 United States Court of Appeals
         FOR THE DISTRICT OF COLUMBIA CIRCUIT



Argued March 23, 2015                 Decided April 10, 2015

                        No. 14-5122

          ADIRONDACK MEDICAL CENTER, ET AL.,
                    APPELLANTS

                             v.

 SYLVIA MATHEWS BURWELL, IN HER OFFICIAL CAPACITY AS
SECRETARY OF THE UNITED STATES DEPARTMENT OF HEALTH
                AND HUMAN SERVICES,
                      APPELLEE


        Appeal from the United States District Court
                for the District of Columbia
                    (No. 1:11-cv-00313)


     Ankur J. Goel argued the cause for appellants. With him
on the briefs was Johnny H. Walker.

   Daniel J. Hettich was on the brief for amici curiae Knox
Community Hospital, et al., in support of appellants.

      Abby C. Wright, Attorney, U.S. Department of Justice,
argued the cause for appellee. With her on the brief were
Ronald C. Machen Jr., U.S. Attorney at the time the brief was
filed, and Michael S. Raab, Attorney.
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    Before: TATEL, Circuit Judge, PILLARD, Circuit Judge,
and EDWARDS, Senior Circuit Judge.

    Opinion for the court filed PER CURIAM.

     PER CURIAM: The Medicare program provides federally
funded healthcare to the elderly and the disabled. See Title
XVIII of the Social Security Act, Pub. L. No. 89-97, 79 Stat.
291 (1965), as amended, 42 U.S.C. § 1395 et seq. Under a
“complex statutory and regulatory regime” called Medicare
Part A, the Government reimburses participating hospitals for
care that they provide to inpatient Medicare beneficiaries.
Good Samaritan Hosp. v. Shalala, 508 U.S. 402, 404 (1993).
“[T]he labyrinthine world of Medicare has two types of
hospitals that enjoy different reimbursement schemes.”
Adirondack Med. Ctr. v. Sebelius, 740 F.3d 692, 694 (D.C.
Cir. 2014). Most hospitals are reimbursed for inpatient
hospital services pursuant to a standardized rate under 42
U.S.C. § 1395ww(d). However, the Social Security Act also
provides a method for calculating reimbursement rates for
certain rural hospitals: those that qualify as “sole community
hospital[s]” (“SCHs”), see id. § 1395ww(d)(5)(D), and those
that qualify as “medicare-dependent small rural hospital[s]”
(“MDHs”), see id. § 1395ww(d)(5)(G).

     Appellants in this case are MDHs and SCHs. They
challenge revisions made by the Secretary of the Department
of Health and Human Services (“Secretary”) to the rules
covering their Medicare reimbursements for inpatient hospital
services. The District Court rejected Appellants’ claims,
Adirondack Med. Ctr. v. Sebelius, 29 F. Supp. 3d 25 (D.D.C.
2014); Adirondack Med. Ctr. v. Sebelius, 935 F. Supp. 2d 121
(D.D.C. 2013), holding, inter alia, that the Secretary acted
within her authority and reasonably in adjusting the disputed
reimbursement requirements under the statute. Appellants
                               3
now urge this court to reverse the judgments of the District
Court in favor of the Secretary, grant their motions for
summary judgment, and remand the case with instructions to
the District Court to enter judgment in favor of Appellants.
After careful review of the record, we hold that the
Secretary’s actions were neither “arbitrary, capricious, [nor]
manifestly contrary to the statute.” Chevron U.S.A., Inc. v.
Natural Res. Def. Council, Inc., 467 U.S. 837, 844 (1984).
We therefore affirm the judgment of the District Court.

                            ****

     When an SCH or MDH discharges a patient insured by
Medicare, it receives reimbursement based on either the
standard federal rate or a hospital-specific rate derived from
its actual costs of treatment in one of the base years specified
in the statute, whichever is higher. 42 U.S.C.
§ 1395ww(d)(5)(D), (G); 42 C.F.R. §§ 412.92, 412.108. The
Secretary determines an MDH or SCH’s hospital-specific
reimbursement rate using the most favorable base year
available.

     To calculate reimbursement for a particular patient, the
Secretary multiplies the hospital’s base rate by the appropriate
group weight – a number representing how resource-intensive
the patient’s condition was to treat. See 42 C.F.R.
§§ 412.78(f), 412.79(e). Each year, the Secretary is required
to revise group weights based on changes in technology and
medical best practices. 42 U.S.C. § 1395ww(d)(4)(C)(i). The
statute also requires that these revisions have no effect on
aggregate Medicare payments – in other words, that they be
budget neutral. Id. § 1395ww(d)(4)(C)(iii). The Secretary
eliminates any variation in aggregate payments by applying a
uniform “budget neutrality adjustment” to all reimbursement
rates throughout the Medicare system. See, e.g., Medicare
                             4
Program; Changes to the Hospital Inpatient Prospective
Payment Systems and Fiscal Year 1994 Rates, 58 Fed. Reg.
30,222, 30,269 (May 26, 1993). The budget adjustments are
cumulative, meaning that the Secretary does not remove the
previous year’s adjustment from the database before
calculating the next year’s adjustment. Id.

     Prior to 2006, the budget neutrality adjustments applied
to the hospital-specific MDH and SCH rates in a
straightforward way: once a base year was chosen and the rate
was calculated, the Secretary applied every budget neutrality
adjustment from 1993 (when Congress began requiring
adjustments) to the present. In 2006, Congress added 2002 as
a new base year for MDHs. The Secretary issued instructions
to fiscal intermediaries (contractors who process and make
claims for Medicare payments) stating that when 2002 was
used as the base year, only adjustments from 2003 forward
would apply. The Secretary inadvertently failed to instruct
that adjustments before 2003 should also be included in the
calculation, as they had been before Congress added the new
base year. In 2008, Congress added 2006 as a new base year
for SCHs, and the Secretary issued similar guidance to fiscal
intermediaries, instructing them to apply only adjustments
from 2007 forward to that base year.

     Six weeks after issuing the 2008 instructions for SCHs,
the Secretary determined that they were erroneous and
rescinded them. In 2009, she changed the 2006 instructions
for MDHs through notice and comment rulemaking.
Medicare Program; Changes to the Hospital Inpatient
Prospective Payment Systems for Acute Care Hospitals and
Fiscal Year 2010 Rates; and Changes to the Long-Term Care
Hospital Prospective Payment System and Rate Years 2010
and 2009 Rates, 74 Fed. Reg. 43,754, 43,896 (Aug. 27, 2009).
Reimbursements to both types of hospitals now incorporate
                              5
all adjustments from 1993 forward, as they did under the pre-
2006 status quo. The principal thrust of Appellants’ challenge
is that the Medicare statute forbids the Secretary from
modifying the hospitals’ reimbursements with budget
neutrality adjustments from years prior to the base year. We
disagree.

                           ****

     In support of their position, Appellants make four
arguments, all of which lack merit. First, Appellants claim
that 42 U.S.C. § 1395ww(b)(3)(C) and (D) bar the Secretary
from applying budget neutrality adjustments from years
preceding the base year. Second, Appellants argue that
Section 1395ww(d)(4)(C)(iii) requires the Secretary to apply
the entire budget neutrality adjustment directly to the group
weights rather than, as the Secretary currently does, to the
overall reimbursement rate. Third, Appellants argue that the
Secretary’s failure to apply the budget neutrality adjustment
directly to the group weight arbitrarily reduces their
reimbursement. Fourth, Appellants argue that the Secretary
was barred from revoking her 2008 instructions without first
pursuing notice and comment rulemaking.

    Appellants’ first argument fails because 42 U.S.C.
§ 1395ww(b)(3)(C) and (D) are irrelevant with respect to the
application of budget neutrality adjustments. The reference to
“applicable percentage increases” in those sections refers
specifically to an inflation adjustment defined at 42 U.S.C.
§ 1395ww(b)(3)(B)(iv). It has no bearing on other aspects of
the reimbursement formula, such as the budget neutrality
adjustment.

   Appellants’ second argument also lacks merit. The clear
command of 42 U.S.C. § 1395ww(d)(4)(C)(iii) requires the
                               6
Secretary to “assure[] that the aggregate payments . . . are not
greater or less than those that would have been made for
discharges in the year without” the annual group weight
adjustments. Id. In other words, the Secretary must maintain
budget neutrality when recalibrating reimbursements under
the statute. Appellants do not dispute that the Secretary’s
adjustments successfully achieve the goal of budget
neutrality. Appellants instead object to the precise
methodology used by the Secretary. Appellants’ arguments,
however, fail to take into account the wide discretion afforded
the Secretary to implement the Medicare reimbursement
formula, including determining how to meet Medicare’s
budget neutrality requirements. See id. (requiring the
Secretary to make adjustments “in a manner that assures”
budget neutrality); id. § 1395ww(d)(5)(I)(i) (authorizing the
Secretary to make “other exceptions and adjustments to such
payment amounts under this subsection as the Secretary
deems appropriate”); Adirondack, 740 F.3d at 694 (describing
the Secretary’s “broad-spectrum grant of authority”). There is
little doubt here that the Secretary’s chosen method of
achieving budget neutrality lies within her broad discretion.

     Appellants’ third argument fares no better. In adjusting
the hospital-specific rates as she did, the Secretary reasonably
chose to achieve budget neutrality pursuant to a method that
spreads the cost of budget neutrality fairly between MDHs,
SCHs, and other hospitals. Appellants have failed to show
that the Secretary’s method requires them to absorb a
disproportionate or unfair share of the budget neutrality
adjustment.

     Finally, Appellants’ last argument – that the Secretary
was required to use notice and comment rulemaking to
rescind the 2008 instructions – has no legal basis in the wake
of the Supreme Court’s decision in Perez v. Mortgage
                              7
Bankers Association, 135 S. Ct. 1199 (2015). The Court’s
decision in Perez issued after Appellants had submitted their
briefs to this court. In light of this intervening development,
Appellants’ counsel readily withdrew the last claim during
oral argument. The court appreciates Appellants’ forthright
treatment of this matter.

                            ****

    The Secretary acted pursuant to express delegations of
authority under the Medicare Act in adjusting the disputed
reimbursement requirements. The determinations made by the
Secretary are neither “arbitrary or capricious in substance,
[n]or manifestly contrary to the statute.” Mayo Found. for
Med. Educ. and Research v. United States, 562 U.S. 44, 53
(2011) (internal quotation marks omitted). They thus “warrant
the Court’s approbation.” Astrue v. Capato ex rel. BNC, 132
S. Ct. 2021, 2034 (2012).
