Mealey's Health Care / ACA

  • November 09, 2020

    Judge Says Insurer Took Too Narrow A View In Denying Health Coverage

    BOZEMAN, Mont. — An insurer rigidly applied narrow guidelines and ignored a woman’s complicated and interconnected mental health issues in denying coverage for her treatment, a federal judge in Montana said Nov. 5 in granting the woman summary judgment on Employee Retirement Income Security Act claims (Jessica U. v. Health Care Service Corp., et al., No. 18-5, D. Mont., 2020 U.S. Dist. LEXIS 207277).

  • November 09, 2020

    Judge Finds Labs Didn’t Exhaust Remedies, Grants Judgment On ERISA Claims

    DALLAS — Out-of-network labs that performed testing for in-network hospitals relied on the appellate process for providers but, because they proceed under an assignment of rights, have not shown that they exhausted the administrative procedure for patients, a federal judge in Texas held Nov 4 in granting summary judgment on Employee Retirement Income Security Act claims but denying tortious interference claims against the labs (Mission Toxicology LLC, et al. v. UnitedHealthcare Insurance Co., et al., Nos. 17-1016, 18-347, W.D. Texas, 2020 U.S. Dist. LEXIS 205919, 2020 U.S. Dist. LEXIS 205927).

  • November 06, 2020

    Judge Won’t Force Government To Produce Record In LGBTQ ACA Rule Challenge

    WASHINGTON, D.C. — A federal judge in the District of Columbia on Nov. 3 said he would not order production of the administrative record in a case challenging rule making surrounding the definition of discrimination under the Patient Protection and Affordable Care Act (ACA), but said he would deny any portion of a pending motion to dismiss that required the record for resolution (Whitman-Walker Clinic, et al. v. U.S. Department of Health and Human Services, et al., No. 20-1630, D. D.C.).

  • November 05, 2020

    Insurer’s Position ‘Impossible To Defend,’ Under Plan, Judge Says

    SALT LAKE CITY — A health insurer’s denial of coverage based on the lack of precertification for the residential treatment services ignores plan language permitting only a $300 reduction in benefits where the claim is coverable but lacks precertification, a federal judge in Utah said Oct. 30 in remanding Employee Retirement Income Security Act claims for a full and fair review (James C., et al. v. Aetna Health and Life Insurance Co., et al., No. 18-717, D. Utah, 2020 U.S. Dist. LEXIS 203053).

  • November 04, 2020

    Magistrate Orders Broad Reprocessing Of ERISA Plaintiffs’ Mental Health Claims

    SAN FRANCISCO — Plaintiffs improperly denied mental health Employee Retirement Income Security Act benefits are entitled to reprocessing of claims — including individuals who never sought post-denial services and those who did and paid out of pocket — and on remand the insurer may rely only on the reasons stated in the original denial, a federal magistrate judge in California said Nov. 3 while largely denying the insurer summary judgment and its motion to decertify three classes (David Wit, et al. v. United Behavioral Health, No. 14-2346, Gary Alexander, et al. v. United Behavioral Health, No. 14-5337, N.D. Calif., 2020 U.S. Dist. LEXIS 205435, 2020 U.S. Dist. LEXIS 205429).

  • November 03, 2020

    ‘Georgia Access Model,’ Reinsurance Program Given Stamp To Replace ACA Market

    WASHINGTON, D.C. — The Centers for Medicare and Medicaid Services (CMS) on Nov. 1 approved the state of Georgia’s health insurance plan, which includes the implementation of a reinsurance program and lowering of individual marketplace insurance premiums, to change how its residents can buy health insurance.

  • November 03, 2020

    Government Asks For Debt Setoffs From Insolvent Insurers In ACA Risk-Corridor Case

    WASHINGTON, D.C. — The government in an Oct. 30 amended answer and counterclaim filed in the U.S. Court of Federal Claims seeks setoffs against risk-corridor liabilities it owes to largely insolvent insurers under the Patient Protection and Affordable Care Act (ACA) risk corridor (Health Republic Insurance Co. v. United States, No. 16-259C, Fed. Clms.).

  • November 02, 2020

    ERISA’s Broader Application Preempts Out-Of-Network Contract Case, Judge Says

    PHOENIX — A provider of addiction and behavioral services relies on outdated precedent, ignoring that federal courts now more broadly apply preemption in Employee Retirement Income Security Act cases, a federal judge in Arizona said Oct. 27 in granting dismissal (The Meadows of Wickenburg Inc., et al. v. United HealthCare Insurance Co., et al., No. 20-1285, D. Ariz., 2020 U.S. Dist. LEXIS 201997).

  • November 02, 2020

    Government Appeals Adverse Ruling In LBGTQ ACA Rule Case

    WASHINGTON, D.C. — The federal government on Oct. 31 indicated that it would appeal a ruling finding plaintiffs have standing to challenge a new rule interpreting the Patient Protection and Affordable Care Act (ACA) and are likely to prevail on claims challenging elimination of “sex stereotyping” from the definition of discrimination (Whitman-Walker Clinic, et al. v. U.S. Department of Health and Human Services, et al., No. 20-1630, D. D.C.).

  • November 02, 2020

    High Court Wants Opinion Of Government In ACA Emotional Distress Damages Case

    WASHINGTON, D.C. — The U.S. Supreme Court on Nov. 2 sought the opinion of the government in a case weighing the availability of emotional distress damages in a Patient Protection and Affordable Care Act (ACA) discrimination case in an order asking the solicitor general to file a brief (Jane Cummings v. Premier Rehab Keller PLLC, et al., No. 20-219, U.S. Sup.).

  • October 30, 2020

    Judge Denies Both Parties Judgment In Deaf Man’s ACA Discrimination Case

    LAS VEGAS — Questions remain about whether a hospital effectively communicated with a deaf individual suffering from two broken wrists and whether any failure to do so constituted deliberate indifference, a federal judge in Nevada said Oct. 27 in declining to grant judgment in a Patient Protection and Affordable Care Act (ACA) discrimination case (Irven Wade v. University Medical Center of Southern Nevada, No. 18-1927, D. Nev., 2020 U.S. Dist. LEXIS 200222).

  • October 29, 2020

    California Fines Blue Cross $1.2M Over Transgender Coverage Failures

    SACRAMENTO, Calif. — The California Department of Managed Care (DMHC) said in an Oct. 28 announcement that it has imposed fines of $1,205,000 on Blue Cross of California Partnership Plan Inc. for failing to make timely payments on two transgender-related procedures found to be medically necessary on appeal.

  • October 27, 2020

    Transgender Teens Challenge Arizona Surgery Exclusion Rule Under ACA

    PHOENIX — Arizona law excluding coverage for male chest reconstruction surgery discriminates against transgender individuals and violates the Patient Protection and Affordable Care Act (ACA), plaintiffs tell a federal judge in the state in an Oct. 26 reply brief in support of a preliminary injunction (D.H., et al. v. Jami Snyder, et al., No. 20-335, D. Ariz.).

  • October 23, 2020

    ACA ‘Prudent Layperson,’ ERISA Suit Revived By 11th Circuit

    ATLANTA — Medical provider advocates adequately plead standing in an Employee Retirement Income Security Act case challenging whether an insurer’s diagnostic-code based coverage system meets the Patient Protection and Affordable Care Act (ACA)’s prudent layperson standard, an 11th Circuit U.S. Court of Appeals panel held Oct. 22 in reversing and remanding (American College of Emergency Physicians, et al. v. Blue Cross and Blue Shield of Georgia, et al., No. 20-11511, 11th Cir., 2020 U.S. App. LEXIS 33293).

  • October 22, 2020

    Government Says LBGTQ ACA Rule Challenge Doesn’t Require Record Production

    WASHINGTON, D.C. — A federal judge in the District of Columbia doesn’t need the administrative record to rule on a motion to dismiss claims that a rule excluding the term “on the basis of sex” results in discrimination against LGBTQ individuals, and the plaintiffs have neither alleged standing nor shown that the case is ripe, the government says in a motion to dismiss and Oct. 20 opposition to a motion to compel production of the administrative record (Whitman-Walker Clinic, et al. v. U.S. Department of Health and Human Services, et al., No. 20-1630, D. D.C.).

  • October 19, 2020

    Judge Adopts Report Denying Judgment To Both Parties In Surgery Benefit Case

    HOUSTON — A federal judge in Texas on Oct. 5 adopted a magistrate judge’s report recommending denying two motions for summary judgment in an Employee Retirement Income Security Act case, saying a surgery provider had not demonstrated entitlement to full compensation, but a health care plan had not shown that it properly calculated or explained reimbursement (Woodlands Outpatient Surgical Center, et al. v. America Bureau of Shipping Inc. Employee Benefit Plan, No. 17-1476, S.D. Texas, 2020 U.S. Dist. LEXIS 185882)

  • October 20, 2020

    Amici Fault Imposition Of Contract Mitigation Rule in ACA Cost-Sharing Case

    WASHINGTON, D.C. — A panel’s liability ruling limiting the government’s liability for Patient Protection and Affordable Care Act (ACA) risk-corridor underpayments requires rehearing to correct the decision’s unprecedented importation of contract mitigation principles, insurers tell a federal appeals court in an Oct. 16 amicus curiae brief (Maine Community Health Options v. United States, No. 19-2102, Fed. Cir.).

  • October 19, 2020

    Conflicts Created By ACA Emotional Distress Damages Mandate Review, Woman Says

    WASHINGTON, D.C. — In barring an emotional distress award in a Patient Protection and Affordable Care Act (ACA) discrimination case, the Fifth Circuit U.S. Court of Appeals created conflicts with precedent from other circuits, the Department of Justice’s position and at least four U.S. Supreme Court decisions, a deaf woman argues in an Oct. 14 reply in support of her petition for certiorari review (Jane Cummings v. Premier Rehab Keller PLLC, et al., No. 20-219, U.S. Sup.).

  • October 19, 2020

    Anti-Assignment Provision Bars Physician’s ERISA Suit, Judge Says

    NASSAU, N.Y. — An anti-assignment provision strips a health care provider of standing to bring an Employee Retirement Income Security Act claim, and a second claim for breach of contract fails regardless of whether it is based in state law or ERISA, a federal judge in New York said Sept. 28 in granting a motion to dismiss (Shuriz Hishmeh, et al. v. Horizon Blue Cross Blue Shield of New Jersey, No. 19-4727, E.D. N.Y., 2020 U.S. Dist. LEXIS 185515).

  • October 19, 2020

    Judge: United States May Seek Debt Setoffs In ACA Risk-Corridor Case

    WASHINGTON, D.C. — The government may amend its answer to seek setoffs against risk-corridor liabilities it owes to largely insolvent insurers under the Patient Protection and Affordable Care Act (ACA) risk corridor, a federal judge in the U.S. Court of Federal Claims said Sept. 30 in finding that amendment would be neither untimely nor prejudicial (Health Republic Insurance Co. v. United States, No. 16-259C, Fed. Clms., 2020 U.S. Claims LEXIS 1898).

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