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Mealey's Health Care / ACA

  • June 24, 2019

    U.S. Supreme Court Decides To Hear Health Insurers Over $12B ACA Dispute

    WASHINGTON, D.C. — The U.S. Supreme Court on June 24 granted certification to health insurers to decide whether the United States evaded its statutory promise to pay them for losses when the government blocked $12 billion in funding under the Patient Protection and Affordable Care Act (ACA) risk-corridor program (Land of Lincoln Mutual Health Insurance Co. v. United States, No. 18-1038, Moda Health Plan Inc., et al. v. United States, No. 18-1028, Maine Community Health Options v. United States, No. 18-1023, U.S. Sup.).

  • June 19, 2019

    Surgery Authorization Invokes ERISA, Requires Dismissing Case, Judge Says

    TRENTON, N.J. — Because a written pre-authorization specifically bases payment for health care services on various provisions in an Employee Retirement Income Security Act plan, resolving the case would require investigation of the plan, a federal judge in New Jersey held June 14 in dismissing a provider’s claims (Comprehensive Spine Care, P.A. v. Oxford Health Insurance Inc., et al., No. 18-13874, D. N.J., 2019 U.S. Dist. LEXIS 100810).

  • June 19, 2019

    Judge Again Dismisses Challenge To California Out-Of-Network Payment Law

    SACRAMENTO, Calif. — An association and individual challenging a California law governing reimbursement for out-of-network health care providers lack standing and sufficient allegations to prevail on the merits, a federal judge in the state held June 14 (Association of American Physicians & Surgeons Inc., et al. v. Shelley Rouillard, et al., No. 16-2441, E.D. Calif., 2019 U.S. Dist. LEXIS 100302).

  • June 19, 2019

    White House Finalizing Rule Promoting Employees To Shop ACA Marketplace

    WASHINGTON, D.C. — Employees could use tax-advantaged funds from employers to purchase health insurance plans in the individual marketplace under an expanded health reimbursement arrangements (HRA) rule the White House on June 14 said it was finalizing.

  • June 18, 2019

    Maryland, IBM Settle Dispute Over ACA Exchange Failure

    BALTIMORE — The state of Maryland, the United States, International Business Machines Corp. (IBM) and Curam Software reached a $14.8 million agreement resolving claims related to the bumpy rollout of the Patient Protection and Affordable Care Act (ACA) health insurance exchanges in the state, Maryland Attorney General Brian E. Frosh announced June 14.

  • June 17, 2019

    Women Appeal ACA Lactation Insurance Coverage Ruling

    DES MOINES, Iowa — The Patient Protection and Affordable Care Act (ACA) requires that insurers list certified lactation specialists (CLS), and a judge’s narrow reading of the mandate finding access to providers sufficient runs contrary to the law, class plaintiffs tell the Eighth Circuit U.S. Court of Appeals in a June 13 opening brief (Jillian York, et al. v. Wellmark Inc., et al., No. 19-1705, 8th Cir.).

  • June 17, 2019

    Parity Act Allegations In ERISA Suit May Proceed, Judge Says

    SALT LAKE CITY — Allegations that a health insurer covers subacute care in surgical settings but denies coverage in mental health settings provides a basis for a couple’s Parity Act claim under the Employee Retirement Income Security Act, a federal judge in Utah said June 14 (Timothy D., et al. v. Aetna Health and Life Insurance Co., et al., No. 18-753, D. Utah, 2019 U.S. Dist. LEXIS 100388).

  • June 17, 2019

    Supreme Court Denies Review In California ACA Contraceptive Rules Spat

    WASHINGTON, D.C. — A court’s ruling enjoining Patient Protection and Affordable Care Act (ACA) contraceptive mandate exemptions in plaintiff states will stand after the Supreme Court on June 17 declined to weigh in on the case (Little Sisters of the Poor Jeanne Jugan Residence v. California, et al., No. 18-1192, U.S. Sup.).

  • June 17, 2019

    9th Circuit Reverses Class Denial In Generic Drug Price-Gouging Case

    SAN FRANCISCO — Both named and unnamed plaintiffs in a drug-pricing class action allege the same injury from the same conduct, satisfying the typicality requirements for a class action, a Ninth Circuit U.S. Court of Appeals panel held June 14 in reinstating the class and expert testimony (Christopher Corcoran, et al. v. CVS Health, et al., No. 17-16996, 9th Cir.).

  • June 13, 2019

    Judge Awards ACA Insurer $19M For Cost-Sharing Program Breaches

    WASHINGTON, D.C. — A federal judge on June 10 concluded that the Patient Protection and Affordable Care Act (ACA)’s cost-sharing program created an obligation and that the government’s failure to make payments constituted a breach of contract and awarded an insurer in excess of $19 million (Maine Community Health Options v. United States, No. 1:17-2057, Fed. Clms., 2019 U.S. Claims LEXIS 625).

  • June 12, 2019

    Judge Dismisses State Law, ERISA Claims In Provider’s Health Insurance Suit

    TRENTON, N.J. — A health care provider’s state law claims require consulting an Employee Retirement Income Security Act plan and are preempted, and the ERISA claims themselves are barred by an anti-assignment provision, a federal judge in New Jersey held May 23 in dismissing the case (East Coast Advanced Plastic Surgery v. Aetna Inc., et al., No. 18-9429, D. N.J., 2019 U.S. Dist. LEXIS 86941).

  • June 11, 2019

    Little Sisters Tell Top Court New Developments Show Need For ACA Review

    WASHINGTON, D.C. — A recent federal district court judge’s ruling in favor of Patient Protection and Affordable Care Act (ACA) contraceptive mandate objectors furthers the case for U.S. Supreme Court review of an issue plaquing lower courts, a petitioner tells the court in a June 10 supplemental brief (Little Sisters of the Poor Jeanne Jugan Residence v. California, et al., No. 18-1192, U.S. Sup.).

  • June 11, 2019

    Judge Rejects Insurer’s ‘Ludicrous’ Surprise Bill Argument, Motion To Dismiss

    NEW YORK — An insurer’s contention that an out-of-network provider never alleges that a stroke sufferer inquired into the availability of in-network emergency surgery is “ludicrous and offensive,” and the procedure clearly falls within the policy’s surprise bill exception to the anti-assignment provision, a federal judge in New York held May 15 in denying a motion to dismiss (Jeffrey Farkas, M.D. LLC v. Group Health Inc., No. 18-8535, S.D. N.Y., 2019 U.S. Dist. LEXIS 83096).

  • June 7, 2019

    Judge: Insurer Shorted Period For Medically Necessary Mental Health Treatments

    SALT LAKE CITY — A federal judge in Utah on June 4 affirmed complete denial of coverage for treatment at one mental health treatment facility under the Employee Retirement Income Security Act, but found treatment at a second medically necessary for longer than the insurer allowed (Mike G., et al. v. BlueCross BlueShield of Texas, No. 17-347, D. Utah., 2019 U.S. Dist. LEXIS 94291).

  • June 7, 2019

    Mental Health Parity Claim Fails For Lack Of Comparison, Judge Says

    SALT LAKE CITY — Even assuming that an insurer erred in denying coverage for inpatient mental health care, plaintiffs lack sufficient comparison to other instances where the insurer approved coverage in other settings to support a Mental Health Parity and Addiction Equity Act claim, a federal judge in Utah held June 5 (Kerry W. and N.W. v. Anthem Blue Cross and Blue Shield, No. 19-67, D. Utah).

  • June 5, 2019

    6th Circuit Affirms Insurer’s HIV Drug Policy Isn’t Discrimination

    CINCINNATI — The Patient Protection and Affordable Care Act (ACA) limits a plaintiff to the standard governing the type of discrimination he is alleging and he may not pick and choose which statute’s standard he wishes to apply, a Sixth Circuit U.S. Court of Appeals panel held June 4 (John Doe v. BlueCross BlueShield of Tennessee Inc., No. 18-5897, 6th Cir., 2019 U.S. App. LEXIS 16785).

  • June 4, 2019

    Class Certification Denied In ACA Lactation Support Insurance Case

    SAN FRANCISCO — Three proposed classes in a Patient Protection and Affordable Care Act (ACA) case challenging insurance coverage for lactation specialists are overly broad, and while Employee Retirement Income Security Act allegations are less problematic, they too are overly broad and do not make clear the relief that could be granted, a federal judge in California said May 23 in denying class certification (Rachel Condry, et al. v. UnitedHealth Group Inc., et al., No. 17-183, N.D. Calif.).

  • June 3, 2019

    Government Wants Association Health Plan Ruling Reversed

    WASHINGTON, D.C. — States lack standing to challenge a Patient Protection and Affordable Care Act (ACA) rule expanding association health plans, and in any case, a judge erred in finding the rule did “violence” to the Employee Retirement Income Security Act (ERISA) definition of an employer, the Department of Labor tells the District of Columbia Circuit U.S. Court of Appeals in an opening brief May 31 (New York, et al. v. U.S. Department of Labor, et al., No. 19-5125, D.C. Cir.).

  • June 3, 2019

    Insurer Appeals After Entry Of $123,849 Judgment In ERISA Benefits Case

    SEATTLE — An insurer on May 31 noticed an appeal challenging a $123,849 judgment awarded to plaintiffs who prevailed in their case claiming improper denial of residential treatment under the Employee Retirement Income Security Act (Todd R., et al. v. Premera Blue Cross Blue Shield of Alaska, No. 17-1041, W.D. Wash.).

  • May 31, 2019

    Insurer Stands Pat In Medicaid Fair Hearing Supreme Court Challenge

    WASHINGTON, D.C. — The Kentucky Supreme Court erred in concluding that a Medicaid recipient’s lack of financial interest left her without standing to a pursue a fair hearing as required by a federal program, a woman argues in a May 15 petition asking the U.S Supreme Court for a writ of certiorari.  The insurer on May 29 told the court that it would not respond to the petition (Lettie Sexton, et al. v. Commonwealth of Kentucky, et al., No. 18-1446, U.S. Sup.).