Mealey's Health Care / ACA

  • July 19, 2019

    Judge: Emergency Room Provision Dooms Claims By Out-Of-Network Surgery Provider

    BROOKLYN, N.Y. — A health insurance plan distinguishes between coverage levels for out-of-network care provided in an emergency setting and the type of brain surgery provided in an inpatient room, a federal judge in New York held in dismissing Employee Retirement Income Security Act claims on June 27 (Jeffrey Farkas, M.D., LLC, et al. v. Cigna Health And Life Insurance Co., et al., No. 18-5232, E.D. N.Y.).

  • July 19, 2019

    Deaf Couple’s ACA Discrimination Claims Largely Rejected By Judge

    SACRAMENTO, Calif. — A man’s repeated requests for an interpreter and a hospital’s apparent attempt at meeting those requests put Patient Protection and Affordable Care Act (ACA) discrimination claims in a unique position that requires jury consideration, a federal judge in California said July 1 in otherwise rejecting the man and his wife’s claims (Mark Bax, et al. v. Doctors Medical Center of Modesta Inc., et al., No. 17-1348, E.D. Calif., 2019 U.S. Dist. LEXIS 110799).

  • July 19, 2019

    En Banc 9th Circuit Considers Stay While Panel Addresses ACA Rule Challenge

    SAN FRANCISCO — The Ninth Circuit U.S. Court of Appeals on July 11 agreed to en banc reconsideration of a panel ruling staying a ruling enjoining a federal rule while a panel considers whether the rule’s restrictions on abortion services and communication violate the Patient Protection and Affordable Care Act (ACA) (California, et al. v. Alex Azar, et al., Essential Access Health Inc. v. Alex M. Azar II, et al., Oregon, et al. v. Alex Azar, et al., Washington, et al. v. Alex M. Azar, et al., Nos. 19-15974, 19-15979, 19-35386, 19-35394, 9th Cir.).

  • July 18, 2019

    District Court Correctly Applied Arbitrary, Capricious Standard Of Review, Panel Says

    DENVER — A district court did not err in applying an arbitrary and capricious standard of review to a health care plan’s denial of benefits for a plan beneficiary’s treatment at a residential center because the plan participant failed to identify any procedural irregularities under the Employee Retirement Income Security Act that would warrant the application of a de novo standard of review, the 10th Circuit U.S. Court of Appeal said July 15 (Mary D. v. Anthem Blue Cross Blue Shield, et al., No. 17-4195, 10th Cir., 2019 U.S. App. LEXIS 20842). 

  • July 18, 2019

    Insurer Says Women Received ACA-Mandated Lactation Services

    DES MOINES, Iowa — Two women received cost-free in-network lactation services in the hospital when they gave birth and incurred costs they claim should be covered under the Patient Protection and Affordable Care Act (ACA) only later when they independently sought out-of-network care, an insurer tells the Eighth Circuit U.S. Court of Appeals in a July 16 brief (Jillian York, et al. v. Wellmark Inc., et al., No. 19-1705, 8th Cir.).

  • July 17, 2019

    Association Health Plan Rule Violates ERISA, ACA, States Say

    WASHINGTON, D.C. — The association health plan rule relies on an unreasonable reading of the Employee Retirement Income Security Act and constitutes an end-run around Patient Protection and Affordable Care Act (ACA) protections, New York and its fellow plaintiffs told the District of Columbia Circuit U.S. Court of Appeals on July 15 (New York, et al. v. U.S. Department of Labor, et al., No. 19-5125, D.C. Cir.).

  • July 17, 2019

    3rd Circuit Affirms Injunction In ACA Birth Control Exemptions Case

    HARRISBURG, Pa. — A federal agency improperly skipped the notice-and-comment period in expanding exemptions to the Patient Protection and Affordable Care Act (ACA) contraceptive mandate, and the resulting final rules violate the statute, a Third Circuit U.S. Court of Appeals panel held July 12 (Commonwealth of Pennsylvania, et al. v. President United States of America, et al., Nos. 17-3752, 18-1253,19-1129, 19-1189, 3rd Cir., 2019 U.S. App. LEXIS 20778).

  • July 15, 2019

    Plaintiffs, Insurer Lay Out Remedies, Certification Claims In Mental Health Case

    SAN FRANCISCO —  Whether a court properly certified a class of plaintiffs with various health care plans who were denied mental health treatments and the extent of remedies available under the Employee Retirement Income Security Act are all before a California federal judge after post-trial briefing July 10 (David and Natasha Wit, et al. v. United Behavioral Health, No. 14-02346, Gary Alexander, et al. v. United Behavioral Health, No. 14-5337, N.D. Calif.).

  • July 10, 2019

    5th Circuit Hears Whether ACA Survives Elimination Of Individual Mandate Tax

    NEW ORLEANS — Whether eliminating the tax associated with Patient Protection and Affordable Care Act (ACA) individual mandate noncompliance brings down the entire law, or whether that portion of the statute can be severed lays with the Fifth Circuit U.S. Court of Appeals after oral arguments July 9 (Texas, et al. v. United States, et al., No. 19-10011, 5th Cir.).

  • July 09, 2019

    ACA Individual Mandate Challenge Parties Tell 5th Circuit Case Remains Live

    NEW ORLEANS — The United States’ change in heart regarding the constitutionality of the Patient Protection and Affordable Care Act (ACA) after the elimination of the noncompliance penalty does not strip the Fifth Circuit U.S. Court of Appeals of jurisdiction over the appeal, parties to the suit told the court on July 5 in advance of oral arguments scheduled for July 10 (Texas, et al. v. United States, et al., No. 19-10011, 5th Cir.).

  • 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).

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