Mealey's Health Care / ACA

  • March 14, 2019

    Judge: Precedent Provides Room For Provider’s Suit Against ERISA Insurer

    BRIDGEPORT, Conn. — There is room for out-of-network health care providers to bring claims against Employee Retirement Income Security Act plan insurers, as long as the claims in no way implicate the plan contract, a federal judge in Connecticut held March 12 (Aesthetic and Reconstructive Breast Center LLC v. United Healthcare Group Inc., No. 18-608, D. Conn., 2019 U.S. Dist. LEXIS 39284; Taylor Theunissen, M.D. LLC v. United Healthcare Group Inc., et al., No. 18-606, D. Conn., 2019 U.S. Dist. LEXIS 39284).

  • March 14, 2019

    Female Athletes Level ACA Discrimination Claims Against Olympic Committee

    DENVER — Allegations that the U.S. Olympic Committee (USOC) and related individuals discriminated against women in violation of Patient Protection and Affordable Care Act (ACA) Section 1557 by permitting the sexual abuse of female athletes under its care are among the bevy of claims brought by 51 female athletes in a March 12 lawsuit in Colorado federal court (Jane L.B. DOE 1, et al. v. United States Olympic Committee, et al., No. 19-737, D. Colo.).

  • March 13, 2019

    ACA Doesn’t Preempt Marketplace Breach Of Contract Suit, Judge Finds

    CINCINNATI — The Patient Protection and Affordable Care Act (ACA) does not preempt a class’s state law claims alleging that their marketplace insurer breached its contract with insureds by misrepresenting the size of its provider network, a federal judge in Ohio said March 11 in remanding the case (Neha Desai, et al. v. CareSource Inc., No. 18-118, S.D. Ohio, 2019 U.S. Dist. LEXIS 38172).

  • March 13, 2019

    North Carolina Health Plan Discriminates Against Transgendered, Employees Say

    GREENSBORO, N.C. — A state employer health plan violates the Patient Protection and Affordable Care Act (ACA) by discriminating against transgendered individuals by denying coverage for related procedures and medicines, plaintiffs allege in a March 11 suit filed in North Carolina federal court (Maxwell Kadel, et al. v. Dale Folwell, et al., No. 19-272, M.D. N.C.).

  • March 12, 2019

    Iowa High Court: Medicaid Must Cover Transgender Surgery

    DES MOINES, Iowa — An administrative rule prohibiting Iowa’s Medicaid program from covering transgender surgery conflicts with state law adding gender identity as a protected class and cannot stand, the Iowa Supreme Court held March 8 (Eerieanna Good, et al. v. Iowa Department of Human Services, No. 18-1158, Iowa Sup.).

  • March 11, 2019

    Amici: Government Pulled Risk Corridor Rug Out From Under ACA Insurers

    WASHINGTON, D.C. — The government should not be permitted to incentivize private companies to participate in its Patient Protection and Affordable Care Act (ACA)  risk corridor program and then retroactively revoke its promises in vague riders, eight amicus curiae parties tell the U.S. Supreme Court in March 8 briefs (Land of Lincoln Mutual Health Insurance Co. v. United States, No. N/A, Moda Health Plan Inc. v. United States, No. 18-1028, Blue Cross and Blue Shield of North Carolina v. United States, No. 17-2154, Maine Community Health Options v. United States, No. 18-1023, U.S. Sup.).

  • March 08, 2019

    Judge: Discrimination Suit Against Wal-Mart, Eye Care Provider May Proceed

    PORTLAND, Ore. — A deaf man adequately alleges that Wal-Mart and its vision center partner violated the Patient Protection and Affordable Care Act (ACA) and various anti-discrimination laws by promising but failing to provide an adequate sign language interpreter, a federal judge in Oregon held March 6 in adopting a magistrate judge’s findings (Larry R. Spiva Jr. v. Walmart, et al., No. 18-1024, D. Ore.).

  • March 07, 2019

    Judge: Drug Abuse Treatment Provider Adequately Alleges Breach Of Contract

    LOS ANGELES — Substance abuse treatment providers adequately plead breach of contract claims against an insurer, but the remainder of their action fails, a California federal judge held March 4 (TML Recovery v. Humana Inc., No. 18-462, MMR Services LLC v. Humana Inc., et al, No. 18-463, C.D. Calif.).

  • March 07, 2019

    2nd Circuit Grants HHS Extension In New York-ACA Risk-Adjustment Program Spat

    NEW YORK — The Second Circuit U.S. Court of Appeals on March 5 gave the U.S. Department of Health and Human Services until June to respond to its request for an opinion on how the Patient Protection and Affordable Care Act (ACA)’s risk-adjustment program interacts and impacts a similar New York program in two insurers’ case challenging whether the state can take proceeds to which the companies were entitled under the federal law (UnitedHealthcare of New York Inc., et al. v. Maria T. Vullo, et al., No. 18-2583, 2nd Cir.).

  • March 06, 2019

    Health Insurer Violated Standard Of Care, Judge Says In ERISA Case

    SAN FRANCISCO — An insurer’s denial of coverage for intensive residential health care and substance abuse treatments violated generally accepted standards of care, a federal magistrate judge in California held March 5 in a pair of Employee Retirement Income Security Act class actions (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.).

  • March 04, 2019

    AARP Says Court Must Vacate ACA Skirting Short-Term Plan Rule

    WASHINGTON, D.C. —  n agency rule extending how long individuals can receive coverage under threadbare health insurance plans threatens the very communities the Patient Protection and Affordable Care Act (ACA) sought to protect, an amicus curiae told a District of Columbia federal judge on March 1 (Association for Community Affiliated Plans, et al. v. United States Department of Treasury, et al., No. 18-2133, D. D.C.).

  • February 28, 2019

    Judge Largely Dismisses Surgery Provider’s ERISA Action

    LOS ANGELES — A medical provider’s claim that plan documents in its Employee Retirement Income Security Act case may differ from other, undisclosed plan documents, does not survive a motion to dismiss, a federal judge in California held Feb. 27 (Beverly Oaks Physicians Surgical Center LLC, et al. v. Blue Cross Blue Shield of Illinois, et al., No. 18-3866, C.D. Calif., 2019 U.S. Dist. LEXIS 31450).

  • February 25, 2019

    Medical Provider’s State Law Claims Survive Dismissal, Federal Judge Says

    TRENTON, N.J. — A surgeon’s state law claims alleging that an insurer failed to fully compensate him for breast surgery services survives a motion to dismiss, as it is not preempted and the state law claims all appear valid at this stage, a federal judge in New Jersey held Feb. 21 (Tzvi Small, M.D. v. Oxford Health Insurance Inc., et al., No. 18-13120, D. N.J., 2019 U.S. Dist. LEXIS 27878).

  • February 25, 2019

    Anti-Assignment Provision A Valid Bar To Provider’s Insurance Suit, Judge Says

    TRENTON, N.J. — A pair of health insurance plans’ anti-assignment provisions are valid and enforceable and bar a provider’s action seeking in excess of $100,000 in Employee Retirement Income Security Act benefits, a federal judge in New Jersey held Feb. 22 (Neurosurgical Associates of NJ PC, et al. v. Aetna Inc., No. 17-13210, D. N.J., 2019 U.S. Dist. LEXIS 28353).

  • February 21, 2019

    Government Urges 3rd Circuit To Reject ACA Birth Control Rules Injunction

    HARRISBURG, Pa. — States lack standing to challenge rules expanding the Patient Protection and Affordable Care Act (ACA) contraceptive mandate exemptions and cannot prevail even if they did because the rules comply with the law and procedural requirements, the federal defendants defending the rules told a Third Circuit U.S. Court of Appeals panel in a Feb. 15 brief (Commonwealth of Pennsylvania, et al. v. President, United States of America, et al., Nos. 17-3752, 18-1253,19-1129, 19-1189, 3rd Cir.).

  • February 21, 2019

    Judges Find United States Owes Insurers Under ACA Cost-Sharing Program

    WASHINGTON, D.C. — Congress created an implied contract when it implemented the Patient Protection and Affordable Care Act (ACA) cost-sharing program, an obligation it breached when it never authorized payments, a pair of U.S. Court of Federal Claims judges held in a trio of rulings issued Feb. 14 and Feb. 15 (Community Health Choice Inc. v. The United States, No. 18-5C, Common Ground Healthcare Cooperative v. The United States, No. 17-877C, Local Initiative Health Authority, et al. v. The United States, No. 17-1542C, Fed. Clms.).

  • February 15, 2019

    Judge Allows Oregon To Intervene In ACA Contraceptive Rules Suit

    SAN FRANCISCO — Oregon filed a timely motion seeking intervention in a suit over Patient Protection and Affordable Care Act (ACA) rules, and adding it as a plaintiff would have no negative impact on the case, a federal judge in California held Feb. 1 (California, et al. v. Alex M. Azar II, et al., No. 17-5783, N.D. Calif.).

  • February 15, 2019

    Judge: Mental Health Provider May Fall Outside Plan’s Wilderness Exclusion

    SALT LAKE CITY — Because an insurer apparently failed to fully assess the services provided by a mental health care provider who happens to provide those services outdoors, its denial was arbitrary and capricious, a federal judge in Utah said Feb. 13 in remanding a case for further review (Michael and Madeline D. v. Anthem Health Plans of Kentucky, No. 17-675, D. Utah, 2019 U.S. Dist. LEXIS 24367).

  • February 15, 2019

    Judge: ‘Surprise Bill’ Assignment Exemption Permits Amended Complaint

    NEW YORK — An exemption in an anti-assignment clause for surprise bills potentially provides grounds for avoiding the exclusion and warrants allowing a brain surgery provider to amend his complaint against a patient’s insurer, a federal judge in New York held Feb. 1 (Jeffrey Farkas, M.D. LLC, et al. v. Group Health Inc., et al., No. 18-8535, S.D. N.Y., 2019 U.S. Dist. LEXIS 17756).

  • February 15, 2019

    Judge Says Provider Must Exhaust Medicare Remedies Before Filing Suit

    CENTRAL ISLIP, N.Y. — A home nursing care provider must exhaust all administrative remedies before filing suit because its claim involves authorization for services covered by a Medicare plan, a federal judge in New York held Jan. 29 (Sarene Services Inc., et al. v. Empire Blue Cross/Blue Shield, an Anthem Co., No. 17-5276, E.D. N.Y., 2019 U.S. Dist. LEXIS 15605).

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