TAMPA, Fla. — Employee Retirement Income Security Act health care plan benefits permit a husband to sue an insurer for denying proton beam therapy for his covered and dependent wife, a federal judge in Florida said July 17 in denying a partial motion to dismiss (Doug Heckman, et al. v. United Healthcare Insurance Co., No. 20-39, M.D. Fla., 2020 U.S. Dist. LEXIS 126223).
SEATTLE — Having actively litigated a case in federal court including the key issue of whether they offer a Health Care Sharing Ministry that is exempt from state and federal law under the Patient Protection and Affordable Care Act (ACA), defendants may not now seek to compel arbitration, a federal judge in Washington state said July 20 (Gerald Jackson, et al. v. The Aliera Companies Inc., et al., No. 19-1281, W.D. Wash., 2020 U.S. Dist. LEXIS 127445).
NEW YORK — New York's unapproved alteration to the Patient Protection and Affordable Care Act (ACA) risk-corridor program impermissibly interferes with and even reverses criteria for fund transfers in the program, a Second Circuit U.S. Court of Appeals panel said July 20 in partially reversing (UnitedHealthcare of New York Inc., et al. v. Linda Lacewell, et al., No. 18-2583, 2nd Cir.).
WASHINGTON, D.C. — The Patient Protection and Affordable Care Act (ACA) permits an agency rule expanding the availability of short-term duration plans, a divided District of Columbia Circuit U.S. Court of Appeals held July 17 (Association for Community Affiliated Plans, et al. v. United States Department of Treasury, et al., No. 19-5212, D.C. Cir.).
PHILADELPHIA — An out-of-network medical provider’s breach of contract and promissory estoppel claims are adequately pleaded and avoid preemption under the Employee Retirement Income Security Act, but its unjust enrichment claim requires the court to rely on the plan and may not proceed, a Third Circuit U.S. Court of Appeals panel said July 17 in deciding for the first time what right to recovery out-of-network providers have (The Plastic Surgery Center P.A. v. Aetna Life Insurance Co., No 18-3381, The Plastic Surgery Center P.A. v. Aetna Health Inc., No. 18-3556, 3rd Cir., 2020 U.S. App. LEXIS 22274).
SEATTLE — A pair of individuals with hearing loss have not shown that a health insurer’s near blanket exclusion on hearing-related treatments constitutes discrimination under the Patient Protection and Affordable Care Act (ACA), but they should be permitted to amend their action, the Ninth Circuit U.S. Court of Appeals held July 14 (Andrea Schmitt, et al. v. Kaiser Foundation Health Plan of Washington, et al., No. 18-35846, 9th Cir., 2020 U.S. App. LEXIS 21902).
BALTIMORE — Maryland’s insurance department did not err in concluding that the evidence supported an insurer’s decision not to cover substance abuse treatments, and the insured cannot now seek partial payment at a rate for outpatient treatment, a Maryland appellate panel said June 17 (United Behavioral Health v. J.D.S, et al., No. 527 September Term 2019, Md. Spec. App., 2020 Md. App. LEXIS 596).
SALT LAKE CITY — Plaintiffs’ claims that a health insurer imposes short-term stays and more stringent care guidelines for residential treatment centers than it does in other medical settings adequately allege a Parity Act violation, even where the plan itself does not facially create such a disparity, a federal judge in Utah said June 24 in declining to dismiss the action (James C., et al. v. Anthem Blue Cross and Blue Shield, No. 19-38, D. Utah, 2020 U.S. Dist. LEXIS 111689).
WASHINGTON, D.C. — A bill calling for $100 billion for state reinsurance programs designed to enhance Patient Protection and Affordable Care Act (ACA) protections and encourage state adoption of the Medicaid expansion passed the U.S. House of Representatives on June 29 on a 234-179 vote.
ST. LOUIS — The Patient Protection and Affordable Care Act (ACA) mandates that insurers cover out-of-network lactation services if they do not offer in-network care, but nothing in the law requires them to expand their networks or provide a list of services offered by each covered provider, the Eighth Circuit U.S. Court of Appeals said July 13 (Jillian York, et al. v. Wellmark Inc., et al., No. 19-1705, 8th Cir.).
BALTIMORE — A Health and Human Services rule requiring insurers to bill premiums for abortion services separately violates the Patient Protection and Affordable Care Act (ACA) prohibition on erecting barriers to care and is arbitrary and capricious, a federal judge in Maryland held July 9 in enjoining the rule (Planned Parenthood of Maryland Inc., et al. v. Alex M. Azar II, et al., No. 20-361, D. Md., 2020 U.S. Dist. LEXIS 121163).
MIAMI — A drug rehabilitation facility’s now abandoned claim that it represents patients in a suit against an insurer resulted in years of costly litigation, but more problematic is the fact that it does not appear to have the power to bring suit at all, a federal judge in Florida said June 30 (Chiron Recovery Center LLC, et al. v. United Healthcare Services Inc., et al., No. 18-81761, S.D. Fla., 2020 U.S. Dist. LEXIS 114353).
SALT LAKE CITY — A provider’s appeal lacked the necessary approval from the insured, and the period for appeals expired before they remedied the flaws, a federal judge in Utah said July 6 in granting judgment in an Employee Retirement Income Security Act case (C.L., et al. v. Newmont USA Limited, et al., No. 18-192, D. Utah).
WASHINGTON, D.C. — The Patient Protection and Affordable Care Act (ACA) granted government agencies “virtually unbridled discretion” over what constitutes preventive care, including the power to issue exemptions for religious and moral objectors to the law’s contraceptive mandate, the U.S. Supreme Court said July 8 in a 7-2 opinion, reversing the Third Circuit and dissolving a nationwide injunction (Little Sisters of the Poor Saints Peter and Paul Home v. Pennsylvania, et al., Donald J. Trump, et al. v. Pennsylvania, Nos. 19-431, 19-454, U.S. Sup.).
FAIRFAX, Va. — Virginia law requiring insurers to pay for emergent care includes a private right of action allowing a provider to sue a patient’s insurer, a Virginia state judge said June 30 (Dominion Surgical Specialties LLC v. Anthem Healthkeepers Inc., No. CL-2019-0010310, Va. Cir., Fairfax Co., 2020 Va. Cir. LEXIS 87).
LOS ANGELES — A federal judge in California on June 30 granted final approval of a California unfair competition law class action settlement resolving claims that patients who visited in-network hospitals were subject to balance billing after receiving treatment from out-of-network providers (Renee MacLaughlan Bozarth, et al. v. Envision Healthcare Corp., et al., No. 17-1935, C.D. Calif., 2020 U.S. Dist. LEXIS 117294).
NEW ORLEANS — A woman who won a “procedural” victory in a federal appeal over an insurer’s partial denial of coverage for hospitalization to treat an eating disorder will have to score a win on the merits of her claim before she seeks an attorney fee award for the cost of that appeal, a panel of the Fifth Circuit U.S. Court of Appeals ruled June 29 (Katherine P. v. Humana Health Plan, Inc., No. 19-50276, 5th Cir., 2020 U.S. App. LEXIS 20404).
SALT LAKE CITY — A magistrate judge did not err in granting discovery into Parity Act and Employee Retirement Income Security Act document production issues in a residential treatment case, a federal judge in Utah said June 26 (Jane Doe v. Intermountain Healthcare Inc., et al., No. 18-00807, D. Utah, 2020 U.S. Dist. LEXIS 112772).
WASHINGTON, D.C. — Absent a tax on those who fail to comply with the Patient Protection and Affordable Care Act (ACA) individual mandate, the logic upholding the provision fails, and the entire law falls as a result, the administration told the U.S. Supreme Court in a June 25 brief (California, et al. v. Texas, et al, No. 19-840, United States House of Representatives v. Texas, et al., No. 19-841, U.S. Sup.).
WASHINGTON, D.C. — The novel coronavirus poses the type of “exceptional circumstance” requiring that Patient Protection and Affordable Care Act (ACA) health care insurance exchanges be opened for a special enrollment period, California and 13 other states tell a federal judge in the District of Columbia in a June 22 amicus curiae brief (Chicago v. Alex M. Azar II, et al., No. 20-1566, D. D.C.).