Ohio v. United States (154 F. Supp. 3d 621, 2016)

OPINION & ORDER

ALGENON L. MARBLEY, UNITED STATES DISTRICT JUDGE

In its most recent challenge to the Patient Protection and Affordable Care Act of 2010, commonly known as “Obamacare,” the State of Ohio takes aim at a lesser-known provision from the law — one designed to stabilize prices in the individual insurance market during the first three years of the Act’s guaranteed-issue .and community-rating reforms. See. 42 U.S.C. § 18061 (known as the “Transitional Reinsurance Program”). Those guaranteed-issue and community-rating reforms, which provide some of the best-known and most essential features of the Affordable Care Act, prohibit insurers from denying coverage or charging higher premiums because of an individual’s pre-existing medical conditions. See id. §§ 300gg, 300gg-1, 300gg-3; King v. Burwell, — U.S.-, 135 S.Ct. 2480, 2485-86, 192 L.Ed.2d 483 (2015) (“The Patient Protection and Affordable Care Act adopts a series of interlocking reforms designed to.expand coverage in the individual health insurance market. First, the Act bars .insurers, from taking a person’s health into account when deciding whether to sell, health insurance or how much to charge.”); Annie.L. Mach & Bernadette Fernandez, Cong. Research Serv., R42069, Private Health Insurance Market Reforms in the Affordable Care Act (ACA) 3-5 (2014).

Because the guaranteed-issue and community-rating reforms extended healthcare insurance to anyone, regardless of their health status, Congress worried that adverse selection (¿a, the tendency for high-risk individuals to buy health insurance and low-risk individuals not to) might lead to proportionally fewer low-risk enrollees, which in turn could cause spikes in insurance premiums. See 42 U.S.C. § 18061(c)(1). As a result, Congress established the Transitional Reinsurance Program to offset (partially) the cost of insuring high-risk enrollees during benefit years 2014, 2015, and 2016. See id. § 18061(b)(1). Under the Transitional Reinsurance Program, Congress sought' to stabilize premiums in the reformed marketplace by collecting contributions from health insurance issuers and group health plans and then using those contributions to fund reinsurance payments to individual-market issuers that cover high-risk (and thus, high-cost) enrollees. Id. In other words, Congress enacted a three-year program designed to reduce premiums for individuals and ensure market stability for insurers while they first adjusted their actuarial estimates to some of the milestone reforms from the Affordable Care Act — i:e., to avoid “death spirals” that would cripple the insurance market.

The State of Ohio and a handful of its instrumentalities and political subdivisions (collectively, “the State”) take umbrage with the Transitional Reinsurance Program, at least insofar as it applies to them. (See Pis.’ Am. Compl., ECF # 13, PagelD 59). The State claims that the health plans it: provides to its employees are not required to make reinsurance contributions because the plans are not “group health plans” within the meaning of the Affordable Care Act. (Id. at ¶40>. Alternatively, the State contends that requiring its health plans to make these contributions violates the Tenth Amendment and the Intergovernmental Tax Immunity Doctrine — two separate components of what the State collectively refers to as “structural” federalism. (Id. at ¶¶ 98-99).

Accordingly, the State argues that this Court should order the federal government to remit any payments the State has made under the Transitional Reinsurance Program; set aside any regulations purporting to apply the program to state or local governmental entities; and enjoin the federal government from collecting any further payments from the State under the program. (Id. at ¶ 100).

The State of Ohio, however, is no stranger to. Affordable Care-. Act challenges. To the contrary, the State’s Attorney General proudly trumpets that his first act in office was joining a twenty-five state • lawsuit challenging the Act in its entirety. See Ohip. Attorney General, http://www.ohioattorneygeneral.gov/About-AG/Mike-Dewine (last visited .Nov. 6, 2015). The Supreme Court of the United States ultimately rebuffed the thrust of that lawsuit, upholding the individual healthcare mandate in the process. See Nat’l Fed. of Indep. Bus. v. Sebelius (NFIB), — U.S. -, 132 S.Ct. 2566, 2594-2600, 183 L.Ed.2d 450 (2012). The Supreme Court did, however, strike down some of the ’Medicaid expansion provisions from the Affordable Care Act as unduly coercive under the Constitution’s Spending Clause, thus handing Ohio a partial victory. Id. at 2601-07.

In 2014, Ohio redoubled its efforts against the Affordable Care Act by leading nineteen states in filing a friend-of-the-court brief in support of a challenge to the contraception-coverage mandate. See Brief of Amici Curiae States of Michigan, Ohio, & 18 Other States for Conestoga, Hobby Lobby, Mardel, Burwell v. Hobby Lobby Stores, Inc., — U.S.-, 134 S.Ct. 2751, 189 L.Ed.2d 675 (2014) (Nos. 13-354, 13-356), 2014 WL 333885. There, the challengers notched a partial victory, as the Supreme Court held that the Religious Freedom Restoration Act of 1993 prohibits the federal government from demanding that closely held corporations provide health-insurance coverage for contraception when doing so violates the sincerely held religious beliefs of the companies’ owners. Hobby Lobby, 134 S.Ct. at 2759.

The State sat out the third Affordable Care Act challenge to reach the Supreme Court, King v. Burwell, — U.S.-, 135 S.Ct. 2480, 192 L.Ed.2d 483 (2015). There, the Court rejected an assault on the law’s provision of premium tax credits to low- and moderate-income Americans who happened to reside in states that chose not to establish independent insurance exchanges. Id. at 2496. In the process, the Court flatly noted that “Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them.” Id.

But the respite did not last long.. Ohio soon joined nineteen other states in urging the Supreme Court to reject an administrative accommodation from the Affordable Care Act for non-profit religious colleges, hospitals, and charities that raise faith-based objections to birth control. See Brief of the States of Texas, Ohio, et al. as Amici Curiae Supporting Petitioners, Little Sisters of the Poor Home for the Aged, Denver, Colo. v. Burwell, 136 S.Ct. 446 (2015) (No. 15-105), 2015 WL 5029191. Although seven of eight federal appeals courts have ruled in the federal government’s favor on this issue, Ohio pressed on, and the Supreme Court granted certiorari to resolve the apparent circuit split. See Adam Liptak, Supreme Court to Hear Another Case on Contraception and Religion, N.Y. Times, Nov. 7, 2015, at A11.

Now, the State takes aim at the Transitional Reinsurance Program. As with much of the State’s previous challenge in NFIB, however, this shot misses the mark. Put simply, Congress -intended for all group health plans, including those operated by state or local governments, to pay into the Transitional Reinsurance Program. The text, structure,- and purpose of the Affordable Care Act (and related statutes) confirm as much. Moreover, Congress and the Department of Health and Human Services did not violate the Constitution when they subjected health plans offered by state and local government employers to the same requirements as those offered by private-sector employers.

Because the State of Ohio’s claims fail as a matter of law, the Court GRANTS the federal government’s Motion to Dismiss this lawsuit and DENIES the State’s Motion for Summary Judgment.

I. BACKGROUND

Congress enacted the Affordable Care Act (or “ACA” for short) to address longstanding concerns over the lack of affordable, universally available healthcare. The ACA contained several provisions that, by now, have become ingrained in the nation’s conscience, through either headline-grabbing litigation or personal experience. These features include the guaranteed-issue and community-ratings provisions described above, 42 U.S.C. §§ 300gg, 300gg-1, 300gg-3; the requirement that most individuals pay a tax penalty if they fail to maintain coverage, T.R.C. § 5000A; federal tax credits that help low-and moderate-income Americans purchase health insurance, I.R.C. § 36B; and a provision allowing younger Americans to stay on their parents’ healthcare plans until they reach age twenty-six, 42 U.S.C. §' 300-gg-14.

The ACA also included a lesser-known provision, the Transitional Reinsurance Program, to help ease the move to a healthcare system where insurance carriers could no longer discriminate against high-risk- individuals in the individual market. See 42 U.S.C. § 18061. .This program targeted volatility and price increases in the individual market as insurers adjusted (perhaps imperfectly at first) to different risk pools. See Patient Protection and Affordable Care Act; HHS Notice qf .Benefit and Payment Parameters for 2014 (Final Rule), 78 Fed. Reg. 15,410, 15,411 (Mar. 11, 2013). In other words, the Transitional Reinsurance Program sought “to.protect against [insurance] issuers’-,.potential perceived need to raise premiums due to the implementation of the 2014 market reform rules, specifically [the] guaranteed availability [provisions]” for high-risk enrollees. Id. at 15,467.

To accomplish these goals, the ACA requires each state, or the Department of Health and Human Services (“HHS”) on the state’s behalf, to establish a reinsurance program under which:

(A) health insurance issuers, and third party administrators on behalf of group health plans, are required to make payments to an applicable reinsurance entity for any plan year beginning in the 3-year period beginning January 1, 2014 ...; and

(B) the applicable reinsurance entity collects payments under subparagraph (A) and uses amounts so collected to make reinsurance payments to health insurance issuers described in subparagraph (A) that cover high risk individuals in .the individual market (excluding grandfathered health plans) for any plan year beginning in such 3-year period.

42 U.S.C. § 18061(b)(1); see- also id. § 18041(a)(1)(c), (c)(1) (establishing HHS’s authority- to create reinsurance programs for states that decline to do so). In Ohio, as in most other states, the federal government operates the reinsurance program on the state’s behalf.

The ACA provides that the total contribution amounts should yield an estimated $25 billion over the three-year life of the program, and those revenues are earmarked for two purposes: (1) $20 billion in “aggregate contribution amounts” that directly fund the reinsurance program; and (2) an additional $5 billion which “shall be deposited into the general fund of the Treasury of the United States and may not be used for the [reinsurance] program See id. § 18061(b)(3)(B)(iii), (b)(3)(B)(iv), and (b)(4). The ACA also permits the collection of ah additional, unspecified amount to-fund the administrative expenses of operating the program. Id. § 18061(b)(3)(B)(ii).

The ACA requires payments from two different Contributing entities — “health insurance issuers” and “group health plans.” M§ 18061(b)(1)(A). The term “health insurance issuer” covers insurance companies, insurance services, and insurance organizations (including HMOs) licensed by state regulators, but it “does not include a group1 health plan.” Id. §. 300gg-91(b)(2). The term “group health plan,” in turn, means “an employee welfare benefit plan (as defined in section 3(1) of the Employee Retirement Income Security Act of 1974 [29 U.S.C.A. § 1002(1)]) to the extent that the plan provides medical care .,. to employees or their dependents ... directly or through insurance, reimbursement, or otherwise.” Id. § 300gg-91(a)(l).

The contribution that health. insurance issuers and group health plans owe is based on their enrollment count multiplied by a predetermined contribution rate for the applicable benefit year. 45 C.F.R. § 153.405(a). Contributing entities maintain responsibility for self-reporting their enrollment counts. Id. § 153.405(b). For the 2014 benefit year, the required contribution rate was $63.00 per enrollee. See Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2016 (Final Rule), 80 Fed. Reg. 10,750, 10,773 (Feb. 27, 2015). That figure dropped to $44.00 per enrollee in benefit year 2015, and will drop further to $27.00 per enrollee in benefit year 2016. Id. Contributing entities may make their payments in one lump-sum on the Fifteenth of January following each benefit year (i.e., January 15, 2015; January 15, 2016; and January 15, 2017), or they may defer one-sixth of their payment until November Fifteenth of each payment year. Id.

The State of Ohio and several of its instrumentalities and political subdivisions have paid their contributions to the Transitional Reinsurance Program for benefit year 2014 under protest; - (See Pis.’ Am. Compl., ECF # 13, ¶¶ 53-69). For example, on January 15, 2015, the State transferred roughly $5.4 million to the federal government for its self-reported count of 85,540 enrollees covered by the Ohio self-insured plan. (Id. at- ¶¶ 58-59). Likewise,1 the four state universities who joined this suit (The University of Akron, Shawnee State University, Bowling Green State University, and Youngstown State University) have transferred nearly $765,000 (combined) for benefit year 2014. (Id. at ¶¶ 61-64). The Ohio Turnpike and Infrastructure Commission ($92,043.00) and Warren County ($94,710.00) also have contributed sums for benefit year 2014 under protest. (Id. at ¶¶ 65, 67-68). And although no other state agencies or local governments joined this suit, “Plaintiffs are informed and believe that Defendants have proceeded to collect other transitional reinsurance tax ’contributions’ from other entities of the government of the State of Ohio” as well. (See id. at ¶ 60).

The State of Ohio and the other six plaintiffs now seek to recoup these monies as an allegedly unlawful applicátion of the Transitional Reinsurance Program to state governments and their instrumental-ities. (Id. at ¶ 100). The State filed suit on January 26, 2015, and amended its complaint on February 23, 2015, to add the Ohio Turnpike and Infrastructure Commission as a plaintiff. (Id. at ¶21). The State asks that this Court: (1) enter judgment in its favor; (2) require the federal government to refund each plaintiff the full amount collected under the Transitional Reinsurance Program; (3) require the federal government to set aside any regulations, directives, or instructions purporting to apply .the program against state or local governments; and (4) enjoin the federal government from collecting any such funds from state or local governments in the future. (Id. at ¶ 100).

Under the parties’ joint proposed scheduling order, which the Court adopted to govern the case (see ECF # 16), this matter comes before the Court oh the federal government’s Motion to Dismiss (ECF # 17) and the State’s Motion for Summary Judgment (ECF #18). Both sides agree that the case presents purely legal issues and therefore have agreed to forego discovery. (See Joint Proposed Scheduling Order, ECF # 15, PagelD 82).

II. STANDARD OF REVIEW

' The federal government moved' to dismiss under Federal Rules of Civil Procedure 12(b)(1) and 12(b)(6). Under these rules, plaintiffs bear the burden of establishing that the Court “has jurisdiction over [their] claim[s]” and that the complaint “contains sufficient factual matter to state a.claim for relief that is plausible on its face.” See Kiser v. Reitz, 765 F.3d 601, 606 (6th Cir.2014) (citations omitted). A claim bears facial plausibility “when the plaintiff pleads factual content that allows the court to draw the reasonable inference that the defendant is liable for the misconduct alleged.” Ashcroft v. Iqbal, 556 U.S. 662, 678, 129 S.Ct. 1937, 173 L.Ed.2d 868 (2009). Where, as here, the defendant facially attacks the court’s subject-matter jurisdiction, “a trial court takes the allegations in the complaint as true,” just as the court would “under [a] 12(b)(6) motion[ ] to dismiss.” Ohio Nat’l Life Ins. Co. v. United States, 922 F.2d 320, 325 (6th Cir.1990).

The State moved for summary judgment under Federal Rule of Civil Procedure 56. Summary judgment is proper only when “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). The moving party bears the burden of proof on both points. Vaughn v. Lawrenceburg Power Sys., 269 F.3d 703, 710 (6th Cir.2001). In determining whether this standard is met, the Court must “view the evidence in the light most favorable to the non-moving party and draw all reasonable inferences in its favor.” Crouch v. Honeywell Int'l Inc., 720 F.3d 333, 338 (6th Cir.2013).

III. ANALYSIS

• The State of Ohio’s latest Affordable Care Act challenge hinges on the answers to three questions: (1) whether this Court may entertain the State’s claims; (2) if so, whether Congress intended the Transitional Reinsurance Program to apply to state and local governments that offer qualifying group health plans; and (3) provided Congress intended as much, whether application of the Transitional Reinsurance Program to state and local governments nevertheless violates the United States Constitution. As explained below, the answers to these questions are “yes,” “yes,” and “no,” respectively. Accordingly, the Court must GRANT the federal government’s Motion to Dismiss and DENY the State’s Motion for Summary Judgment.

A. The Court May Entertain the State’s Statutory Claims.

The federal government briefly challenges the Court’s power to entertain the State’s statutory claims, which are contained in Counts One and Two of the Amended Complaint. (See Defs.’ Mot. to Dismiss, ECF # 17, PagelD 98-99). As explained below, the federal government’s jurisdictional and other threshold chai-lenges lack merit., This Court may adjudicate the case in its entirety.

1. Binding Precedent Establishes. Jurisdiction Over the State’s Tax-Refund Claim.

In Count One, the State argues that the federal government must remit monies paid under the Transitional Reinsurance Program as an illegally or erroneously assessed or collected tax. (Pis.’ Am. Compl., ECF #13, ¶¶ 78-81). The State invokes this Court’s jurisdiction under 28 U.S.C. § 1346(a)(1), which provides original, concurrent jurisdiction in the district courts and the -United States-Court of Federal Claims for “[a]ny civil action against the United States for the recovery of any internal-revenue tax alleged to have been erroneously or illegally assessed or collected.” Essentially, the State seeks a tax refund.

The federal government argues that the contributions imposed under the Transitional Reinsurance Program do not constitute an “internal-revenue tax,” and- thus, do not fall under the jurisdictional grant from 28 U.S.C. § 1346(a)(1). The federal government cites a recent case from the Tenth Circuit, where that court held that a “coal reclamation fee” assessed by the Department of the Interior did not constitute an “internal-revenue tax” within the meaning of § 1346(a)(1); thus depriving the district court of subject-matter jurisdiction. Wyodak Res. Dev. Corp. v. United States, 637 F.3d 1127, 1129 (10th Cir.2011) (holding that plaintiffs claim properly belonged “only in the Court of Federal claims under 28 U.S.C. § 1491”).

The Sixth Circuit, however, takes a “broader view” of the term “internal-revenue tax,” at least as that term appears in 28 U.S.C. § 1346(a)(1). See Horizon Coal Corp. v. United States, 43 F.3d 234, 239 (6th Cir.1994) (per curiam). Under this Circuit’s binding precedent, that term “refer[s] not [just]-to [revenue raised under] the Internal Revenue Code, but [also] to [all] revenue generated within the boundaries of the United States, as opposed to ‘external’ 'revenue, which is derived from foreign sources’ through means such as import and custom duties.” Id. Thus, the very same coal reclamation fees that do not support jurisdiction in the district courts of the Tenth Circuit plainly do support jurisdiction in the district courts of this Circuit. Id.

To its credit, the federal government acknowledges Horizon Coal, and merely raises this jurisdictional issue -to preserve it on appeal.- (Defs.’ Mot. to Dismiss, ECF # 17, PagelD 98 (“Defendants acknowledge that the Sixth Circuit has construed the term ‘internal-revenue tax’ to encompass all ‘revenue generated within the boundaries of the United States,’ ... but respectfully preserve the argument that Horizon Coal was wrongly decided. See Wyodak, 637 F.3d at 1131 (criticizing Horizon Coal).”)). To the extent the federal government seeks to preserve this issue on appeal, it has done so.

Nevertheless, unless, and until the Sixth Circuit applies a different gloss to the term “internal-revenue tax” from 28 U.S.C. § 1346(a)(1), this Court remains bound by Horizon Coal, which provides jurisdiction to adjudicate Count One from the State’s Amended Complaint.

2, The Court May Hear the State’s . Administrative-Procedures-Act Claim.

In Count Two, the State argues that the federal government’s application of the Transitional Reinsurance Program to state and local governments constitutes an arbitrary and capricious agency action that must be set aside under the Administrative Procedures Act-(“APA”). (Pis.- Am. Compl., ECF #13, ¶¶ 82-90). The State invokes this' Court’s power under 5 U.S.C. § 704, which authorizes judicial review for “final agency action[s]' for which there is no other adequate remedy in a court.” See Bangura v. Hansen, 434 F.3d 487, 500 (6th Cir.2006) (“To state a claim for relief under the APA, a plaintiff must allege that his or her injury stems from-a final agency action for which there is no other adequate remedy in court.”).

The federal government argués, however, that the State lacks a cause' of .action under the APA because the State has not identified a specific “final agency action” that it challenges. See 5 U.S.C. § 704 (“Agency action made renewable by statute and final agency action for which there is no other adequate remedy in a court are subject to judicial review.”); see also Jama v. Dep’t of Homeland Sec., 760 F.3d 490, 494 n. 4 (6th Cir.2014) (“If there was no final agency action ... there is no doubt that appellant would lack a cause of action under the APA.” (quotation omitted)). To be clear, the final agency action requirement from 5 U.S.C. § 704 is not jurisdictional in the traditional sense.but, rather, goes to whether the State can make out a claim under the APA. Jama, 760 F.3d at 494 n. 4. Nevertheless, because both parties have briefed this point as a “threshold” issue, the Court addresses it at the outset of this Opinión before proceeding in earnest to the State’s statutory and constitutional arguments.

The federal government’s assertion' that HHS has not taken a “final agency action” seems too clever by half. In short, the federal government contends that any payments . the State made were “voluntary” and not as a result of a final agency action from which “rights or obligations have been determined, or from which legal consequences will flow.” (Defs.’ Mot. to Dismiss, ECF # 17, PageID 99 (quoting Bennett v. Spear, 520 U.S. 154, 177-78, 117 S.Ct. 1154, 137 L.Ed.2d 281 (1997)); see also Defs.’ Reply Br., ECF # 21, PageID 197-98 (“Plaintiffs ■... apparently consulted the statute, determined that they were required to make the transitional reinsurance contributions, and then complied without prompting.”)). But the federal government nowhere suggests that HHS is in the process of returning these “voluntar/’ contributions, despite a demand letter from the State of Ohio seeking such a return — not to mention this -lawsuit. (See Pis.’ Am. CompL, ECF #13, ¶¶ 53-56).

As a practical matter, the federal government cannot have it both ways. If the State’s payments were'“voluntary” but do not accord with HHS’s final position, thén HHS should remit the money. If, however, HHS intends to keep the money under its view .of the Transitional Reinsurance Program’s applicability, then such a decision would' be tantamount to the “consummation of the agency’s decision-making process .... by which rights-or obligations have been determined, or from which legal consequences will flow.” Bennett, 520 U.S. at 178, 117 S.Ct. 1154 (quotations omitted) (contrasting a “tentative recommendation” from “a final- and binding determination”); see also Air Brake Sys., Inc. v. Mineta, 357 F.3d 632, 638 (6th Cir.2004) (“The finality‘inquiry, we are told, is a ’flexible’ and ‘pragmatic’ one.” (quotation omitted)); cf. Appalachian Power Co. v. EPA, 208 F.3d 1015, 1022 (D.C.Cir.2000) (holding that agency’s settled position, upon which it will insist that state and local authorities comply with its understanding, is renewable under the APA).

The Court finds it telling that state and local government employers across the country believe they too must make contributions under the Transitional Reinsurance Program rather than await further guidance or agency action from HHS. See, e.g., Information Regarding the Affordable Care Act for Employers Participating in HealthChoice as of November 2014., Oklahoma’s Official Web Site (Nov. 18, 2014), https://www.ok.gov/sib/Coordinators/ Insurance_Coordinator/ACA_Info_for_ Employers.html (noting that Oklahoma’s group health plan for state employees “is responsible for reporting and paying the Transitional Reinsurance Fee for all persons covered by [the plan]”); Heather Ker-rigan, Public Employers Seek to Soften Impact of Obamacare Fees and Taxes, Governing Magazine (Sept. 11, 2013), http://www.goveming.com/ blogs/fed-watch/gov-obamacare-cadillac-tax-reinsurance-fee.html (explaining that the Affordable Care Act’s “transitional reinsurance fee will require state and local government employers to pay'$63 per covered individual each year” and noting the steps that McHenry County, Illinois, was taking to pay its $160,000 “transitional reinsurance fee”).

And, as a' legal matter, the Court finds that HHS has rendered a “final agency action” through its notice-and-comment rulemaking. See Appalachian Power, 208 F.3d at 1020-21 & n. 12 (noting that notice-and-comment rulemaking published in the Federal Register constitutes final agency action for APA review); Navistar Int’l Transp. Corp. v. EPA, 941 F.2d 1339, 1361 (6th Cir.1991) (holding that “the final, renewable agency action was taken” when appropriate administrator “signed- the final rulemaking document designated [in the Federal Register]’’).

In HHS’s (first) final rule governing the Transitional Reinsurance Program, the agency .established that “[a] contributing entity must .[generally] make reinsurance contributions on behalf of its group health plans and health insurance coverage.” See Patient Protection and Affordable Care Act; Standards Related to Reinsurance, Risk Corridors, and Risk Adjustment (Final Rule), 77 Fed. Reg. 17,220, 17,250 (Mar. 23, 2012) (to be codified at 45 C.F.R. § 153.400(a)(1)), In the preamble to. that rule, HHS explained that it was “adding paragraph (a)(1), which clarifies, that all contributing entities must make reinsurance contributions on behalf of all group health plans and health insurance coverage they represent .... For example, contributing entities are required to make reinsurance contributions on, behalf of ... State and local government employee plans....” Id. at 17,235 (emphasis added).

HHS revisited the matter on December 7, 2012. See Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2014 (Proposed Rule), 77 Fed. Reg. 73,118, 73,207 (Dec. 7, 2012) (to be" codified at 45 C.F.R. § 153.400(a)(1)). There, HHS proposed several exceptions to the contribution requirements described above, including an exception for “health insurance coverage ... not considered to be part Of an issuer’s commercial book of business.” Id. In the preamble to the.proposed rule, HHS, explained that, although “the Affordable Care Act refers to a ‘commercial book of business,”’ the agency was interpreting that phrase broadly, “to refer to [most] large and small employer group policies.” Id. at 73,153. HHS then noted, “while products offered by an issuer under Medicare Part C or D would be part of a ‘governmental’ book of business, not a commercial book of business,” plans or coverage “offered by ... a State government ... to employees (or retirees or dependents) because of a current or former employment relationship would be part of a commercial book of business,” and thus, subject to the reinsurance contribution. Id. (emphasis added).

When HHS finalized this proposed rule governing contributing entities and exclusions, the department confirmed that healthcare plans and coverage offered to state employees were subject to reinsurance contributions. See Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2014 (Final Rule), 78 Fed. Reg. 15,410, 15,528 through 15,529 (Mar. 11, 2013) (to be codified at 45 C.F.R. § 153.400(a)(l)-(2)) (providing thirteen exceptions to the reinsurance program contribution, but not mentioning plans, offered by state or local governments). In the preamble to that rule, HHS explained as follows:

Section 1341(b)(3)(B)(i) of the Affordable Care Act refers to a “commercial book of business,” which we proposed to interpret to refer to large and small group health insurance policies .... [A] plan or coverage offered by the Federal government, a State government, or a Tribe to employees .,. because of a current or former employment relationship would be part of a commercial book of business. We 'are finalizing the provisions as proposed.

Comment: One commenter agreed that coverage offered to Federal, State, or Tribal employees should be subject to reinsurance contributions, and that this coverage would be part of an issuer’s commercial book of business. Another commenter stated that since Federal and State employee plans make up a significant share of the market’s large group enrollment, these plans should be included ... for purposes of the reinsurance contribution.

Response: For reinsurance purposes, we agree that insured coverage offered to Federal,' State, ■ or Tribal employees is part of an issuer’s commercial book of business. As discussed in the preamble to the proposed rule, we interpret “commercial book of business” to refer to insured large and'small group policies and individual market policies.

Id., at 15,457; see also American Benefits Council, Summary: HHS Releases Neio Proposed Regulations Regarding Transitional Reinsurance Program, 6 (Dec. 12, 2012), http://www.americanbenefitscouncil. org/getpub.cfm?path=documents2012/hcr_ trp-regs_summary-cml21212.pdf (“Per the preamble to the Final Regulations, contributing entities must make reinsurance contributions on behalf of plans in the Federal Employees Health Benefits Program, state and local government employee plans, and grandfathered health plans.”).

This final rule, signed by HHS Secretary Kathleen Sebelius on February 17, 2013, and codified at 45 C.F.R. § 153.400(a)(l)-(2), constitutes a “final, reviewable agency action” under the APA. See. Navistar Int’l Transp., 941 F.2d at 1361.

In sum, this Court has jurisdiction to hear the State’s tax refund claim from Count One under 28 U.S.C. § 1346(a)(1), as interpreted by Horizon Coal. Moreover, the State has made out a cause of action for Count Two under the Administrative Procedures Act because HHS has taken a final agency action, thus permitting judicial review.

B. Congress Intended the Transitional Reinsurance Program ,to Apply to State and Local Goyernments that Offer Qualifying Group Health Plans.

Having the power to hear the State’s statutory claims does not mean that the Court agrees with them. Far from it. Instead, the Court finds that Congress intended the Transitional Reinsurance Program to apply to state and local government employers in the same manner that the program applies to private-sector employers. The text, structure, and purpose of the Affordable Care Act and related statutes compel this result.

The central question in this case is whether Congress intended for state and local government employers to make transitional reinsurance contributions under 42 U.S.C. § 18061. In answering that question, the Court looks first to the statutory language that Congress employed: “If the statutory language is plain, [the Court] must enforce it according to its terms.” King, 135 S.Ct. at 2489. Yet “oftentimes the ‘meaning — or ambiguity — of certain words or phrases may only become evident when placed' in context.’” Id. (quoting FDA v. Brown & Williamson Tobacco Corp., 529 U.S. 120, 132, 120 S.Ct. 1291, 146 L.Ed.2d 121 (2000)). As such, “when deciding whether the language is plain, [the Court] must read the words in their context and with a.view to their place in.the overall statutory scheme.” Id. (quotation omitted). The Courts duty, “after all, is to construe statutes, not isolated provisions.” Id. (quotation omitted).

1. “Non-Federal Governmental Plans” Offering Qualifying Medical Care Constitute a Subset of “Group Health Plans” Under the Public Health Service Act, Which Provides the Operative Definition for this Dispute.

As noted, the ACA requires reinsurance contributions from two different contributing entities — “health, insurance issuers” and “group health plans.” See 42 U.S.C. § 18061(b)(1)(A). Section 18061 does not define the terms “health insurance issuers” or “group health plans.” Nor, for that matter, does the ACA itself define those terms. Instead, the ACA provides that the definitions from the Public Health Service Act (“PHSA”), which the ACA substantially amended, apply to Title I of the ACA unless otherwise indicated. See 42 U.S.C.- § 18111 (“Unless specifically provided for otherwise, the definitions .contained in [Title 42] section 300gg-91 ... shall apply with respect to [Title I of the ACA].”).

The PHSA, in turn, defines “health insurance issuer” to mean “an insurance company, insurance service, or insurance organization ...' which is licensed to engage in the business of insurance in a State and which is subject to State law which regulates insurance.” 42 U.S.C. § 300gg-91 (b)(2). All parties to this suit agree that the State of Ohio and its political subdivisions do not qualify as contributing entities under the “health insurance issuer” prong.

• The PHSA elsewhere defines' “group health'plan” to mean “an employee welfare benefit plan (as defined in section 3(1) of the Employee Retirement Income Security Act of 1974 [29 U.S.C.A. § 1002(1)]) to the extent that the plan provides medical care ... to employees or their dependents ... directly or through insurance, reimbursement, or otherwise.” Id. § 300-gg-91(a)(l). The question, then, is whether the State’s employer-sponsored healthcare plans qualify as “group health plans” within the meaning of the PHSA.

The answer to that question is “yes,” and the reason is straightforward: “non-Federal governmental plans,” which the PHSA defines separately, constitute a subset of “group health plans,” thereby ensuring that the State’s healthcare plans qualify as “group health plans” • under the PHSA and, as a result, with respect to the Transitional Reinsurance Program as well.

Under 42 U.S.C. § 300gg-91(d)(8)(c), the term “non-Federal governmental plan” means “a governmental plan that is not a Federal governmental plan.” Accordingly, under the PHSA’s cross-referenced definition, “non-Federal Governmental plan” means “a plan established or maintained for its employees ..'. by the government' of any State or political subdivision thereof, or by any agency or instrumentality of any of the foregoing.” See id. § 300gg-91(d)(8)(a) (referring, in turn, to ,29 U.S.C. § 1002(32)). Congress plainly understands the term “group health plan” to encompass “non-Federal governmental plans” (including state and local governmental health plans) under the PHSA, and thus, the ACA. This understanding manifests itself in the text, structure, and purpose of the relevant statutes.

a. “Non-Federal Governmental Plans” Constitute a Subset of “Group Health Plans”'Because the PHSA Permits Non-Federal Governmental Plans to Exempt Themselves from Several Requirements that Otherwise Would Apply to the Broader Set .of Group Health Plans.

Congress first demonstrated its understanding that non-Federal governmental plans constitute a subset of group health plans whén it enabled some of these governmental health plans to opt out of several requirements that otherwise would apply to the broader , set • of group health plans. See 42 U.S.C, § 300gg-21(a)(2)(A). Section 300gg-21(a), aptly entitled “Limitation on- application of provisions relating to group health plans,” , permits self-insured non-Federal governmental plans to exempt; themselves from certain healthcare requirements when “the plan sponsor of a nonfederal governmental plan which is a group health plan to which the provisions of subpai-ts 1 and 2 otherwise apply makes an election.” Id. § 300gg-21(a)(2)(A).

This opt-out provision, which permits self-insured non-Federal governmental plans to exempt themselves from requirements that otherwise would apply to “group health plans” under the PHSA (namely, subparts 1 and 2 of 42 U.S.C. Chapter 6A, Subchapter XXV), would be entirely superfluous if state and local governmental health plans were not group health plans under the PHSA in the first instance. The Court is reluctant to, render this opt-out provision superfluous, and the State has not explained satisfactorily how its reading of the ACA and the PHSA would avoid such a result. See Ford Motor Co. v. United States, 768 F.3d 580, 587 (6th Cir.2014) (“We must -interpret statutes as a whole, giving effect to each word and making every effort not to interpret a provision -in a manner that renders other provisions of the same statute inconsistent, meaningless, or superfluous.” (quotation omitted)),

b. “Non-Federal Governmental Plans” Constitute a Subset of “Group Health Plans” Because Any Other Interpretation Would Render Many of the ACA’s Statutory Revisions Meaningless.

By enacting the ACA, Congress reinforced its understanding that non-Federal governmental plans (i e., state and local governmental health plans) constitute a subset of group health plans under both the PHSA and the ACA. Irtdeed, Congress took care when enacting the ACA to restructure the provisions described above by which self-insured non-Federal governmental plans may opt out from certain healthcare coverage requirements. These statutory revisions would be meaningless were the Court to interpret the statutes as the State desires — to exclude non-Federal governmental, plans from the broader category of “group health plans.”

Prior to enactment of the ACA, self-insured non-Federal governmental plans could opt out of all five statutory sections contained in Title 42, Chapter 6A, Sub-chapter XXV, Part A, subparts 1 and 2 of the United States Code. The relevant sub-parts formerly appeared in the United States Code as follows:

SUBCHAPTER XXV — REQUIREMENTS RELATING TO HEALTH INSURANCE COVERAGE

PART A — GROUP MARKET REFORMS

SUBPART 1 — PORTABILITY, ACCESS, AND RENE1VABILITY REQUIREMENTS

300gg. Increased portability through limitation on preexisting condi- < tion exclusions.

300gg-l. Prohibiting discrimination against individual participants and beneficiaries based on health status.

SUBPART 2 — OTHER REQUIREMENTS

300gg-4. Standards relating to benefits for mothers and newborns.

300gg-5. Parity in mental health and substance use disorder benefits.

300gg-6. Required coverage for reconstructive surgery following .mastectomies.

See 42 U.S.C., Chapter 6A Subchapter XXV (2006 edition).

Because 42 U.S.C. § 300gg-21(a)(2)(A) permits self-insured non-Federal governmental plans to exempt themselves from “the provisions of subparts 1 and 2,” the consequence was that, prior to the ÁCA, such plans could exempt themselves from all of the requirements listed above. In other words, self-funded state and local governmental health plans could opt out of limitations on preexisting condition exclusion periods, requirements for special enrollment periods, and prohibitions against discriminating based on a participant’s health status, among other requirements. See Steve Larsen, Amendments to the HI-PAA Opt-Out Provision Made by the Affordable Care Act, Dep’t of Health & Human Servs., Office of Consumer Info. & Ins. Oversight, 1 (Sept. 21, 2010), https:// www,ems.gov/CCIIO/Resourees/Files/ Downloads/ópt-out-memo.pdf [hereinafter “ACA Opt-Out Memo”].

Congress changed all-that by enacting the ACA. Athough the ACA left subpart 2 in place, it removed subpart 1 and created two new subparts — subparts I and II. See Patient Protection and Affordable Care Act, Pub. L. No. 111-148, § 1001, 124 Stat. 119,130-31 (2010) (creating subpart II); id. § 1201,124 Stat. at 154 (striking subpart 1 and creating subpart I). In so doing, Congress moved some of the provisions that had been in subpart 1 into the new subpart I, including the prohibition on discrimination in coverage and pricing based on an individual’s' health status. See 42 U.S.C. § 300gg-4. Congress also placed many of the ACA’s signature reforms in the newly created subpart II, including: (1) the prohibition on lifetime or annual coverage limits; (2) required coverage of preventive health services; and (3) the extension of dependent coverage until age twenty-six. See id. §§ 300gg-ll, 300gg-13, and 300gg-14; see also ACA Opt-Out Memo at 1 (“The Affordable Care Act made a number of changes, with the result that sponsors of self-funded, nonfederal governmental plans can no longer opt out of as many requirements .... ”). The ACA also amended the scope of the opt-out provision by categorically barring the ability to opt out of sub-parts I and II. 42 U.S.C. § 300gg-21(a)(2)(E).

If Congress believed (as the State argues) that non-Federal governmental plans are not “group health plans” under the PHSA, then the careful statutory revisions just described (including the decision to create two new subparts, move provisions from old subparts to new ones, and amend the scope of the opt-out provision) would be meaningless. The only explanation for Congress’s actions is that it intended to limit the provisions from which non-Federal governmental plans could opt-out — a task that would be pointless if such plans were never “group health plans” subject to the PHSA in the first instance. Here again, the Court must construe non-Federal governmental plans as a subset of group health plans to avoid rendering Congress’s actions meaningless. See United States v. Deen, 706 F.3d 760, 755 (6th Cir.2013).

c. “Non-Federal Governmental Plans" Constitute a Subset of “Group Health Plans” Because Any Other Interpretation Yields a Null Set mth Respect to the PHSA’s Enforcement Provisions.

In addition to rendering the opt-out provision from 42 U.S.C. § 300gg-21(a)(2)(A) superfluous, and Congress’s efforts to narrowly tailor that provision meaningless, the State’s statutory argument ignores another indication that non-Federal governmental plans constitute a subset of group health plans. As the federal government correctly notes, the PHSA enforcement section, which includes the ability to levy fines for ACA violations, generally vests primary enforcement authority in the states. See 42 U.S.C. § 300gg-22(a)(l). But this enforcement provision grants the federal government primary enforcement authority with respect to “group health plans that are non-Federal governmental plans.” Id. § 300gg — 22(b)(1)(B); see also id. § 300gg-22(b)(2)(B)(ii) (referring to liability for “a group health plan that is a non-Federal governmental plan”). If the State’s interpretation were correct, in that a plan offered by a state or local governmental employer is never a “group health plan,” then the statute’s reference to “group health plans that are non-Federal governmental plans” yields a null set. Put differently, the State’s preferred statutory interpretation leads to unintelligible and meaningless results with respect to one of the ACA’s primary enforcement mechanisms. That cannot be right. See Fed. Express Corp. v. U.S. Postal Serv., 151 F.3d 536, 542 (6th Cir.1998) (“A statute should be construed to accord meaning and effect to each of its provisions.”).

d. “Non-Federal Governmental Plans” Constitute a Subset of “Group Health Plans” Because Any Other Interpretation Would Exempt State and Local Governmental Plans From the Most Significant Reforms Contained in the ACA.

Finally, a fair reading of the PHSA, as amended by, the ACA, confirms that non-Federal Governmental Plans constitute a subset of group health plans because any other interpretation would exempt state and local governmental health plans from the most significant reforms enacted in the ACA.

For example, if the State were correct in its view that such plans do not qualify as “group health plans” for purposes of the Transitional Reinsurance Program then, by implication, state and local governmental health plans would be exempt from— among others — the following key provisions of the PHSA, as amended by the ACA:

• 42 U.S.C. § 300gg-3, which bars a “group health plan” from, imposing preesixting condition exclusions;

• 42 U.S.C. § 300gg-4, which bars a “group health plan” from limiting eligibility on the basis of health status related factors;

• 42 U.S.C. § 300gg-6(b),. which requires a “group health plan” to ensure that annual cost-sharing remains limited;

• 42 U.S.C. § 300gg-7; which prohibits a “group health plan” from imposmg any defined waiting periods in excess of 90 days;

• 42 U.S.C. § 300gg-ll, which bars a “group health plan” from establish- . ing lifetime or annual dollar limits on healthcare benefits;

• • 42 U.S.C. § 300gg-12, which generally bars a “group'health plan” from rescinding coverage once issued;

• 42 U.S.C. § 300gg-13, which requires a “group health plan” to cover or provide various preventive health services with no cost-sharing; and

• 42 U.S.C. § 300gg-14, which requires a “group health plan” that offers dependent coverage to make ■ such coverage available until dependents reach-¡the age of twenty-six;

Put differently, if the State’s health plans do not qualify ■ as “group health plans,” then- they would be free from the overall regulatory ¡structure imposed by the PHSA as amended by the ACA. Under this interpretation, those plans could deny employees coverage based on preexisting conditions; cap benefits on an annual or lifetime basis; terminate a participant’s coverage, at-will if he or she became too expensive; avoid paying for preventive care; and deny dependent coverage to participants’ children .before they reached age twenty-six (among other actions listed above and contained -elsewhere in subparts I and II).

Surely Congress did not intend such a dramatic departure from the overall aim of the Affordable Care Act when it employed the same term — “group health plans” — in the Transitional Reinsurance Program. See Brown & Williamson Tobacco Corp., 529 U.S. at 133, 120 S.Ct. 1291 (“It is a fundamental canon of statutory construction that the words of a statute must be read in - their context and with a view to their place in the-overall statutory scheme.” (quotation omitted)); see also King, 135 S.Ct. at 2492 (noting approvingly that courts “cannot interpret federal statutes to negate their own stated purposes” (quotation omitted)). After all, “[o]ne ordinarily assumes that identical words used in different parts of the same act are intended to have* the same meaning.” Util. Air Regulatory Grp. v. EPA, — U.S. -, 134 S.Ct. 2427, 2441, 189 L.Ed.2d 372 (2014).

To be sure, the presumption that the same term means the same thing throughout the same act does not always apply. See id. In fact, the Supreme Court recently hinted that the presumption of consistent usage may not apply with respect to a different phrase from the ACA — “established by the State” — because rigid adherence to the presumption may have cut against Congressional intent to provide tax credits to low-and moderate-income Americans. See King, 135 S.Ct. at 2493 & n. 3 (noting that “the presumption of consistent usage readily yields to context,” but avoiding the issue “[bjecause the other provisions cited.by the dissent are not at issue here”). But in this case, the State offers no explanation (beyond a desire not to pay) for why Congress meant one thing with respect to “group health plans” when enacting the landmark healthcare reforms contained in 42 U.S.C. Chapter 6A, Sub-chapter XXV, Part A, Subparts I and II, or one of the ACA’s primary enforcement mechanisms, 42 U.S.C. § 300gg-22, yet meant another thing with respect to funding the Transitional Reinsurance Program. Accordingly, the Court will follow the presumption of consistent usage especially where, as here, Congress repeatedly demonstrated its understanding that non-Federal governmental health plans constitute a subset of “group health plans” under the PHSA and the ACA.

e. The State’s Arguments to the Contrary Lack Merit. .

Against this straightforward reading of the Affordable Care Act, the State points to several statutory phrases that it believes show that non-Federal governmental plans are not group health plans. As explained below, the State’s arguments lack merit.

First, the State points to ' I.R.C. § 4377(b)(1)(B), a provision of the Internal Revenue Code that states “governmental entities shall not be exempt from the fees” relating to the Patient Centered Outcomes Research Institute (“PCORI”), except as then provided. See I.R.C. § 9511(e) (providing that funding for PCORI shall come from fees imposed under I.R.C. §§ 4375-4377); id. § 4375 (establishing PCORI fees for certain “health insurance policies]”); id. § 437& (establishing PCORI fees for certain “self-insured health plan[s]”); id. § 4377 (providing special rules for PCORI fees). The State contends that the language from § 4377(b)(1)(B) shows that Congress knew how to impose fees on state and local governments when that was its intent.

But the fees the State points to are imposed under the Internal Revenue Code, not the PHSA, and are imposed on “health insurance policies],” see I.R.C. § 5375(a), and “health plan[s],” id. § 5376(a), not “group health plans.” As such, this provision sheds little light on the meaning of “group health plans” as that term appears in the PHSA. If anything, resorting to the Internal Revenue Code favors the federal government’s position. Elsewhere, the Internal Revenue Code provides several definitions of “minimal essential [healthcare] coverage,” which most individuals must obtain to avoid a tax penalty under the ACA. See I.R.C. § 5000A(a), (f); see also NFIB, 132 S.Ct. at 2580, (describing the ACA’s “individual mandate”). There, Congress provided that “minimal essential coverage” includes “[coverage under an eligible employer-sponsored plan,”- which, in turn, means, “with respect to any employee, a group health plan ... offered by.an employer to the employee which is ... a governmental plan (within the meaning of section 2791(d)(8) of the Public Health Service Act) [42 U.S.C. § 300gg-l(d)(8)].” I.R.C. § 5000A(f)(l)(B), (f)(2)(A) (emphasis added). These provisions reinforce the notion that Congress understood governmental plans (including non-Federal governmental plans) to constitute a type of “group health plan” under the PHSA and the ACA. After all, I.R.C. § 5000A(f)(2)(A) explicitly lists “a governmental plan” as a type of “group health plan.” And it makes no sense to interpret the ACA in a manner that simultaneously excludes non-Federal governmental plans from most of the ACA’s landmark coverage reforms, but then endorses those plans as “minimal essential coverage” for purposes of satisfying the individual mandate.

Second, the State points to 42 U.S.C. § 300bb-l, a provision from the Consolidated Omnibus Budget Reconciliation Act of 1985 (“COBRA”), which amended the PHSA by requiring “each group health plan that is maintained by any State” to offer a temporary extension of healthcare coverage that otherwise might be terminated upon certain qualifying events. See 42 U.S.C. § 300bb-l(a) (describing the requirements for COBRA “continuation coverage”). The State suggests that this provision, which- includes the modifier “maintained by any State,” shows that “Congress when it wanted to include governmental entities simply added explicit language doing'just that.” (Pis.’ Mot. for Suram. J., EOF # 18, PagelD 145 (emphasis omitted)).

In truth, this provision speaks specifically to governmental plans because Congress placed COBRA’s primary continuation coverage requirements for group health plans in the Employee Retirement Income Security Act of 1974 (“ERISA”). See 29 U.S.C. §§ 1161-1169 (listing COBRA continuation-coverage amendments). And, as explained in some detail, infra, Section III.B.2,, Congress excluded governmental plans from ERISA’s substantive requirements, including the continuation-coverage requirements from §§ 1161-1169. See 'id. § 1003(b)(1). For that reason, it became necessary to include government-only language someplace else, thus explaining the “virtual mirror image” continuation-coverage requirements in both Title 29, Chapter 18 (ERISA) and Title 42, Chapter 6A (the PHSA). See Williams v. New Castle Cnty., 970 F.2d 1260, 1264 (3d Cir.1992) (explaining that COBRA amendments to the PHSA “fill this gap [from ERISA] by providing similar protection to beneficiaries losing coverage” under governmental plans). Thus, the modifying language from 42 U.S.C. § 300bb-l(a) shows only that ERISA excludes governmental plans from its substantive requirements, a point about which there is no disagreement; this language says nothing about whether non-Federal governmental plans constitute “group health plans” for purposes of the Transitional Reinsurance Program.

The State’s reliance on the definitions section of the COBRA amendments fares no better. See 42 U.S.C. § 300bb-8(l). There, Congress defined the term “group health plan” (for purposes of the COBRA continuation-coverage amendments to the PHSA)- to mean “a plan (including a self-insured plan) of, or contributed to by, an employer ... or employee organization to provide health care” to current or past employees and their families. See id. (cross-referencing the definition from I.R.C. § 5000(b)). In the cross-referenced definition for “group health plan” from the Internal Revenue Code, Congress specified that “[f]or purposes of this section, the term ‘employer’ does not include a Federal or other governmental entity.” I.R.C. § 5000(d). The State latches onto this definition and says “Aha!”: The modifying language “maintained by any State” from 42 U.S.C. § 300bb-l(a) shows that the term “group health plan,” as used elsewhere throughout the PHSA, must exclude governmental plans.

Not so. Whatever else this cross-referenced definition means for the excise tax imposed by I.R.C, § 5000, it remains apparent that. the separate definition of “group health plan” found in the COBRA amendments must include governmental entities. Otherwise, there could never, be a “group health plan that is maintained by [a] State,” as contemplated in 42 U.S.C. § 300bb-l(a). Under the State’s interpretation, that phrase would become gibberish, sounding something like this: “each plan (including a self-insured plan) of, or contributed to by, an employer — not including a Federal or other governmental entity — ... that is maintained by [a] State ... by any political subdivision of such a State, or by any agency or instrumentality of. such a State or political subdivision ....” See id.; id. § 300bb-8(l); I.R.C. § 5000(b), (d). The Court is unwilling to interpret these statutes that way. Instead, the Court views Congress’s treatment.of “group health plans” in the definitions section of the COBRA amendments as consistent with its treatment of such plans elsewhere -in the PHSA — i.e., it too includes governmental entities.

Third, the State points to 42 U.S.C. § 1395w-132(c)(3), which defines the term “group health plan” for purposes of one section of the Medicare Modernization Act of 2003 (“MMA”). See id., § 1395w-132(c) (providing definitions “[f]or purposes of this section”). The State argues that because this definition includes both the definition of “group health plan” from 29 U.S.C. § 1167(1) and “Federal and State Governmental plans,” Congress must have understood the term “group health plan” ordinarily to -exclude such governmental plans in the PHSA. See 42 U.S.C. § 1395w-132(c)(3).

This argument lacks merit for two reasons. For starters, the statute that the State relies on does not fall under the PHSA. Instead, that statute falls under the Social Security Act, codified in Title 42, Chapter 7, and it limits its definitions to a single section therein. Id. Thus, whatever § 1395w-132(e)(3) might say about the MMA’s definition of group health plan, it says very little about the PHSA’s definition, contained separately at 42 U.S.C. § 300gg-91(a)(l). Moreover, the State again overlooks the interplay between the COBRA amendments to ERISA and ERISA’s governmental plan exclusion. The MMA defines “group health plan” by cross-referencing the definition from the COBRA amendments to ERISA. Id. § 1395w-132(c)(3) (cross-referencing 29 U.S.C. § 1167(1)). As explained, ERISA excludes governmental plans from its substantive requirements. See 29 U.S.C. § 1003(b)(1). Thus, by pointing to ERISA’s continuing-coverage definition of “group health plan” but then supplementing that definition to include governmental plans, the MMA simply suggests that Congress wanted to ensure that those plans did not fall through the cracks in other statutes (like the MMA) that derive their meaning from ERISA’s substantive requirements: Cf. Williams, 970 F.2d at 1264. There is no such worry with respect to the Transitional Reinsurance Program, because that statute does not define “group health plan” in relation to any of ERISA’s substantive requirements, such as the COBRA amendments.

Fourth, the State points to 42 U.S.C. § 300gg-41(b)(l), which describes a person “whose most recent creditable coverage wás under a group health plan, governmental plan, or church plan” when discussing who qualifies as an “eligible individual” for one of the PHSA’s guaranteed availability provisions. See 42 U.S.C. § 300gg-41(a)(1), (b)(1) (“In this part, the term ‘eligible individual’ means an individual — ■ ... for whom ... the aggregate of the periods of creditable coverage (as defined in [42 U.S.C. § 300gg-3(c)]) is 18 or more months and ... whose most recent prior creditable coverage was under a group health plan, governmental plan, or church plan (or health insurance coverage offered in connection with any such plan) .... ”); see also id. § 300gg-3(c)(l)(A), (I) (defining “creditable coverage” and listing “[a] group health plan” and “[a] public health plan (as defined in regulations)” separately). The State argues that if the phrase “group health plan” necessarily subsumes governmental plans, then the definitions from §§ 300gg-41(b)(l) and 300gg-3(c)(l) would be redundant.

On its face, this appears to be the State’s strongest argument. On closer inspection, however, this' language at best shows that in one provision of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), which amended the PHSA, the drafters were overly cautious. See HIPAA, Pub. L. No. 104-191, § 111(a), 110 Stat. 1936, 1978-1979 (1996) (codified at 42 U.S.C. § 300gg-41-(b)(l)) (adding definition of “eligible individual” with reference to recent prior “creditable coverage” (as defined in [42 U.S.C. § 300gg-3(c)(l)])