Mealey's Health Care / ACA
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February 08, 2023
4 New Suits Challenge 2014 ACA Transitional Reinsurance Program Payments
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.
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February 08, 2023
Judge Vacates Rule Implementing No Surprises Act Arbitration Process
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.
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February 07, 2023
Certification In ACA Transitional Reinsurance Row Claims Nearly $183M In Damages
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).
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February 06, 2023
Dueling Rehearing Petitions Claim Error In 8th Circuit ACA Discrimination Ruling
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.
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February 06, 2023
4th Circuit Won’t Stay ACA Gender-Affirming Care Coverage Case, Hears Arguments
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.
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February 06, 2023
Amicus To Take Part In 1st Circuit Oral Argument On Whether TPA Is ERISA Fiduciary
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.
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February 02, 2023
Judge: J&J Discount Drug Program Case Escapes Preemption, Pleading Arguments
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.
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February 02, 2023
Court Vacates $185M Class Counsel Award In ACA Risk-Corridor Suit
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.
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January 31, 2023
3rd Circuit: HHS Overstepped With Discount Drug Contract Pharmacy Rule
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.
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January 30, 2023
9th Circuit Reverses ERISA Claim Reprocessing In Residential Treatment Case
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.
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January 30, 2023
9th Circuit Won’t Review Class Certification Ruling In ACA Transgender Case
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.
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January 30, 2023
Timeliness, Record Issues Doom Residential Treatment Case, Judge Says
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.
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January 30, 2023
Insurer: Provider’s Suit An Attempt At Avoiding Health Care Cost Laws
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.
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January 30, 2023
Provider Derides Insurer’s ‘Hide The Ball Scheme’ As Breach Of Contract
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.
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January 27, 2023
Texas Court Denies Petition After Emergency Care Law Ruling
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.
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January 26, 2023
Managed Care Group Urges Review Of Medicaid Private Right Of Action Ruling
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.
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January 25, 2023
Bad Faith Claim Survives, But Oklahoma Insurance Law Can’t Gird Negligence Claim
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.
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January 25, 2023
Judge Finds Errors And Contradictions In Wilderness Treatment Coverage Case
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.
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January 20, 2023
Ghost Rates Among Surprise Billing Rule Flaws, Providers Say
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.
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January 19, 2023
Insurer Escapes Claims It Underpaid For Care In Network Savings Program
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.