Mealey's Health Care / ACA

  • May 13, 2019

    United States Says Congress Never Finalized ACA Cost-Sharing Payments

    WASHINGTON, D.C. — Congress never appropriated funds for the Patient Protection and Affordable Care Act (ACA) cost-sharing reduction program and, thus, never created a duty to make those payments, the United States tells a U.S. Court of Federal Claims judge in a May 9 reply (Blue Cross And Blue Shield of North Dakota v. The United States, No. 18-1983C, Fed. Clms.).

  • May 10, 2019

    Judge: ERISA Claims Fall, But Medical Provider’s State Law Claims Live On

    FORT LAUDERDALE, Fla. — A medical provider’s Employee Retirement Income Security Act claims fail because it has not shown that it exhausted its administrative remedies, but its state law claims are not preempted simply because some may invoke ERISA and largely may proceed, a federal judge in Florida said May 9 (GVB MD LLC, et al. v. United Healthcare Insurance Co., No. 19-20727, S.D. Fla.).

  • May 10, 2019

    Government Says Insurers Can’t Recover ACA Risk-Corridor Funds

    WASHINGTON, D.C. — The United States told the Supreme Court on May 8 that the Patient Protection and Affordable Care Act’s risk corridor never entitled insurers — some of them now defunct — to subsidies and that Congress’ latter actions erased any duty the law imposed (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.).

  • May 08, 2019

    Pharmacy Can’t Support Claims Insurer Applied Disparate Treatment, Judge Says

    RALEIGH, N.C. — The little guidance on a North Carolina law requiring that insurers treat pharmacies equally does not support the conclusion that denying access for failing to meet the network standards violates the statute, a federal judge in North Carolina held May 7 (Senderra RX Partners LLC v. Blue Cross Blue Shield of North Carolina, No. 18-871, M.D. N.C.).

  • May 08, 2019

    Anti-Assignment Provisions Cut Some Claims From Out-Of-Network Providers’ Suit

    LOS ANGELES — Various anti-assignment provisions largely preclude 24 of the 164 claims brought by out-of-network health care providers, a federal judge in California held May 3 (Infoneuro Group, et al. v. Aetna Life Insurance Co., No. 16-5083, C.D. Calif.).

  • May 06, 2019

    1st Circuit Reinstates Challenge To ACA Contraception Rules

    BOSTON — While the exact amount of Massachusetts’ alleged injury from rules granting expanded employers expanded exemptions to the Patient Protection and Affordable Care Act (ACT) may not be known, it stands to reason that it is not zero and provides injury and standing, a First Circuit U.S. Court of Appeal panel held May 2 (Massachusetts v. United States Department of Health and Human Services, et al., No. 18-1514, 1st Cir., 2019 U.S. App. LEXIS 13293).

  • May 06, 2019

    Insurance Classes Lay Out Proposed Remedies; Insurer Seeks Decertification

    SAN FRANCISCO — A judge’s conclusion that an insurer violated the standards of care in denying coverage for intensive residential health care and substance abuse treatments requires changes to its business practices and court instruction on the processing of claims, plaintiffs in two Employee Retirement Income Security Act class actions told a federal judge in California on May 3.  But in a motion seeking decertification of the class filed the same day, the insurer says the plaintiffs have not shown that common issues dominate the case (David and Natasha Wit, et al. v. United Behavioral Health, No. 14-02346, Gary Alexander, et al. v. United Behavioral Health, No. 14-5337, N.D. Calif.).

  • May 06, 2019

    Government Appeals Finding That ACA Association Rule Violates ERISA

    WASHINGTON, D.C. — The Department of Labor on May 1 appealed to the District of Columbia Circuit U.S. Court of Appeals a ruling invalidating a Patient Protection and Affordable Care Act (ACA) rule expanding the availability of association health plans that the court found did “violence” to the Employee Retirement Income Security (ERISA) definition of an employer (New York, et al. v. U.S. Department of Labor, et al., No. 19-5125, D.C. Cir.).

  • May 06, 2019

    Class Claims Health Insurer Improperly Characterizes Prostate Cancer Treatment

    MIAMI — United Healthcare Insurance Co. (UHC) improperly categorizes proton beam radiation therapy (PBRT) as experimental in an effort to save money despite decades of its use as a prostate cancer treatment, a putative class alleges in an April 22 complaint in Florida federal court (Richard Cole, et al. v. United Healthcare Insurance Co., No. 19-21258, S.D. Fla.).

  • May 02, 2019

    Government, Appellees Tell 5th Circuit ACA Must Fall Absent Mandate Penalty

    NEW ORLEANS — Individuals and states challenging the Patient Protection and Affordable Care Act (ACA) have sufficient injury for standing and properly demonstrated that the law is unconstitutional in the absence of the individual mandate penalty, the federal government and two other parties told a Fifth Circuit U.S. Court of Appeals May 1 (Texas, et al. v. U.S.A., et al., No. 19-10011, 5th Cir.).

  • May 01, 2019

    Finding ACA Violation, Federal Judge Enjoins Abortion Guidance Rule

    SAN FRANCISCO — A final rule restricting dissemination of information about abortion violates the Patient Protection and Affordable Care Act (ACA) and Title X, a federal judge in California held April 26 (California, et al. v. Alex Azar, et al., Essential Access Health Inc. v. Alex M. Azar II, et al., Nos. 19-1184, 19-1195, N.D. Calif., 2019 U.S. Dist. LEXIS 71171).

  • April 30, 2019

    Insured Can’t Tie Payment Claims To Health Plan, Judge Says

    TRENTON, N.J. — An insured fails to tie her surgery provider’s alleged entitlement to payment to anything in her health care plan, a federal judge in New Jersey said April 29 in dismissing claims (K.S. v. Thales USA Inc., et al., No. 17-7489, D. N.J. 2019 U.S. Dist. LEXIS 71389).

  • April 30, 2019

    Insurer Launches Daubert Challenges As Plaintiffs Seek ACA Lactation Classes

    SAN FRANCISCO — As insureds on April 5 wrapped up their efforts at certifying a trio of classes involving alleged violations of the Patient Protection and Affordable Care Act (ACA)’s lactation coverage rules, an insurer on April 11 filed reply briefs in a series of Daubert challenges seeking exclusion of the experts offered in support of the motion (Rachel Condry, et al. v. UnitedHealth Group Inc., et al., No. 17-183, N.D. Calif.).

  • April 30, 2019

    Patient’s Assignment Limited To Benefits, Federal Judge Finds

    SAN FRANCISCO — A dialysis patient’s assignment of “any cause of action” applies only to claims for benefits under the Employee Retirement Income Security Act, and an insurer’s decision not to cover dialysis does not violate Medicare law, a federal judge in California held April 5 (DaVita Inc., et al. v. Amy’s Kitchen Inc., et al., No. 18-6975, N.D. Calif., 2019 U.S. Dist. LEXIS 59387).

  • April 26, 2019

    Federal Judge Grants Discovery In Health Insurance Air Transport Coverage Case

    OKLAHOMA CITY — A federal judge in Oklahoma on April 23 granted plaintiffs additional time for discovery into their individual action against a health insurer they claim failed to properly cover air transport costs for their newborn child (Christina and Jeffrey Terry, et al. v. Health Care Service Corp., No. 18-415, W.D. Okla., 2019 U.S. Dist. LEXIS 68601).

  • April 18, 2019

    Women Appeal ACA Lactation Insurance Coverage Ruling

    DES MOINES, Iowa — A federal appeals court on April 17 gave two women until June to file their brief challenging an Iowa federal judge’s conclusion that a health insurer provided sufficient access to lactation support services under the Patient Protection and Affordable Care Act (ACA) (Jillian York, et al. v. Wellmark Inc., et al., No. 19-1705, 8th Cir.).

  • April 17, 2019

    Surgery Provider Pushes Waiver Of Assignment Defense In ERISA Action

    SANTA ANA, Calif. — Having approved medical procedures and then denied claims, an insurer cannot now point to the existence of anti-assignment provisions as the reason in a late attempt to avoid paying, a provider told a California judge on April 8 in an Employee Retirement Income Security Act case (California Surgical Institute Inc., et al. v. Aetna Life and Casualty [Bermuda] Ltd., et al., No. 18-2157, C.D. Calif.).

  • April 16, 2019

    Woman Claims Hospital Violated ACA, Ignored Requests For Interpreter

    PHOENIX — A hospital staff discriminated against a deaf woman by lacking proper training on how to identify when a patient requires a live, in-person interpreter, violating the Patient Protection and Affordable Care Act (ACA) and other statutes, the woman claims in a March 21 complaint filed in Arizona federal court (Ella Mae Hammack v. Scottsdale Healthcare Hospitals, et al., No. 19-1890, D. Ariz.).

  • April 16, 2019

    Judge Remands 32 Health Insurance Actions Seeking Payment From Aetna

    FORT MYERS, Fla. — Florida law lends an independent basis for some of a provider’s 32 cases against an Employee Retirement Income Security Act health insurer, and sufficient questions remain over the balance of the claims to grant remand, a federal judge in Florida said March 29 (Premier Inpatient Partners LLC, et al. v. Aetna Health and Life Insurance Co., No. 18-621, M.D. Fla., 2019 U.S. Dist. LEXIS 62678).

  • April 16, 2019

    Health Plan Documents Lack Anti-Assignment Provision, Federal Judge Says

    CENTRAL ISLIP, N.Y. — An administrative service agreement (ASA) is not a plan document, and the anti-assignment provision referenced therein does not bar a patient from assigning rights to a provider, a New York federal judge held March 20 (Long Island Neurological Associates v. Highmark Blue Shield, et al., No. 18-81, E.D. N.Y., 2019 U.S. Dist. LEXIS 46176).

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