Mealey's Health Care / ACA

  • February 23, 2017

    Judge Remands Implied Insurance Contract Claims As Outside ERISA

    NEWARK, N.J. — A neurosurgical specialist’s claim seeking payment for out-of-network care is based on an implied contract providing a separate and independent basis for recovery and thus is not preempted by ERISA, a federal judge in New Jersey held Feb. 17 in remanding the case (North Jersey Brain & Spine Center v. Aetna Life Insurance Co., et al., No. 16-1544, D. N.J., 2017 U.S. Dist. LEXIS 22710).

  • February 23, 2017

    ACA Reinsurance Program Applies To State Employers, 6th Circuit Affirms

    CINCINNATI — The Patient Protection and Affordable Care Act (ACA)’s reinsurance program applies to state employers, the Sixth Circuit U.S. Court of Appeals affirmed Feb. 17 (The State of Ohio, et al. v. United States of America, et al., No. 16-3093, 6th Cir., 2017 U.S. App. LEXIS 2844).

  • February 22, 2017

    Judge Dismisses Action Involving Hawaii’s Doomed ACA Exchange

    HONOLULU — A contractor’s action against directors and officers arising from the collapsed Hawaii Patient Protection and Affordable Care Act (ACA) health exchange fails to incorporate the type of separate third-party duty sufficient for a negligence claim, a federal judge in Hawaii held Feb. 16 (Mansha Consulting LLC v. Cliff Alakai, et al., No. 16-582, D. Hawaii, 2017 U.S. Dist. LEXIS 22084).

  • February 22, 2017

    Parties In House’s Funding Spat Over ACA Ask Court To Extend Stay

    WASHINGTON, D.C. — The House of Representatives and the U.S. Department of Health and Human Services (HHS) have asked for a three-month stay of their appeal over funding of the Patient Protection and Affordable Care Act (ACA) so that they may continue to work out a potential resolution, according to a Feb. 21 District of Columbia Circuit U.S. Court of Appeals filing (United States House of Representatives v. Thomas E. Price, et al., No. 16-5202, D.C. Cir.).

  • February 17, 2017

    HHS Proposes Changes In Attempt To Stabilize ACA Marketplace Risk Pools

    WASHINGTON, D.C. — The U.S. Department of Health and Human Services (HHS) on Feb. 17 published a proposed rule designed to stabilize the Patient Protection and Affordable Care Act (ACA) marketplaces.

  • February 17, 2017

    Citing Sick ACA Exchanges, Humana Bows Out Of Market In 2018

    LOUISVILLE, Ky. — Insurer Humana Inc. will exit all Patient Protection and Affordable Care Act (ACA) exchanges in 2018, the company announced Feb. 14, saying it continues to see unbalanced risk pools in the marketplace and would focus on its Medicare Advantage business.

  • February 16, 2017

    Government Challenges Broadness Of ACA Pricing Data Injunction In Appeal

    WASHINGTON, D.C. — The Freedom of Information Act (FOIA) does not permit an injunction requiring ongoing release of Patient Protection and Affordable Care Act (ACA) insurance plan pricing data without regard for exemptions or future changes, the government told a federal appeals court on Feb. 13 (Center for the Study of Services d/b/a Consumers’ Checkbook v. United States Department of Health and Human Services, et al., No. 16-5296, D.C. Cir.).

  • February 16, 2017

    Liquidator Of Insolvent ACA Insurer Wants Claims Appeal Examiner Applications

    NEW YORK — The liquidator of an insolvent insurer operated as a co-op under the Patient Protection and Affordable Care Act recently invited candidates for appointment of referees and medical claims examiners to review liquidation estate claim appeals (In the Matter of the Liquidation of Health Republic Insurance of New York, Corp., No. 450500/2016, N.Y. Sup., New York Co.).

  • February 14, 2017

    Judge Dismisses Claims Against Insurance Plans In Same-Sex Couple’s Suit

    BROOKLYN, N.Y. — Health plans named in a same-sex couple’s lawsuit claiming discrimination arising from the denial of insurance coverage for in vitro procedures are not subject to suit, a federal judge in New York held Feb. 11 (Humphrey O. Uddoh and Plamen Koev v. United Healthcare, et al., No. 16-1002, E.D. N.Y., 2017 U.S. Dist. LEXIS 19415).

  • February 14, 2017

    Tax Court Finds Jurisdiction Over Ambiguous Notice In ACA Tax Rebate Case

    WASHINGTON, D.C. — Jurisdiction exists over a case involving the denial of a Patient Protection and Affordable Care Act (ACA) premium rebate, a federal tax court held Feb. 2 (Timothy M. Dees v. Commissioner of Internal Revenue, No. 29397-15, U.S. Tax, 2017 U.S. Tax Ct. LEXIS 20).

  • February 14, 2017

    Judge Dismisses Claims From Hepatitis C Coverage Action

    TRENTON, N.J. — A federal judge in New Jersey on Feb. 7 dismissed injunctive relief and punitive damages claims arising from an alleged scheme to limit insurance approvals of the hepatitis C drug Harvoni (Jackson T. Horowtiz v. United Health Group, et al., No. 16-2322, D. N.J.).

  • February 14, 2017

    Judge: ERISA Preempts Provider’s Contract Claim Against Insurer

    GREENSBORO, N.C. — A substance abuse provider’s claims that an insurer failed to pay for medically necessary treatments are preempted by ERISA or fail to state a claim, a federal judge in North Carolina held Feb. 9 (Bobby P. Kearney, M.D., PLLC, v. Blue Cross and Blue Shield of North Carolina, et al., No. 16-191, M.D. N.C., 2017 U.S. Dist. LEXIS 18428).

  • February 10, 2017

    Judge Grants Insurer Partial Judgment In $214M ACA Risk-Corridor Suit

    WASHINGTON, D.C. — An insurer is entitled to summary judgment on the liability of the United States under the Patient Protection and Affordable Care Act (ACA) risk-corridor program, a federal claims court judge held Feb. 9 while dismissing the government’s arguments related to jurisdiction (Moda Health Plan Inc. v. The United States of America, No. 16-649C, Fed. Clms.).

  • February 10, 2017

    Judge Keeps Alive Patient’s Suit Against Hospital Over Billing Practices

    BIRMINGHAM, Ala. — A for-profit hospital’s release of a lien and return of a settlement check does not quash the standing of a patient who claims that it has a practice of improperly billing health insurers, a federal judge in Alabama held Feb. 7 (Marilyn R. Scroggins, et al. v. LifePoint Health, et al., No. 16-338, M.D. Ala., 2017 U.S. Dist. LEXIS 16875).

  • February 8, 2017

    Final Approval Granted To United Healthcare’s Settlement Of Harvoni Drug Coverage

    MIAMI — A federal judge in Florida on Feb. 2 granted final approval to a class action settlement in which United Healthcare Inc. agreed to remove certain restrictions on coverage for treatment of hepatitis C with the prescription drug Harvoni (Ilissa M. Jones, et al. v. United Healthcare Services, Inc., et al., No. 15-cv-6114-RLR, S.D. Fla.).

  • February 8, 2017

    Judge Orders Liquidation Of ACA Health Care Provider

    TRENTON, N.J. — A New Jersey judge on Feb. 3 ordered a Patient Protection and Affordable Care Act (ACA) consumer-operated and oriented plan insurer’s liquidation and appointed the state’s insurance commissioner as liquidator (In the Matter of Freelancers Consumer Operated and Oriented Program of New Jersey d/b/a Health Republic Insurance of New Jersey, No. MCR-C-000063-16, N.J. Super., Mercer Co., Chanc. Div.).

  • February 7, 2017

    Judge Finds ERISA Exempts Self-Funded Plan From ACA Requirements

    MINNEAPOLIS — A self-funded Employee Retirement Income Security Act (ERISA) plan falls outside the Patient Protection and Affordable Care Act (ACA)’s essential health benefits requirement, a federal judge in Minnesota said Feb. 2 in adopting a report and recommendation partially rejecting insurance coverage claims arising from a fireworks accident (Jeffrey Jay Henrikson v. Choice Products USA LLC, et al., No. 16-1317, D. Minn.).

  • February 3, 2017

    Parties Dismiss Action Alleging Failure To Pay Under ACA Risk-Corridor

    BALTIMORE — A judge on Feb. 2 approved a stipulated dismissal in an action alleging the government failed to pay an insurer millions of dollars under the Patient Protection and Affordable Care Act (ACA) risk corridor program (Evergreen Health Cooperative Inc. v. United States Department of Health and Human Services, et al., No. 16-2039, D. Md.).

  • February 3, 2017

    In Opening Salvo, Insurer Argues ACA Mandates Yearly Risk-Corridor Payments

    WASHINGTON, D.C. — The government did not make an “informed, reasoned decision” in deciding to make the Patient Protection and Affordable Care Act (ACA) risk-corridor program budget-neutral, but instead simply reneged on its promises and ignored the statutory language mandating annual payments, an insurer told a federal appeals court Jan. 31 (Land of Lincoln Mutual Health Insurance Co. v. The United States of America, No. 17-1224, Fed. Cir.).

  • February 2, 2017

    Judge Stays Transgender Man’s Claim Alleging Discrimination Under ACA

    MINNEAPOLIS — Either a recent nationwide injunction against implementing a rule defining sex discrimination under the Patient Protection and Affordable Care Act (ACA) or the Supreme Court’s grant of a petition for review warrant staying related federal claims, a federal judge in Minnesota held Jan. 30 (Jakob Tiarnan Rumble v. Fairview Health Services, d/b/a Fairview Southdale Hospital and Emergency Physicians P.A., No. 14-2037, D. Minn., 2017 U.S. Dist. LEXIS 13316).