Mealey's Health Care / ACA

  • August 12, 2019

    Women:  Insurer Can’t Create Barriers To ACA-Mandated Lactation Services

    ST. LOUIS — The Patient Protection and Affordable Care Act (ACA) cannot simultaneously require coverage for lactation services while permitting insurers to place administrative barriers that make obtaining that care impossible, two women tell the Eighth Circuit U.S. Court of Appeals in an Aug. 7 reply brief (Jillian York, et al. v. Wellmark Inc., et al., No. 19-1705, 8th Cir.).

  • August 08, 2019

    Mental Health Treatments Weren’t Medically Necessary, Judge Finds

    BOSTON — Even on the expanded record required by the First Circuit U.S. Court of Appeals, the evidence does not support the conclusion that a woman’s residential mental health treatments met the definition of medically necessary care, a federal judge in Massachusetts held Aug. 7 (Jane Doe v. Harvard Pilgrim Health Care Inc., et al., No. 15-10672, D. Mass.).

  • August 07, 2019

    Judge: Failure To Cure Communication Issues Keeps Couple’s Case Alive

    PHOENIX — Allegations that hospital defendants repeatedly ignored or redirected a couple’s requests for an interpreter, rendering communication impossible, support claims for discrimination under the Patient Protection and Affordable Care Act (ACA) and other federal laws, a federal judge in Arizona held in an order granting summary judgment entered Aug. 6 (Daniel Bustos, et al. v. Dignity Health, et al., No. 17-2882, D. Ariz., 2019 U.S. Dist. LEXIS 129969).

  • August 06, 2019

    Judge Dismisses Emergency Air Transport Benefit Claims

    NEW HAVEN, Conn. — Claims seeking payment for emergency air ambulance transport between Puerto Rico and Florida from a host insurer are misdirected, lack evidence that the defendants intentionally induced conduct or are preempted, a federal judge in Connecticut held Aug. 5 in dismissing them (Estate of Carol A. Kenyon v. L+M Healthcare Health Reimbursement Account, et al., No. 19-93, D. Conn.).

  • August 02, 2019

    Lack Of Preauthorization Dooms Mental Health Coverage Case, Judge Says

    SALT LAKE CITY — Failure to adequately follow an insurer’s procedures for obtaining out-of-network coverage dooms a suit seeking benefits covering a mental health treatment facility, a federal judge in Utah held July 25 (Robert O., et al. v. Harvard Pilgrim Health Care Inc., et al., No. 17-1251, D. Utah).

  • July 26, 2019

    Judge: Hospital’s Efforts At Meeting Needs Doom Discrimination Claims

    CHARLOTTE, N.C. — A deaf man’s discrimination claims fail where there is evidence that the medical facility attempted to meet his needs, and the claims’ demise also dooms his Patient Protection and Affordable Care Act (ACA) claim, a federal judge in North Carolina held July 23 (Neil Basta v. Novant Health Inc., et al., No. 19-64, W.D. N.C.).

  • July 25, 2019

    Insurer Calls On Court To Reject Reconsidering Sleep Center Ruling

    TRENTON, N.J. — Though unhappy with a court’s conclusion that the Employee Retirement Income Security Act and an anti-assignment provision squelch most of its suit, a health care provider offers no new evidence and is stuck with the ruling, an insurer told a federal judge in New Jersey July 22 (Sleep Tight Diagnostic Center, et al. v. Aetna Inc., et al., No. 18-3556, D. N.J.).

  • July 25, 2019

    8th Circuit Crashes Air Transport Provider’s ERISA Reimbursement Suit

    ST. LOUIS — A patient did not assign Employee Retirement Income Security Act equitable relief rights to an emergency air transport provider, and nothing in the allegations requires that the insurer pay the full bill, an Eighth Circuit U.S. Court of Appeals panel held July 23 (Air Evac EMS Inc. v. USAble Mutual Insurance Co., et al., No. 18-2264, 8th Cir., 2019 U.S. App. LEXIS 21938).

  • July 23, 2019

    ERISA Claims For Benefits, Equitable Relief Proceed In Residential Treatment Case

    BOSTON — Whether a health plan covers an adolescent’s residential treatment requires a deeper dive into the facts, a federal judge in Massachusetts said July 19 in permitting an Employee Retirement Income Security Act benefit claim and saying dismissing the equitable relief at this stage of the litigation was premature (Brent S., et al. v. Blue Cross Blue Shield of Massachusetts Inc., No. 17-11569, D. Mass., 2019 U.S. Dist. LEXIS 120415).

  • July 23, 2019

    Judge Largely Grants Aetna’s Motion To Dismiss Sleep Center’s Suit

    TRENTON, N.J. — A sleep study provider’s claims are largely preempted by the Employee Retirement Income Security Act, and there is insufficient evidence that the insurer’s conduct waived anti-assignment provisions, a federal judge in New Jersey held June 28 (Sleep Tight Diagnostic Center, et al. v. Aetna Inc., et al., No. 18-3556, D. N.J.).

  • July 23, 2019

    Judge: ERISA, Parity Act Claims Survive, But Not ACA Discrimination Claim

    SAN FRANCISCO — Allegations that an insurer improperly reduced reimbursement rates in the mental health context largely support a woman’s claims invoking the Employee Retirement Income Security Act and federal law, but she cannot avoid that the Patient Protection and Affordable Care Act (ACA) leaves enforcement of an anti-discrimination provision to the government, a federal judge in California held July 18 (Jane Smith v. United Healthcare Insurance Co., No. 18-6336, N.D. Calif., 2019 U.S. Dist. LEXIS 120151).

  • July 23, 2019

    Citing Lack Of ERISA Claims, Judge Sends Surgery Provider’s Suit To State Court

    TRENTON, N.J. — An anti-assignment provision prevents a surgery provider from becoming an Employee Retirement Income Security Act beneficiary, and nowhere does it allege a colorable claim under the law, a federal judge in New Jersey said July 16 in adopting a magistrate judge’s report and recommendation (East Coast Advanced Plastic Surgery v. Blue Cross Blue Shield of Texas, et al., No. 19-6175, D. N.J.).

  • July 22, 2019

    Judge:  ACA Short-Term Plan Rule Survives Summary Judgment

    WASHINGTON, D.C. — Rules expanding short-term limited duration health plans do not exceed agency authority and do not conflict with the Patient Protection and Affordable Care Act (ACA), a federal judge in the U.S. District Court for the District of Columbia said July 19 (Association for Community Affiliated Plans, et al. v. United States Department of Treasury, et al., No. 18-2133, D. D.C., 2019 U.S. Dist. LEXIS 120834).

  • July 19, 2019

    Supreme Court Wants Response In Medicaid Fair Hearing Challenge

    WASHINGTON, D.C. — Months after the defendants waived their right to respond to a petition for certiorari and the case was set for conference, the U.S. Supreme Court on July 18 asked for a response in a case challenging an insured’s right to a hearing under Medicaid (Lettie Sexton, et al. v. Commonwealth of Kentucky, et al., No. 18-1446, U.S. Sup.).

  • July 19, 2019

    Federal Judge Denies Injunction In Title X, Abortion Rule Challenge

    PORTLAND, Maine — Federal rules requiring separation between Title X services and abortion services remain in place after a federal judge in Maine denied an injunction on July 3, while suggesting that although he didn’t believe the policy made much sense, it was not his place to play “Oracle of Delphi heroically saving the republic” (The Family Planning Association of Maine, et al. v. United States Department of Health and Human Services, et al., No. 19-100, D. Maine, 2019 U.S. Dist. LEXIS 111164)

  • 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.).

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