Mealey's Health Care / ACA

  • October 19, 2020

    Judge Adopts Report Denying Judgment To Both Parties In Surgery Benefit Case

    HOUSTON — A federal judge in Texas on Oct. 5 adopted a magistrate judge’s report recommending denying two motions for summary judgment in an Employee Retirement Income Security Act case, saying a surgery provider had not demonstrated entitlement to full compensation, but a health care plan had not shown that it properly calculated or explained reimbursement (Woodlands Outpatient Surgical Center, et al. v. America Bureau of Shipping Inc. Employee Benefit Plan, No. 17-1476, S.D. Texas, 2020 U.S. Dist. LEXIS 185882)

  • October 20, 2020

    Amici Fault Imposition Of Contract Mitigation Rule in ACA Cost-Sharing Case

    WASHINGTON, D.C. — A panel’s liability ruling limiting the government’s liability for Patient Protection and Affordable Care Act (ACA) risk-corridor underpayments requires rehearing to correct the decision’s unprecedented importation of contract mitigation principles, insurers tell a federal appeals court in an Oct. 16 amicus curiae brief (Maine Community Health Options v. United States, No. 19-2102, Fed. Cir.).

  • October 19, 2020

    Conflicts Created By ACA Emotional Distress Damages Mandate Review, Woman Says

    WASHINGTON, D.C. — In barring an emotional distress award in a Patient Protection and Affordable Care Act (ACA) discrimination case, the Fifth Circuit U.S. Court of Appeals created conflicts with precedent from other circuits, the Department of Justice’s position and at least four U.S. Supreme Court decisions, a deaf woman argues in an Oct. 14 reply in support of her petition for certiorari review (Jane Cummings v. Premier Rehab Keller PLLC, et al., No. 20-219, U.S. Sup.).

  • October 19, 2020

    Anti-Assignment Provision Bars Physician’s ERISA Suit, Judge Says

    NASSAU, N.Y. — An anti-assignment provision strips a health care provider of standing to bring an Employee Retirement Income Security Act claim, and a second claim for breach of contract fails regardless of whether it is based in state law or ERISA, a federal judge in New York said Sept. 28 in granting a motion to dismiss (Shuriz Hishmeh, et al. v. Horizon Blue Cross Blue Shield of New Jersey, No. 19-4727, E.D. N.Y., 2020 U.S. Dist. LEXIS 185515).

  • October 19, 2020

    Judge: United States May Seek Debt Setoffs In ACA Risk-Corridor Case

    WASHINGTON, D.C. — The government may amend its answer to seek setoffs against risk-corridor liabilities it owes to largely insolvent insurers under the Patient Protection and Affordable Care Act (ACA) risk corridor, a federal judge in the U.S. Court of Federal Claims said Sept. 30 in finding that amendment would be neither untimely nor prejudicial (Health Republic Insurance Co. v. United States, No. 16-259C, Fed. Clms., 2020 U.S. Claims LEXIS 1898).

  • October 16, 2020

    5th Circuit Vacates Ruling Dismissing Various ACA Challenges

    NEW ORLEANS — The Fifth Circuit U.S. Circuit Court of Appeals on Oct. 15 vacated rulings dismissing a pro se plaintiff’s claims for prospective and retroactive relief of various provisions of the Patient Protection and Affordable Care Act (ACA), saying various changes in the law required a more thorough analysis (John J. Dierlam v. Donald J. Trump, et al., No. 18-20440, 5th Cir., 2020 U.S. App. LEXIS 32632).

  • October 16, 2020

    Majority Says Dialysis Provider Was Properly Assigned Rights To Bring ERISA Claim

    CINCINNATI — The majority of the Sixth Circuit U.S. Court of Appeals on Oct. 14 reversed a district court’s ruling that a health insurance administrator’s decision to make all dialysis companies out-of-network providers does not violate the Medicare Secondary Payor Act (MSPA) and found that the provider’s assignment of rights form clearly conferred a right on the provider to bring a claim for unpaid benefits under the Employee Retirement Income Security Act (DaVita Inc., et al. v. Marietta Memorial Hospital Employee Health Benefit Plan, et al., No. 19-4039, 6th Cir., 2020 U.S. App. LEXIS 32398).

  • October 14, 2020

    No Need For Review Of ACA Emotional Distress Damages Ruling, Provider Says

    WASHINGTON, D.C. — The Patient Protection and Affordable Care Act (ACA) does not permit the imposition of emotional distress damages in a case where a deaf and blind woman claims that she was denied an interpreter, a health care provider told the U.S. Supreme Court in a Sept. 24 opposition to certiorari (Jane Cummings v. Premier Rehab Keller PLLC, et al., No. 20-219, U.S. Sup.).

  • October 12, 2020

    Judge Reconsiders, Says Health Care Litigation Didn’t Waive Arbitration Rights

    SEATTLE — A motion seeking dismissal did not produce a merits determination inconsistent with arbitration rights, but rather simply a conclusion that plaintiffs adequately pleaded claims involving a trio of defendants who allegedly sold health care sharing ministry plans under the Patient Protection and Affordable Care Act (ACA), a federal judge in Washington said Oct. 7, vacating an earlier ruling and granting a motion to compel arbitration (Gerald Jackson, et al. v. The Aliera Companies Inc., et al., No. 19-1281, W.D. Wash., 2020 U.S. Dist. LEXIS 185339).

  • October 12, 2020

    Department Of Labor Says Court Erred In Finding Health Benefits Properly Denied

    BOSTON — In an Oct. 7 amicus curiae brief, the U.S. Department of Labor contends that a district court erred in finding that health insurance coverage is excluded for nonrestorative speech therapy because the appellant, a 5-year-old who suffers from autism spectrum disorder, and his parents are authorized to bring a claim for the denied benefits under the Employee Retirement Income Security Act (N.R., et al. v. Raytheon Co., et al., No. 20-1639, 1st Cir.).

  • October 06, 2020

    Federal Judge Permits Discovery Into Parity Act Case

    SALT LAKE CITY — The distinct nature of Parity Act claims over the allegedly improper denial of insurance coverage for mental health treatments requires discovery exceeding the administrative record to which Employee Retirement Income Security Act cases are generally limited, a federal judge in Utah said Sept. 30 (David S., et al. v. United Healthcare Insurance Co., No. 18-803, D. Utah, 2020 U.S. Dist. LEXIS 182120).

  • October 06, 2020

    9th Circuit Affirms Hospital's Judgment, Finds Anti-Assignment Clause Flawed

    SACRAMENTO, Calif. — A purported anti-assignment provision falls outside governing Employee Retirement Income Security Act health insurance plan documents, but even if applicable, the language would not support excluding assignment or payment to a provider, a divided Ninth Circuit U.S. Circuit Court of Appeals said Oct. 2 in affirming judgment in favor of a hospital (Martin Luther King Jr. Community Hospital v. Community Insurance Co., et al., No. 19-55052, 9th Cir., 2020 U.S. App. LEXIS 31441).

  • October 01, 2020

    Provider Survives Insurer's Dismissal Attempt On Remand, Judge Says

    SAN FRANCISCO — A surgery provider adequately alleges that an insurer should be estopped from untimely raising an anti-assignment provision and demonstrates entitlement to benefits under an insurance health care plan, a federal judge in California said Sept. 25 in extending a Ninth Circuit U.S. Circuit Court of Appeals ruling and denying dismissal (California Spine and Neurosurgery Institute v. Blue Cross of California, No. 18-4777, N.D. Calif.).

  • September 30, 2020

    Provider's Contract Action Accrued At Claim Denial, Federal Judge Says

    LOS ANGELES — A breach of contract claim accrued when an insurer denied coverage, putting the provider's suit outside the four-year window for such claims, a federal judge in California said in dismissing the claim Sept. 29 (IV Solutions Inc., et al. v. Empire HealthChoice Assurance Inc., et al., No. 17-5616, C.D. Calif., 2020 U.S. Dist. LEXIS 179444).

  • September 30, 2020

    In Urging Rehearing, Insurer Cites 'Enormous' Impact Of Liability Ruling

    WASHINGTON, D.C. — A ruling freeing the government from liability for mandated Patient Protection and Affordable Care Act (ACA) cost-sharing payments where insurers raised premiums unnecessarily imputes contract concepts into what should be a straightforward application of statutory law, an insurer says in a Sept. 28 petition for rehearing with a federal circuit court, warning of the "enormous" stakes (Maine Community Health Options v. United States, No. 19-2102, Fed. Cir.).

  • September 29, 2020

    Judge Says Parity Act Claim Survives Dismissal, Isn't Duplicative

    SALT LAKE CITY — Two individuals adequately allege that their insurer imposes coverage standards on mental health services that it does not impose on analogous services in the medical and surgical setting, and nothing precludes them from bringing their Mental Health Parity and Addiction Equity Act claim in addition to an Employee Retirement Income Security Act action, a federal judge in Utah said Sept. 24 (Denise M. v. Cigna Health and Life Insurance Co., et al., No. 19-764, D. Utah, 2020 U.S. Dist. LEXIS 176154).

  • September 29, 2020

    ERISA, Sherman Act Claims Dismissed From Health Insurance Payment Case

    NEW YORK — A single Employee Retirement Income Security Act claim challenging a health insurer's reimbursement practices is all that remains of a plastic surgeon's case after a judge concluded Sept. 23 that a lack of monopoly power, claims duplication and preemption call for largely granting the company's motion to dismiss (Michael E. Jones, et al. v. Aetna Inc., et al., No. 19-9683, S.D. N.Y.).

  • September 29, 2020

    California Governor Signs Mental Health Insurance Coverage Legislation

    SACRAMENTO, Calif. — California Gov. Gavin Newson on Sept. 25 signed legislation designed to overhaul and modernize the state's mental health coverage law by imposing more comprehensive mental health coverage requirements on insurers while placing limits on the ability of insurers to avoid coverage. 

  • September 28, 2020

    ACA Lactation Coverage Class Can't Secure Certification

    CHICAGO — Women allegedly denied coverage for lactation services mandated by the Patient Protection and Affordable Care Act (ACA) fail to adequately allege that their insurer had an actual policy of denying the claims or imposing cost-sharing, a federal judge in Illinois said Sept. 24 in declining to certify the class (Laura Briscoe, et al. v. Health Care Service Corporation, et al., No. 1:16-cv-10294, N.D. Ill., 2020 U.S. Dist. LEXIS 175618).

  • September 28, 2020

    CBO Won't Reconsider Short-Term Insurance Plan Calculations

    WASHINGTON, D.C. — Recent research into short-term, limited-duration insurance (STLDI) plans differs significantly enough from Congressional Budget Office (CBO) standards that it does not require reevaluating whether most enrollees in such plans are receiving actual insurance coverage, the CBO said in a Sept. 25 report.

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