McCall

We granted review in this case, limited to the issue whether state law claims against a health maintenance organization (HMO), arising out of its refusal to provide services under a Medicare-subsidized health plan, fall within the exclusive review provisions of the Medicare Act requiring exhaustion of administrative remedies. ( 42 U.S.C. § 1395 et seq.) *415 As will appear, some disagreement exists among state and federal courts on this question, which has not yet been addressed by the United States Supreme Court. We conclude the claims made here do not fall within Medicare’s exclusive review provisions. Accordingly, we affirm the judgment of the Court of Appeal.

Facts

On review of the judgment of the Court of Appeal reversing the superior court’s orders sustaining defendants’ demurrers, we examine the complaint de novo to determine whether it alleges facts sufficient to state a cause of action under any legal theory, such facts being assumed true for this purpose. (Santa Monica Beach, Ltd. v. Superior Court (1999) 19 Cal.4th 952, 957 [ 81 Cal.Rptr.2d 93 , 968 P.2d 993 ]; Blank v. Kirwan (1985) 39 Cal.3d 311, 318 [ 216 Cal.Rptr. 718 , 703 P.2d 58 ].)

George McCall, who…

The Medicare Act ( 42 U.S.C. § 1395 et seq.) (hereafter sometimes referred to as Medicare or the Act) is a massive federally insured program that covers health services for the elderly and disabled. Congress has decreed that any enrollee of a Medicare health maintenance organization (HMO) plan who wishes to challenge the HMO’s denial of health services under Medicare must do so through Medicare’s administrative review process; if that process yields a final decision that is adverse to the enrollee, then judicial review must be sought in federal court. (42 U.S.C. § 1395ff.)

Disregarding that congressional mandate and key United States Supreme Court authority, the majority opinion allows virtually any Medicare HMO plan enrollee to bring suit in state court to challenge an HMO’s denial of Medicare benefits. Enrollees may bypass Medicare’s exhaustion requirements simply by styling their challenges as claims for tort damages. As a result, questions regarding which medical procedures are or should be covered by Medicare may now be decided outside of Medicare’s exclusive review process by California judges and juries on an ad hoc basis.

Congress acted deliberately to ensure uniform…

We granted review in this case, limited to the issue whether state law claims against a health maintenance organization (HMO), arising out of its refusal to provide services under a Medicare-subsidized health plan, fall within the exclusive review provisions of the Medicare Act requiring exhaustion of administrative remedies. ( 42 U.S.C. § 1395 et seq.) As will appear, some disagreement exists among state and federal courts on this question, which has not yet been addressed by the United States Supreme Court. We conclude the claims made here do not fall within Medicare's exclusive review provisions. Accordingly, we affirm the judgment of the Court of Appeal.

On review of the judgment of the Court of Appeal reversing the superior court's orders sustaining defendants' demurrers, we examine the complaint de novo to determine whether it alleges facts sufficient to state a cause of action under any legal theory, such facts being assumed true for this purpose. ( Santa Monica Beach, Ltd. v. Superior Court (1999) 19 Cal.4th 952, 957 , 81 Cal.Rptr.2d 93 , 968 P.2d 993 ; Blank v. Kirwan (1985) 39 Cal.3d 311, 318 , 216 Cal.Rptr. 718 , 703 P.2d 58 .)

George McCall, who…