Mealey's Health Care / ACA

  • December 13, 2021

    High Court Seeks U.S. View On ERISA Fiduciary Dispute Over Insurer, PBM Price-Setting

    WASHINGTON, D.C. — The U.S. Supreme Court on Dec. 13 invited the solicitor general to file a brief expressing the United States’ views on a petition by health plans and individual subscribers for review of a ruling that a health benefits provider and a pharmacy benefits manager (PBM) were not acting as fiduciaries under the Employee Retirement Income Security Act when they set prescription drug prices.

  • December 09, 2021

    Judge: U.S. Cannot Use Administrative Offset To Make ‘End-Run Around’ Liquidation

    WASHINGTON, D.C. — A federal judge on Nov. 30 held that the U.S. government cannot use an administrative offset to make an “end-run around” a state liquidation process, “particularly not where the government elected to participate in that process and had its claim decided,” finding that the Nevada commissioner of Insurance as receiver for the Nevada Health CO-OP (NHC) is entitled to judgment on all claims in her lawsuit alleging that the government improperly withheld payments under the Patient Protection and Affordable Care Act (ACA).

  • December 07, 2021

    Insurer Opposes Objections To Discovery Order In Antitrust Coverage Suit

    KANSAS CITY, Kan. — An insurer that recently assumed an insolvent excess insurer’s responsibility for claims and defenses in an antitrust coverage dispute filed an opposition on Nov. 23 to Blue Cross Blue Shield of Kansas Inc.’s objection to a Kansas federal magistrate judge’s discovery order.

  • December 08, 2021

    Supreme Court Grants More Time To Respond In ACA Sovereign Immunity Case

    WASHINGTON, D.C. — The U.S. Supreme Court on Dec. 3 granted an 45-day extension of time to respond to a petition over the objections of the state employees’ health plan, which argued that such a delay forces it to face summary judgment motions and potentially a trial before resolution of whether it is entitled to sovereign immunity from Patient Protection and Affordable Care Act discrimination claims.

  • December 08, 2021

    Health Plan Defendants Seek To Strike ACA Summary Judgment Motion

    WASHINGTON, D.C. — After plaintiffs filed a pair of summary judgment motions in a case alleging that a state employee health plan’s exclusion on transgender procedures violates the Patient Protection and Affordable Care Act prohibition on discrimination, defendants asked the court on Dec. 6 to strike them and for expedited consideration, saying the more than 12,000 combined words fail to comply with local rules and court rulings.

  • December 01, 2021

    California Court Won’t Publish Ruling Affirming Verdict In UCL Emergency Care Case

    LOS ANGELES — A California appellate court Nov. 30 declined to publish its opinion finding that a judge properly excluded an injunctive relief claim under California’s unfair competition law (UCL) while also affirming the exclusion of certain evidence and expert testimony and dismissal of tort claims arising from alleged underpayment for emergency services.

  • November 30, 2021

    Court Hears Arguments Over Emotional Distress Damages In ACA Discrimination Case

    WASHINGTON, D.C. — Whether the Patient Protection and Affordable Care Act (ACA) and the underlying anti-discrimination statutes from which it borrows put a federal funding recipient on notice of the potential for emotional distress damages or whether such damages are more akin to punitive damages and must be clearly imposed by Congress came before the U.S. Supreme Court during oral arguments on Nov. 30.

  • November 29, 2021

    In Appeal Of Denied Benefits, Panel Says Merits Challenge Forfeited

    WASHINGTON, D.C. — The District of Columbia U.S. Circuit Court of Appeal on Nov. 23 rejected efforts by an appellant to obtain coverage under his Employee Retirement Income Security Act-governed benefits plan for mental health treatment sought by a dependent, leaving intact findings by a District of Columbia federal judge that the denial of benefits was supported by substantial evidence.

  • November 24, 2021

    Judge Further Trims Insurer’s Fraudulent Billing Claims Against Laboratories

    BRIDGEPORT, Conn. — An insurer’s claims that laboratories fraudulently billed it are subject to the presumption of laches but not barred by the doctrine, but it states a claim against only two of the six defendants, a federal judge in Connecticut said Nov. 22 in partially granting a motion to dismiss.

  • November 23, 2021

    Judge:  Fiduciary Claims Impermissibly Seek Damages, ERISA Preempts State Claim

    ST. LOUIS — Plaintiffs’ Employee Retirement Income Security Act fiduciary claims impermissibly seek damages, and the statute preempts state law parity act claims in a residential treatment case against a self-funded plan, a federal judge in Missouri said Nov. 19 in dismissing claims.

  • November 19, 2021

    Judge: ACA, RA Claims Lack Evidence Of Intentional Discrimination

    CHARLOTTE, N.C. — Even if the Patient Protection and Affordable Care Act covers health care recipients’ companions, discrimination claims under the law still rise and fall with the Rehabilitation Act, and a man lacks evidence that isolated failures during a single visit to a hospital for the birth of his child constitute intentional discrimination, a federal judge in North Carolina said Nov. 16 in dismissing the man’s suit.

  • November 18, 2021

    ‘Unauthorized Health Insurance Plans’ Are ‘Illegal Contracts,’ Members Argue

    AKRON, Ohio — Members of health insurance plans filed a class complaint in a federal Ohio court on Oct. 21, seeking a declaration that the plans “were and are illegal contracts” and a ruling that Liberty HealthShare Inc.’s CEOs or directors are personally liable upon finding Liberty an unauthorized and insolvent insurer under Virginia Code Annotated Section 38.2-215.

  • November 18, 2021

    DOL’s Tobacco Wellness Claims Proceed; Out-Of-Network ERISA Payment Claims Fail

    COLUMBUS, Ohio — The secretary of Labor lacks authority to challenge out-of-network reimbursement methodology under the Employee Retirement Income Security Act because there are no alleged plan losses, but some of the claims stemming from a self-insured wellness plan’s failure to provide tobacco users an alternative means of meeting a health-related reward may proceed, a federal judge in Ohio said Nov. 17 in a mixed ruling on motions to dismiss.

  • November 16, 2021

    Health Plan: Sovereign Immunity Covers ACA Gender Dysphoria Coverage Case

    GREENSBORO, N.C. — The Patient Protection and Affordable Care Act’s incorporation of discrimination statutes did not constitute a waiver of sovereign immunity by the states, a health plan covering North Carolina university employees tell the U.S. Supreme Court in a Nov. 2 petition urging it to accept review and end the “deep uncertainty” states face in the wake of a ruling allowing transgender discrimination claims to proceed.

  • November 16, 2021

    Deaf Woman Says Precedent Supports Emotional Distress Damages In ACA Case

    WASHINGTON, D.C. — Precedent supports awards of compensatory damages such as those for emotional distress in a case alleging discrimination in the provision of health care in violation of the Patient Protection and Affordable Care Act (ACA), a deaf and blind woman told the U.S. Supreme Court Nov. 2.

  • November 15, 2021

    5th Circuit Denies Rehearing En Banc On ERISA Benefit Denial

    NEW ORLEANS — The Fifth Circuit U.S. Court of Appeals in an Oct. 25 order denied panel rehearing and rehearing en banc regarding a decision that upheld a health plan benefit denial under the Employee Retirement Income Security Act, declining an appellee’s request to reevaluate its “substantial evidence” standard for reviewing such denials.

  • November 15, 2021

    Supreme Court Grants Stipulation Dismissing ACA Disparate Impact Case

    SAN FRANCISCO — The U.S. Supreme Court on Nov. 12 granted a joint motion dismissing a case involving the interplay between federal discrimination law and the Patient Protection and Affordable Care Act and whether together they recognize disparate impact cases.

  • November 11, 2021

    Providers: Texas Law Permits Emergency Care Billing, Quantum Meruit Claims

    AUSTIN, Texas — The Texas Supreme Court should affirm that the state’s emergency care laws require payment for out-of-network emergency at the usual and customary rate, that providing care to insureds can form the basis of a quantum meruit claim and that providers have standing to pursue their case, emergency care providers tell the court in a Nov. 8 brief on the merits.

  • November 10, 2021

    Government Downplays Need For Review Of ACA-Medicaid Actuarial Soundness Ruling

    WASHINGTON, D.C. — Congress and federal agencies are permitted to create standards governing the dispersing of federal funds and even rely on private entities for guidance on highly technical issues, the federal government told the U.S. Supreme Court on Nov. 8 in urging it to deny review of a challenge to a ruling upholding the ACA-Medicaid actuarial soundness rule.

  • November 10, 2021

    California Unfair Competition Law Hospital Pricing Suit Won’t Get Rehearing

    SAN FRANCISCO — A California appeals court on Nov. 8 declined to rehear a case in which it found that even under the most generous standard, a man never establishes that a hospital’s failure to disclose that it imposes an emergency room fee separate from its listed charges constitutes unfair conduct under the California unfair competition law (UCL) or the California Consumers Legal Remedies Act (CLRA).

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