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Mealey's Health Care / ACA

  • August 17, 2017

    Judge: Denial Of In-Patient Mental Health Coverage Accords With Plan Benefits

    SALT LAKE CITY — A health insurer properly applied the terms of its plan in concluding that a long-suffering child’s mental health issues did not necessitate in-patient treatment, a federal judge in Utah held Aug. 10 (Tracy O., et al. v. Anthem Blue Cross Life and Health Insurance Co., et al., No. 16-422, D. Utah, 2017 U.S. Dist. LEXIS 127326).

  • August 17, 2017

    Pair Of Claims Survive Health Insurer’s Motion To Dismiss ERISA Case

    NEWARK, N.J. — A health insurer impermissibly raises evidence outside the pleadings in a motion to dismiss an assignee’s Employee Retirement Income Security Act claims and incorrectly portrays a claim for breach of fiduciary duty as simply seeking benefits for which the plan provides, a federal judge in New Jersey held Aug. 7 in partially granting a motion to dismiss (Lourdes Specialty Hospital of Southern New Jersey, et al. v. Anthem Blue Cross Blue Shield, No. 16-07631, D. N.J., 2017 U.S. Dist. LEXIS 124730).

  • August 17, 2017

    Agency Decision At Heart Of ACA Program Deadline Spat Unreviewable, Judge Says

    HOUSTON — Courts lack jurisdiction over federal agency decisions, a judge held Aug. 2 in saying he could not reconsider a ruling dismissing claims challenging a Centers for Medicare and Medicaid Services (CMS) decision not to extend the deadline for complying with a Patient Protection and Affordable Care Act (ACA) cost-saving program (Physicians ACO LLC v. Sylvia Mathews Burwell, et al., No. 15-00803, S.D. Texas, 2017 U.S. Dist. LEXIS 121382).

  • August 17, 2017

    Judge Declines Reconsideration Of ACA Out-Of-Network Lactation Coverage Ruling

    WASHINGTON, D.C. — An insurer’s alternative interpretation of the Patient Protection and Affordable Care Act (ACA)’s lactation services mandate did not require consideration of an affidavit stating that the company complied with the law, a federal judge in the District of Columbia held Aug. 14 in declining to reconsider a motion to dismiss (Lindsay Ferrer, et al. v. CareFirst Inc., et al., No. 16-2162, D. D.C., 2017 U.S. Dist. LEXIS 110304).

  • August 17, 2017

    Judge Largely Allows ACA Lactation Insurance Coverage Suit To Proceed

    SAN FRANCISCO — To the extent an insurer covers lactation services required by the Patient Protection and Affordable Care Act (ACA), allegations that it makes finding or using those providers impossible support a class action, a federal judge in California held Aug. 15 in largely denying a motion to dismiss (Rachel Condry, et al. v. UnitedHealth Group Inc., et al., No. 17-183, N.D. Calif., 2017 U.S. Dist. LEXIS 130089).

  • August 16, 2017

    CBO Sees Higher Premiums, Deficit, From Elimination Of ACA Cost Sharing

    WASHINGTON, D.C. — Removing the Patient Protection and Affordable Care Act (ACA)’s cost-sharing subsidies would come at the cost of larger federal deficits and substantially higher premiums for silver-tier plans, but after some initial turmoil would likely result in slightly broader coverage at roughly the same levels as baseline estimates, according to a Congressional Budget Office (CBO) analysis released Aug. 15.

  • August 15, 2017

    Judge Finds Insurer Entitled To More Than $52M Under ACA Risk Corridor

    WASHINGTON, D.C. — The government owes an insurance group more than $52 million under the first two years of the Patient Protection and Affordable Care Act (ACA) risk-corridor program, a federal judge said Aug. 4 in partially granting the insurers relief (Molina Healthcare of California Inc., et al. v. The United States, No. 17-97, Fed. Clms., 2017 U.S. Claims LEXIS 919).

  • August 11, 2017

    Walgreens, CVS Hit With Class Suits Alleging Generic Drug Overpricing

    CHICAGO — Two groups of consumers, both represented by Hagens Berman, filed two separate class complaints, one in the U.S. District Court for the District of Rhode Island on Aug. 7 and the second in the U.S. District Court for the Northern District of Illinois on Aug. 9, accusing CVS Health Corp. and Walgreens Boots Alliance Inc., respectively, of fraudulently driving up the cost of generic drugs (Megan Schultz, et al. v. CVS Health Corporation, No. 17-359, D. R.I., David Grabstald, et al. v. Walgreens Boots Alliance, Inc., No. 17-5789, N.D. Ill.).

  • August 9, 2017

    Federal Claims Judge: Congress Properly Barred ACA Payments To Plan

    WASHINGTON, D.C. — The U.S. Court of Federal Claims on July 31 ruled that Congress timely barred the use of appropriate funds to pay money due to a community health exchange under the Risk Corridors Program of the Affordable Care Act (ACA), 42 U.S. Code § 18062 (2012) (Maine Community Health Options v. The United States, No. 16-967C, Fed. Clms., 2017 U.S. Claims LEXIS 906).

  • August 4, 2017

    Judge: Isolated Problems Don’t Support Fiduciary Duty Claim Against Insurer

    SAN DIEGO — An insurer appears to have compensated an insured in every instance where its error caused him to spend above his out-of-pocket maximum, and nothing suggests that the problem arises out of a failure to properly conduct its fiduciary duty, a federal judge in California held July 14 (Timothy Gendreau, et al. v. California Physicians’ Service, et al., No. 15-2455, S.D. Calif., 2017 U.S. Dist. LEXIS 109888).

  • July 28, 2017

    Director Dismissed From Suit Involving ACA Navigator Grant Revocation

    BENTON, Ill. — The handful of communications the person in charge of the Patient Protection and Affordable Care Act (ACA) navigator grant program made to an applicant in Illinois does not give the state personal jurisdiction over a suit alleging improper revocation of that grant, a  federal judge held July 18 (R&B Receivables Mgmt. Corp. v. United States HHS, No. 15-8109, N.D. Ill., 2017 U.S. Dist. LEXIS 111559).

  • July 28, 2017

    GOP Defectors Doom Party’s ‘Skinny Bill’ Repeal Of ACA

    WASHINGTON, D.C. — Senate Republicans failed to secure votes from three of their own, dooming the so called “skinny repeal” of the Patient Protection and Affordable Care Act (ACA) in an early morning vote on July 28.

  • July 25, 2017

    United States House Urges Appeals Court To Overturn ACA Risk-Corridor Ruling

    WASHINGTON, D.C. — Congress never intended to make the Patient Protection and Affordable Care Act (ACA) risk-corridor program an open-ended liability and its choice of language makes that clear, the U.S. House of Representatives told a federal appeals court on July 17 (Moda Health Plan Inc. v. The United States of America, No. 2017-1994, Fed. Cir.).

  • July 24, 2017

    Judge Largely Allows Consultant’s Claims In ACA Cost-Reduction Program Spat

    CLEVELAND — The record suggests that a consulting company knew as much as one could expect it to know about a Patient Protection and Affordable Care Act (ACA) program designed to reduce medical costs and whether the consultant or its client is responsible for the failure of the contract remains a question, a federal judge in Ohio held July 20 (Enable Healthcare Inc. v. Cleveland Quality Healthnet LLC, No. 16-2395, N.D. Ohio, 2017 U.S. Dist. LEXIS 113273).

  • July 24, 2017

    Judge: Insurer’s Denial Of Coverage For Wilderness Programs Permissible

    MIAMI — An insurer’s exclusion of wilderness treatment programs is not a blanket bar, but is based on the frequent failure of those facilities to meet certain general coverage criteria, and thus does not violate federal law by treating mental health coverage differently from more general treatments, a federal judge in Florida held July 20 in dismissing ERISA claims (Steven Welp, et al. v. Cigna Health and Life Insurance Co., et al., No. 17-80237, S.D. Fla.).

  • July 21, 2017

    Government Says Failed ACA Insurer Should File Case In Federal Claims Court

    COLUMBIA, S.C. — A failed Patient Protection and Affordable Care Act (ACA) co-operative insurer’s liquidator should file his lawsuit challenging a federal loan repayment demand in the U.S. Court of Federal Claims, the government says in a July 19 motion filed in South Carolina federal court (Raymond G. Farmer v. United States of America, et al., No. 17-cv-00956, D. S.C.).

  • July 18, 2017

    United States Urges Court To Overturn Partial Judgment In ACA Risk-Corridor Suit

    WASHINGTON, D.C. — The purpose and structure of the Patient Protection and Affordable Care Act (ACA) risk-corridor program show that Congress intended the program to mitigate insurers’ risk, not eliminate their risk while putting taxpayers on the hook for potentially uncapped liability, the United States told the Federal Circuit U.S. Court of Appeals on July 10 (Moda Health Plan Inc. v. The United States of America, No. 2017-1994, Fed. Cir.).

  • July 18, 2017

    Judge Finds Standing In ACA Out-Of-Network Lactation Coverage Suit

    WASHINGTON, D.C. — A trio of women successfully allege standing in their class action claiming that an insurer improperly charged them for out-of-network lactation services in violation of the Patient Protection and Affordable Care Act (ACA), a federal judge in the District of Columbia held July 17 (Lindsay Ferrer, et al. v. CareFirst Inc., et al., No. 16-2162, D. D.C., 2017 U.S. Dist. LEXIS 110304.)

  • July 18, 2017

    Insolvent Insurer Accuses Government Of Withholding ACA Funds

    WASHINGTON, D.C. — The United States failed to make good on its promise to pay millions of dollars under the Patient Protection and Affordable Care Act (ACA) risk-corridor program, an insolvent insurer alleges in a July 6 complaint filed in the U.S. Court of Federal Claims (Nancy G. Atkins, et al. v. The United States of America, No. 17-906C, U.S. Fed. Clms.).

  • July 17, 2017

    Judge: Even If Duplicative, Breach Of Fiduciary Duty Claim Survives Dismissal

    NEWARK, N.J. — Even if potentially duplicative of other relief, a doctor’s Employee Retirement Income Security Act breach of fiduciary duty claim seeking full payment from an insurer survives the motion-to-dismiss stage, a federal judge in New Jersey held July 6 in finding that regulations governing claims procedures lack a private right of action (Rahul Shah, M.D., on assignment of Lorraine J. v. Aetna, No. 17-195, D. N.J., 2017 U.S. Dist. LEXIS 104750).