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Mealey's Health Care / ACA

  • September 12, 2018

    States Want Unlawful 2018 ACA Fees Enjoined, Oppose Stay Of Disgorgement

    DALLAS — A federal judge in Texas granted five states’ request for expedited consideration of a motion seeking to amend their complaint to seek immediate injunctive relief of ACA fees found to be unlawfully imposed against them.  That same day, the states filed a motion opposing stay of a final judgment ordering disgorgement in the case, but agreed that interlocutory appeal was appropriate (State of Texas, et al. v. United States of America, et al., No. 15-151, N.D. Texas, 2018 U.S. Dist. LEXIS 154274).

  • September 12, 2018

    Chiropractor Can’t Untwist State Payment Claims From ERISA Preemption

    BROOKLYN, N.Y. — Assignment of benefits a chiropractor received and his New York state law claims seeking full payment from an insurer fall under the Employee Retirement Income Security Act and are preempted, a federal judge in New York held Sept. 7 (Jamie Bassel, D.C., P.C. v. Aetna Health Insurance Co. of New York, et al., No. 17-51779, E.D. N.Y., 2018 U.S. Dist. LEXIS 153070).

  • September 6, 2018

    Judge: Government Owes ACA Insurer $5 Million In Cost-Sharing Payments

    WASHINGTON, D.C. — Congress’ failure to appropriate funds for the Patient Protection and Affordable Care Act (ACA) cost-reduction program does not negate the law’s mandate that the payments be made, a federal claims court judge held Sept. 4 in finding that the government owes an insurer more than $5 million (Montana Health Co-Op v. The United States of America, No. 18-143C, Fed. Clms.).

  • September 6, 2018

    No Need For En Banc Review, Government Says In ACA Risk-Corridor Cases

    WASHINGTON, D.C. — Congress’ subsequent actions clearly and unequivocally limited payments in the Patient Protection and Affordable Care Act (ACA) risk corridor to income received through the program, regardless of the language it used in enacting the program, the government said Aug. 31 in urging the Federal Circuit U.S. Court of Appeals to deny a series of insurer’s request for en banc rehearing (Land of Lincoln Mutual Health Insurance Co. v. United States, No. 17-1224, Moda Health Plan Inc. v. United States, No. 17-1994, Blue Cross and Blue Shield of North Carolina v. United States, No. 17-2154, Maine Community Health Options v. United States, No. 17-2395, Fed. Cir.).

  • September 5, 2018

    9th Circuit Sends Mental Health Insurance Coverage Case To State Court

    SEATTLE — State law claims alleging that an insurer uses specially crafted guidelines to avoid providing third-party mental health coverage invokes a duty distinct from those imposed by ERISA and belongs in state court, the Ninth Circuit U.S. Court of Appeals held Sept. 4 (Karen Hansen, et al. v. Group Health Cooperative, No. 16-35684, 9th Cir.).

  • September 4, 2018

    Federal Judge Dismisses ERISA, ACA Claims In Fentanyl Coverage Case

    NEW YORK — Despite plaintiffs’ conclusory legal statements, there is no evidence that a pharmacy benefits administrator acted in an arbitrary or capricious way in limiting its coverage of fentanyl to cases of breakthrough cancer pain, nor that the plan was unclear or intentionally discriminated against a woman in violation of the ACA, a federal judge held Aug. 29 (Rebecca Weinreb, et al. v. Xerox Business Services, et al., No. 16-6823, S.D. N.Y., 2018 U.S. Dist. LEXIS 147706).

  • August 31, 2018

    CDC Report Says Rate Of Uninsured Remained Steady

    WASHINGTON, D.C. — Despite fears that certain changes could undermine Patient Protection and Affordable Care Act (ACA) enrollment, the number of uninsured individuals remained steady at 8.8 percent through the first three months of 2018, according to a new government report.

  • August 30, 2018

    Judge Denies Judgment In Residential Treatment Insurance Denials Case

    SALT LAKE CITY — Any irregularities in a health insurer’s handling of two residential treatment claims do not warrant de novo review, and the record does not support the conclusion that the insurer abused its discretion in denying coverage for treatment two children received, a federal judge in Utah held Aug. 27 (Sandy Jo H., et al. v. Cigna Behavioral Health, et al., No. 17-110, D. Utah, 2018 U.S. Dist. LEXIS 146065).

  • August 30, 2018

    Judge: Medical Provider’s Anti-Assignment Arguments Contradict ERISA Precedent

    TRENTON, N.J. — A medical provider’s claim that an Employee Retirement Income Security Act plan’s anti-assignment provision involves only the insured’s right to assign benefits, not the power to do so, is contrary to district and circuit precedent, a federal judge in New Jersey said Aug. 27 (University Spine Center, et al. v. United Healthcare, No. 17-8575, D. N.J.).

  • August 30, 2018

    9th Circuit Reinstates California Abortion Disclosure Challenge

    SACRAMENTO, Calif. — A district court judge erred in concluding that crisis pregnancy centers (CPCs) were unlikely to prevail on their free speech claims challenging a California abortion-disclosure law and on remand should reconsider in light of more recent precedent, the Ninth Circuit U.S. Court of Appeals held Aug. 28 (A Woman’s Friend Pregnancy Resource Clinic, et al. Xavier Becerra, et al., No. 15-17517, 9th Cir., 2018 U.S. App. LEXIS 24327).

  • August 29, 2018

    Court Reinstates Class Action Involving Reasonable Medical Cost Determinations

    SEATTLE — Allegations that an insurer imposes a formulaic policy in determining what constitutes reasonable medical costs in a given geographic area form the basis of a Washington state consumer protection act claim, a state appellate court held Aug. 24 (Folweiler Chiropractic, et al. v. American Family Insurance Co., No. 76448-9-I, Wash. App., Div. 1, 2018 Wash. App. LEXIS 2029).

  • August 24, 2018

    Federal Judge Sanctions Insurer Over Incorrect Administrative Exhaustion Argument

    LOS ANGELES — Attorneys’ failure to investigate whether their health insurance client’s administrative appeals process applied to a contracted provider prior to arguing that the plaintiff failed to exhaust such remedies warrants imposing sanctions, a federal judge in California held Aug. 22 (Prime Healthcare Services Inc. v. Humana Insurance Co., et al., No. 16-1097, C.D. Calif.).

  • August 21, 2018

    11th Circuit Finds ACA Section 1557 Case Lacks Necessary Discrimination

    ATLANTA — Regardless of the standard applying in Patient Protection and Affordable Care Act (ACA) Section 1557 cases, the law at the very least requires evidence of discrimination an African-American dermatologist cannot produce in support of her allegation that a company selectively enforces its anti-assignment provision against women and minorities, a panel of the 11th Circuit U.S. Court of Appeals held Aug. 20 (W.A. Griffin v. Verizon Communications Inc., et al., No. 17-14761, 11th Cir., 2018 U.S. App. LEXIS 23146).

  • August 21, 2018

    Judge Rejects ACA Claims In Medicaid Case, But Enjoins Some Conduct

    RALEIGH, N.C. — Although a class’s Patient Protection and Affordable Care Act (ACA) discrimination claims against North Carolina officials fail, a federal judge said Aug. 9 that he would grant a modified injunction preventing the state from terminating Medicaid benefits (Marcia Hawkins, et al. v Mandy Cohen, et al., No. 17-581, E.D. N.C., 2018 U.S. Dist. LEXIS 134316).

  • August 21, 2018

    Judge Rejects Insurers’ Challenge To New York Risk Adjustment Program

    NEW YORK — Two insurers’ lawsuit challenging how New York’s risk adjustment program interacts with a similar Patient Protection and Affordable Care Act (ACA) program must be dismissed, a federal judge in the state held, finding Aug. 10 that while he had jurisdiction, the federal law did not preempt state attempts at regulating insurance markets (UnitedHealthcare of New York Inc., et al. v. Maria T. Vullo, et al., No. 17-7694, S.D. N.Y., 2018 U.S. Dist. LEXIS 136380).

  • August 17, 2018

    Religious Employers Partially Granted Attorney Fees In ACA Dispute

    HANNIBAL, Mo. — Two religious employers who had challenged the contraceptive mandate included under the Patient Protection and Affordable Care Act (ACA) were awarded nearly $400,000 in attorney fees and expenses on Aug. 9 by a Missouri federal magistrate judge following the federal government’s decision to drop its opposition to their motion for a permanent injunction (Sharpe Holdings, Inc., et al. v. United States Department of Health and Human Services, et al., No. 12-92, E.D. Mo., 2018 U.S. Dist. LEXIS 134297).

  • August 14, 2018

    Claims Trimmed In Suit Over Denial Of Coverage For Outdoor Treatment Program

    SEATTLE — A Washington federal judge on Aug. 9 narrowed the claims in a class complaint filed by a teenager seeking reimbursement for an outdoor mental health treatment program, dismissing with prejudice a claim that the denial of reimbursement was improper under the Employee Retirement Income Security Act and claims seeking to enforce the plan and for equitable remedies, to the extent that they relied on a violation of the Affordable Care Act (ACA) (A.Z., et al. v. Regence Blueshield, et al., No. 17-1292, W.D. Wash., 2018 U.S. Dist. LEXIS 134669).

  • August 3, 2018

    Judge Increases Class Size, Settlement Fund In Autism Insurance Coverage Case

    BENTON, Ill. — A federal judge in Indiana on Aug. 1 said he would permit 62 additional plaintiffs into a class action alleging that an insurer denied applied behavioral analysis (ABA) autism treatments in violation of Indiana law and the Employee Retirement Income Security Act and noted that the defendant agreed to increase the settlement fund resolving the claims by $325,000 (W.P., et al. v. Anthem Insurance Companies Inc., No. 15-562, S.D. Ind.).

  • August 3, 2018

    Cities Sue Federal Officials, Claim Neglect In Administration Of ACA

    BALTIMORE — Having failed to pass legislation repealing the Patient Protection and Affordable Care Act (ACA), President Donald Trump now hopes to undermine it through neglect and sabotage, a collection of states and cities allege in an Aug. 2 complaint filed in Maryland federal court (Columbus, et al. v. Donald J. Trump, et al., No. 18-2364, D. Md.).

  • August 2, 2018

    Out-Of-Network Health Care Provider Isn’t Seeking ERISA Benefits, Judge Says

    TRENTON, N.J. — An out-of-network provider is not a beneficiary of an Employee Retirement Income Security Act plan, and because the plan includes an anti-assignment provision, it cannot sue to recover benefits under the law, a federal judge in New Jersey held July 31 in remanding the action (Advanced Orthopedics and Sports Medicine Institute v. Blue Cross Blue Shield of New Jersey, et al., No. 17-11807, D. N.J.).