United States District Court, E.D. Wisconsin
DECISION AND ORDER
WILLIAM E. DUFFIN U.S. Magistrate Judge.
Fresenius Medical Care Midwest Dialysis, LLC, Bio-Medical
Applications of Wisconsin, Inc., and Wisconsin Renal Care
Group, LLC (collectively, Fresenius) provide dialysis
treatments to patients who suffer from end stage renal
disease, a chronic kidney disease. (ECF No. 54, ¶¶
1-3; ECF No. 56, ¶ 1.)
Humana Insurance Company, Humana Wisconsin Health
Organization Insurance Corporation, and/or Humana, Inc.
(collectively, Humana) provided or administered health
benefit plans for defendants Holy Redeemer Academy, Mee
Enterprises, Inc., Spiros Industries Inc., OEC Graphics,
Inc., Ascential Service LLC, Meat Processors Inc., Building
Service, Inc., and Kald Tool & Die Corporation. Persons
covered by these plans received dialysis from Fresenius, and
under an agreement with Fresenius Humana reimbursed Fresenius
up to an annual limit of $30, 000 per person. (ECF No. 56,
¶ 12.) Contending that this annual limit on dialysis
benefits is unlawful as of 2013 in light of the Patient
Protection and Affordable Care Act (ACA), Pub. L. No.
111-148, Fresenius filed this action.
parties have filed cross-motions for partial summary
judgment. The briefing on the motions is complete and the
motions are ready for resolution. All parties consented to
the full jurisdiction of a magistrate judge. (ECF Nos. 4,
38.) The court has jurisdiction pursuant to 29 U.S.C. §
1132(e)(1) and 28 U.S.C. § 1331.
court shall grant summary judgment if the movant shows that
there is no genuine dispute as to any material fact and the
movant is entitled to judgment as a matter of law.”
Fed.R.Civ.P. 56(a). Not all factual disputes will preclude
summary judgment. Carroll v. Lynch, 698 F.3d 561,
563 (7th Cir. 2012). A factual dispute is only
“genuine” when the “evidence is such that a
reasonable jury could return a verdict for the nonmoving
party.” Id. The “court may not make
credibility determinations, weigh the evidence, or decide
which inferences to draw from the facts; these are jobs for a
factfinder.” Washington v. Haupert, 481 F.3d
543, 550 (7th Cir. 2007) (quoting Payne v. Pauley,
337 F.3d 767, 770 (7th Cir. 2003)). “To survive summary
judgment, the non- movant must produce sufficient admissible
evidence, taken in the light most favorable to it, to return
a jury verdict in its favor.” Fleishman v.
Cont'l Cas. Co., 698 F.3d 598, 603 (7th Cir. 2012)
(quoting Berry v. Chi. Transit Auth., 618 F.3d 688,
690-91 (7th Cir. 2010)).
enacted the ACA in 2010 in an effort to comprehensively
reform the nation's health care system. Nat'l
Fed'n of Indep. Bus. v. Sebelius, 567 U.S. 519, 590,
132 S.Ct. 2566, 2609, 183 L.Ed.2d 450, 500 (2012) (Ginsburg,
J., dissenting in part). The ACA is a sprawling and
complicated piece of legislation comprising ten titles and
spanning over 900 pages with hundreds of provisions.
Id. at 538-39. Most relevant here, the ACA generally
barred insurers from imposing annual or lifetime limits on
anything that is an “essential health benefit”.
(ECF No. 56, ¶ 17.) This prohibition on annual caps for
essential health benefits was phased in so that for plans
beginning on or after September 23, 2012, the limit could be
no less than $2 million. 45 C.F.R. § 147.126(d)(1)(iii)
(Oct. 1. 2013 ed.). The limit was eliminated entirely for
plan years starting in 2014. There is no dispute that the
ACA's requirements regarding essential health benefits
apply to the defendants and their plans.
health benefit” is a term of art under the ACA that
Congress left to the Secretary of the Department of Health
and Human Services (HHS) to define. 42 U.S.C. §
18022(b). Having said that, Congress said that the Secretary
shall make sure essential health benefits include at least
the following general categories and the items and services
covered within the categories:
(A) Ambulatory patient services.
(B) Emergency services.
(D) Maternity and newborn ...