WASHINGTON, D.C. — Alleging illegal exaction of contributions under the Transitional Reinsurance Program (TRP) of the Patient Protection and Affordable Care Act (ACA), four entities that say they have self-insured, self-administered employee health and welfare benefit plans (SISAs) have filed separate suits in the U.S. Federal Claims Court against the government.
TYLER, Texas — While the government rephrased language governing the No Surprises Act (NSA) arbitration process that a court found troublesome, its resulting final rule continues to improperly restrict arbitrators and overweight certain factors, a federal judge in Texas said.
WASHINGTON, D.C. — The government would owe 354 self-insured, self-administered (SISA) employee health and welfare benefit plans damages totaling $182,826,889.42 under a certification of class membership filed in the U.S. Federal Claims Court in a case concerning the Transitional Reinsurance Program (TRP) of the Patient Protection and Affordable Care Act (ACA).
ST. LOUIS — Associational standing requires only evidence that any single member of an association faces a threat, a Catholic benefits association tells the Eighth Circuit U.S. Court of Appeals in urging rehearing in a Patient Protection and Affordable Care Act (ACA) discrimination case, while the government fires back in its own petition, saying that no agency is contemplating enforcing gender-based rules and that litigation is premature.
RICHMOND, Va. — A federal appeals court heard oral arguments over whether a state health plan’s exclusion on gender-affirming care constituted discrimination under Patient Protection and Affordable Care Act Section 1557 after declining to stay a ruling enjoining a state health care plan from imposing the exclusion.
BOSTON — The U.S. Labor secretary’s office will participate in Feb. 7 oral argument before the First Circuit U.S. Court of Appeals as amicus curiae in a dispute over whether the third-party administrator (TPA) of a self-funded plan is a fiduciary under the Employee Retirement Income Security Act.
TRENTON, N.J. — State law and contract claims stemming from an insurance scheme that allegedly offloads costs onto a drug maker’s discount drug program are not preempted by the Employee Retirement Income Security Act and are adequately pleaded, a federal judge in New Jersey said.
WASHINGTON, D.C. — A federal appeals court vacated a $185 million award for class counsel in a Patient Protection and Affordable Care Act risk corridor suit, saying the trial court’s cursory conclusion about the reasonableness of the request for 5% of the recovery did not properly include a lodestar cross check as required by the class notice.
PHILADELPHIA — A discount drug program’s silence on contract pharmacies renders the government’s attempt at requiring manufacturers to make their drugs available to an unlimited number of those pharmacies unlawful, a Third Circuit U.S. Court of Appeals majority said Jan. 30.
SAN FRANCISCO — A district court properly certified a class of insureds alleging breach of fiduciary duty in a case involving the handling of residential treatments, but because the class specifically disclaimed any claims for benefits, reprocessing was an inappropriate remedy, a Ninth Circuit U.S. Court of Appeals panel said.
TACOMA, Wash. — The Ninth Circuit U.S. Court of Appeals on Jan. 27 denied an insurer’s petition to appeal in which the company argued that certification was improper because determining the medical necessity of gender-affirming care required individualized inquiry, that the class sought individual monetary rewards and that any court ruling would not provide complete relief to the class.
SEATTLE — An insurer’s explanation that an insured’s symptoms were not acute enough to qualify for residential treatments meets the standard adequately explaining the grounds for its decision, and nothing else in the record was ignored or misrepresented, a federal judge in Washington said.
LOS ANGELES — A medical provider’s efforts at additional reimbursement for post-stabilization care are simply an effort to avoid precedent and government regulations capping the price for such care in government-funded health care systems, a California Medi-Cal insurer tells a California appeals court.
SAN DIEGO — A substance abuse treatment provider tells a California appeals court it provided life-saving treatments on an insurer’s promise of compensation, only to be told after the treatments that the insurer believed that it had no contractual obligation to make payments, a “hide the ball scheme” that would be unacceptable in any other setting and permits breach of contract and California unfair competition law (UCL) claims.
AUSTIN, Texas — In the wake of its ruling finding no private right of action in the state’s emergency care laws, the Texas Supreme Court on Jan. 27 denied a petition in a third and related case brought by hospitals, according to the court’s docket.
WASHINGTON, D.C. — A divided Seventh Circuit U.S. Court of Appeals turned what should have been a routine compensation dispute between health care providers and Medicaid managed care payers on its head by creating a “novel and unjustified private right of action” within federal law, a trade organization argues in support of a petition for review before the U.S. Supreme Court.
OKLAHOMA CITY — Allegations that an insurer provided shifting explanations for denying coverage for proton beam therapy (PBT) keep a bad faith claim alive, but an Oklahoma law precluding insurers from heightening the standard for such treatment cannot form the basis for a negligence per se claim, a federal judge in Oklahoma said in partly granting a motion to dismiss.
SEATTLE — An insurer’s and plan’s erroneous assessments of which state agency enjoyed proper licensing powers and their denial of coverage for wilderness treatment in direct contradiction of plan language providing for coverage at licensed treatment facilities constitutes an abuse of discretion, a federal judge in Washington said in granting plaintiffs’ motion for summary judgment and ordering the insurer and plan to cover the cost of the treatments.
DALLAS — “Ghost rates” and the use of potentially enormous geographic regions to determine contracted rates haunt an agency rule and combined with delayed payment determinations are directly contradictory to the clear language of the No Surprises Act (NSA), which puts providers on unequal footing and renders the rule both unfair and unlawful, a group of medical providers tell a Texas federal judge.
MIAMI — A medical provider’s contract is with a network savings program, not a participating insurer, and calls verifying insurance coverage do not evidence an agreement to make specific payments for five surgeries, a federal judge in Florida said.