tt%-''-'-0'>.&f. O%4on an& Ala3a +ot( ali%& t(% tan3itional oli*.

>7. A+3%nt t(i3 tan3itional oli*, (i*( a3 not annon*%& ntil aft%

Mo&a an& ot(% i33%3 +%4an 3%llin4 ;alifi%& H%alt( Plan3 fo 0', illion3 of

in&ii&al3 (o (a& %=i3tin4 in&ii&al a%t *o%a4% t(at &i& not *ol it(

'5


16/35

t(% ACA ol& (a% (a& t(at *o%a4% t%inat%& an& t(3 ol& (a%

tan3ition%& to a ;alifi%& H%alt( Plan %ff%*ti% ana ', 0'. T(%3% ot%ntial

;alifi%& H%alt( Plan %noll%%3, (o %n&%& a+l% to 3ta in t(%i ol& lan3 n&%

t(% tan3itional oli*, %% 4%n%all l%33 %=%n3i% t(an t(o3% (o %%

nin3%& io to t(%i ;alifi%& H%alt( Plan %noll%nt, +%*a3% t(% fo%

4o i3 l%33 li%l to (a% nt%at%& (%alt( *a% *on&ition3. T(3, t(% i3 ool fo

;alifi%& H%alt( Plan3 in O%4on an& Ala3a a3 o% %=%n3i% t(an *ol& (a%

+%%n anti*iat%& (%n in3%3 3%t t(%i %i3.

>8. In it3 No%+% 0'> annon*%%nt of t(% tan3ition oli*, CM"

%*o4niG%& t(at ;alifi%& H%alt( Plan i33%3 (a& 3%t at%3 +a3%& on t(% a33tion

t(at in&ii&al3 (o (a& %=i3tin4 in&ii&al a%t *o%a4% t(at &i& not *ol

it( t(% ACA ol& (a% tan3ition%& to a ;alifi%& H%alt( Plan %ff%*ti% ana

', 0', 3o%t(in4 t(at ol& (a%n *( l%33 f%B%ntl &% to t(% n%

tan3ition oli*. CM" a33%& i33%3 an& 3tat% in3an*% *oi33ion%3 t(at t(%

i3 *oi&o3 a%nt3 ol& at l%a3t atiall off3%t an lo33%3 ai3in4 ot of t(%

n% tan3ition oli*:

T(o4( t(i3 tan3itional oli* a3 not anti*iat%& +

(%alt( in3an*% i33%3 (%n 3%ttin4 at%3 fo 0', t(%i3 *oi&o o4a 3(ol& (%l a%lioat%nanti*iat%& *(an4%3 in %i %%n%.

d.

'6


17/35

>/. On Ma*( 5, 0', CM" annon*%& t(at it a3 %=t%n&in4 it3

tan3itional oli* fo to %a3, i.e., to oli* %a3 +%4innin4 on o +%fo% O*to+%

', 0'6. M%oan& fo ?a Co(%n, Di., CCIIO, CM", nsurance Standards

#ulletin Series / )*tension of 0ransitional Policy t+rou(+ 1ctober &, $%&2 Ma. 5,

0'), available at (tt3:KK.*3.4oK**iioK%3o*%3K%4lation3-an&-

4i&an*%K&onloa&3Ktan3ition-to-*oliant-oli*i%3-0>-06-0'5.&f. On #%+a

/, 0'6, CM" %=t%n&%& it a4ain + on% %a, to oli* %a3 +%4innin4 on o +%fo%

O*to+% ', 0'7, oi&%& t(at all oli*i%3 %n& + D%*%+% >', 0'7. See

M%oan& fo Q%in Coni(an, Di. CIIOO, CM", nsurance Standards

#ulletin Series / "F1R-A01" / )*tension of 0ransitional Policy t+rou(+

Calendar 3ear $%&4 #%+. /, 0'6), available at (tt3:KK.*3.4oKCCIIO

K$%3o*%3K$%4lation3-an&-?i&an*%KDonloa&3Kfinal-tan3ition-+ll%tin--/-

'6.&f.

E. Pro$ra% De*elo(%et" ! ,-/ ad ,-1.

0. Mo&a H%alt(


18/35

il%%nt t(% i3 *oi&o3 o4a in a 1+&4%t n%tal ann%.2 !!S "otice

of #enefit and Payment Parameters for $%& , 7/ #%&. $%4. '>,7, '>,787, '>,8/

Ma. '', 0') %ff. Ma ', 0'). T(i3 a3 not in*on3i3t%nt it( %io3 HH"

3tat%%nt3, a3 it a3 3il a %&i*tion + HH" t(at t(% o4a ol& +% +&4%t

n%tal, i.e., t(at t(% a44%4at% aont3 of a%nt3 o%& to ;alifi%& H%alt(

Plan3 (o3% %=%n&it%3 %=*%%&%& t(% ta4%t aont3 ol& +% off3%t +

a%nt3 %*%i%& + HH" fo ;alifi%& H%alt( Plan3 (o3% %=%n&it%3 f%ll

3(ot of t(% ta4%t aont3. HH" &i& not in&i*at% t(at it ol& il%%nt t(% i3

*oi&o3 o4a in a +&4%t n%tal ann% %%n if a%nt3 to HH" +

;alifi%& H%alt( Plan3 (o3% *o3t3 f%ll 3(ot %% not 3ffi*i%nt to *o% HH"


19/35

ann%, to t(% oint (%% i33%3 a% %i+3%& in fll fo t(% %io3 %a.

See CM", $i3 Coi&o3 an& 9&4%t N%talit A. '', 0'), available at

(tt3:KK.*3.4oKCCIIOK$%3o*%3K#a*t-"(%%t3-an&-#A;3KDonloa&3KfaB-

i3-*oi&o3-0-''-0'.&f. Aft% all i33%3 %*%i%& fll i3 *oi&o3

%i+3%%nt o%& fo t(% %io3 %a, an %ainin4 fn&3 ol& +% 3%& to

fn& *%nt %a a%nt3. d. CM".

. 3t a ont( lat%, in Ma 0', HH" al%& aa fo it3 Ail

0' B%3tion3 an& an3%3 + %affiin4 t(at it (a& t(% l%4al at(oit to a it3

%nti% i3 *oi&o3 o+li4ation3 %4a&l%33 of t(% aont of a%nt3 t(%

?o%n%nt %*%i%& t(o4( t(% o4a. "%*ifi*all, in a l%tt% to t(%

?o%n%nt A**onta+ilit Offi*% ?AO) &at%& Ma 0, 0', HH" 3tat%& t(at

t(% CM"


20/35

L%tt% fo @illia 9. "*(ltG, ?%n%al Con3%l, HH", to lia C. Matta,

A33i3tant ?%n%al Con3%l, ?AO Ma 0, 0'). T(%n, on% %% lat%, in t(%

#inal $l%ain4 fo E=*(an4% an& In3an*% Ma%t "tan&a&3 fo 0'5 an&

9%on&, HH" %it%at%& t(at it a3 l%4all o+li4at%& to a% i3 *oi&o3

a%nt3 in fll. @(il% HH" 1anti*iat%& t(at i3 *oi&o3 *oll%*tion3 ill +%

3ffi*i%nt to a fo all i3 *oi&o a%nt3,2 HH" %=lain%& t(at, 1in t(%

nli%l %%nt of a 3(otfall fo t(% 0'5 o4a %a, HH" %*o4niG%3 t(at t(%

Affo&a+l% Ca% A*t %Bi%3 t(% "%*%ta to a% fll a%nt3 to i33%32 an&

t(3 1HH" ill 3% ot(% 3o*%3 of fn&in4 fo t(% i3 *oi&o3 a%nt3,

3+%*t to t(% aaila+ilit of aoiation3.2 )*c+an(e and nsurance -arket

Standards for $%& and #eyond , 7/ #%&. $%4. >0,0, >0,60 Ma 7, 0').

>. On "%t%+% >0, 0', t(% !.". ?o%n%nt A**onta+ilit Offi*%

1?AO2) i33%& a %ot on t(% ACA $i3 Coi&o3 Po4a, in (i*( it

*on*l&%& t(at t(% CM" Po4a Mana4%%nt fn& fo #i3*al %a 1#2) 0'

oi&%3 t(% ?o%n%nt it( t(% at(oit an& aoiation3 to a% fll i3

*oi&o3 a%nt3. ?AO, !!S5Risk Corridors Pro(ram, 9->56>0 "%t. >0,

0'), available at (tt:KK4ao.4oKa33%t3K670K666//.&f.

0


21/35

F. Re$&lator) A((ro*al of Moda Health+" ,-1 0&al!f!ed Health

Pla".

. Mo&a H%alt( 3+itt%& it3 ;alifi%& H%alt( Plan at%3 to Ala3a 3tat%

%4lato3 on l '0, 0' 3all 4o) an& l ', 0' in&ii&al). Ala3a

3tat% %4lato3 ao%& Mo&a H%alt(


22/35

@a3(in4ton Ma%tla*% *%tifi%& Mo&a H%alt(->5, '8 "tat. '>0, (i*( *ontain%& t(% folloin4

oi3ion:

"EC. 7. Non% of t(% fn&3 a&% aaila+l% + t(i3 A*tfo t(% #%&%al Ho3ital In3an*% T3t #n& o t(%#%&%al "l%%ntal M%&i*al In3an*% T3t #n&, o


23/35

tan3f%%& fo ot(% a**ont3 fn&%& + t(i3 A*t to t(%1C%nt%3 fo M%&i*a% an& M%&i*ai& "%i*%3Po4aMana4%%nt2 a**ont, a +% 3%& fo a%nt3 n&% 3%*tion '>+)') of P+li* La '''J'8 %latin4 toi3 *oi&o3).

5>. On l ', 0'5, in a l%tt% to 3tat% (%alt( in3an*% *oi33ion%3,

CM" %affi%& it3 *oit%nt to ain4 fll i3 *oi&o3 a%nt3, on ti%

an& in fll. CM" 3tat%&:

CM" %ain3 *oitt%& to t(% i3 *oi&o o4a.A3 3tat%& in o final a%nt noti*% fo 0'6, 1@%

anti*iat% t(at i3 *oi&o3 *oll%*tion3 ill +% 3ffi*i%ntto a fo all i3 *oi&o3 a%nt3. HH" %*o4niG%3t(at t(% Affo&a+l% Ca% A*t %Bi%3 t(% "%*%ta toa% fll a%nt3 to i33%3.2

Q%in . Coni(an, C(i%f E=%*ti% Offi*% 1CEO2), H%alt( In3an*%

Ma%tla*%, Di., CCIIO, CM", to "tat% In3an*% Coi33ion%3 l ', 0'5)

available at (tt3:KK.*3.4oK**iioK%3o*%3Kl%tt%3K&onloa&3K&oi-

*oi33ion%-l%tt%-7-0-'5.&f.

5. Ho%%, on O*to+% ', 0'5 %=a*tl to %a3 aft% Mo&a H%alt(

+%4an 3%llin4 0' ;alifi%& H%alt( Plan3 an& on% %a aft% Mo&a H%alt( +%4an

3%llin4 0'5 ;alifi%& H%alt( Plan3 CM" annon*%& t(at t(% i3 *oi&o3

o4a ol& +% 1+&4%t n%tal2 an& t(at t(% ?o%n%nt ol& not a% t(%

fll i3 *oi&o3 a%nt3 fo 0'. CM" 3tat%& t(at ;alifi%& H%alt( Plan

i33%3 (o3% a*tal %=%n3%3 %=*%%&%& t(%i anti*iat%& ta4%t aont3 (a&

3+itt%& *lai3 to t(% ?o%n%nt fo .87 +illion in i3 *oi&o3 a%nt3,

>


24/35

an& t(at ;alifi%& H%alt( Plan i33%3 (o3% a*tal %=%n3%3 f%ll 3(ot of t(% ta4%t

aont o%& t(% ?o%n%nt >6 illion in i3 *oi&o3 *(a4%3. CM" 3tat%&

t(at it ol& a ;alifi%& H%alt( Plan i33%3 to (o on% a3 o%& onl

'.6 %*%nt of t(%i 0' i3 *oi&o3 *lai3 >6 illion &ii&%& + .87

+illion). CM" a33%t%& t(at t(% 87. %*%nt 3(otfall ol& %%ntall +% ai& ot

of 0'5 an& 0'6 i3 *oi&o3 *(a4%3, +t oi&%& no %=lanation a3 to (o

t(i3 .5 +illion 3(otfall fo *al%n&a %a 0' .87 +illion in3 >6 illion)

ol& o *ol& +% *lo3%& + aont3 o%& + ;alifi%& H%alt( Plan3 fo 0'5 an&

0'6. See CM", $i3 Coi&o3 Pa%nt Poation $at% fo 0' O*t. ', 0'5),

available at (tt3:KK.*3.4oKCCIIOKPo4a3-an&-Initiati%3KP%i-

"ta+iliGation-Po4a3KDonloa&3K$i3Coi&o3Pa%ntPoation$at%fo0'

.&f.

55. On No%+% '/, 0'5, CM" %l%a3%& a 3tat%%nt titl%& 1$i3

Coi&o3 Pa%nt an& C(a4% Aont3 fo 9%n%fit %a 0'.2 T(% 3tat%%nt

in*l&%& i33%-l%%l &ata on t(% i3 *oi&o3 *(a4%3 an& a%nt3 fo t(% 0'

+%n%fit %a. It al3o *onfi%& t(at t(% 0' i3 *oi&o3 a%nt aont3 ill

+% oat%& at '.6 %*%nt, an& it in&i*at%& t(at HH" ol& +%4innin4 %ittin4

a%nt3 to in3%3 in D%*%+% 0'5. CM", $i3 Coi&o3 Pa%nt an&

C(a4% Aont3 fo 9%n%fit %a 0' No. '/, 0'5), available at


25/35

(tt3:KK.*3.4oKCCIIOK$%3o*%3K$%4lation3-an&-?i&an*%KDonloa&3K$C

_O+li4ation_?i&an*%_''-'/-'5.&f.

56. "%*tion 5 of t(% Con3oli&at%& Aoiation3 A*t, 0'6, P+. L.

No. ''-''>, %na*t%& on D%*%+% '8, 0'5, *ontain%& a oi3ion i&%nti*al to

"%*tion 7 of t(% Con3oli&at%& an& #t(% Continin4 Aoiation3 A*t, 0'5.

57. Con4%33 (a3 not %%al%& o a%n&%& "%*tion '> of t(% ACA.

58. Mo&a H%alt( %t all 3tatto an& %4lato %Bi%%nt3 t(at

;alifi%& H%alt( Plan3 3t 3ati3f to ati*iat% in an& %*%i% a%nt3 fo t(%

$i3 Coi&o3 Po4a.

H. R!"# Corr!dor" Pa)%et" O2ed to Moda Health.

5/. In a l%tt% &at%& O*to+% 8, 0'5, o% to %a3 aft% Mo&a H%alt(

+%4an 3%llin4 ;alifi%& H%alt( Plan3 in t(% Ma%tla*%3, Q%in . Coni(an,

C(i%f E=%*ti% Offi*% of t(% H%alt( In3an*% Ma%tla*%3, foall notifi%&

Mo&a H%alt( t(at it ol& +% ai& ao=iat%l '.6 %*%nt of it3 0' i3

*oi&o3 a%nt3 fo Ala3a an& O%4on, t(% to 3tat%3 fo (i*( it i3 o%& 3*(

a%nt3:

a. A**o&in4 to CM"


26/35

+. CM" %3tiat%& t(at it ill a% i3 *oi&o3 a%nt3 of '56,'>6

fo Mo&a H%alt( fo Mo&a H%alt(


27/35

Q%in . Coni(an, CEO, H%alt( In3. Ma%tla*%3, Di., CIIOO, to $o+%t

?oot%%, P%3. F CEO, Mo&a H%alt( O*t. 8, 0'5).

60. #o t(% 0'5 a%nt %a, t(% ?o%n%nt o%3 Mo&a H%alt(

'0',8,05 in i3 *oi&o3 a%nt3:

a. #o Ala3a, Mo&a H%alt( i3 o%& '6,70>,'/' fo it3 in&ii&al

a%t ;alifi%& H%alt( Plan3 an& ,>77,5>/ fo it3 3all 4o

;alifi%& H%alt( Plan3.

+. #o O%4on, Mo&a H%alt( i3 o%& 65,08,> fo it3 in&ii&al

a%t ;alifi%& H%alt( Plan3 an& 7,70/,/0 fo it3 3all 4o

;alifi%& H%alt( Plan3.

*. #o @a3(in4ton, Mo&a H%alt( i3 o%& /,/67,58 fo it3 in&ii&al

a%t ;alifi%& H%alt( Plan3.

6'. T(% ?o%n%nt (a3 annon*%& t(at, nl%33 an& ntil t(% ?o%n%nt

*oll%*t3 3ffi*i%nt i3 *oi&o3 a%nt3 to %%t it3 .5 +illion ot3tan&in4

o+li4ation fo t(% 0' i3 *oi&o3 a%nt3, t(% ?o%n%nt ill not a an

of t(% i3 *oi&o3 a%nt3 it o%3 to Mo&a H%alt( fo 0'5. See supra RR',

5J55, 5/. It i3 (i4(l nli%l t(at t(% ?o%n%nt ill %*%i% i3 *oi&o3

a%nt3 3ffi*i%nt to %%t it3 .5 +illion ot3tan&in4 o+li4ation fo t(% 0' i3

*oi&o3 a%nt3, an& a3 a %3lt, t(% ?o%n%nt i3 (i4(l nli%l to a an

of t(% i3 *oi&o3 a%nt3 it o%3 to Mo&a H%alt( fo 0'5.

7


28/35

6. T(% %i at%3 Mo&a H%alt( 3%t fo it3 ;alifi%& H%alt( Plan3

%% lo% t(an t(% ol& (a% +%%n in t(% a+3%n*% of t(% ?o%n%nt


29/35

Ala3a 3tat% %4lato3 3iilal o(i+it%& Mo&a H%alt( fo i33in4 n% oli*i%3

o %n%in4 %=i3tin4 oli*i%3 in Ala3a. T(% %4lato a*tion3 in Ala3a an&

O%4on %% *a3%& + t(% ?o%n%nt


30/35

(%alt( *a% 33t% fo it3 n%to, liit it3 %noll%nt, an& liit it3 %i

a%nt otion3. T(% anti*iat%& fail% of t(% ?o%n%nt to a% it3 0'5 i3

*oi&o3 a%nt3 *a3%& Mo&a H%alt( to ft(% liit it3 oi&% n%to,

4%o4a(i* 3%i*% a%a, an& %noll%nt in O%4on fo 0'7, %3ltin4 in a 70

%*%nt o%*t%& n%t %noll%nt lo33 fo 0'5 to 0'7.

CLAIM FOR RELIEF

COUNT ONE

34!olat!o" of Sect!o 5/,6 Stat&tor) Madate" ad Stat&tor) A&thor!t)7

68. Plaintiff %-all%4%3 an& in*ooat%3 RR 'J67 of t(% Colaint a3 if 3%t

fot( fll (%%in.

6/. "%*tion '> of t(% ACA an& 5 C.#.$. '5>.5'0 %Bi% t(%

?o%n%nt to a Balifi%& in3%3 3tattoil &%fin%& aont3 a3 at of t(%

$i3 Coi&o3 Po4a.

70. Mo&a H%alt( 3ati3fi%& all 3tatto an& %4lato %Bi%%nt3 fo

ati*iation in an& a%nt3 n&% t(% $i3 Coi&o3 Po4a in 0' an& 0'5.

7'. T(% ?o%n%nt fail%& to oi&% t(% i3 *oi&o3 a%nt3 o%& to

Mo&a H%alt( fo 0', in iolation of "%*tion '> an& 5 C.#.$. '5>.5'0.

"%*ifi*all, + ain4 onl '',8>,708 of t(% total 8/,6,>0 to (i*( Mo&a

H%alt( i3 %ntitl%&, t(% ?o%n%nt o%3 Mo&a H%alt( an a&&itional 78,',7 in

0' i3 *oi&o3 a%nt3.

>0


31/35

7. T(% ?o%n%nt (a3 annon*%& t(at it ill not a an of t(%

'0',8,05 in i3 *oi&o3 a%nt3 o%& to Mo&a H%alt( fo 0'5, in

iolation of "%*tion '> an& 5 C.#.$. '5>.5'0, nl%33 an& ntil t(%

?o%n%nt %*%i%3 3ffi*i%nt i3 *oi&o3 a%nt3 to a t(% %nti% .5

+illion it 3till o%3 in 0' i3 *oi&o3 o+li4ation3. T(% ?o%n%nt (a3 al3o

annon*%& t(at it ill not a t(% %nti%t of t(% '0',8,05 in i3 *oi&o3

a%nt3 o%& to Mo&a H%alt( fo 0'5, in iolation of "%*tion '> an& 5

C.#.$. '5>.5'0, nl%33 an& ntil t(% ?o%n%nt %*%i%3 3ffi*i%nt i3

*oi&o3 a%nt3 to *o% all of it3 0'5 i3 *oi&o3 o+li4ation3 to all i33%3.

N%it(% of t(%3% %%nt3 i3 %a3ona+l %&i*ta+l%.

7>. T(% %% fail% of Con4%33 to aoiat% fn&3, it(ot ft(%

o&3 o&ifin4 o %%alin4, %=%33l o + *l%a ili*ation, t(% 3+3tanti%

la, &o%3 not &%f%at a ?o%n%nt o+li4ation *%at%& + 3tatt%. T(% ?o%n%nt

i3 o+li4at%& to a% fll a%nt to an %ntit 3*( a3 Mo&a H%alt(, 3in4 t(%

&4%nt #n&. Mo&a H%alt( i3 %ntitl%& to fll a%nt fo t(% &4%nt #n&

of t(% 78,',7 in 0' i3 *oi&o3 a%nt3 an& '0',8,05 in 0'5 i3

*oi&o3 a%nt3.

7. Mo&a H%alt( i3 al3o %ntitl%& to fll a%nt +a3%& on an ot(%

aaila+l% fn&3 o l%4al t(%oi%3.

COUNT T8O

>'


32/35

3'reach of I%(l!ed9!9Fact Cotract7

75. Plaintiff %-all%4%3 an& in*ooat%3 RR 'J7 of t(% Colaint a3 if 3%t

fot( fll (%%in.

76. Mo&a H%alt( an& CM" %nt%%& into an ili%&-in-fa*t *onta*t

%Biin4 CM" to a% i3 *oi&o3 a%nt3 to Mo&a H%alt( in t(% aont

3%*ifi%& in "%*tion '> an& CM"


33/35

7/. Mo&a H%alt( 3ati3fi%& it3 *onta*tal o+li4ation3 + 3%llin4 an&

oi&in4 ;alifi%& H%alt( Plan *o%a4% to Balifin4 in&ii&al3 in 0' an&

0'5.

80. T(% ?o%n%nt +%a*(%& it3 *onta*tal &t to Mo&a H%alt( +

ain4 onl '',8>,708 of t(% total 8/,6,>0 to (i*( Mo&a H%alt( i3 %ntitl%&

in i3 *oi&o3 a%nt3 fo 0'.

8'. T(% ?o%n%nt anti*iatoil +%a*(%& it3 *onta*tal o+li4ation3 to

Mo&a H%alt( + annon*in4 t(at it ill not a an of t(% '0',8,05 in i3

*oi&o3 a%nt3 o%& to Mo&a H%alt( fo 0'5, nl%33 an& ntil t(%

?o%n%nt %*%i%3 3ffi*i%nt i3 *oi&o3 a%nt3 to a t(% %nti% .5

+illion it 3till o%3 in 0' i3 *oi&o3 o+li4ation3. T(% ?o%n%nt al3o

anti*iatoil +%a*(%& it3 *onta*t + annon*in4 t(at it ill not a t(% %nti%t

of t(% '0',8,05 in i3 *oi&o3 a%nt3 o%& to Mo&a H%alt( fo 0'5,

nl%33 an& ntil t(% ?o%n%nt %*%i%3 3ffi*i%nt i3 *oi&o3 a%nt3 to

*o% all of it3 0'5 i3 *oi&o3 o+li4ation3 to all i33%3. N%it(% of t(%3%

%%nt3 i3 %a3ona+l %&i*ta+l%.

8. T(% %% fail% of Con4%33 to aoiat% fn&3 &o%3 not &%f%at t(%

?o%n%nt>


34/35

a%nt fo t(% &4%nt #n& of t(% 78,',7 in 0' i3 *oi&o3

a%nt3 an& '0',8,05 in 0'5 i3 *oi&o3 a%nt3.

8>. Mo&a H%alt( i3 al3o %ntitl%& to fll a%nt +a3%& on an ot(%

aaila+l% fn&3 o l%4al t(%oi%3.

PRA:ER FOR RELIEF

@HE$E#O$E, Plaintiff %3%*tfll a33 t(i3 Cot to %nt% &4%nt in it3 fao

an& a4ain3t D%f%n&ant an& to:

A A2ard Pla!t!ff %oetar) rel!ef e;&al to the d!fferece bet2eethe a%o&t Pla!t!ff rece!*ed ! r!"# corr!dor" (a)%et" for ,-/

ad ,-1 &der Sect!o 5/, ad the a%o&t !t "ho&ld rece!*e or

"ho&ld ha*e rece!*ed &der Sect!o 5/,<

' A2ard da%a$e" "&"ta!ed b) the Pla!t!ff6 ! the a%o&t e;&al to

the d!fferece bet2ee the a%o&t Pla!t!ff rece!*ed ! r!"#

corr!dor" (a)%et" for ,-/ ad ,-1 &der Sect!o 5/, ad the

a%o&t !t "ho&ld rece!*e or "ho&ld ha*e rece!*ed &der Sect!o

5/,<

I. A2ard Pla!t!ff "&ch add!t!oal da%a$e" ad other %oetar)

rel!ef a" !" a*a!lable &der a((l!cable la2<

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35/35

$%3%*tfll 3+itt%&,

K3K "t%%n . $o3%n+a

"t%%n . $o3%n+aCounsel of Record

3o3%n+a*o.*o)Caolin% M. 9on*+on*o.*o)P(ili . P%i3*(%i3*(*o.*o)

Coin4ton F 9lin4 LLPOn% CitC%nt% 850 T%nt( "t%%t, N.@.@a3(in4ton, D.C., 000'0) 66-60000) 778-55

n% ', 0'6 Counsel for Plaintiff

Documents

Moda Health Plans Lawsuit