Mealey's Health Care / ACA
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September 03, 2019
Insurers Say Congress Never Repealed Risk Corridor, Still Owes Billions Under ACA
WASHINGTON, D.C. — Appropriations riders simply limited Patient Protection and Affordable Care Act (ACA) risk-corridor funding and cannot be read as repealing payments obligations under the program, five insurers told the U.S. Supreme Court on Aug. 30 (Land of Lincoln Mutual Health Insurance Co. v. United States, No. 18-1038, Moda Health Plan Inc., et al. v. United States, No. 18-1028, Maine Community Health Options v. United States, No. 18-1023, U.S. Sup.).
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August 28, 2019
Health Insurer Asks U.S. High Court To Take Up Case Over Coverage
WASHINGTON, D.C. — Louisiana Health Service & Indemnity Co., doing business as Blue Cross and Blue Shield of Louisiana (BCBSLA), filed a petition for a writ of certiorari on Aug. 14 asking the U.S. Supreme Court to decide whether a federal court may expand the boundary of a state law and whether medical providers may pursue an action under the Employee Retirement Income Security Act (Louisiana Health Service & Indemnity Co. v. Encompass Office Solutions, Inc., No. 19-196, U.S. Sup.).
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August 26, 2019
Plaintiffs Seek Class Status Of Autism Treatment Exclusion Action
SEATTLE — Plaintiffs challenging an insurer’s blanket exclusion of applied behavior analysis therapy as used for those with autism asked a federal court in Washington on Aug. 15 to certify the case as a class action (J.R., et al. v. Blue Cross and Blue Shield of Illinois, et al., No. 18-01191, W.D. Wash.).
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August 21, 2019
Orthopedic Provider, Aetna Square Off Over $335,000 In Unpaid Bills
TRENTON, N.J. — A health insurer ask a federal judge in New Jersey to dismiss an orthopedic medical provider’s “kitchen-sink approach” to allegations in a July 17 memo, but the provider says in an Aug. 20 opposition that Aetna relies on outdated plan documents and attacks claims pleaded in the alternative (Somerset Orthopedic Associates, et al. v. Aetna Inc., et al., No. 19-12544, D. N.J.).
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August 21, 2019
Judge: Lack Of Plan Documents Dooms Expanded Health Care Coverage Class
TRENTON, N.J. — A proposed class of self-insured health plans in which Aetna Life Insurance Co. allegedly imposes undisclosed internal standards for coverage would require access to plan documents the plaintiffs have not submitted, a federal judge in New Jersey said Aug. 20 in dismissing the expanded class (E.S., et al. v. Marsh & McLennan Companies Inc. Benefits Administration Committee, et al., No. 17-3351, D. N.J., 2019 U.S. Dist. LEXIS 141163).
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August 20, 2019
Couple Wants 10th Circuit To Hear Case Alleging Health Care Discrimination
SALT LAKE CITY — A Utah federal judge on Aug. 13 granted summary judgment to an interpreter service accused of discrimination under the Patient Protection and Affordable Care Act (ACA) and other laws. The couple filed a notice on Aug. 18 that they intended to take the issue to the 10th Circuit U.S. Court of Appeals (Zach Johnston, et al. v. Intermountain Healthcare, et al., No. 18-3, D. Utah).
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August 16, 2019
Judge: Conclusory Claims Doom ERISA, State Law Health Insurance Case
FORT LAUDERDALE, Fla. — Failure to exhaust administrative remedies provides an absolute bar to Employee Retirement Income Security Act claims, and there is no evidence that the provider’s services conferred a benefit on the insurer, dooming the remainder of the case, a federal magistrate judge in Florida said Aug. 14 (GVB MD LLC, et al. v. United Healthcare Insurance Co., No. 19-20727, S.D. Fla.).
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August 14, 2019
Aetna Asks Court For Sanction Over Health Care Providers’ Unresponsiveness
LOS ANGELES — Aetna Life Insurance Co. asked a federal judge in California on Aug. 13 for dismissal of what remains of an Employee Retirement Income Security Act case as a sanction for health care providers’ failure to comply with a court deadline for settlement negotiations (Infoneuro Group, et al. v. Aetna Life Insurance Co., No. 16-5083, C.D. Calif.).
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August 14, 2019
Judge: No Jurisdiction To Hear Health Insurer Liquidator’s Offset Case
CHICAGO — A federal judge in Illinois on Aug. 13 held that she lacked jurisdiction over a case filed by an insolvent health insurer’s liquidator against the Centers for Medicare and Medicaid Services (CMS) and the U.S. government in which the liquidator sought to have an offset payment system be declared unlawful (Kevin Fry v. Centers for Medicare and Medicaid Services, et al., No. 19-1320, N.D. Ill., 2019 U.S. Dist. LEXIS 136175).
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August 14, 2019
Florida Court Won’t Revive Out-Of-Network Coverage Case
JACKSONVILLE, Fla. — Collateral estoppel prevents a woman from pursuing breach of contract claims in a health insurance coverage case, and conduct regulated by the office of insurance is exempt from the state’s unfair competition law, a Florida appeals court held Aug. 13 (Meghan Hotchkiss v. Blue Cross and Blue Shield of Florida Inc., No. 1D17-4097, Fla. App., 1st Dist., 2019 Fla. App. LEXIS 12382).
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August 12, 2019
Conflicting Evidence Dooms Mental Health ERISA Claim, Judge Says
BROOKLYN, N.Y. — Simply arguing that a health insurer could have or should have covered residential mental health treatments is not enough to support an Employee Retirement Income Security Act suit, a federal magistrate judge in New York said July 30 (Samuel Halberg, et al. v. United Behavioral Health, et al., No. 16-6622, E.D. N.Y., 2019 U.S. Dist. LEXIS 128966).
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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.).
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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.).
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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).
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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.).
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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).
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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.).
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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.).
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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).
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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).