Mealey's Health Care / ACA

  • May 11, 2023

    Insurer Granted Summary Judgment In Autism Evidence-Based Insurance Coverage Case

    MADISON, Wis. — A couple has not shown that an insurer’s decision not to cover certain autism spectrum disorder (ASD) treatments deviated from a plan’s evidence-based approach, that its standards were outdated or that it treated mental health treatments differently from similar medical or surgical treatments, a federal judge in Wisconsin said in granting summary judgment to the insurer.

  • May 08, 2023

    Judge: Plaintiffs In ERISA Row Over Cross-Plan Offsetting Lack Standing

    MINNEAPOLIS — Dismissing the first amended complaint (FAC) in an Employee Retirement Income Security Act case without prejudice, a Minnesota federal judge ruled that the plaintiffs failed to plead an injury in fact in the putative class suit over the practice known as “cross-plan offsetting.”

  • May 05, 2023

    Medical Insurers Seek Dismissal Of COVID-Testing Lab’s Reimbursement Claims

    NEWARK, N.J. — In a lawsuit brought by a medical testing laboratory seeking reimbursement for COVID-19 testing from a group of health insurers, the insurers moved to dismiss the laboratory’s amended complaint, contending that the laboratory insufficiently pleaded a cause of action under the Employment Retirement Income Security Act and failed to allege that a valid contract existed between the parties so as to provide for state law causes of action.

  • May 05, 2023

    5th Circuit Affirms Proton Therapy Ruling In Favor Of Throat Cancer Patient

    NEW ORLEANS — Affirming a ruling requiring a health insurer to pay for a throat cancer patient’s proton beam therapy (PBT), a Fifth Circuit U.S. Court of Appeals panel said in an unpublished per curiam opinion that a lower court used the right standard of review and the insurer’s denial of coverage was not supported by substantial evidence.

  • May 04, 2023

    3rd Circuit Affirms Dismissal Of FCA Claims Against AmeriHealth In ACA Dispute

    PHILADELPHIA — The Third Circuit U.S. Court of Appeals on May 3 affirmed a district court’s dismissal of a relator’s suit alleging that AmeriHealth defrauded the federal government in violation of the federal False Claims Act (FCA) by falsely certifying compliance with New Jersey regulations, finding that certifying compliance was not required to receive payment for health insurance plans listed on New Jersey’s federally operated exchange pursuant to the Patient Protection and Affordable Care Act (ACA).

  • May 03, 2023

    Judge Remands Insurance Payment Spat For Clarification Of Methodology

    TRENTON, N.J. — An insurance company never referenced the gap methodology it now claims it used in determining an autism-care provider’s reimbursement, leaving the court “at a loss” for how it could conclude that the rate was reasonable, a federal judge in New Jersey said in remanding the Employee Retirement Income Security Act case to the administrator for clarification.

  • May 02, 2023

    ACA Asbestos Program Suit Parties Parry Bid To Quash Subpoenas To U.S. Agencies

    MISSOULA, Mont. — The United States says in a motion to quash that an agency already produced almost all the information two subpoenas seek and that further searches into whether a medical facility meets the criteria for “qualified physicians” under a special Patient Protection and Affordable Care Act program involving Libby, Mont., asbestos exposures “will simply waste time while yielding ever diminishing returns.” But in a joint response, the parties in the federal litigation in Montana say the subpoenas are not burdensome and that to the extent the answers to the subpoena questions are self-evident, the questions should be easy to answer.

  • May 02, 2023

    HIV Group Says Copayment Drug Program Challenge Justiciable

    WASHINGTON, D.C. — A government notice legalizing insurers’ copayment accumulator programs rescinded an existing prohibition on including them in Patient Protection and Affordable Care Act (ACA) copay calculations and “flatly guts” the argument that the issue is not justiciable, a group of plaintiffs told a federal judge in the District of Columbia on May 1.

  • May 01, 2023

    Texas Court: Insurance Arbitration Doesn’t Mandate Data, Detailed Ruling

    FORT WORTH, Texas — Nothing in the arbitration statute governing out-of-network insurance payment disputes mandates that the state database include any specific evidence or that the arbitrator provide a detailed explanation of a decision, a Texas appeals court said in affirming an award.

  • May 01, 2023

    Panel Reverses Dismissal Of UCL Suit For ‘Hidden’ Fee Charged After ER Visit

    FRESNO, Calif. — A California appellate panel on April 28 reversed a trial court’s dismissal of a patient’s putative class action against a medical services provider, which he accused of violating California’s unfair competition law (UCL) for charging him a more than $8,000 undisclosed emergency room fee after finding that the trial court’s dismissal improperly created a “safe harbor” protecting the provider from conduct that was not mandated by state and federal pricing disclosure requirements.

  • May 01, 2023

    Government Seeks Stay Of ACA Preventive Care Ruling Pending Appeal

    NEW ORLEANS — Various U.S. government officials and a group of amici curiae asked the Fifth Circuit U.S. Court of Appeals to stay the nationwide vacatur of the Patient Protection and Affordable Care Act (ACA)’s preventive care mandate pending appeal, saying undoing more than a decade’s worth of action ensuring cost-effective access to health care lacks legal justification and threatens public health.

  • April 28, 2023

    Joint Status Report Filed In Risk-Corridor Dispute Involving Insolvent Insurers

    WASHINGTON, D.C — The federal government and a subclass member filed a joint status report in liquidated insurers’ suit seeking a declaratory judgment that the government owes insurers millions of dollars under the Patient Protection and Affordable Care Act (ACA) risk-corridor program, with the parties not disputing the amounts owed but the type of judgment to be entered against the subclass member.

  • April 26, 2023

    Justice: Insurer’s Undisclosed Coverage Standards Permit Breach Of Contract Claim

    ROCHESTER, N.Y. — Allegations that an insurer essentially eliminated the possibility of receiving medically necessary care at an otherwise approved residential treatment center by relying on undisclosed standards supports a breach of contract claim, a justice in New York said in denying the insurer’s motion.

  • April 26, 2023

    1st Circuit Affirms That TPA Is Not A Functional Fiduciary, Avoids Assets Question

    BOSTON — In an April 25 opinion upholding a ruling that the third-party administrator (TPA) of a self-funded health plan was not a functional fiduciary under the Employee Retirement Income Security Act, a First Circuit U.S. Court of Appeals panel did not decide a question it said “the parties and their amici vigorously dispute” — “whether the working capital amount remained a Plan asset once paid to” the TPA.

  • April 26, 2023

    California Court Revives UCL Mental Health Coverage Claims Against Kaiser

    SAN FRANCISCO — Allegations that individuals paid for mental health insurance coverage they couldn’t access as a result of Kaiser Foundation Health Plan Inc.’s policy of underfunding its integrated providers successfully establishes a nontrivial injury sufficient for standing under the California unfair competition law (UCL), a state appellate court said in also reversing summary judgment on April 25 on Parity Act and Unruh Act claims.

  • April 24, 2023

    Advocacy Group Defends Drug Co-Pay Programs As Balancing Marketplace

    WASHINGTON, D.C. — Co-pay accumulator programs mitigate the marketing and profits effects drug manufacturers reap from co-pay coupons and return the market to status quo, America’s Health Insurance Plans says in an amicus curiae brief to a federal court in the District of Columbia.

  • April 24, 2023

    Insurer: ERISA Rehearing Arguments ‘Overblown,’ Reprocessing Ruling Proper

    SAN FRANCISCO — An insurer told a Ninth Circuit U.S. Court of Appeals panel that the plan required only that any covered procedure qualify as a generally accepted level of medical care and did not require coverage of all such procedures and that the court’s rejection of reprocessing of claims as futile recognized existing law and did not eliminate reprocessing as a remedy under the Employee Retirement Income Security Act.

  • April 20, 2023

    Assignee: Contract Claims Survive Preemption; Fee Forgiveness Evidence Lacking

    SANTA ANA, Calif. — State law claims alleging that an insurer made payment promises escape preemption under the Employee Retirement Income Security Act, the insurer produced next to no evidence for why it believed the provider was conducting a fee forgiveness scheme and the company’s contention that the majority of the 106 plans at issue were self funded suggests that at least some were fully funded, an assignee tells the Ninth Circuit U.S. Court of Appeals in an opening brief.

  • April 19, 2023

    Insurer Says Insured Has No Grounds To Challenge Mental Health Claim Denials

    PASADENA, Calif. — An insurer told the Ninth Circuit U.S. Court of Appeals that a man never alleged improper denial of benefits because he cannot point to any plan provision requiring coverage of his mental health and substance abuse claims and so instead recast his case as one seeking equitable relief.

  • April 19, 2023

    Parties Discuss 8 Cases, Advance Arguments In ACA Reinsurance Row

    WASHINGTON, D.C. — Notable filings in a U.S. Court of Federal Claims case over the Transitional Reinsurance Program (TRP) of the Patient Protection and Affordable Care Act (ACA) include a status report outlining the parties’ positions on eight similar suits commenced in the last few months by entities that say they are SISAs — self-insured, self-administered employee health and welfare benefit plans.

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