Helfrich v. Blue Cross & Blue Shield Assoc , 804 F.3d 1090 ( 2015 )

FILED
United States Court of Appeals
PUBLISH Tenth Circuit
UNITED STATES COURT OF APPEALS October 29, 2015
Elisabeth A. Shumaker
TENTH CIRCUIT Clerk of Court
LEE ANN HELFRICH,
Plaintiff Counter Defendant -
Appellant,
v.
BLUE CROSS AND BLUE SHIELD
ASSOCIATION,
Defendant Counterclaimant -
Appellee,
and No. 14-3179
BLUE CROSS AND BLUE SHIELD OF
KANSAS CITY,
Defendant - Appellee.
______________________________
UNITED STATES OF AMERICA;
ASSOCIATION OF FEDERAL
HEALTH ORGANIZATIONS,
Amici Curiae.
APPEAL FROM THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF KANSAS
(D.C. No. 2:13-CV-02620-EFM-JPO)
Matthew W.H. Wessler, Public Justice, P.C., Washington, D.C., (Sarah E. Belton, Public
Justice, P.C., Oakland, California, and David A. Hoffman, Donald W. Vasos, Vasos Law
Offices, Fairway, Kansas, with him on the briefs), for Plaintiff Counter Defendant -
Appellant.
Anthony F. Shelley (Adam P. Feinberg, with him on the brief), of Miller & Chevalier
Chartered, Washington, D.C., for Defendant Counterclaimant - Appellee Blue Cross and
Blue Shield Association, and Defendant - Appellee, Blue Cross and Blue Shield of
Kansas City.
Henry C. Whitaker, Assistant United States Attorney, Appellate Staff, (Joyce R. Branda,
Acting Assistant Attorney General, Barry R. Grissom, United States Attorney, and Alisa
B. Klein, Assistant United States Attorney, Appellate Staff, and Susan G. Whitman,
Deputy Assistant General Counsel, U.S. Office of Personnel Management, Washington,
D.C., with him on the brief) U.S. Department of Justice, Washington, D.C., for Amicus
Curiae, United States of America.
David M. Ermer, Jason C. Suter, Ermer Law Group, Washington, D.C., for Amicus
Curiae, Association of Federal Health Organizations.
Before LUCERO, HARTZ, and HOLMES, Circuit Judges.
HARTZ, Circuit Judge.
Lee Ann Helfrich received benefits through her federal-employee health-insurance
plan, the Blue Cross and Blue Shield Service Benefit Plan (the Plan), for the treatment of
injuries she sustained in a car accident. After Ms. Helfrich reached a settlement with the
other driver’s insurance company, Blue Cross and Blue Shield Association (BCBSA) and
Blue Cross and Blue Shield of Kansas City (BCBSKC) sought reimbursement for the
benefits paid, as provided in the terms of the Plan. Ms. Helfrich appeals from the
2
judgment of the United States District Court for the District of Kansas requiring her to
reimburse BCBSA and BCBSKC (together Blue Cross) because the Federal Employees
Health Benefits Act of 1959 (FEHBA) preempts a Kansas insurance regulation
prohibiting subrogation and reimbursement clauses in insurance contracts. Exercising
jurisdiction under 28 U.S.C. § 1291, we affirm. Ms. Helfrich must reimburse Blue Cross
because federal common law displaces the Kansas antisubrogation regulation, which, if
applied to the Plan, would conflict with uniquely federal interests. Alternatively, giving
weight to the views of the Office of Personnel Management (OPM) regarding the
meaning of FEHBA’s preemption provision, 5 U.S.C. § 8902(m)(1), we hold that the
reimbursement provision in the Plan “relate[s] to the nature, provision, or extent of
coverage or benefits,” id., and therefore supersedes state law.
I. BACKGROUND
A. The Plan
FEHBA establishes a program to provide health insurance for federal employees
and annuitants. See 5 U.S.C. §§ 8901–8914 (2012 ed. and Supp. I). Its purpose is to
provide affordable quality healthcare to government employees. See Doe v. Devine,
703 F.2d 1319, 1329 n.41 (D.C. Cir. 1983) (“FEHBA’s goal is to ensure maximum health
benefits for employees ‘at the lowest possible cost to themselves and to the
Government.’” (quoting H.R. Rep. No. 86-957, at 4 (1959)).
FEHBA authorizes OPM to enter into contracts with insurance carriers and
promulgate regulations to carry out the program. See 5 U.S.C. § 8902(a); id. § 8913(a).
3
OPM has contracted with BCBSA for the Plan, which is administered by local Blue
Cross and Blue Shield companies. See id. § 8903(1). Under FEHBA the federal
government pays approximately 70% of an enrollee’s premium, and the enrollee pays the
remainder. See id. § 8906(b); 80 Fed. Reg. 29,203. Premiums from the government and
enrollees are deposited into the Employees Health Benefits Fund within the United States
Treasury. See 5 U.S.C. § 8909(a). BCBSA, like other experience-rated carriers, draws
from the Fund as necessary to pay for benefit claims and administrative expenses, see
48 C.F.R. § 1632.170(b); id. § 1652.216-71(b), and the government pays a negotiated fee
for its services, see id. § 1615.404-4. In other words, any premiums that are not used to
pay benefits or administrative expenses remain the property of the government, and
BCBSA earns its profit from the service fee. Community-rated carriers, in contrast, set
premiums based on the attributes of the insured pool, receive premiums from the Fund,
and pay benefit claims; the difference between premiums and the cost of benefits is their
profit. See id. § 1632.170(a). Any surplus in the Fund may be used at OPM’s discretion
to reduce premiums or increase benefits. See 5 U.S.C. § 8909(b); 5 C.F.R. §
890.503(c)(2).
FEHBA requires that OPM’s contracts with carriers “contain a detailed statement
of benefits offered and shall include such maximums, limitations, exclusions, and other
definitions of benefits as [OPM] considers necessary or desirable.” 5 U.S.C. § 8902(d).
The contract between OPM and BCBSA states that “[t]he Carrier shall provide the
benefits as described in the agreed upon brochure text” attached as an appendix, J. App.,
4
Vol. 1 at 57; the brochure is “the official statement of benefits,” id. at 131.1 It provides
that the enrollee is “obligated to all terms, conditions, and provisions of [the] contract.”
Id. at 58. Among those provisions is the grant to the carrier of the rights of subrogation
and reimbursement (sometimes collectively referred to as subrogation). The contract
states that if an enrollee receives benefits from the carrier for treatment of an injury
caused by a third party, “the Carrier shall have the right to be subrogated and succeed to
any rights of recovery against any person or organization from whom the [enrollee] is
legally entitled to receive all or part of those same benefits . . . .” Id. at 84. The carrier
may also be reimbursed—i.e., “recover directly from the [enrollee] all amounts received
by the [enrollee] by suit, settlement, or otherwise from any third party or its insurer . . .
for benefits which have also been paid under [the] contract.” Id. BCBSA is required to
make “a reasonable effort to seek recovery of amounts to which it is entitled to recover in
cases which are brought to its attention.” Id. (It appears that this requirement does not
extend to pursuing subrogation (as opposed to reimbursement) because the carrier is not
“required to recover any amounts from any person . . . who causes an injury . . . for which
the [enrollee] makes claims for benefits.” Id.). Reimbursement and subrogation
recoveries obtained by experience-rated carriers like BCBSA must be returned to the
Treasury Fund. See 48 C.F.R. § 31.201-5; id. § 1631.201-70(a),(g); id. § 1652.216-
1
We use the language from the contract and brochure that were operative in 2012.
Because Ms. Helfrich’s treatment occurred in both 2012 and 2013, we will footnote any
difference in the 2013 contract and brochure language.
5
71(b)(2)(i). According to OPM, “FEHB carriers were reimbursed by approximately $126
million in subrogation recoveries in [2014].” Federal Employees Health Benefits
Program: Subrogation and Reimbursement Recovery, 80 Fed. Reg. 29,203 (May 21,
2015).
The contract also provides that “[t]he Carrier’s subrogation rights, procedures and
policies, including recovery rights, shall be in accordance with the provisions of the
agreed upon brochure text.” Id. at 61.2 The attached brochure says that if a third party
causes injury to an enrollee and the Plan “paid benefits for that injury,” all recoveries the
enrollee obtains “must be used to reimburse [the Plan] in full for benefits [it] paid.” Id. at
140. The Plan is entitled to reimbursement even if the enrollee is not “made whole” for
all damages, and the Plan’s right of recovery is “not subject to reduction for attorney’s
fees and costs”; but the Plan may, in its discretion, reduce its share of the recovery based
on these considerations. Id. (internal quotation marks omitted). Further, if the enrollee
does not seek damages, he or she must permit the Plan to initiate recovery on his or her
behalf. Finally, the Plan may “enforce [its] right of recovery by offsetting future
benefits.” Id. at 141.
B. The Preemption Provision
2
The 2013 contract includes additional language: “The Carrier’s subrogation rights,
procedures and policies, including recovery rights, for payments with respect to benefits
shall be in accordance with the provisions of the agreed upon brochure text.” Id. at 104
(emphasis added).
6
FEHBA’s preemption provision, 5 U.S.C. § 8902(m)(1), states: “The terms of any
contract under this chapter which relate to the nature, provision, or extent of coverage or
benefits (including payments with respect to benefits) shall supersede and preempt any
State or local law, or any regulation issued thereunder, which relates to health insurance
or plans.” In June 2012, OPM issued a letter to all FEHBA carriers expressing its
position that contractual rights to reimbursement and subrogation fall within the purview
of § 8902(m)(1) and thus override state laws that relate to health insurance or plans. On
January 7, 2015, OPM published in the Federal Register a proposed rule addressing the
preemption of state laws limiting subrogation and reimbursement. See 80 Fed. Reg. 931.
After notice and comment, OPM promulgated the final rule on May 21, 2015 (while this
litigation was pending). See id. at 29,203. The rule states, “All health benefit plan
contracts shall provide that the Federal Employees Health Benefits (FEHB) carrier is
entitled to pursue subrogation and reimbursement recoveries, and shall have a policy to
pursue such recoveries in accordance with the terms of this section.” Id. at 29,204
(codified at 5 C.F.R. § 890.106(a)). The rule also requires that contracts containing
subrogation or reimbursement clauses “provide that benefits and benefit payments are
extended to a covered individual on the condition that the FEHB carrier may pursue and
receive subrogation and reimbursement recoveries pursuant to the contract.” Id. (codified
at 5 C.F.R. § 890.106(b)(2)). Finally, the rule declares that state laws limiting
subrogation and reimbursement are preempted under § 8902(m)(1):
7
A carrier’s rights and responsibilities pertaining to subrogation and
reimbursement under any FEHB contract relate to the nature, provision, and
extent of coverage or benefits (including payments with respect to benefits)
within the meaning of 5 U.S.C. 8902(m)(1). These rights and
responsibilities are therefore effective notwithstanding any state or local
law, or any regulation issued thereunder, which relates to health insurance
or plans.
Id. at 29,205 (codified at 5 C.F.R. § 890.106(h)).
C. This Litigation
Ms. Helfrich is a federal employee enrolled in the Plan; BCBSKC administers the
Plan in her area. In December 2012, Ms. Helfrich was in a car accident and suffered
serious injuries. She received $76,561.88 in benefits from the Plan in connection with
her injuries. Ms. Helfrich asserted a claim against the other driver in the accident and
settled with the driver’s insurer for the policy limit of $100,000. Blue Cross then sought
reimbursement for the benefits paid according to the terms of the Plan. In response,
Ms. Helfrich filed a petition against Blue Cross in Kansas state court seeking a
declaration that the subrogation clause in the Plan is unenforceable under Kansas law and
that § 8902(m)(1) does not preempt the Kansas antisubrogation regulation, which
provides that “[n]o insurance company or health insurer . . . may issue any contract or
certificate of insurance in Kansas containing a subrogation clause, or any other policy
provision having a purpose or effect similar to that of a subrogation clause, applicable to
coverages providing for reimbursement of medical, surgical, hospital, or funeral
expenses.” Kan. Admin. Regs. 40-1-20. The parties appear to assume that the regulation
encompasses reimbursement claims by an insurer.
8
Blue Cross removed the case to federal court3 and BCBSA filed a counterclaim
seeking reimbursement of $76,561.88, a declaration that Ms. Helfrich was obligated to
reimburse the Plan, and a declaration that a lien existed against Ms. Helfrich’s settlement
proceeds. Blue Cross moved for judgment on the pleadings, arguing that Kansas
antisubrogation law is preempted under § 8902(m)(1) and, alternatively, that federal
common law displaces the application of the Kansas regulation. The district court held
that § 8902(m)(1) preempted Kansas law and granted judgment in favor of Blue Cross.
II. DISCUSSION
“We review a district court’s grant of a motion for judgment on the pleadings de
novo, using the same standard that applies to a Rule 12(b)(6) motion.” Colony Ins. Co. v.
Burke, 698 F.3d 1222, 1228 (10th Cir. 2012) (internal quotation marks omitted). We
affirm the district court’s grant of judgment on the pleadings for Blue Cross on the
grounds that (1) federal common law displaces the Kansas antisubrogation regulation and
(2) the FEHBA preemption provision overrides the regulation. Although the district
court did not address the first ground or some of the reasoning supporting the second, we
can properly rely on them to affirm because Blue Cross raised them below, they were
briefed, and Blue Cross raises them again on appeal. See Havens v. Johnson, 783 F.3d
776, 782 (10th Cir. 2015).
3
Blue Cross first claimed federal jurisdiction under 28 U.S.C. § 1442(a)(1) but later also
claimed diversity jurisdiction under 28 U.S.C. § 1332(a) (BCBSKC is a citizen of
Missouri).
9
A. Federal Common Law
Blue Cross argues that federal common law displaces the Kansas antisubrogation
regulation under the doctrine set forth in Boyle v. United Technologies Corp., 487 U.S.
500 (1988). In Boyle a United States Marine helicopter copilot was killed when his
helicopter crashed off the coast of Virginia. See id. at 502. The copilot survived the
crash but was unable to escape from the helicopter and drowned. See id. The plaintiff,
on behalf of the copilot’s heirs and estate, brought a diversity action against the
contractor that built the helicopter for the United States, claiming that it was liable under
Virginia tort law for a defectively designed escape hatch, which opened out instead of in,
see id. at 502–03, as stated in the contract specifications, see id. at 509. Ultimately the
Supreme Court held that even in the absence of an applicable statute, federal law
protected a federal contractor against design-defect liability under state law if “(1) the
United States approved reasonably precise specifications; (2) the equipment conformed to
those specifications; and (3) the supplier warned the United States about the dangers in
the use of the equipment that were known to the supplier but not to the United States.”
Id. at 512. Because the path taken by the Court to reach that conclusion is essential to our
analysis, we review it in some detail.
First, the Court rejected the plaintiff’s argument that it could not recognize a
federal-law defense to the state design-defect claim in the absence of a statute conferring
that immunity. Although acknowledging the general validity of the plaintiff’s position, it
noted that “a few areas, involving uniquely federal interests, are so committed by the
10
Constitution and laws of the United States to federal control that state law is pre-empted
and replaced, where necessary, by federal law of a content prescribed (absent explicit
statutory directive) by the courts—so-called federal common law.” Id. at 504 (citation
and internal quotation marks omitted). The Court said that its precedents had identified
two uniquely federal interests that “border[ed]” the dispute before it. Id. First, the Court
“ha[d] held that obligations to and rights of the United States under its contracts are
governed exclusively by federal law.” Id. Second, the Court “ha[d] found to be of
peculiarly federal concern, warranting the displacement of state law, . . . the civil liability
of federal officials for actions taken in the course of their duty.” Id. at 505.
Boyle did not precisely concern either interest; but the Court found the differences
unimportant. “[T]he reasons for considering these closely related areas to be of ‘uniquely
federal’ interest,” said the Court, “apply as well to the civil liabilities arising out of the
performance of federal procurement contracts.” Id. at 505–06. Regarding the first
interest, the Court acknowledged that the case did “not involve an obligation to the
United States under its contract, but rather liability to third persons.” Id. at 505. The
contractor’s design-defect tort liability, however, arose “out of performance of the
contract” and such liability had been traditionally regarded as closely related to the
contract for the allegedly defective item. Id. Similarly, the Court recognized that even
though the case “involve[d] an independent contractor performing its obligation under a
procurement contract, rather than an official performing his duty as a federal employee,”
11
in both circumstances “there is obviously implicated the same interest in getting the
Government’s work done.” Id.
The Court concluded that these reasons made “civil liabilities arising out of the
performance of federal procurement contracts” a matter of uniquely federal interest. Id.
at 506. The Court added that this view was nothing new, pointing out that in 1940 the
Court had held that a federal contractor could not be liable in a private suit for erosion
allegedly caused by dike construction work, saying that “‘if the authority to carry out the
project was validly conferred, that is, if what was done was within the constitutional
power of Congress, there is no liability on the part of the contractor for executing its
will.’” Id. (brackets omitted) (quoting Yearsley v. W.A. Ross Constr. Co., 309 U.S. 18,
20–21 (1940)). Thus, although the dispute in Boyle was between private parties, the
interests of the United States were still directly implicated. See id. at 506–07.
Displacement of state law, however, requires more than just the presence of a
uniquely federal interest. “Displacement will occur only where . . . a significant conflict
exists between an identifiable federal policy or interest and the operation of state law, or
the application of state law would frustrate specific objectives of federal legislation.” Id.
at 507 (brackets, citation, and internal quotation marks omitted). Displacement of state
law on these grounds could be necessary even if preemption of state law would otherwise
not be in order:
The conflict with federal policy need not be as sharp as that which must
exist for ordinary pre-emption when Congress legislates in a field which the
States have traditionally occupied. Or to put the point differently, the fact
12
that the area in question is one of unique federal concern changes what
would otherwise be a conflict that cannot produce pre-emption into one
that can.
Id. at 507–08 (emphasis added) (citation, footnote, and internal quotation marks omitted).
The extent of the preemption could vary. “In some cases, for example where the federal
interest requires a uniform rule, the entire body of state law applicable to the area
conflicts and is replaced by federal rules.” Id. at 508 (citing Clearfield Trust Co. v.
United States, 318 U.S. 363 (1943)). But in other cases “the conflict is more narrow, and
only particular elements of state law are superseded.” Id.
On the other hand, no conflict, no displacement. The Court discussed its prior
opinion in Miree v. DeKalb County, 433 U.S. 25, 26–27 (1977), as an example of a case
in which there was no adequate federal interest and no conflict with federal policy. In
Miree the plaintiffs alleged that a plane crashed because the County had a garbage dump
too close to the airport, closer than permitted in the County’s grant contracts with the
Federal Aviation Administration (FAA). See id. at 26‒27. They argued that they could
sue under state law as third-party beneficiaries of the contracts. See id. at 27. The Court
held that state law, rather than federal common law, applied to the plaintiffs’ claims
because “[t]he operations of the United States in connection with FAA grants . . . would
[not] be burdened or subjected to uncertainty by variant state-law interpretations
regarding whether those with whom the United States contracts might be sued by third-
party beneficiaries to the contracts.” Id. at 30. “[A]ny federal interest in the outcome of
the question before [the Court] [was] far too speculative, far too remote a possibility to
13
justify the application of federal law to transactions essentially of local concern.” Id. at
32–33 (internal quotation marks omitted). In contrast, the federal interest in Boyle was
quite real. As the Boyle Court said, “The imposition of liability on Government
contractors will directly affect the terms of Government contracts: either the contractor
will decline to manufacture the design specified by the Government, or it will raise its
price.” 487 U.S. at 507. Further, the plaintiffs in Miree were “not seeking to impose
upon the person contracting with the Government a duty contrary to the duty imposed by
the Government contract” but instead were seeking to enforce “the contractual duty
itself.” Id. at 508. Boyle, however, was “at the opposite extreme from Miree” because
Virginia’s tort-law duty of care was “precisely contrary” to the duty imposed by the
government contract. Id. at 509.
Finally, Boyle had to formulate when a contractor’s tort liability for a design
defect that appears in the contract’s specifications creates “a significant conflict with
federal policy or interests.” Id. (internal quotation marks omitted). Not every tort claim
would present such a conflict. “If, for example, a federal procurement officer orders, by
model number, a quantity of stock helicopters that happen to be equipped with escape
hatches opening outward, it is impossible to say that the Government has a significant
interest in that particular feature.” Id.
For guidance, the Court turned to the Federal Tort Claims Act (FTCA). The
FTCA waives sovereign immunity to allow suits against the United States for injuries
caused by negligence or wrongful conduct by federal employees if a private person
14
would be liable for the same conduct. See 28 U.S.C. § 1346(b). The statute recognizes
an exception, however, for discretionary acts. Suit is not allowed on “[a]ny claim . . .
based upon the exercise or performance or the failure to exercise or perform a
discretionary function or duty on the part of a federal agency or an employee of the
Government, whether or not the discretion involved be abused.” Id. § 2680(a). The
Court viewed “the selection of the appropriate design for military equipment . . . [as]
assuredly a discretionary function.” Boyle, 487 U.S. at 511. And it thought:
[S]tate tort suits against contractors would produce the same effect sought
to be avoided by the FTCA exemption[, because] [t]he financial burden of
judgments against the contractors would ultimately be passed through,
substantially if not totally, to the United States itself, since defense
contractors will predictably raise their prices to cover, or to insure against,
contingent liability for the Government-ordered designs.
Id. at 511–12. The Court concluded that the contractor should not be liable in tort if the
government would not have been. “It makes little sense,” said the Court, “to insulate the
Government against financial liability for the judgment that a particular feature of
military equipment is necessary when the Government produces the equipment itself, but
not when it contracts for the production.” Id. at 512. In other words, in that
circumstance—when state law was contrary to a contract term actually selected by the
federal agency (a “discretionary” decision)—there would be a “significant conflict”
between government policy and state tort liability of the contractor. The requirements set
forth by the Court for contractor design-defect liability ensured that contractor immunity
15
would be available when the design defect was the product of a discretionary decision by
the government.
In our view, the analysis in Boyle requires the displacement of the Kansas
antisubrogation regulation in the context of the Blue Cross claim against Ms. Helfrich.
The concurrence suggests that Boyle’s analysis applies only to the displacement of state
tort law. But the policy considerations expressed in Boyle are independent of the nature
of the state cause of action. The state laws addressed by the precedents relied on in Boyle
were not just tort laws. See, e.g., Clearfield Trust, 318 U.S. 363 (commercial paper);
Miree, 433 U.S. 25 (third-party-beneficiary claim). Boyle introduced the FTCA’s
discretionary-function standard as simply a test to determine whether there was a
significant conflict between a term of a government contract and state law—the conflict
was significant if the term was the informed discretionary decision of the contracting
officer. State law—whether tort law or otherwise—must yield if it conflicts with such a
contractual term in an area of uniquely federal interests.
There can be little debate that the contract between BCBSA and the government
and the provision of affordable quality healthcare to government employees are both
matters of “uniquely federal” interest. “The United States no doubt has an overwhelming
interest in attracting able workers to the federal workforce and in the health and welfare
of the federal workers upon whom it relies to carry out its functions.” Empire Healthcare
Assurance, Inc. v. McVeigh, 547 U.S. 677, 701 (2006) (internal quotation marks omitted).
16
And the reimbursement provision in the Plan (whose negotiation by government
officials “is assuredly a discretionary function,”4 Boyle, 487 U.S. at 511) serves important
purposes that are undermined by antisubrogation laws. For experience-rated carriers like
Blue Cross, the money recovered through subrogation or reimbursement is used either to
reduce premiums (paid largely by the government) or to increase coverage. See 5 U.S.C.
§ 8909(b); 5 C.F.R. § 890.503(c)(2). The conflict between the state regulation and the
federal contractual requirement that Blue Cross pursue the reimbursement claim against
Ms. Helfrich is a stark one, starker than in Boyle. In Boyle the prospect of tort liability
could deter a contractor from doing the government’s bidding or cause it to raise the
contract price. Here, state law outright forbids Blue Cross from fulfilling its contractual
obligation to bring a reimbursement claim.5
There is also a strong federal interest in uniformity that is undermined by allowing
state law to override the subrogation and reimbursement requirements of the federal
contract. See United States v. Kimbell Foods, Inc., 440 U.S. 715, 728 (1979) (“federal
4
Contrary to the assertion by the concurrence, the decision by OPM to include the
subrogation provision in the Plan is the type of policy decision that is protected by the
discretionary-function exception to liability under the FTCA. See, e.g., Garcia v. U.S.
Air Force, 533 F.3d 1170, 1175‒76 (10th Cir. 2008).
5
The concurrence suggests that collecting $126 million a year through subrogation and
reimbursement is not a significant interest because that sum is a small fraction of total
insurance premiums. But the size of that fraction is irrelevant. Boyle did not consider
whether allowing tort claims against contractors would lead to a large percentage increase
in the defense budget.
17
programs that by their nature are and must be uniform in character throughout the Nation
necessitate formulation of controlling federal rules” (internal quotation marks omitted)).
Recognition of state antisubrogation laws would create unfairness within the ranks of
government employees. Those in states without such laws would have to pay
reimbursements that are then used to benefit enrollees throughout the country, even those
who live in states where they could keep their tort recoveries without paying
reimbursements. See FMC Corp. v. Holliday, 498 U.S. 52, 60 (1990) (“Pennsylvania’s
antisubrogation law . . . requires plan providers to calculate benefit levels in Pennsylvania
based on expected liability conditions that differ from those in States that have not
enacted similar antisubrogation legislation. Application of differing state subrogation
laws to plans would therefore frustrate plan administrators’ continuing obligation to
calculate uniform benefit levels nationwide.”). The legislative history of FEHBA
confirms the congressional interest in uniformity. In enacting the FEHBA provision
preempting certain state laws (a provision we address more fully in the next section of the
opinion), Congress expressed concern that the imposition of state-law requirements on
FEHBA contracts would result in “[a] lack of uniformity of benefits for enrollees in the
same plan which would result in enrollees in some States paying a premium based, in
part, on the cost of benefits provided only to enrollees in other States.” H.R. Rep. No.
95-282, at 4 (1977); see also 80 Fed. Reg. at 29,203 (supplementary information
introducing OPM’s recent rule explains that the preemption of state antisubrogation laws
18
“furthers Congress’s goals of . . . enabling uniform, nationwide application of FEHB
contracts”).
The force of these propositions is especially strong in the context of the contract
between BCBSA and OPM, because BCBSA acts as only a service agent between the
federal government and its own employees, and the relationship between the government
and its employees is generally immune from state interference. As explained above,
BCBSA is an experience-rated carrier. BCBSA does not receive the premiums. They are
deposited in a fund from which BCBSA withdraws the amount necessary to pay its
administrative expenses and benefit claims. BCBSA does not have skin in the game; it
does not underwrite the risk in the insurance coverage. It merely acts as a facilitator for
OPM, presumably because its expertise provides cost savings and efficiencies for the
program. If OPM chose to handle this service in-house, there would be no doubt that it
could enforce a provision in the Plan requiring enrollees to make reimbursements out of
tort recoveries. We are aware of no case allowing state law to override a requirement in a
contract governing the relationship between the federal government and an employee,
and there is hardly an area in which a state would have less of a legitimate interest than
this employment relationship.6 To allow state law to override a provision in such a
contract would permit just the interference with federal functions that courts have refused
6
We note, by the way, that the Kansas antisubrogation regulation apparently does not
apply to self-insured single-employer plans. See Unified Sch. Dist. 259 v. Sloan,
871 P.2d 861, 867 (Kan. Ct. App. 1994).
19
to countenance.7 To paraphrase Boyle, it makes little sense to permit the government to
enforce a reimbursement requirement when it administers the Plan itself but not when it
contracts out the administration. See 487 U.S. at 512 (“It makes little sense to insulate
the Government against financial liability for the judgment that a particular feature of
7
See United States v. New Mexico, 455 U.S. 720, 735 (1982) (principal purpose of tax-
immunity doctrine is “forestalling ‘clashing sovereignty,’ by preventing the States from
laying demands directly on the Federal Government” (citation omitted) (quoting
M’Culloch v. Maryland, 17 U.S. 316, 430 (1819))); United States v. Seckinger, 397 U.S.
203, 209 (1970) (“federal law controls the interpretation of the contract” between the
United States and a private plumbing contractor); United States v. Standard Oil Co.,
332 U.S. 301, 305‒06 (1997) (“Perhaps no relation between the Government and a
citizen is more distinctively federal in character than that between it and members of its
armed forces. To whatever extent state law may apply to govern the relations between
soldiers or others in the armed forces and persons outside them or nonfederal
governmental agencies, the scope, nature, legal incidents and consequences of the
relation between persons in service and the Government are fundamentally derived from
federal sources and governed by federal authority.”); United States v. Allegheny Cnty.,
322 U.S. 174, 183 (1944) (“The validity and construction of contracts through which the
United States is exercising its constitutional functions [and] their consequences on the
rights and obligations of the parties . . . present questions of federal law not controlled by
the law of any state.”); Arizona v. California, 283 U.S. 423, 451 (1931) (“The United
States may perform its functions without conforming to the police regulations of a
state.”); Johnson v. Maryland, 254 U.S. 51, 56–57 (1920) (“[E]ven the most
unquestionable and most universally applicable of state laws, such as those concerning
murder, will not be allowed to control the conduct of a marshal of the United States
acting under and in pursuance of the laws of the United States. It seems to us that the
immunity of the instruments of the United States from state control in the performance of
their duties extends to a requirement that [employees of the United States Post Office]
desist from performance until they [obtain driving licenses from the State]. Such a
requirement does not merely touch the Government servants remotely by a general rule
of conduct; it lays hold of them in their specific attempt to obey orders and requires
qualifications in addition to those that the Government has pronounced sufficient.”
(citation omitted)); Gilman v. United States, 206 F.2d 846, 848–49 (9th Cir. 1953) (“the
question of the duty owed by a Government employee to the Government is one to be
determined by federal and not by state law”), aff’d, 347 U.S. 507 (1954).
20
military equipment is necessary when the Government produces the equipment itself, but
not when it contracts for the production.”).
The Seventh Circuit considered a similar issue in Downey v. State Farm Fire &
Casualty Co., 266 F.3d 675 (7th Cir. 2001), in which an insured brought suit against his
insurer on a policy bought through the National Flood Insurance Program (NFIP). See id.
at 678, 681–82. The court noted that under the program the private insurer, State Farm,
remitted all premiums, minus a fee, to the Federal Emergency Management Agency
(FEMA), and if the insurer paid a claim it was reimbursed by FEMA. See id. at 679.
State Farm acted merely as an administrative agent, selling policies and processing
claims for FEMA. See id. at 679–80. The court concluded that the federal interest
justified the application of federal law to the suit:
FEMA runs a federal program, and because it bears the risk on all NFIP
contracts, FEMA’s duties are at issue whenever an NFIP policy is
interpreted. Replacing “FEMA” with “State Farm” in the caption of the
case changes nothing; a judgment against State Farm and a judgment
against FEMA have identical effects: FEMA pays. And though we were
concerned with the formal parties to this action when we interpreted [a
jurisdictional provision of the NFIP], here we are concerned with the
federal interest invoked by the dispute’s subject matter.8
Id. at 681.
The Supreme Court’s decision in O’Melveny & Myers v. FDIC, 512 U.S. 79
(1994), does not conflict with our analysis. The Federal Deposit Insurance Corporation
8
Downey’s holding that there was federal jurisdiction over the suit may not survive
McVeigh, 547 U.S. 677, but this does not affect its discussion of the federal interest.
21
(FDIC), as receiver of a California-chartered federally insured savings and loan (S&L)
sued attorneys who provided services to the S&L for negligence and breach of fiduciary
duty with respect to fraudulent conduct by S&L officers. See id. at 81‒82. One defense
of the attorneys was that, under California law, knowledge of the fraud must be imputed
to the S&L, and therefore to the FDIC. See id. at 82‒83. The FDIC argued that federal,
not state, law governed imputation and federal law would not recognize the defense. See
id. at 83. The Court saw no conflict with federal law that would require the displacement
of state law governing imputation. See id. at 85, 89. It observed that the FDIC had
“identified no significant conflict with an identifiable federal policy or interest.” Id. at
88.
Several statements by the Court might at first seem to argue against displacement
of state law in our case. But not after a closer look. First, the Court rejected the FDIC’s
argument that California law could compromise federal interests because “state rules
regarding the imputation of knowledge might deplete the deposit insurance fund.” Id.
(brackets and internal quotation marks omitted). The FDIC’s argument proved too much.
“[N]either [the relevant statute] nor the prior law sets forth any anticipated level for the
fund, so what [the FDIC] must mean by ‘depletion’ is simply the forgoing of any money
which, under any conceivable legal rules, might accrue to the fund.” Id. In other words,
a general interest in preventing the depletion of the fund was not sufficient because there
was no limiting principle. In our case, however, the government’s interest, which is not a
lawyer’s construct but is expressed in a federal contract, is not untethered; it is limited to
22
recovering funds to prevent the boon of double recoveries for some enrollees and to use
the money instead to increase employee benefits or reduce premiums.
Second, the Court in O’Melveny & Myers declared that in that case “[t]here [was]
not even at stake that most generic (and lightly invoked) of alleged federal interests, the
interest in uniformity.” Id. But here we have the federal interest in uniform treatment of
federal employees—in particular, not requiring some to subsidize others in ways (such as
an antisubrogation law) not available to all.
And finally, O’Melveny & Myers said that the Court would not “adopt a court-
made rule to supplement federal statutory regulation that is comprehensive and detailed;
matters left unaddressed in such a scheme are presumably left subject to the disposition
provided by state law.” Id. at 85. But this statement arose in the context of a statute that
provided detail about the terms on which the FDIC could sue as receiver, creating
“special federal rules of decision regarding claims by, and defenses against, the FDIC as
receiver.” Id. at 86. In contrast, FEHBA is silent regarding claims by insurers against
enrollees or tortfeasors; subrogation and reimbursement rules are not mentioned. To be
sure, FEHBA has a preemption provision; but even if the provision does not cover
reimbursement claims (a proposition we reject in the next section of this opinion), that
limitation cannot override the strong federal interests in displacing state law in our case.
See Geier v. Am. Honda Motor Co., 529 U.S. 861, 869 (2000) (express “pre-emption
provision, by itself, does not foreclose (through negative implication) any possibility of
implied conflict pre-emption” (brackets and internal quotation marks omitted)); Boyle,
23
487 U.S. at 507‒08 (“the fact that the area in question is one of unique federal concern
changes what would otherwise be a conflict that cannot produce pre-emption into one
that can” (footnote omitted)); United States v. Northrop Corp., 59 F.3d 953, 961 n.4
(9th Cir. 1995) (“[W]e do not think that the Supreme Court in O’Melveny intended to
foreclose the possibility of displacing, with a federal common law rule, a state rule of
decision that would conflict with specific policies of a comprehensive federal scheme.”);
cf. Freightliner Corp. v. Myrick, 514 U.S. 280, 288 (1995) (“The fact that an express
definition of the pre-emptive reach of a statute ‘implies’—i.e., supports a reasonable
inference—that Congress did not intend to pre-empt other matters does not mean that the
express clause entirely forecloses any possibility of implied pre-emption.”).
Nor is our ruling in tension with McVeigh, 547 U.S. 677, a case in which a
FEHBA insurer sought reimbursement from an enrollee out of a tort settlement. McVeigh
did not say that state law necessarily controlled reimbursement claims under a FEHBA
contract. It held only that there was no federal-question jurisdiction over such a
reimbursement claim, thus requiring dismissal of the insurer’s claim. See id. at 683.
(There is no jurisdictional issue in our case, given the diversity of citizenship of the
parties.)
On the issue of displacement of state law, McVeigh, if anything, supports our
conclusion. It acknowledged the federal interest in reimbursement claims, saying that
“distinctly federal interests are involved” in a carrier’s claim for reimbursement (though
these interests are not sufficient to confer jurisdiction). 547 U.S. at 696. In particular,
24
“reimbursements are credited to a federal fund, and the OPM–BCBSA master contract
could be described as ‘federal in nature’ because it is negotiated by a federal agency and
concerns federal employees.” Id. The Court also noted the federal interest in uniform
treatment of federal employees. See id. at 686 (purpose of § 8902(m)(1) is “[t]o ensure
uniform coverage and benefits under plans OPM negotiates for federal employees”).
To be sure, such federal interests do not necessarily require displacement. The
Court explained that under Boyle, “the involvement of an area of uniquely federal interest
establishes a necessary, not a sufficient, condition for the displacement of state law.” Id.
at 692 (ellipsis and internal quotation marks omitted). Noting that the Second Circuit had
determined that the carrier had not shown a significant conflict between a federal interest
and state law (no state antisubrogation law was mentioned), the Court said, “Unless and
until that showing is made, there is no cause to displace state law, much less to lodge this
case in federal court.” Id. at 693. Implicit in this statement, however, is that a state
regulation that directly conflicts with federal interests must be displaced. And the Second
Circuit, without rebuke by the Supreme Court, said as much. See Empire HealthChoice
Assurance, Inc. v. McVeigh, 396 F.3d 136, 142 (2d Cir. 2005) (Sotomayor, J.) (“We
recognize the possibility that at a later stage in the proceedings, a significant conflict
might arise between New York state law and the federal interests underlying FEHBA,
such that the dispute would satisfy both prongs of Boyle. If, for example, [the estate’s
administrator] were to defend herself in reliance upon a state law that was meant to
advance a particular state policy, [the carrier] could argue that such state law—whether
25
statutory or common law—conflicts with federal interests and requires the application of
federal common law. This possibility, however, is insufficient to confer federal
jurisdiction.”). In this case there is certainly such a conflict, with the state law
attempting to nullify a provision in the FEHBA contract.
Ms. Helfrich relies on McVeigh’s statement that “the reimbursement right in
question, predicated on a FEHBA-authorized contract, is not a prescription of federal
law.” Id.; see also id. (carrier’s “contract-derived claim for reimbursement is not a
creature of federal law” (brackets and internal quotation marks omitted)); id. at 692
(reimbursement and subrogation provisions in OPM-BCBSA contract “are linked
together and depend upon a recovery from a third party under terms and conditions
ordinarily governed by state law”). But even if that is of critical importance in
determining whether a claim arises under federal law for purposes of federal jurisdiction,
it is hardly dispositive on the issue of displacement of state law. Indeed, the
displacement issue (under federal common law) does not arise if a federal statute sets
forth the controlling standard. Although reimbursement is generally governed by state
law, federal law may nonetheless displace aspects of that law. After all, a design-defect
tort claim is a creature of state law, but that did not preclude the displacement of part of
that law in Boyle. See 487 U.S. at 512.
We conclude that the Kansas antisubrogation regulation is displaced by federal
law in this case.
B. Express Preemption
26
Blue Cross also raises FEHBA’s preemption provision as a ground for overriding
the Kansas antisubrogation regulation. The provision states:
The terms of any contract under this chapter which relate to the nature,
provision, or extent of coverage or benefits (including payments with
respect to benefits) shall supersede and preempt any State or local law, or
any regulation issued thereunder, which relates to health insurance or plans.
5 U.S.C. § 8902(m)(1).9
The Supreme Court discussed this provision in McVeigh. Although the issue in
that case was federal-question jurisdiction, not the preemption of state law, the Court’s
observations are nevertheless relevant. It said that the provision is “unusual in that it
renders preemptive contract terms in health insurance plans, not provisions enacted by
Congress,” and thus “warrants cautious interpretation.” McVeigh, 547 U.S. at 697. It
also noted the provision’s ambiguity, at least with respect to reimbursement:
Section 8902(m)(1) is a puzzling measure, open to more than one
construction, and no prior decision seems to us precisely on point. Reading
the reimbursement clause in the master OPM–BCBSA contract as a
condition or limitation on “benefits” received by a federal employee, the
clause could be ranked among “[contract] terms . . . relat[ing] to . . .
coverage or benefits” and “payments with respect to benefits,” thus falling
within § 8902(m)(1)’s compass. On the other hand, a claim for
reimbursement ordinarily arises long after “coverage” and “benefits”
9
Section 8902(m)(1) was originally enacted in 1978. Until amended in 1998, the
preemption was more restricted. The provisions of a FEHBA contract preempted only
“any State or local law, or any regulation issued thereunder, which relates to health
insurance or plans to the extent that such law or regulation is inconsistent with such
contractual provisions.” 5 U.S.C. § 8902(m)(1) (effective to Oct. 18, 1998) (emphasis
added).
27
questions have been resolved, and corresponding “payments with respect to
benefits” have been made to care providers or the insured. With that
consideration in view, § 8902(m)(1)’s words may be read to refer to
contract terms relating to the beneficiary’s entitlement (or lack thereof) to
Plan payment for certain health-care services he or she has received, and
not to terms relating to the carrier’s postpayments right to reimbursement.
Id. (citation omitted, ellipses in original). The Court, however, did not need to choose
between these “plausible constructions” because “even if FEHBA’s preemption provision
reaches contract-based reimbursement claims, that provision is not sufficiently broad to
confer federal jurisdiction.” Id. at 698.
Given the Supreme Court’s statement that the provision is ambiguous regarding
the preemptive effect of reimbursement clauses, Ms. Helfrich argues that we must apply
the well-established presumption against preemption, see, e.g., Wyeth v. Levine, 555 U.S.
555, 565 (2009), and conclude that Kansas law is not preempted. But that presumption
does not apply here for much the same reason that, as discussed in the prior section of
this opinion, federal law displaces the Kansas antisubrogation regulation. The Supreme
Court has at least twice recognized a federal-interest exception to the general
presumption against preemption.
In Buckman Co. v. Plaintiffs’ Legal Committee, 531 U.S. 341, 344 (2001),
individuals who claimed to have been injured by the implantation of orthopedic bone
screws brought state tort claims alleging that a consulting company made fraudulent
representations to the Food and Drug Administration (FDA) while seeking approval to
market the screws. The Supreme Court held that the plaintiffs’ state-law fraud-on-the-
28
agency tort claims were impliedly preempted by the Federal Food, Drug, and Cosmetic
Act, as amended by the Medical Device Amendments of 1976 (MDA). See id. at 344,
348. Although common-law claims for fraud are a traditional feature of state common
law, the Court did not apply the presumption against preemption because “[p]olicing
fraud against federal agencies is hardly a field which the States have traditionally
occupied.” Id. at 347 (internal quotation marks omitted). “To the contrary, the
relationship between a federal agency and the entity it regulates is inherently federal in
character because the relationship originates from, is governed by, and terminates
according to federal law.” Id. Further, the consulting company’s “dealings with the FDA
were prompted by the MDA, and the very subject matter of [the company’s] statements
were dictated by that statute’s provisions.” Id. at 347–48. Thus, the case did not
implicate “federalism concerns and the historic primacy of state regulation of matters of
health and safety.” Id. at 348 (internal quotation marks omitted).
Similarly, in United States v. Locke, 529 U.S. 89, 108 (2000), the Court said that
“an ‘assumption’ of nonpre-emption is not triggered when the State regulates in an area
where there has been a history of significant federal presence.” The issue in Locke was
the preemption of state regulations governing tanker-ship operations and design. See id.
at 94. The presumption against preemption was inapplicable because these laws touched
upon “national and international maritime commerce,” a field in which “Congress ha[d]
legislated . . . from the earliest days of the Republic, creating an extensive federal
statutory and regulatory scheme.” Id. at 108.
29
This court has followed that lead. In US Airways, Inc. v. O’Donnell, 627 F.3d
1318, 1325 (10th Cir. 2010), we considered whether New Mexico liquor laws applied to
airline flights in the state. We said that the presumption against preemption did not apply
to the preemption of a state’s regulation of an airline’s alcoholic-beverage service
because “the field of aviation safety has long been dominated by federal interests.” Id. at
1325 (internal quotation marks omitted). This despite the constitutional recognition of
the state interest in regulation of liquor, see U.S. Const. amend. XXI, § 2 (“The
transportation or importation into any State, Territory, or possession of the United States
for delivery or use therein of intoxicating liquors, in violation of the laws thereof, is
hereby prohibited.”), which was discussed at length later in our opinion, see O’Donnell,
627 F.3d at 1329‒31.
The federalism concern (respecting state sovereignty) behind the presumption
against preemption has little purchase in this case. The preemption provision does not
affect the relationships between private citizens. Section 8902(m)(1) governs only
contracts for the benefit of federal employees. It is an understatement to say that “there
has been a history of significant federal presence,” Locke, 529 U.S. at 108, in the area of
federal employment. Congress has legislated on the matter from the outset.
We therefore turn to the interpretation of the language of § 8902(m)(1) without
consideration of the presumption. Again, state law is preempted with respect to the terms
of a FEHBA contract “which relate to the nature, provision, or extent of coverage or
benefits (including payments with respect to benefits).” § 8902(m)(1). Ms. Helfrich has
30
little to say on the matter beyond echoing what McVeigh said about the possibility that
the terms coverage and benefits are limited to “Plan payment for certain health-care
services [an enrollee] has received, and not to terms relating to the carrier’s postpayments
right to reimbursement.” 547 U.S. at 697. Ms. Helfrich’s view, as the Supreme Court
said in McVeigh, is a plausible one. But the Court also said that the contrary view—the
one taken by Blue Cross and by the United States as amicus—is also plausible. Our task,
then, is to use the tools of statutory interpretation to arrive at the best construction of the
preemption provision. In our view, these tools strongly support Blue Cross.
To begin with, the subrogation and reimbursement requirements in the Plan are
tied directly to “payments with respect to benefits.” § 8902(m)(1). They are triggered
when a third party injures an enrollee and the Plan “pa[ys] benefits for that injury.” J.
App., Vol. 1 at 140. If the enrollee recovers from the third party, those recoveries “must
be used to reimburse [the Plan] in full for benefits [it] paid.” Id. The Plan may “enforce
[its] right of recovery by offsetting future benefits.” Id. at 141. And if the enrollee does
not seek to recover from the third party, she must permit the Plan to initiate recovery on
her behalf. Thus, a carrier’s contractual right to reimbursement and subrogation arises
from its payment of benefits; and an enrollee’s ultimate entitlement to benefit payments
is conditioned upon providing reimbursement from any later recovery or permitting the
Plan to recover on the enrollee’s behalf. No wonder that the reimbursement and
subrogation requirements are contained in the Plan’s “statement of benefits.” Id. at 131.
We note that several circuit courts have interpreted an ERISA provision authorizing civil
31
actions to “recover benefits due . . . under the terms of [a] plan,” 29 U.S.C. §
1132(a)(1)(B), as encompassing suits disputing a plan’s reimbursement efforts. See
Levine v. United Healthcare Corp., 402 F.3d 156, 163 (3d Cir. 2005) (“Where, as here,
plaintiffs claim that their ERISA plan wrongfully sought reimbursement of previously
paid health benefits, the claim is for ‘benefits due’ . . . .”); Arana v. Ochsner Health Plan,
338 F.3d 433, 437–38 (5th Cir. 2003); Singh v. Prudential Health Care Plan, Inc., 335
F.3d 278, 291 (4th Cir. 2003). But see Wurtz v. Rawlings Co., 761 F.2d 232, 242 (2d Cir.
2014).
Further, the reimbursement and subrogation provisions of the Plan have a second
close connection to benefits. Any recovery through these provisions goes to a Treasury
fund that may be used to reduce premiums or to increase benefits. See 5 U.S.C.
§ 8909(b); 5 C.F.R. § 890.503(c)(2).
The legislative history of § 8902(m)(1) also lends some support. The history
reveals a concern about state interference with cost-cutting measures and the uniform
treatment of federal employees across the nation. The House Report on the original
measure expressed fear that the imposition of state-law requirements on FEHBA
contracts would result in “[i]ncreased premium costs to both the Government and
enrollees, and [a] lack of uniformity of benefits for enrollees in the same plan which
would result in enrollees in some States paying a premium based, in part, on the cost of
benefits provided only to enrollees in other States.” H.R. Rep. No. 95-282, at 4 (1977);
see also H.R. Rep. 105-374, at *9 (1997) (“this bill broadens the preemption provisions
32
in current law to strengthen the ability of national plans to offer uniform benefits and
rates to enrollees regardless of where they may live”); S. Rep. 95-903, at *2 (1978)
(purpose of preemption provision “is to establish uniformity in benefits and coverage”
under FEHBA and “at the same time . . . to recognize the rights of states to determine
who is to provide health services” (capitalization omitted)). In addition, Congress wanted
to “prevent carriers’ cost-cutting initiatives from being frustrated by State laws.” H.R.
Rep. No. 105-374, at 9 (1997). To be sure, nothing in this history specifically refers to
reimbursement and subrogation; and Ms. Helfrich can fairly argue that the absence of
such references implies that those procedures are exempted from the preemption
provision. On balance, however, we think that the expressions of congressional intent
suggest preemption here.
The position of Blue Cross has been embraced in the decisions by other federal
courts, which have said that FEHBA preempts state laws limiting subrogation and
reimbursement. See Shields v. Gov’t Emps. Hosp. Ass’n, 450 F.3d 643, 648 (6th Cir.
2006), overruled on other grounds by Adkins v. Wolever, 554 F.3d 650, 652 (6th Cir.
2009); MedCenters Health Care v. Ochs, 26 F.3d 865 (8th Cir. 1994), overruled on
jurisdictional grounds by McVeigh, 547 U.S. 677; Bell v. Blue Cross & Blue Shield of
Okla., No. 5:14-CV-05046, 2014 WL 5597265, at *6‒8 (W.D. Ark. Nov. 3, 2014)
(following MedCenters); Calingo v. Meridian Res. Co., No. 11 CV 628(VB), 2013 WL
1250448, at *4 (S.D.N.Y. Feb. 20, 2013); cf. Bryan v. Office of Pers. Mgmt., 165 F.3d
1315, 1320 (10th Cir. 1999) (interpreting § 8902(m)(1) broadly to preempt state law
33
allowing courts to award attorney fees to the prevailing party in a suit between an insured
and insurer). The state courts are divided. Compare Thurman v. State Farm Mut. Auto
Ins. Co., 598 S.E.2d 448, 451 (Ga. 2004) (state law preempted), and Aybar v. N.J. Transit
Bus Operations, Inc., 701 A.2d 932, 937 (N.J. Super. Ct. App. Div. 1997) (same), with
Nevils v. Grp. Health Plan, Inc., 418 S.W.3d 451, 457 (Mo. 2014) (en banc) (No
preemption because “[t]he subrogation provision in favor of [the FEHBA carrier] creates
a contingent right to reimbursement and bears no immediate relationship to the nature,
provision or extent of [the enrollee’s] insurance coverage and benefits . . . .”), vacated
and remanded 135 S. Ct. 2886 (2015), Kobold v. Aetna Life Ins. Co., 309 P.3d 924, 928
(Ariz. Ct. App. 2013) (same), vacated and remanded 135 S. Ct. 2886 (2015), and
Hillenbrand v. Meyer Med. Grp., S.C., 720 N.E.2d 287, 292‒94 (Ill. App. Ct. 1999)
(application of common-fund doctrine not preempted).
Strongly buttressing the decisions finding preemption is a recent regulation issued
by OPM, the agency responsible for administering FEHBA.10 FEHBA authorizes OPM
to “prescribe regulations necessary to carry out this chapter.” 5 U.S.C. § 8913(a). The
regulation, promulgated on May 21, 2015, requires all contracts to impose the
10
Blue Cross could not have raised below an argument based on this regulation because
OPM had not yet proposed it. But Blue Cross did argue that the district court should
defer to an OPM letter expressing its position that contractual rights to reimbursement
and subrogation fall within the purview of § 8902(m)(1). In response to a request from
this court after OPM promulgated the final rule, the parties and the United States
submitted supplemental briefing regarding whether OPM’s position in the final rule is
entitled to deference.
34
subrogation and reimbursement requirements as a “condition of and a limitation on the
nature of benefits or benefit payments and on the provision of benefits under the plan’s
coverage”; describes the scope of the requirements; and concludes that they “relate to the
nature, provision, and extent of coverage or benefits (including payments with respect to
benefits) within the meaning of 5 U.S.C. § 8902(m)(1).” 80 Fed. Reg. at 29,204–05. The
proposed rule, published on January 7, 2015, explained that this interpretation of
§ 8902(m)(1) furthers Congress’s goal of reducing health-care costs because subrogation
and reimbursement recoveries tend to lead to lower premiums, 70% of which are paid by
the federal government; advances the federal interest in national uniformity in benefits
and administration in order to avoid uncertainty, litigation, and disparate treatment of
enrollees; and is consistent with OPM’s understanding that a carrier’s right to subrogation
and reimbursement recovery is “a condition of the payments that enrollees are eligible to
receive for benefits.” 80 Fed. Reg. at 932; see 80 Fed. Reg. at 29203 (“Supplementary
Information” preceding Final Rule).
Blue Cross and the United States argue that we must defer to OPM’s interpretation
of § 8902(m)(1) under Chevron U.S.A., Inc. v. Natural Resources Defense Council, Inc.,
467 U.S. 837 (1984). They may be correct. Two years ago the Supreme Court
emphasized the breadth of Chevron, holding that it applied even to statutory provisions
that could be considered jurisdictional. It wrote:
Chevron is rooted in a background presumption of congressional intent:
namely, that Congress, when it left ambiguity in a statute administered by
an agency, understood that the ambiguity would be resolved, first and
35
foremost, by the agency, and desired the agency (rather than the courts) to
possess whatever degree of discretion the ambiguity allows. Chevron thus
provides a stable background rule against which Congress can legislate:
Statutory ambiguities will be resolved, within the bounds of reasonable
interpretation, not by the courts but by the administering agency.
City of Arlington v. FCC, 133 S. Ct. 1863, 1868 (2013) (citation and internal quotation
marks omitted). The Court noted that “[o]ne of [its] opinions explicitly says that no
exception exists to the normal deferential standard of review for jurisdictional or legal
questions concerning the coverage of an Act.” Id. at 1871 (brackets and internal
quotation marks omitted). With regard to preemption, the Court wrote, “We have even
deferred to the FCC’s assertion that its broad regulatory authority extends to pre-empting
conflicting state rules.” Id. “And,” said the Court, “we have applied Chevron where
concerns about agency self-aggrandizement are at their apogee: in cases where an
agency’s expansive construction of the extent of its own power would have wrought a
fundamental change in the regulatory scheme.” Id. at 1872. In response to the contention
that Chevron deference was encroaching on matters of traditional local concern, the
Court said, “[T]his case has nothing to do with federalism. [The applicable provision of
the Telecommunications Act] explicitly supplants state authority by requiring zoning
authorities to render a decision ‘within a reasonable period of time,’ and the meaning of
that phrase is indisputably a question of federal law.” Id at 1873. Rather, “[t]his is, at
bottom, a debate not about whether the States will be allowed to do their own thing, but
about whether it will be the [agency] or the federal courts that draw the lines to which
they must hew.” 133 S. Ct. at 1873 (internal quotation marks omitted). Moreover, the
36
delegation of general authority to promulgate regulations extends to all matters “within
the agency’s substantive field.” Id. at 1874. Because “the whole includes all of its
parts,” courts need not try to discern whether “the particular issue was committed to
agency discretion.” Id. The Court concluded:
Where Congress has established a clear line, the agency cannot go beyond
it; and where Congress has established an ambiguous line, the agency can
go no further than the ambiguity will fairly allow. But in rigorously
applying the latter rule, a court need not pause to puzzle over whether the
interpretive question presented is jurisdictional. If the agency’s answer is
based on a permissible construction of the statute, that is the end of the
matter.
Id. at 1874–75 (internal quotation marks omitted).
Strong stuff. One could easily infer from this language that Chevron applies to an
agency interpretation of a preemption provision in a statute it administers. And, indeed,
the Court has applied Chevron in just that situation. See Cuomo v. Clearing House Ass’n,
557 U.S. 519, 525 (2009) (but finding agency’s construction improper because statute’s
ambiguity did not stretch so far). Given the ambiguity in § 8902(m)(1), application of
Chevron deference would require us to adopt OPM’s reasonable view.
On the other hand, Arlington made no mention of the Court’s repeated statements
in recent years that it will merely give some weight to an agency’s view on preemption,11
11
See PLIVA, Inc. v. Mensing, 131 S. Ct. 2567, 2575 n.3 (2011) (“Although we defer to
the agency’s interpretation of its regulations, we do not defer to an agency’s ultimate
conclusion about whether state law should be pre-empted.”); Williamson v. Mazda Motor
of Am., Inc., 562 U.S. 323, 335 (2011) (“the agency’s own views should make a
difference” (internal quotation marks omitted)); Wyeth, 555 U.S. at 576 (“In prior cases,
Continued . . .
37
although we note that in only two cases did the Court reject the agency position (which in
neither case had appeared in a regulation promulgated by the agency)12. But we need not
decide whether deference beyond “some weight” is required, because even under the less
deferential standard we would adopt OPM’s conclusion. As stated in Wyeth,
[A]gencies . . . have a unique understanding of the statutes they administer
and an attendant ability to make informed determinations about how state
requirements may pose an obstacle to the accomplishment and execution of
the full purposes and objectives of Congress. The weight we accord the
agency’s explanation of . . . the federal scheme depends on its
thoroughness, consistency, and persuasiveness.
555 U.S. at 577 (citation and internal quotation marks omitted). As the agency that has
negotiated FEHBA contracts for federal employees for years, OPM has deep knowledge
of the impact and interrelationships of contractual provisions. Its longstanding and
we have given ‘some weight’ to an agency’s views about the impact of tort law on federal
objectives when ‘the subject matter is technica[l] and the relevant history and background
are complex and extensive.’”); Riegel v. Medtronic, Inc., 552 U.S. 312, 326 (2008) (“We
have found it unnecessary to rely upon that agency view because we think the statute
itself speaks clearly to the point at issue. If, however, we had found the statute
ambiguous and had accorded the agency’s current position deference, the dissent is
correct that—inasmuch as mere Skidmore deference would seemingly be at issue—the
degree of deference might be reduced by the fact that the agency’s earlier position was
different.” (citation omitted)); Geier, 529 U.S. at 883 (“We place some weight upon [the
Department of Transportation’s] interpretation of [the regulation’s] objectives and its
conclusion, as set forth in the Government’s brief, that a tort suit such as this one would
stand as an obstacle to the accomplishment and execution of those objectives.” (original
brackets and internal quotation marks omitted)); Medtronic, Inc. v. Lohr, 518 U.S. 470,
495 (1996) (“our interpretation of the pre-emption statute is substantially informed by
those regulations”).
12
See PLIVA, 131 S. Ct. at 2575 n.3 (rejecting view of U.S. amicus brief); Br. for U.S. as
Amicus Curiae Supporting Resp’ts, PLIVA, Inc. v. Mensing, Nos. 09-993, 09-1039 &
09-1501 (U.S. Mar. 2, 2011); Wyeth, 555 U.S. at 580–81 (preamble to rule).
38
persuasively explained view that subrogation and reimbursement provisions are directly
tied to employee health benefits and advance the congressional purposes served by
§ 8902(m)(1) is, in our view, of sufficient weight to persuade us to agree with its
conclusion regarding preemption.
Ms. Helfrich contends that the district court’s ruling implicates serious
constitutional concerns because the Supremacy Clause does not permit contractual terms
to preempt state laws, as § 8902(m)(1) provides. We are skeptical of this argument. The
effect of the contractual provision here is no greater than the effect of the design
specification in the contract in Boyle, where the Supreme Court held that the specification
could override state tort law. See 487 U.S. at 512‒13. And we note that then-Circuit
Judge Sotomayor said in the Second Circuit opinion in McVeigh that the provision could
be construed to avoid the constitutional problem. See 396 F.3d at 144–45 (“[W]e can
reasonably construe § 8902(m)(1) as requiring that, in cases involving the ‘terms of any
contract under [FEHBA] which relate to the nature, provision, or extent of coverage or
benefits,’ federal law ‘shall supersede and preempt any State or local law, or any
regulation issued thereunder, which relates to health insurance or plans.’ 5 U.S.C.
§ 8902(m)(1). . . . The federal law preempting state law may be federal common law or
the FEHBA statute provisions themselves, but it must be law—not contract terms.”). In
any event, because Ms. Helfrich did not raise this argument below and has not argued for
plain-error review on appeal, we need not address it. See Richison v. Ernest Grp., Inc.,
634 F.3d 1123, 1130‒31 (10th Cir. 2011). Ms. Helfrich says that she did not forfeit the
39
argument because “[i]t is the district court’s interpretation of § 8902(m)(1) that pits the
text of FEHBA’s preemption provision against the Supremacy Clause,” so the
constitutionality of the provision “only arose when the district court rejected the narrow
interpretation urged . . . below.” Aplt. Reply Br. at 25 n.8. We disagree. When Blue
Cross argued below that § 8902(m)(1) preempted the Kansas antisubrogation regulation,
Ms. Helfrich had the opportunity to argue that § 8902(m)(1) was unconstitutional. There
was no need to wait for the district court’s interpretation. A party with two possible
arguments to support its position cannot hold one in reserve and raise it on appeal only
after losing on the other. See Price v. Wolford, D.O., 608 F.3d 698, 706 (“A party must
make its arguments before the court rules. It cannot keep an arrow in its quiver in
reserve, for use in case the judge says at the end of the contest that all the expended
arrows missed the mark.”).
III. CONCLUSION
For the foregoing reasons, we AFFIRM the judgment of the district court.
40
14-3179, Helfrich v. Blue Cross and Blue Shield Association
LUCERO, J., concurring.
I join the majority as to part II.B. I write separately to express my disagreement
with my colleagues’ application of federal common law preemption.
The majority primarily rests its analysis on Boyle v. United Technologies Corp.,
487 U.S. 500 (1988). Under Boyle, federal law preempts state law if: (1) the area of law
concerns uniquely federal interests; and (2) “a significant conflict exists between an
identifiable federal policy or interest and the operation of state law, or the application of
state law would frustrate specific objectives of federal legislation.” Id. at 504-505, 507
(citations omitted). Because I agree that FEHB contract terms present uniquely federal
interests, the relevant question concerns Boyle’s second prong, the “significant conflict”
requirement.1
A significant conflict with a federal interest exists if a claim is based on “the
exercise or performance or the failure to exercise or perform a discretionary function or
duty on the part of a federal agency or an employee of the Government.” Id. at 511
(quotation omitted). This rule stems from a provision of the Federal Tort Claims Act
preserving government immunity against claims implicating agency discretion. Id.
(citing 28 U.S.C. § 2680(a)). The purpose of that provision was to “prevent judicial
1
The second prong analysis is limited to the “significant conflict” requirement
because there is no federal legislation concerning FEHB subrogation terms, aside from
FEHBA’s general preemption provision to which the federal common law analysis is
inapplicable given our holding that the statute expressly preempts state anti-subrogation
laws.
‘second-guessing’ of legislative and administrative decisions . . . through the medium of
an action in tort.” United States v. S.A. Empresa de Viacao Aerea Rio Grandense (Varig
Airlines), 467 U.S. 797, 814 (1984) (emphasis added).
Extending the rule to a contract claim unmoors it from its purpose. Declining to
extend the rule to actions in contracts is consistent with Boyle, where the court essentially
granted § 2680(a) tort immunity to government contractors. See Boyle, 487 U.S. at 530
(Brennan, J., dissenting) (stating that the decision is “premised on the proposition that
any tort liability indirectly absorbed by the Government so burdens governmental
functions as to compel us to act when Congress has not” (emphasis added)). Because the
test Boyle enunciated is limited to actions in tort, I would not apply it to the contract
claim in this case.
Moreover, even if we were to apply the Boyle test to a contract claim, the majority
does not properly engage the test’s second prong. The majority opinion does not define
“significant conflict”; instead it spends several pages fortifying its conclusions that the
federal interest in this case—the government’s desire for system-wide uniformity and
cost control—is significant, and that the conflict with state law is “stark.” (Majority Op.
17.) But Boyle rejected the proposition that a “stark” conflict with state law is sufficient
to support preemption. Boyle, 487 U.S. at 509 (even if state law is “precisely contrary to
the duty imposed by the Government contract . . . , it would be unreasonable to say that
there is always a significant conflict between the state law and a federal policy or
interest”). The majority ignores this aspect of Boyle and instead reads the case as
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affirming that “a state regulation that directly conflicts with federal interests must be
displaced.” (Majority Op. 25.)
I cannot agree. A “significant conflict” must arise from an act based on federal
agency discretion. Boyle, 487 U.S. at 511. Courts have struggled to enunciate the
boundaries of this discretion. See S.A. Empresa, 467 U.S. at 813 (“[I]t is . . . impossible .
. . to define with precision every contour of the discretionary function exception”). But
it must have a limit, lest it swallow the entire Federal Tort Claims Act. In Boyle, the
Court concluded that a government decision was discretionary because it involved “not
merely engineering analysis but judgment as to the balancing of many technical, military,
and even social considerations, including specifically the trade-off between greater safety
and greater combat effectiveness.” 487 U.S. at 511. In the present case, the government
decision is not as complex. Whether to include subrogation clauses in FEHB contracts
implicates uniformity and cost-savings concerns, but does not implicate technical or
military considerations, engineering analyses, tradeoffs between greater safety and
greater combat effectiveness, or anything comparable. Instead, it simply involves a cost-
benefit analysis weighing the value of additional funds in the federal coffer against that of
an increase in the ability of federal employees to recover healthcare costs. This decision
may involve some discretion—just as nearly every government decision does—but the
balancing act falls well short of the level of discretion exercised in Boyle.
To understand the minimal importance of any discretion exercised in this case, it is
instructive to consider the impact of subrogation (recovery from a third party) and
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reimbursement (recovery directly from the insured) on the asserted goals of uniformity
and cost. The federal government’s interest in uniformity is undermined if FEHB
contracts do not require insurers to pursue reimbursement or to recover under
subrogation. But the contract at issue grants the insurer a significant role in pursuing
both remedies. It provides that the insurer must make a “reasonable effort to seek
recovery of amounts to which it is entitled to recover [through subrogation] in cases
which are brought to its attention.” But, the insurer “shall not be required to recover any
amounts from any [third party]” under subrogation. And if, as in this case, the insurer
seeks reimbursement directly from the insured federal employee, the contract permits—
but does not require—the insurer to seek recovery, contrary to the majority’s reading.2
Thus, the insurer retains significant discretion in determining when to forego subrogation,
and possesses full discretion in deciding if, when, and how to pursue reimbursement.
The FEHB regime does not provide employees with uniform results because insurers can
decide if they will recover, thereby allowing some federal employees to keep third-party
recoveries while forcing others to pay them back. Federal employees thus pay higher
premiums to support double recoveries for some policyholders subject to insurers’
whims, just as they do when some states exempt their own citizens from subrogation
2
To conclude that the insurer is required to use reasonable efforts to seek
reimbursement, the majority first removes the reference to subrogation in the contract
term that states “[t]he obligation of the Carrier to recover amounts through subrogation is
limited to making a reasonable effort to seek recovery . . . .” (Majority Op. 5.) The
majority then holds that this language does not apply to subrogation, and instead applies
to an entirely separate clause governing reimbursement. I cannot agree with this reading.
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provisions through the democratic process.
The amount of cost-savings afforded by subrogation and reimbursement likewise
suggests that the government interest is not significant. Across all states (most of which
allow subrogation clauses), total subrogation recoveries amount to approximately 0.3% of
the premiums paid into FEHB. Moreover, as explained above, the government leaves the
decision of when to pursue cost-savings to the insurers. If the government interests were
truly significant, one would expect it to obligate insurers to pursue reimbursement and to
recover through subrogation.
To conclude that the government interests in the case at bar deserve much weight,
the majority analogizes FEHB insurers to the military contractors in Boyle, and observes
that it makes little sense to insulate the government against liability where it produces
equipment directly but not where it contracts for production. (Majority Op. 20-21.) This
analogy merely raises the question: would agency discretion shield the government from
financial liability if the government issued insurance directly, and not through private
insurers? Not under § 2680(a) because the claim does not sound in tort. And even if it
did, the impact of allowing subrogation terms in FEHB contracts does not rise to the level
of import of the decisions at issue in Boyle.
The majority also errs in its attempt to distinguish O’Melveny & Myers v. FDIC,
512 U.S. 79 (1994). In O’Melveny the Court concluded that the government’s general
desire to avoid foregoing any money that might accrue to a federal fund was insufficient
to support preemption without some limiting principle. Id. at 88. The majority states that
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FEHB reimbursement provisions are “limited to recovering funds to prevent the boon of
double recoveries for some enrollees.” (Majority Op. 22-23.) But, if this is the limiting
principle, it has no teeth. The contract terms are not limited to those cases involving
double-recovery. To the contrary, the official statement of benefits expressly provides
that the insurer may recover “even if [the insured] is not ‘made whole’ for all of [her]
damages in the recoveries that [she] receive[s].” Helfrich alleges that the recovery from
BCBS and from the offending driver’s insurance together left $30,000 of her medical
bills unaddressed. Accepting this well-pled allegation as true and construing it in the
light most favorable to the plaintiff, Estes v. Wyoming Dep’t of Transp., 302 F.3d 1200,
1203 (10th Cir. 2002), Helfrich did not receive a double-recovery. She did not even
cover her costs. The reimbursement provisions are over-inclusive, as they allow more
than just double recoveries, and under-inclusive, because insurers may decide not to
collect even if the insured did receive a double-recovery. To the extent that preventing
double-recovery is a limiting principle, it has no application in this case.
The majority’s reasoning would exempt federal contracts from the contours of
state law anytime the government finds that law economically inconvenient. We should
not grant such broad authority to federal agencies. Instead, we should limit our
preemption analysis to the relevant statute and the agency’s implementing regulations.
For these reasons, I do not join the majority’s federal common law discussion.
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