Mealey's Health Care / ACA

  • April 09, 2021

    Georgia Court To Decide Whether Filed-Rate Doctrine Bars Insurance Plan Fraud Case

    ATLANTA — The Georgia Court of Appeals on March 31 agreed to decide whether the filed-rate doctrine precludes claims that an insurer fraudulently inflated its in-network provider list for Patient Protection and Affordable Care Act (ACA)-compliant plans.

  • April 07, 2021

    High Court Asked Whether ACA Allows Disparate Impact Discrimination Claim

    SAN FRANCISCO — The U.S. Supreme Court on April 5 gave respondents until June 1 to respond to a pharmacy benefit manager’s petition asking whether the Patient Protection and Affordable Care Act (ACA) and the discrimination statutes from which it borrows permit a disparate impact cause of action for a class action challenging the company’s policy of offering preferred rates only for mail order delivery of HIV/AIDS drugs.

  • March 31, 2021

    Judge:  ERISA Dooms State Law Behavioral Health Claims; Federal Claims Also Fall

    SAN JOSE, Calif. — Patients and not behavioral health providers are the directly injured party in a suit alleging racketeering and antitrust claims, and because sorting out the proper payment necessarily invokes Employee Retirement Income Security Act plans, conflict preemption dooms the state law claims, a federal in California said March 29 in dismissing a suit seeking in excess of a million dollars in allegedly uncompensated care.

  • March 31, 2021

    Proton Beam Therapy Implied Covenant Claims Against Employer Fail

    TAMPA, Fla. — A man seeking reimbursement for his proton beam therapy establishes that an employer retained final authority over appeals but points to nothing in the plan suggesting that the employer retained control over what the plan considered medically necessary or labeled as experimental or investigational, a federal judge in Florida said March 26 in dismissing a breach of implied covenant of good faith and fair dealing claim.

  • March 29, 2021

    Judge Reverses Mental Health Coverage Denial, Citing Procedural Violations

    SALT LAKE CITY — By repeatedly citing only the medical necessity of mental health treatments while failing to address substance abuse issues or the difference between acute and subacute levels of care an insurer violated its obligations under the Employee Retirement Income Security Act, a federal judge in Utah said March 24 in reversing and remanding the case for a proper claims process.

  • March 29, 2021

    Court:  Discrimination Case Arises Under ACA; 4-Year Statute Of Limitations Applies

    NEW YORK — The federal catchall four-year statute of limitations applies to a woman’s discrimination claim against a hospital because it is the Patient Protection and Affordable Care Act (ACA) that imposes the obligations at issue, even though the statute also borrows from other laws, a Second Circuit U.S. Court of Appeals panel said March 24 in vacating a lower court ruling.

  • March 22, 2021

    Judge: Residential Treatment Claims Against Insurer Fail ERISA, Parity Act Tests

    COLUMBIA, S.C. — A self-funded health insurance plan did not abuse its discretion when it denied coverage for residential treatments under the Employee Retirement Income Security Act, and its requirement that an individual needs 24-hour care to qualify does not treat mental health care differently than similar surgical and medical care, a federal judge in South Carolina said March 17 in granting the insurer judgment.

  • March 19, 2021

    Parties: Intervention Moot In Soon-To-Be-Dismissed Title X, ACA Regulation Spat

    WASHINGTON, D.C. — Petitioners to a challenge targeting Title X abortion rules and Patient Protection and Affordable Care Act (ACA) regulations told the U.S. Supreme Court March 18 their stipulated dismissal leaves no case in which to intervene and urged the court deny such motions by various states and pro-life groups.

  • March 19, 2021

    North Dakota Air Ambulance Law Not Insurance Related, Preempted, 8th Circuit Says

    ST. LOUIS — North Dakota law banning balance billing and subscription services by air ambulance providers are not related to the business of insurance and are preempted by the Airline Deregulation Act, an Eighth Circuit U.S. Court of Appeals said March 17 in ordering judgment for the company.

  • March 18, 2021

    Insurer Prevails On ERISA, Parity Act Claims; ACA Autism Therapy Claim Proceeds

    INDIANAPOLIS — An insurance plan’s blanket exclusion on autism treatments dooms both facial and as-applied challenges under the Employee Retirement Income Security Act and Parity Act, but because a health care provider who receives federal funds offers the self-funded plan, the discrimination claim brought under the Patient Protection and Affordable Care Act (ACA) may proceed, a federal judge in Indiana said March 16 in partially granting judgment to the defendants.

  • March 17, 2021

    ACA Impact Foreseen, Hospital Charity Care Mandate Proper, Court Says

    SACRAMENTO, Calif. — The Patient Protection and Affordable Care Act’s (ACA) reduction in the number of uninsured was foreseen in 2010 when California and a health care company attached charity care conditions to the sale of a hospital and the state did not err in declining to modify the requirement, a California appeals court said in affirming denial of a petition for writ of administrative mandamus March 15.

  • March 16, 2021

    Federal Judge: Deficiencies Require Vacating Some ACA Marketplace Rules

    BALTIMORE — A federal judge in Maryland on March 3 found rules governing review of marketplace health plans and calculations over taxes and premiums under the Patient Protection and Affordable Care Act (ACA) flawed and said the agency’s actions are so deficient as to require vacatur.

  • March 16, 2021

    Insurers Want High Court Review Of ACA Ruling Reducing Cost-Sharing Payments

    WASHINGTON, D.C. — Appellate court rulings permitting the government to reduce its Patient Protection and Affordable Care Act (ACA) cost-sharing obligations through other payments violates recent U.S. Supreme Court precedent addressing an identical statutory mandate, two insurers tell the nation’s top court in Feb. 24 petitions for writ of certiorari.

  • March 15, 2021

    Anti-Assignment Clause Bars Breast Reconstruction Payment Suit, Judge Says

    NEWARK, N.J. — A medical plan’s anti-assignment provision precludes a provider’s lawsuit, and rules governing the ability of a representative to pursue claims apply only to internal appeals, not federal lawsuits, a federal judge in New Jersey said March 4 in granting dismissal.

  • March 15, 2021

    Insurer An ERISA Fiduciary; Parity Act Claims Survive, Judge Says

    OAKLAND, Calif. — An insurer’s ability to make benefits decision qualifies it as a fiduciary, and the plan’s exclusion of primary treatment options for autism violates the Parity Act, a federal judge in California said March 5 in largely adopting the plaintiffs’ summary judgment arguments in an Employee Retirement Income Security Act case.

  • March 15, 2021

    Judge Says RICO Claim Survives Dismissal In Outpatient Payment Suit

    LOS ANGELES — Plaintiffs allege that a health care cost management company was a co-schemer in a campaign designed to mislead providers and pay the lowest amounts possible and cannot escape Racketeer Influenced and Corrupt Organizations Act claims by attempting to differentiate and separate its conduct, a federal judge in California said March 11 in denying a motion to dismiss.

  • March 15, 2021

    Judge: Parity Act Challenge To Medical Necessity Drug Treatment Denials Proceeds

    INDIANAPOLIS — Allegations that an insurer singles out mental health care for presumptive denials based on medical necessity support a Parity Act claim, but the insured’s death warrants dismissing injunctive relief claims, a federal judge in Indiana said March 11.

  • March 12, 2021

    Federal Judge Remands Contract Breach, UCL Claims That Don’t Derive From ERISA

    LOS ANGELES — A California federal judge on March 2 remanded an addiction treatment provider’s complaint against an insurer for breach of contract and violations of California’s unfair competition law (UCL) to state court after finding that the suit was improperly removed because the provider’s claims could not have been brought under the Employee Retirement Income Security Act.

  • March 10, 2021

    Insolvent Insurers: Government Reverse-Preempted From Seeking Setoffs Of Debts

    WASHINGTON, D.C. — A dispute subclass of insolvent insurers on Feb. 26 reiterated their argument asking the U.S. Court of Federal Claims to dismiss the U.S. government’s counterclaims for setoff, breach of statutory and regulatory duties, arguing that the government is reverse-preempted under the McCarran-Ferguson Act from seeking setoffs of debts against risk-corridor liabilities owed to the insurers under the Patient Protection and Affordable Care Act (ACA) risk corridor.

  • March 09, 2021

    Medicaid-ACA Actuarial Fee Case Untimely, Unsuccessful, 5th Circuit Says

    NEW ORLEANS — States’ Administrative Procedure Act claim to a 2002 Medicaid actuarial soundness rule is untimely, there was nothing unlawful about the Patient Protection and Affordable Care Act (ACA) delegating authority to a private entity and constitutional challenges to the ACA rule fail, a Fifth Circuit U.S. Court of Appeals panel said Feb. 21 in partially affirming lower court rulings after a petition for rehearing.

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