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Mealey's Health Care / ACA

  • October 17, 2018

    Magistrate Judge Won’t Sever Government-Sponsored Plan From Health Care Action

    CENTRAL ISLIP, N.Y. — While the employers, plans and claims differ, a chiropractor’s action seeking compensation for medical care he provided stems from a common health insurance administrator’s reliance on its internal guidelines, a federal magistrate judge in New York held Oct. 12 in denying a motion to sever one of the defendants and recommending that the court deny a motion to dismiss that defendant (Raymond A. Semente, D.C., P.C. v. Empire Healthcare, et al., No. 14-5823, E.D. N.Y., 2018 U.S. Dist. LEXIS 177086).

  • October 16, 2018

    Out-Of-Network Surgery Provider’s Reimbursement Suit Preempted, Judge Says

    TRENTON, N.J. — While brought under state law claims, a surgery provider’s action seeks reimbursement from an ERISA plan, and the fact that a court may have to only quickly reference that plan does not prevent preemption, a federal judge in New Jersey held Sept. 26 (The Plastic Surgery Center, P.A. v. Aetna Life Insurance Co., No. 17-13467, D. N.J., 2018 U.S. Dist. LEXIS 166514).

  • October 16, 2018

    Judge: De Facto Administrator Doctrine Doesn’t Apply To Health Benefits Manager

    MOBILE, Ala. — Precedent clearly limits the de facto administrator doctrine to employers and does not apply in a case naming an ERISA plan’s behavioral health benefits manager, a federal judge in Alabama held Sept. 26 (E.G., et al. v Companion Benefit Alternatives Inc., No. 18-265, S.D. Ala., 2018 U.S. Dist. LEXIS 165204).

  • October 15, 2018

    Judge Reopens Case Challenging Denial Of Coverage For Brand-Name Seizure Medicine

    TRENTON, N.J. — A federal judge on Oct. 10 reopened a case after the plaintiff filed an amended complaint he hopes cures deficiencies in his original complaint alleging that his health insurer improperly denied coverage for his brand-name seizure medication (Scott E. Tellep v. Oxford Health Plans, et al., No. 18-392, D. N.J.).

  • October 11, 2018

    Judge Widens Damages, Narrows Testimony In ACA Transgender Exclusion Case

    MADISON, Wis. — Two transgender individuals may seek damages for psychological pain and suffering they experienced from the alleged blanket discrimination in the form of a health plan’s exclusion for gender confirmation surgery, while the defendants’ past positions limit them to evidence that third-party insurers may have not have found the procedure medically necessary, a Wisconsin federal judge overseeing a Patient Protection and Affordable Care Act (ACA) discrimination case held Oct. 8 (Alina Boyden and Shannon Andrews v. Wisconsin Department of Employee Trust Funds, et al., No. 17-264, W.D. Wis.).

  • October 10, 2018

    Insurers, Law Firm Settle ERISA Case Involving Asbestos Trust Fund Recoveries

    DALLAS — Health insurers and an asbestos litigation firm on Oct. 5 settled a Texas federal court case alleging that the firm withheld bankruptcy trust recoveries to which the Employee Retirement Income Security Act and Medicare insurance plans were contractually entitled for costs associated with treating the firm’s plaintiffs (Humana Inc., et al. v. Shrader & Associates LLP, No. 16-354, S.D. Texas).

  • October 9, 2018

    Hearing Treatment Exclusion Doesn’t Violate ACA, Judge Finds

    SEATTLE — A blanket exclusion on coverage for noncochlear hearing procedures and devices does not discriminate against those with hearing loss, a federal judge in Washington held Sept. 24 in dismissing Patient Protection and Affordable Care Act (ACA) Section 1557 claims (E.S., et al. v. Regence BlueShield, et al., No. 17-1609 W.D. Wash., 2018 U.S. Dist. LEXIS 163287).

  • October 2, 2018

    Advocates Want New ACA Short-Term Health Plan Rule Enjoined

    WASHINGTON, D.C. — Health care insurance advocates asked a federal judge on Sept. 28 to enjoin newly issued Patient Protection and Affordable Care Act (ACA) rules expanding the definition of short-term plans (Association for Community Affiliated Plans, et al. v. United States Department of Treasury, et al., No. 18-2133, D. D.C.).

  • October 1, 2018

    Supreme Court Denies Review In Medicare Administrative Exhaustion Case

    WASHINGTON, D.C. — A hospital group on Oct. 1 lost its bid for U.S. Supreme Court review on the question of whether noncontracted Medicare providers must exhaust administrative remedies before filing suit even when enrollees’ interests are not impacted (Atlanta Medical Center Inc., et al. v. Care Improvement Plus South Central Insurance Co., No. 17-1283, U.S. Sup.).

  • September 27, 2018

    Federal Government Says Pennsylvania Lacks Injury, ACA Case Lacks Merit

    HARRISBURG, Pa. — Pennsylvania lacks standing, filed its suit in the wrong district and cannot hope to prevail on the merits of its challenge to Patient Protection and Affordable Care Act (ACA) rules expanding religious and moral exclusions to the law’s birth control mandate, the government tells the Third Circuit U.S. Court of Appeals in a brief filed Sept. 24 (Commonwealth of Pennsylvania, et al. v. Donald J. Trump, et al., Nos. 17-3752, 18-1253, 3rd Cir.).

  • September 26, 2018

    Panel Finds Error In Remand Of Dispute Between Insolvent Insurer, U.S. Government

    CHICAGO — A federal court erred in remanding to a state court a dispute between the U.S. Department of Health and Human (HHS) and an insolvent insurer’s liquidator over the government’s setoff of its own debt payments by first paying down the insolvent insurer’s debt, the Seventh Circuit U.S. Court of Appeals ruled Sept. 25 (Jennifer Hammer v. U.S. Department of Health and Human Services, No. 18-2523, 7th Cir., 2018 U.S. App. LEXIS 27368).

  • September 26, 2018

    ACA Discrimination Claims Over Transgender Surgery Exclusion Head To Trial

    MADISON, Wis. — A federal judge on Sept. 24 cut some damage claims from an upcoming trial on an insurance policy’s prohibition on gender reassignment treatments after finding that the plaintiffs could proceed on allegations that the exclusion violated the Patient Protection and Affordable Care Act (ACA) and other federal law (Alina Boyden and Shannon Andrews v. Wisconsin Department of Employee Trust Funds, et al., No. 17-264, W.D. Wis.).

  • September 24, 2018

    Employer Can’t Escape Mother’s ACA Suit Over Gender Dysphoria

    MINNEAPOLIS — An employer and third-party administrator cannot escape a former employee’s Patient Protection and Affordable Care Act (ACA) lawsuit claiming that they discriminated against her son by denying coverage for gender reassignment surgery, a federal judge in Minnesota held Sept. 20 (Brittany R. Tovar v. Essentia Health, Innovis Health LLC d/b/a Essentia Health West and HealthPartners Inc., No. 16-100, D. Minn.).

  • September 18, 2018

    Health Insurer Says ERISA Preempts, Pleading Deficiencies Defeat UCL Claim

    LOS ANGELES — An out-of-network substance abuse services provider’s claims are preempted by the Employee Retirement Income Security Act, and the provider fails to adequately plead its California unfair competition law (UCL) claim, an insurer tells a California federal judge in a reply Sept. 14 (Miriam Hamideh Ph.D., et al. v. Anthem Blue Cross Life and Health Insurance Co., et al., No. 18-3044, C.D. Calif.).

  • September 18, 2018

    Hearing Treatments Exclusion Isn’t Discriminatory, Federal Judge Says

    SEATTLE — A pair of individuals with hearing loss have not shown that a health insurer’s exclusion for most hearing-related treatments constitutes discrimination under the Patient Protection and Affordable Care Act (ACA), a federal judge in Washington held Sept. 14 (Andrea Schmitt, et al. v. Kaiser Foundation Health Plan of Washington, et al., No. 17-1611, W.D. Wash., 2018 U.S. Dist. LEXIS 157308).

  • September 18, 2018

    Washington Top Court Deciding If Proton Beam Therapy Is ‘Medically Necessary’

    SEATTLE — Whether a health insurance policy’s “medically necessary” language required coverage of a man’s proton beam therapy confronts the Washington Supreme Court after it recently received supplemental briefing (John Strauss, et al. v. Premera Blue Cross, No. 74600-6-I, Wash. Sup.).

  • September 17, 2018

    Newly Created Short-Term Health Plan Rule Violates ACA, APA, Advocates Claim

    WASHINGTON, D.C. — The federal government’s attempt to create a loophole creating a “parallel individual insurance market” finds no support in the text, structure or purpose of the Patient Protection and Affordable Care Act (ACA), a coalition of health care advocates alleges in Sept. 14 complaint in District of Columbia federal court (Association for Community Affiliated Plans, et al. v. United States Department of Treasury, et al., No. 18-2133, D. D.C.).

  • September 17, 2018

    Maryland Seeks Ruling That Recent Changes Didn’t Invalidate ACA

    BALTIMORE — Illegal administrative actions seeking to undermine the Patient Protection and Affordable Care Act (ACA) threaten Maryland with “immediate and long-term harm,” the state alleges in a Sept. 13 complaint seeking a declaration that the law remains constitutional (Maryland v. United States, et al., No. 18-2849, D. Md.).

  • September 13, 2018

    Judge Finds Woman Lacks Standing To Challenge ACA Mandate Rules

    DENVER — A woman never alleges that her employer has or is likely to invoke newly issued rules broadening exemptions to the Patient Protection and Affordable Care Act (ACA)’s contraceptive mandate and, thus, lacks standing to pursue her action, a federal judge in Colorado held Sept. 11 (Jessica Campbell v. Donald Trump, et al., No. 17-2455, D. Colo., 2018 U.S. Dist. LEXIS 154593).

  • September 13, 2018

    Judge: Fiduciary Duty Claim In Wilderness Therapy ERISA Case Survives, Judge Says

    NEW YORK — An insurer’s alleged coverage for skilled nursing and rehabilitation while imposing a blanket exclusion on wilderness therapy adequately pleads a violation of the mental health parity law, a federal judge in New York held Sept. 11 while denying a motion to dismiss an ERISA breach of fiduciary duty claim (William Gallagher, et al. v. Empire Healthcare Assurance Inc., et al., No. 16-9105, S.D. N.Y.).