Mealey's Health Care / ACA
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November 16, 2020
Government, Hospitals Battle Over Price Disclosure Rule In Federal Appeals Court
WASHINGTON, D.C. — A District of Columbia U.S. Circuit Court of Appeals panel on Oct. 15 heard oral arguments in a case questioning whether a hospital price disclosure rule effective January 2021 merely requires advertising of various existing price tiers or imposes impossible hurdles that would have the “perverse” outcome of mandating that hospitals list prices no patient actually pays (The American Hospital Association, et al. v. Alex M. Azar II, et al., No. 20-5193, D.C. Cir.).
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November 16, 2020
Insurer Wants Rehearing In 9th Circuit Anti-Assignment Clause Case
SACRAMENTO, Calif. — No precedent supports a court’s cherry-picking of which documents it wanted included as health insurance plan documents, and had it properly considered all the documents, it would have found that anti-assignment provisions barred a hospital’s Employee Retirement Income Security Act claim seeking reimbursement, an insurer argues in an Oct. 16 petition for rehearing and en banc rehearing (Martin Luther King Jr. Community Hospital v. Community Insurance Co., et al., No. 19-55053, 9th Cir.).
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November 16, 2020
Judge Declines Transfer Of ACA Transgender Discrimination Case
PHOENIX — A federal judge in Arizona refused to permit transfer of a Patient Protection and Affordable Care Act (ACA) transgender discrimination case on Oct. 20, saying it differs sufficiently from a further advanced transgender discrimination case already before her (Russell B. Toomey v. State of Arizona, et al., No. 19-35, D. Ariz.).
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November 13, 2020
Judge Rejects Expert Challenge In Deaf Woman’s ACA Discrimination Case
BATON ROUGE, La. — Any flaw in testimony based on an expert’s visit to a hospital and review of its policies produced in support of a Patient Protection and Affordable Care Act (ACA) discrimination claim can be raised during cross-examination, a federal judge in Louisiana said Nov. 10 in denying reconsideration (Sandra King v. Our Lady of the Lake Hospital Inc., No.17-530, M.D. La., 2020 U.S. Dist. LEXIS 209958).
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November 11, 2020
Panel: Denial Of Benefits For Out-Of-State Treatment No Parity Act Violation
SAN FRANCISCO — A federal judge in California did not err in finding that two state and federal statutes that require health plans governed by the Employee Retirement Income Security Act to cover mental illnesses and physical illnesses equally were not violated by a denial of benefits for the treatment of anorexia, the Ninth Circuit U.S. Court of Appeals held Nov. 9 (Suzanne Stone v. UnitedHealthcare Insurance Co., et al., No. 19-16227, 9th Cir., 2020 U.S. App. LEXIS 35276).
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November 10, 2020
Supreme Court Again Confronts Standing, Taxing Power In ACA Mandate Case
WASHINGTON, D.C. — Whether the Patient Protection and Affordable Care Act (ACA) individual mandate’s failure to produce revenue creates an injury, how the zeroing out of the tax affects precedent finding the tax as the basis for the law’s constitutionality, congressional intent in eliminating the tax and whether the provision can be severed from the law as a whole all came before the U.S. Supreme Court in Nov. 10 oral arguments (California, et al. v. Texas, et al, No. 19-840, Texas, et al. v. California, et al., No 19-1019, U.S. Sup.).
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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).
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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).
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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.).
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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).
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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).
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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.
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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.).
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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).
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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.).
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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.).
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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).
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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.
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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.).
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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).