Mealey's Health Care / ACA

  • January 02, 2020

    Appeals Panel Reverses Judgment For Insurer In ACA Risk-Adjustment Case

    ALBUQUERQUE, N.M. — The government could not have acted in an arbitrary and capricious manner because it properly evaluated and investigated methods of imposing Patient Protection and Affordable Care Act (ACA) risk-adjustment charges, a 10th Circuit U.S. Court of Appeals panel held Dec. 31 (N.M. Health Connections v. United States HHS, No. 18-2186, 10th Cir., 2019 U.S. App. LEXIS 38739).

  • January 02, 2020

    Judge Dismisses Conclusory, ‘Stunning’ Health Coverage Allegations

    HARRISBURG, Pa. — A claim by a man with cancer that his health insurer misrepresented coverage lacks support and his claim that he didn’t know his health maintenance organization limited his coverage “is stunning,” a federal judge in Pennsylvania said in dismissing claims on Dec. 27 (Adam Brown v. Kaiser Foundation Health Plan of the Mid-Atlantic States Inc., No. 19-1190, M.D. Pa., 2019 U.S. Dist. LEXIS 221471).

  • January 02, 2020

    Liquidators Appeal Dismissal Of Claims Over Offset Under ACA Reinsurance Program

    WASHINGTON, D.C. — The liquidators for an insolvent insurer gave notice on Dec. 23 that they are appealing a U.S. Court of Federal Claims judge’s dismissal of their state law claims against the U.S. government over violation of South Carolina insurance law following the government’s offset of $36 million under the reinsurance program of the Patient Protection and Affordable Care Act (ACA) (Raymond G. Farmer, et al. v. The United States, No. 18-1484, Fed. Clms.).

  • December 20, 2019

    U.S. Government Appeals Ruling On Offsetting Insolvent Insurer’s Debt Under ACA

    WASHINGTON, D.C. — The U.S. government said on Dec. 19 that it is appealing to the Federal Circuit U.S. Court of Appeals a federal judge’s finding that Colorado insurance liquidation law bars its health agency from using money owed to an insolvent Colorado insurer to pay debts owed under the Patient Protection and Affordable Care Act’s (ACA) reinsurance and risk-adjustment programs (Michael Conway v. The United States, No. 18-1623, Fed. Clms., 2019 U.S. Claims LEXIS 1306).

  • December 19, 2019

    Class Survives UnitedHealth’s Facility-Fee Certification Challenge

    NEW YORK — A federal judge in New York on Dec. 18 denied a motion for reconsideration, saying that a certified class did not include patients who assigned their Employee Retirement Income Security Act rights to health care providers and that the issue involved predominance more than commonality (The Medical Society of the State of New York, et al. v. UnitedHealth Group Inc., et al., No. 16-5265, S.D. N.Y.).

  • December 19, 2019

    5th Circuit Finds ACA Individual Mandate Unconstitutional

    NEW ORLEANS — The Patient Protection and Affordable Care Act (ACA) individual mandate is unconstitutional with its payment set at zero, a majority of a Fifth Circuit U.S. Court of Appeals panel held Dec. 18, but it remanded the case for a closer inspection of whether the provision could be severed from the entire law (Texas, et al. v. United States, et al., No. 19-10011, 5th Cir.).

  • December 16, 2019

    Government Will Appeal $1.58B ACA Cost-Sharing Class Judgment

    WASHINGTON, D.C. — In a Dec. 16 filing, the federal government indicated that it will appeal a nearly $1.6 billion judgment for its failure to make Patient Protection and Affordable Care Act (ACA) cost-sharing payments for 2017 and 2018 (Common Ground Healthcare Cooperative v. The United States, No. 17-877, Fed. Clms.).

  • December 11, 2019

    Lipedema Sufferer’s Liposuction Coverage Claims Proceed, Judge Says

    SAN FRANCISCO — A woman adequately alleges that her insurer denies coverage for liposuction treatments for lipedema, despite covering surgeries needed to reduce pain and improve functionality in other settings, a federal judge in California said in declining to dismiss her case Dec. 10 (Michala Kazda v. Aetna Life Insurance Co., No. 19-2512, N.D. Calif.).

  • December 11, 2019

    Utah Federal Judge Considers Wilderness Therapy Parity Act Claim

    SALT LAKE CITY — A federal judge in Utah on Dec. 10 heard arguments about whether a family adequately pleaded that an insurer improperly denied coverage for wilderness therapy and withheld judgment on the insurer’s motion to dismiss the Mental Health Parity and Addiction Act claim (Candace B., et al. v. Blue Cross and Blue Shield of Rhode Island, No. 19-39, D. Utah).

  • December 10, 2019

    Insurers, Government Battle Over ACA Risk-Corridor Payments

    WASHINGTON, D.C. — The U.S. Supreme Court heard arguments on Dec. 10 about whether the Patient Protection and Affordable Care Act (ACA)’s “shall pay” language created a financial obligation for the government or at all times remained contingent on later congressional funding (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.).

  • December 10, 2019

    Surgery Provider’s Suit Seeking Payment From Insurers Survives Dismissal

    ALAMEDA, Calif. — A surgery provider’s preauthorization conversations with insurers led it to believe it that would be paid its usual and customary rates, a federal judge in California said Nov. 20 in denying a motion to dismiss (California Spine and Neurosurgery Institute v. Oxford Health Insurance Inc., et al., No. 19-3533, N.D. Calif., 2019 U.S. Dist. LEXIS 202556).

  • December 10, 2019

    Magistrate Judge Says Medical Provider’s Suit Belongs In State Court

    TRENTON, N.J. — The record is largely silent as to whether a medical provider has valid assignments from insureds, and even if it had standing under the Employee Retirement Income Security Act, its claims do not directly involve such a plan, a federal magistrate judge in New Jersey said Nov. 25 in recommending remand (North Jersey Brain & Spine Center v. United Healthcare Insurance Co., et al., No. 18-15631, D. N.J.).

  • December 10, 2019

    Judge: Medical Transport Prevails Against Authorization, Necessity Arguments

    CHICAGO — Only a health plan’s participating providers must obtain preauthorization for nonemergency transport, and absent evidence of a closer qualified provider, there exists no reason to conclude that air transport to the facility in question was not medically necessary, a federal judge in Illinois held Nov. 26 (Aviation West Charters LLC v. Health and Welfare Plan for Employees of Anjinomoto USA Inc., et al., No. 18-7431, N.D. Ill., 2019 U.S. Dist. LEXIS 204908).

  • December 05, 2019

    Judge Orders Insurer To Turn Over Documents In Mental Health Coverage Spat

    SALT LAKE CITY — A health insurer and plan must produce documents related to an insured’s mental health treatments and how they determine medical necessity in that setting as well as surgical settings, a federal judge in Utah said Dec. 2 in reserving rulings on motions to dismiss and to amend a complaint (James C., et al. v. Anthem Blue Cross and Blue Shield, No. 19-38, D. Utah).

  • November 26, 2019

    Judge Finds Standing But Not Sufficient Allegations In Parity Act Case

    SALT LAKE CITY — Debts incurred when a health insurer denied coverage for a child’s treatments provide the parents with standing, but their attempts to recover the amount through the Mental Health Parity and Addiction Act rely on conclusory statements and are better addressed by the Employee Retirement Income Security Act, a federal judge in Utah said Nov. 21 (John R., et al. v. United Behavioral Health, et al., No. 18-35, D. Utah).

  • November 26, 2019

    Discovery Moves Forward In Health Coverage Spat While Court Considers Judgment

    SALT LAKE CITY — A health insurer cannot avoid discovery in a case alleging that its improperly denied coverage for mental health and substance abuse treatment simply because there is a pending summary judgment motion, a federal magistrate judge held Nov. 21 (Robert L., et al. v. Cigna Health & Life Insurance Co., et al., No. 18-976, D. Utah, 2019 U.S. Dist. LEXIS 202914).

  • November 21, 2019

    Contracted Rate Allegations Escape ERISA Removal, Federal Judge Finds

    NEW ORLEANS — A medical provider’s suit seeking compensation for what it claims are the rates an insurer agreed to pay for insured’s treatments alleges the type of independent obligation separate from the Employee Retirement Income Security Act plan, a federal judge in Louisiana said Nov. 18 (Crescent City Surgical Center v. United Healthcare of Louisiana, et al., No. 19-12586, E.D. La., 2019 U.S. Dist. LEXIS 199009).

  • November 21, 2019

    Disparate Mental Treatment Allegations Satisfy Parity Act Standard, Judge Says

    SALT LAKE CITY — Allegations that a health insurer applied different standards for medical necessity in the mental health realm compared to traditional surgical and medical procedures adequately allege a violation of federal law, a federal judge in Utah said Nov. 18 (Peter E., et al. v. United Healthcare Services Inc., et al., No. 17-435, D. Utah, 2019 U.S. Dist. LEXIS 200603).

  • November 21, 2019

    Judge:  Entering Partial Final Judgment Avoids Injustice In ACA Cost-Sharing Case

    WASHINGTON, D.C. — Seeking to prevent the injustice that would arise from preventing an insurer from collecting post-judgment interest on nearly $18 million to which a court found it was entitled under the Patient Protection and Affordable Care Act (ACA) cost-sharing program for years 2017 and 2018, a federal judge on Nov. 18 granted partial final judgment (Local Initiative Health Authority for L.A. Co, et al. v. The United States, No. 17-1542C, Fed. Clms., 2019 U.S. Claims LEXIS 1779).

  • November 18, 2019

    Parties Settle Health Insurance Payment Spat After Case Survives Dismissal Motion

    PORTLAND, Ore. — A federal judge on Nov. 13 granted in part a motion to stay and extend case deadlines pending a settlement in a case challenging compensation from a health insurer (Dwayne Brandon v. Health Net Health Plan of Oregon Inc., No. 19-356, D. Ore.).

Can't find the article you're looking for? Click here to search the Mealey's Health Care / ACA archive.