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Mealey's Health Care / ACA

  • June 28, 2017

    Government Wants Insurer’s $400M ACA Risk-Corridor Suit Stayed Pending Appeals

    WASHINGTON, D.C. — The government asked a federal judge on June 22 to stay a case alleging more than $400 million in Patient Protection and Affordable Care Act (ACA) risk-corridor underpayments while the appellate court grapples with identical issues in two other cases (Health Net Inc. v. The United States of America, No. 16-1722, Fed. Clms.).

  • June 27, 2017

    California Democrats Nix Single-Payer Measure

    SACRAMENTO, Calif. — California Democrats announced June 23 that they would not push a vote on a bill aimed at implementing single-payer health care in the state.

  • June 22, 2017

    Senate Republican’s Unveil Health Care Legislation

    WASHINGTON, D.C. — Senate Republicans finally unveiled their latest stab at a health care bill June 22, the most recent step in a winding attempt to repeal the Patient Protection and Affordable Care Act (ACA).

  • June 22, 2017

    Oklahoma Top Court: No Preemption Where ERISA Plan Is ‘Factual Backdrop’

    OKLAHOMA CITY — On remand, a trial court must consider whether a woman’s class action claiming that a hospital improperly sought collection from her in violation of its contract with her insurer invokes an Employee Retirement Income Security Act plan or whether the plan is merely part of the “factual backdrop” of the case, a divided Oklahoma Supreme Court held June 21 (Elizabeth Cates v. INTEGRIS Health Inc., No. 114314, Okla. Sup., 2017 Okla. LEXIS 53).

  • June 20, 2017

    Class Claims Blue Cross Improperly Denies Women Necessary Cancer Drugs

    DAVIE, Fla. — Blue Cross and Blue Shield (BCBS) of Florida Inc. deceptively markets its pharmacy benefits as covering all medically necessary drugs while denying medically necessary drugs to women suffering from cancer, according to a Florida state court class action filed June 13 (Robin Chusid and Mitchel Chusid v. Blue Cross and Blue Shield of Florida Inc., No. CACE17010947, Fla. 17th Jud. Cir.).

  • June 20, 2017

    Medica Reverses Course, Will Be Sole ACA Insurer In Iowa But At A Cost

    DES MOINES, Iowa — Health insurance provider Medica Holding Co. announced June 19 that it will remain in Iowa’s Patient Protection and Affordable Care Act (ACA) exchanges, a move that will help the state avoid becoming the first without an ACA insurer in the majority of its counties, but comes tied to a  request for a 43.5 percent premium increase.

  • June 20, 2017

    Judge Certifies Class In Mental Health Insurance Coverage Denial Case

    SAN JOSE, Calif. — A federal judge in California on June 15 granted class certification to a group of plaintiffs seeking reprocessing of mental health insurance claims after their insurer allegedly imposed overly strict definitions of medically necessary care in contravention of the plans’ terms (Charles Des Roches, et al. v. California Physicians’ Service, et al., No. 16-2848, N.D. Calif., 2017 U.S. Dist. LEXIS 92573).

  • June 19, 2017

    Service Provider Tells Court ACA Costs Warranted Rate Review

    SACRAMENTO, Calif. — Costs incurred in complying with the Patient Protection and Affordable Care Act (ACA)’s employer mandate are sufficiently linked to a nonprofit’s services to warrant additional government funding, and a party need not continually bang its head against the wall in an effort to exhaust administrative remedies when the outcome is clear, a provider of services for the developmentally disabled told a California appeals court June 8 (Social Vocational Services Inc. v. Santi Rogers, et al., No. C083251, Calif. App., 3rd Dist.).

  • June 15, 2017

    Insurer’s Coverage Confirmation Is Not Promise To Pay Provider, Judge Says

    CHICAGO — An insurer’s pre-procedure confirmation of insurance is not a promise to pay an out-of-network provider’s charges, a federal judge in Illinois held June 13 in granting judgment on state law claims (Advanced Ambulatory Surgical Center Inc. v. Connecticut General Life Insurance Co., No. 13-7227, N.D. Ill., 2017 U.S. Dist. LEXIS 90807).

  • June 15, 2017

    Judge: ACA Provider Discrimination Provision Lacks Private Enforcement

    NEWARK, N.J. — A Patient Protection and Affordable Care Act (ACA) provision precluding discrimination against providers acting within their license or certification lacks a right of action, dooming a chiropractor group’s claim that an insurer intentionally places its members in less desirable coverage tiers, a federal judge in New Jersey held June 13 (The Association of New Jersey Chiropractors Inc. and Robert Blozen, D.C., v. Horizon Healthcare Services Inc., et al., No. 16-8400, D. N.J.).

  • June 15, 2017

    8th Circuit Dismisses Appeal In Insolvent Insurer’s ACA Suit Against Government

    ST. LOUIS — The Eighth Circuit U.S. Court of Appeals on June 13 dismissed an appeal of a ruling that an insolvent insurer’s case 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 (Doug Ommen, in his capacity as liquidator of CoOpportunity Health Inc.; Dan Watkins, in his capacity as special deputy liquidator of CoOpportunity Health Inc. v. U.S. Department of Health and Human Services, et al., No. 17-1662, 8th Cir.).

  • June 15, 2017

    Court: ACA Doesn’t Bar Balance-Billing Ban, But Discrimination Case Well Pleaded

    LOS ANGELES — A doctor adequately alleges that California officials disciplined her under regulations barring balance billing based on her race and sex but provides no support for her claim that the Patient Protection and Affordable Care Act (ACA) permits the practice, a California appellate court held June 12 (Jeannette Martello v. California Department of Managed Health Care, et al., No. BS144854, Calif. App., 2nd Dist., 2017 Cal. App. Unpub. LEXIS 4021).

  • June 14, 2017

    Judge: Suit Challenges Rate, Not Entitlement To Payment, Evades ERISA Preemption

    DALLAS — A hospital group’s state law claims challenge the rate an insurer paid and do not involve a dispute over the right to compensation, providing an independent duty and escaping ERISA preemption, a federal judge in Texas held June 9 (Kindred Hospitals Limited Partnership d/b/a Kindred Hospital Houston Medical Center, et al. v. Aetna Life Insurance Co., et al., No. 16-3379, N.D. Texas, 2017 U.S. Dist. LEXIS 89285).

  • June 13, 2017

    Court: Provider-Insurer Contract Renders Attempt To Recover From Tort Improper

    CINCINNATI — A medical provider must seek compensation from an insurer with which it has a contract, and its letter to an attorney attempting to recover from any tort settlement or judgment an insured received seeks compensation in violation of Ohio law, the Sixth Circuit U.S. Court of Appeals held June 12 (Keith Raymond; Timothy Strunk, et al. v. Avectus Healthcare Solutions; Mercy Health, No. 16-4172, 6th Cir., 2017 U.S. App. LEXIS 10351).

  • June 12, 2017

    Court Agrees To Same Merits Panel For Both ACA Risk-Corridor Appeals

    WASHINGTON, D.C. — A federal appeals court on May 30 granted insurers’ request that the same merits panel hear two appeals involving the Patient Protection and Affordable Care Act (ACA) risk corridors (Land of Lincoln Mutual Health Insurance Co. v. The United States of America, No. 17-1224, Moda Health Plan Inc. v. United States, No. 17-1994, Fed. Cir.).

  • June 12, 2017

    Mother Seeks Rehearing, Certified Question In Gender Discrimination Suit

    MINNEAPOLIS — A mother whose insurer denied coverage for her child’s gender reassignment asked the Eighth Circuit U.S. Court of Appeals for en banc review on June 7 after a panel of the court affirmed dismissal of her action.  In the alternative, the woman asked the court to take the unusual step of certifying a post-opinion question to the Minnesota Supreme Court (Brittany R. Tovar v. Essentia Health, Innovis Health LLC d/b/a Essentia Health West and HealthPartners Inc., No. 16-3186, 8th Cir.).

  • June 9, 2017

    Insurer Tells of ‘Bait-And-Switch’ In ACA Risk Corridors

    WASHINGTON, D.C. — The government enticed insurers to the Patient Protection and Affordable Care Act (ACA) marketplace with promises to pay them under the risk-corridor program and then flip-flopped on the deal, leaving catastrophic losses and hardship in its wake, an insurer told a federal appeals court on May 22 (Land of Lincoln Mutual Health Insurance Co. v. The United States of America, No. 17-1224, Fed. Cir.).

  • June 9, 2017

    Judge Stays Failed ACA Insurers’ Risk-Corridor Action

    COLUMBIA, S.C. — Liquidators’ Patient Protection and Affordable Care Act (ACA) risk-corridor suit on behalf of an insurer should be stayed to see if resolution of two other similar cases on appeal can speed resolution of the case, a federal judge held June 7 (Raymond G. Farmer, in his capacity as Liquidator of Consumers’ Choice Health Insurance Company, et al. v. The United States of America, No. 17-363, Fed. Clms., 2017 U.S. Claims LEXIS 630).

  • June 8, 2017

    California Court Won’t Reconsider Drug Center’s Out-Of-Network Payment Case

    SAN DIEGO — A California appeals court on June 8 declined to reconsider its conclusion that a drug treatment center cannot be treated as an emergency service provider for purposes of calculating out-of-network payments (Pacific Bay Recovery Inc. v. California Physicians Services Inc., No. D070561, Calif. App., 4th Dist., Div. 1).

  • June 8, 2017

    Judge Finds Allegation That Plaintiffs Exhausted Other Remedies Keeps Case Alive

    CINCINNATI — A man and his son’s allegation that they exhausted all available administrative remedies keeps their Employee Retirement Income Security Act case alleging the failure to pay benefits alive, a federal judge in Ohio held June 6 in adopting a magistrate judge’s report (Michael W. Mattingly, et al. v. Humana Health Plan Inc., No. 15-781, S.D. Ohio).