Rencare, Ltd. v. Humana Health Plan of Texas, Inc., 04-50087.

CourtUnited States Courts of Appeals. United States Court of Appeals (5th Circuit)
Citation395 F.3d 555
Docket NumberNo. 04-50087.,04-50087.
PartiesRENCARE, LTD., Plaintiff-Appellant, v. HUMANA HEALTH PLAN OF TEXAS, INC., doing business as Humana Health Plan of San Antonio; Humana HMO of Texas, Inc., Defendants-Appellees.
Decision Date30 December 2004
395 F.3d 555
RENCARE, LTD., Plaintiff-Appellant,
v.
HUMANA HEALTH PLAN OF TEXAS, INC., doing business as Humana Health Plan of San Antonio; Humana HMO of Texas, Inc., Defendants-Appellees.
No. 04-50087.
United States Court of Appeals, Fifth Circuit.
December 30, 2004.
Rehearing En Banc Denied March 15, 2005.

Page 556

Randolph P. Tower, Jeffrey Jason Jowers, Clemens & Spencer, Edgar Carroll Morrison (argued), Jackson Walker, San Antonio, TX, for Plaintiff-Appellant.

Richard Glenn Foster (argued), Porter, Rogers, Dahlman & Gordon, San Antonio, TX, Jennifer R. Henderson, Porter, Rogers, Dahlman & Gordon, Corpus Christi, TX, for Defendants-Appellees.

Appeal from the United States District Court for the Western District of Texas.

Before BENAVIDES, DENNIS and CLEMENT, Circuit Judges.

BENAVIDES, Circuit Judge:


RenCare appeals the district court's dismissal of RenCare's claims for failure to exhaust administrative remedies and the district court's partial denial of RenCare's motion to remand its claims to state court. Because RenCare's claims against Humana are not inextricably intertwined with a claim for Medicare benefits and because there are, in fact, no administrative appeal procedures for RenCare to pursue, we reverse both the district court's dismissal of RenCare's claims and the district court's partial denial of RenCare's motion to remand its claims to state court.

I. BACKGROUND

The Medicare program, which provides medical insurance for the aged and disabled, is administered by the Center for Medicare and Medicaid Services ("CMS"), a division of the U.S. Department of Health and Human Services ("HHS"). The Medicare Act, 42 U.S.C. §§ 1395-1395ggg (2000), consists of three parts, labeled parts A, B, and C. Part C, added in 1997, contains the Medicare + Choice ("M+C") plan, 42 U.S.C. §§ 1395w-21 to 2395w-28, which provides medical benefits to its enrollees through a range of coverage plans, 42 U.S.C. § 1395w-21(a)(2), and is administered by private, managed health care organizations. 42 U.S.C. § 1395w-27. In addition to the medical services available under Parts A and B, individual plans may offer supplemental benefits and may require the enrollee to pay a premium fee. See 42 U.S.C. § 1395w-22(a)(1), (a)(3); 42 U.S.C. § 1395w-24; 42 C.F.R. §§ 422.100(c), 422.101-422.102, 422.502(a)(3)(i); 42 C.F.R. §§ 422.300-422.312. M+C organizations receive fixed monthly payments from CMS. 42 U.S.C. § 1395w-23(a)(1)(A).

Humana is a Texas HMO under contract with CMS to provide medical care to M+C beneficiaries. Under its contract with CMS, Humana receives a fixed amount per month for each enrolled M+C patient regardless of the value of services

Page 557

the patient actually receives. In October, 2000, Humana contracted RenCare to provide kidney dialysis services to Humana's enrollees, including its M+C enrollees. Humana and RenCare later became embroiled in a dispute over reimbursement for end stage renal dialysis services that RenCare provided to Humana enrollees. As a result, RenCare sued Humana in Texas state court for breach of contract, detrimental reliance, fraud, and violations of state law.

Humana moved for removal of the claims to federal district court, arguing that RenCare's claims were preempted by the Medicare Act and thus properly belonged only in federal court. After the district court granted Humana's motion, RenCare requested that the case be remanded to state court. The district court retained jurisdiction over RenCare's claims as they related to M+C enrollees and remanded to state court RenCare's claims relating to the Humana commercial enrollees. Subsequently, the district court dismissed the claims that remained in federal court, finding that RenCare had failed to exhaust its administrative remedies under the Medicare Act.

RenCare now appeals the district court's partial denial of its motion to remand its claims to state court and the dismissal of its claims for failure to exhaust administrative remedies. RenCare argues that its claims do not arise under federal law and thus are not subject to federal jurisdiction or federal administrative remedies. We agree.

II. ANALYSIS

42 U.S.C. § 405(h), made applicable to the Medicare Act by 42 U.S.C. § 1395ii, provides that § 405(g) is the sole avenue for judicial review of all "claims arising under" the Medicare Act. Under § 405(g), a final decision of the Secretary of Health and Human Services ("Secretary") may be reviewed by a federal court. Regulations promulgated by the Secretary, see 42 U.S.C. § 1395hh, indicate that a final decision is issued only after a case has progressed through all the levels of administrative review provided for each Part of the Medicare Act. See 42 C.F.R §§ 405.701-405.753 (reconsideration and appeals under Part A); 42 C.F.R. §§ 405.801-405.877 (appeals under Part B); 42 C.F.R. §§ 422.560-422.626 (grievances, organization determinations, and appeals under Part C).

A claim arises under the Medicare Act if "both the standing and the substantive basis for the presentation" of the claim is the Medicare Act, Heckler v. Ringer, 466 U.S. 602, 606, 104 S.Ct. 2013, 80 L.Ed.2d 622 (1984) (quoting Weinberger v. Salfi, 422 U.S. 749, 760-61, 95 S.Ct. 2457, 45 L.Ed.2d 522 (1975)), or if the claim is "inextricably intertwined" with a claim for Medicare benefits, see id. at 623, 104 S.Ct. 2013; see also Affiliated Prof'l Home Health Care Agency v. Shalala, 164 F.3d 282, 286 (5th Cir.1999) (finding that even though claims were presented as constitutional claims, they were inextricably intertwined with a claim of entitlement to Medicare benefits and thus subject to the exhaustion requirements of the Medicare Act).

We review the district court's determination that RenCare's claims arise under the Medicare Act de novo. See First Gibraltar Bank, FSB v....

To continue reading

Request your trial
67 cases
  • Hous. Methodist Hosp. v. Humana Ins. Co.
    • United States
    • U.S. District Court — Southern District of Texas
    • 17 d1 Julho d1 2017
    ...Services ("CMS"), a division of the U.S. Department of Health and Human Services ("HHS"). See RenCare, Ltd. v. Humana Health Plan of Texas, Inc., 395 F.3d 555, 556 (5th Cir. 2004). The Medicare Act, 42 U.S.C. §§ 1395 – 1395fff, consists of five parts, labeled parts A, B, C, D, and E. See Me......
  • Alvarado Hosp., LLC v. Price
    • United States
    • U.S. Court of Appeals — Federal Circuit
    • 22 d2 Agosto d2 2017
    ...either the standing or the substantive basis for the presentation of Prime Hospitals' claim. Cf. RenCare, Ltd. v. Humana Health Plan of Tex., Inc. , 395 F.3d 555, 557 (5th Cir. 2004) (finding that the standing and substantive basis for claims that are based on state law, such as breach of c......
  • National Athletic v. U.S. Dept., Human Serv., 3:05-CV-1098-G.
    • United States
    • U.S. District Court — Northern District of Texas
    • 25 d4 Agosto d4 2005
    ...avenues for review before a district court has jurisdiction to hear the plaintiff's claim. RenCare, Ltd. v. Humana Health Plan of Texas, Inc., 395 F.3d 555, 557 (5th Cir.2004). "42 U.S.C. § 405(h), made applicable to the Medicare Act by 42 U.S.C. § 1395ii, provides that § 405(g) is the sole......
  • True Health Diagnostics, LLC v. Azar, CIVIL ACTION NO. 9:19-CV-00110-MJT
    • United States
    • U.S. District Court — Eastern District of Texas
    • 22 d1 Julho d1 2019
    ...question jurisdiction "if the claim is inextricably intertwined with a claim for Medicare benefits." RenCare, Ltd. v. Humana Health Plan of Texas, Inc. , 395 F.3d 555, 557 (5th Cir. 2004) (internal quotations omitted). The term "arising under" is broadly construed to encompass all claims fo......
  • Request a trial to view additional results

VLEX uses login cookies to provide you with a better browsing experience. If you click on 'Accept' or continue browsing this site we consider that you accept our cookie policy. ACCEPT