1. Home
  2. |Insights
  3. |Supreme Court Rules in Favor of Health Plans in Landmark $13 Billion Affordable Care Act Case

Supreme Court Rules in Favor of Health Plans in Landmark $13 Billion Affordable Care Act Case

Client Alert | 1 min read | 04.28.20

On April 27, the U.S. Supreme Court issued a decision in Maine Cmty. Health Options et al v. United States, ruling in favor of Maine and companion insurers in the long running Affordable Care Act §1342 “risk corridors” litigation, and confirming the government’s obligation to pay insurers approximately $13 billion for their work related to the ACA. Under the risk corridors program, the government and the health plans shared risk during the first three years of the ACA exchanges, and had reciprocal statutory payment obligations; however, after the health plans performed, the government refused to make full payment, arguing that Congress’ refusal to appropriate funds vitiated the government’s payment obligation. Reversing the Federal Circuit, the Supreme Court held that the statute contained an unambiguous payment mandate, which was not repealed or otherwise suspended by Congress’ failure to make appropriations available. While a failure to appropriate funds prevents agencies from making the payment, the failure does not relieve the United States of its obligation to pay. Speaking for the majority, Justice Sonia Sotomayor wrote: “These holdings reflect a principle as old as the Nation itself: The Government should honor its obligations. Soon after ratification, Alexander Hamilton stressed this insight as a cornerstone of fiscal policy. ‘States,’ he wrote, ‘who observe their engagements . . . are respected and trusted: while the reverse is the fate of those . . . who pursue an opposite conduct.’” C&M partner Steve McBrady called the decision “important” noting that it “cements bedrock principles of fairness into money mandating statute jurisprudence.” Crowell & Moring represented Maine Community Health Options.

Contacts

Insights

Client Alert | 4 min read | 08.07.25

File First, Facts Later? Eleventh Circuit Says That Discovery Can Inform False Claims Act Allegations in Amended Complaints

On July 25, 2025, the Eleventh Circuit Court of Appeals issued its decision in United States ex. rel. Sedona Partners LLC v. Able Moving & Storage Inc. et al., holding that a district court cannot ignore new factual allegations included in an amended complaint filed by a False Claims Act qui tam relator based on the fact that those additional facts were learned in discovery, even while a motion to dismiss for failure to comply with the heightened pleading standard under Federal Rule of Civil Procedure 9(b) is pending.  Under Rule 9(b), allegations of fraud typically must include factual support showing the who, what, where, why, and how of the fraud to survive a defendant’s motion to dismiss.  And while that standard has not changed, Sedona gives room for a relator to file first and seek out discovery in order to amend an otherwise deficient complaint and survive a motion to dismiss, at least in the Eleventh Circuit.  Importantly, however, the Eleventh Circuit clarified that a district court retains the discretion to dismiss a relator’s complaint before or after discovery has begun, meaning that district courts are not required to permit discovery at the pleading stage.  Nevertheless, the Sedona decision is an about-face from precedent in the Eleventh Circuit, and many other circuits, where, historically, facts learned during discovery could not be used to circumvent Rule 9(b) by bolstering a relator’s factual allegations while a motion to dismiss was pending.  While the long-term effects of the decision remain to be seen, in the short term the decision may encourage relators to engage in early discovery in hopes of learning facts that they can use to survive otherwise meritorious motions to dismiss....

View All Insights