Mealey's Health Care / ACA

  • March 24, 2017

    Judge Nixes Class In Insureds’ Suit Claiming Pharmacy Gouged On Generic Drugs

    SAN FRANCISCO — The variety of contracts at issue and evidence that at least some of the contracted pharmacy benefit managers (PBMs) understood that a pharmacy’s usual and customary rate did not include the rate offered for generic drugs in its membership program defeat a motion for class certification of insured purchasers of generic drugs, a federal judge in California held March 21 (Christopher Corcoran, et al. v. CVS Health, et al., No. 15-3504, N.D. Calif., 2017 U.S. Dist. LEXIS 40783).

  • March 24, 2017

    ERISA Not The Vehicle For Health Centers’ Suits Against Insurers, 9th Circuit Says

    SAN FRANCISCO — Health care centers designated to receive direct payment from a health plan administrator for medical services cannot file suit in federal court under the Employee Retirement Income Security Act because they lack both direct statutory authority and derivative authority through assignment under ERISA’s civil enforcement provisions, a Ninth Circuit U.S. Court of Appeals panel held March 22 (DB Healthcare, LLC, et al. v. Blue Cross Blue Shield of Arizona, Inc., No. 14-16518, Advanced Women’s Health Center, Inc. v. Anthem Blue Cross Life and Health Insurance Company, No. 14-16612, 9th Cir., 2017 U.S. App. LEXIS 5082).

  • March 24, 2017

    HHS Tells Top Court Review Not Warranted In West Virginia’s ACA Challenge

    WASHINGTON, D.C. — A judge properly concluded that any injury West Virginia suffered from the Patient Protection and Affordable Care Act (ACA)’s administrative fix is political and too intangible for standing purposes, a government agency said March 10 in urging the nation’s top court not to review the case (State of West Virginia, ex rel. Patrick Morrisey v. United States Department of Health and Human Services, No. 16-721, U.S. Sup.; 2017 U.S. S. Ct. Briefs LEXIS 887).

  • March 22, 2017

    Government: Jurisdiction Ruling Moots Liquidators’ Appeal In ACA Assets Case

    ST. LOUIS — A judge’s finding that she lacks jurisdiction over a suit involving the proper handling of Patient Protection and Affordable Care Act (ACA) assets moots an insolvent insurer’s liquidators’ interlocutory appeal challenging a ruling denying them a preliminary injunction, the government told the Eighth Circuit U.S. Court of Appeals on March 17 (Nick Gerhart, et al. v. United States Department of Health and Human Services, et al., No. 16-3477, 8th Cir.).

  • March 22, 2017

    Judge Finds Jurisdiction Lacking In Insolvent Insurer’s Suit Over ACA Payments

    ST. LOUIS — An insolvent insurer’s suit against the government over its handling of the Patient Protection and Affordable Care Act (ACA) risk corridor and how it offset debts properly belongs before the U.S. Court of Federal Claims, a federal judge in Iowa said March 17 in finding that she lacked jurisdiction and entering judgment (Nick Gerhart, et al. v. United States Department of Health and Human Services, et al., No. 16-151, S.D. Iowa, 2017 U.S. Dist. LEXIS 37620).

  • March 22, 2017

    Drug Makers, Benefit Managers Hit With Class Suit Alleging Insulin Pricing Scheme

    NEWARK, N.J. — Three drug makers and the three largest pharmacy benefit managers have engaged in a pricing scheme to drive up the cost of diabetes insulin — by more than 150 percent in the last five years — in violation of the Racketeer Influenced and Corrupt Organizations Act, the Employee Retirement Income Security Act of 1974, the Sherman Act and numerous state laws, four consumers and Type 1 Diabetes Defense Foundation allege in a March 17 class complaint filed in the U.S. District Court for the District of New Jersey (Julia Boss, et al. v. CVS Health Corporation, et al., No. 17-1823, D. N.J.).

  • March 16, 2017

    Oregon Federal Judge Refuses To Certify Class Of Naturopath Patients

    PORTLAND, Ore. — An Oregon federal judge on March 9 denied a motion to certify a class of persons who were enrolled in an employer-issued health plan administered by Health Net Health Plan of Oregon who claimed that the plan discriminated against naturopathic physicians, finding that the plaintiffs lacked standing to sue because they could not show that they suffered an injury-in-fact (Eileen Fox-Quamme, et al. v. Health Net Health Plan of Oregon Inc., et al., No. 3:15-cv-01248, D. Ore., 2017 U.S. Dist. LEXIS 35964).

  • March 14, 2017

    Judge Keeps Alive Parts Of Suit Alleging IT Provider Missed ACA Deadlines

    ORLANDO, Fla. — A medical provider adequately alleges breach of contract and fraud claims stemming from an information technology provider’s failure to meet Patient Protection and Affordable Care Act (ACA) deadlines, while false advertising and breach of fiduciary duty claims fail, a federal judge in Florida held March 10 (North Brevard Hospital District, d/b/a Parrish Medical Center v. McKesson Technologies Inc., No, 16-637, M.D. Fla., 2017 U.S. Dist. LEXIS 34515).

  • March 14, 2017

    Man’s Brand-Name Drug Coverage Suit Proceeds, Federal Judge Says

    DALLAS — A man’s claims that an insurer misrepresented the extent of its brand-name drug coverage survive a motion to dismiss, a federal judge in Texas held March 2 in adopting a magistrate judge’s recommendations that Patient Protection and Affordable Care Act (ACA) and other claims proceed (Nicholas D. Mosser v. Aetna Life Insurance Co. and eHealth Insurance Services Inc., No. 15-430, E.D. Texas).

  • March 14, 2017

    Hospitals, Trade Group Prevail In Overpayment Calculation Process Challenge

    CONCORD, N.H. — Medicaid hospital overpayment calculations articulated in a frequently asked questions (FAQ) section of an agency website are substantive rules and required a notice-and-comment period, a federal judge in New Hampshire held March 6 in entering judgment for a hospital group (New Hampshire Hospital Association, et al. v. Sylvia Matthews Burwell, et al., No. 15-460, D. N.H.).

  • March 14, 2017

    Insurer Seeks Balance Of $52M Owed Under ACA Risk Corridor

    WASHINGTON, D.C. — The government paid an arbitrary pro rata share of amounts due under the Patient Protection and Affordable Care Act (ACA) risk-corridor program, despite written admissions that it owes all $52,378,111.20, an insurer in various states alleges in a Jan. 23 complaint filed in the U.S. Court of Federal Claims (Molina Healthcare of California Inc., et al. v. The United States of America, No. 17-97, U.S. Fed. Clms.).

  • March 14, 2017

    Republican Health Plan Leaves Additional 24M Without Insurance, CBO Says

    WASHINGTON, D.C. — The Republican health care plan would see premiums increase over the next couple years, though they would fall below current averages after that, would reduce the deficit by $337 billion over the next 10 years, but would result in 24 million individuals losing insurance, according to a March 13 Congressional Budget Office (CBO) analysis.

  • March 13, 2017

    Judge Finds Jurisdiction, Orders Briefing On Funding In ACA Risk-Corridor Suit

    WASHINGTON, D.C. — An insurer alleges a sufficient injury to pursue claims that the government is failing to make required payments under the Patient Protection and Affordable Care Act (ACA) risk-corridor program, a federal judge held March 9 while ordering more briefing on what impact Congress’ subsequent decision not to fully fund the program has on available judicial remedies (Maine Community Health Options v. The United States of America, No. 16-967, Fed. Clms.).

  • March 10, 2017

    House Committee Approves Legislation Easing Way For ACA Repeal

    WASHINGTON, D.C. — Republicans took another step toward dismantling the Patient Protection and Affordable Care Act (ACA) on March 9, with the U.S. States House Energy and Commerce Committee approving draft legislation designed to ease the way for the repeal and replacement of the law.

  • March 10, 2017

    Judge Stays ACA Risk-Corridor Case Pending Appellate Ruling

    WASHINGTON, D.C. — A federal judge on March 8 granted an unopposed motion to stay a Patient Protection and Affordable Care Act (ACA) risk-corridor challenge until a federal appeals court weighs in on the issue (Blue Cross of Idaho Health Service Inc. v. The United States of America, No. 16-1384, Fed. Clms.).

  • March 8, 2017

    Judge Finds Insurer Properly Denied Coverage, Rescinded Policy

    CONCORD, N.H. — A man’s belief that he suffered from a heart condition rather than heart disease and his unsubstantiated claims that he disclosed as much to his insurer does not save his action challenging its denial of benefits or rescission of coverage under a pre-existing condition clause, a federal judge in New Hampshire held March 3 in granting summary judgment on the insurer’s counterclaims (Warren Wallis v. HCC Life Insurance Co., No. 15-525, D. N.H., 2017 U.S. Dist. LEXIS 30360).

  • March 8, 2017

    Republicans Opt To Keep Popular ACA Provisions In Proposed Replacement

    WASHINGTON, D.C. — House Republicans on March 7 unveiled their plan for replacing the Patient Protection and Affordable Care Act (ACA), keeping many of the law’s most popular aspects while killing off many of the law’s taxes and altering how the government offers tax credits.

  • March 6, 2017

    Judge Permits Late Class Claims In Insurance Spat Involving Autism Treatment

    BENTON, Ill. — Plaintiffs’ failure to include class allegations in their complaint does not excuse the oversight, but because an insurer was on notice of the claims, the late addition does not warrant denying leave to amend in a case challenging the reduction of coverage for autism treatments, a federal judge in Indiana held Feb. 15 (W.P., et al. v. Anthem Insurance Companies Inc., No. 15-562, S.D. Ind., 2017 U.S. Dist. LEXIS 21424).

  • March 2, 2017

    Judge Rejects Coverage For Prostate Cancer Sufferer’s Proton Beam Therapy

    KNOXVILLE, Tenn. — The fact that other insurers might accept proton beam therapy as a treatment for prostate cancer does not save a man’s challenge to his insurer’s rejection of the treatment as experimental, a federal judge in Tennessee held Feb. 15 (Donald K. Turner v. Alcoa Inc., et al., No. 15-270, E.D. Tenn., 2017 U.S. Dist. LEXIS 21092).

  • 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).