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Mealey's Health Care / ACA

  • October 9, 2018

    Hearing Treatment Exclusion Doesn’t Violate ACA, Judge Finds

    SEATTLE — A blanket exclusion on coverage for noncochlear hearing procedures and devices does not discriminate against those with hearing loss, a federal judge in Washington held Sept. 24 in dismissing Patient Protection and Affordable Care Act (ACA) Section 1557 claims (E.S., et al. v. Regence BlueShield, et al., No. 17-1609 W.D. Wash., 2018 U.S. Dist. LEXIS 163287).

  • October 2, 2018

    Advocates Want New ACA Short-Term Health Plan Rule Enjoined

    WASHINGTON, D.C. — Health care insurance advocates asked a federal judge on Sept. 28 to enjoin newly issued Patient Protection and Affordable Care Act (ACA) rules expanding the definition of short-term plans (Association for Community Affiliated Plans, et al. v. United States Department of Treasury, et al., No. 18-2133, D. D.C.).

  • October 1, 2018

    Supreme Court Denies Review In Medicare Administrative Exhaustion Case

    WASHINGTON, D.C. — A hospital group on Oct. 1 lost its bid for U.S. Supreme Court review on the question of whether noncontracted Medicare providers must exhaust administrative remedies before filing suit even when enrollees’ interests are not impacted (Atlanta Medical Center Inc., et al. v. Care Improvement Plus South Central Insurance Co., No. 17-1283, U.S. Sup.).

  • September 27, 2018

    Federal Government Says Pennsylvania Lacks Injury, ACA Case Lacks Merit

    HARRISBURG, Pa. — Pennsylvania lacks standing, filed its suit in the wrong district and cannot hope to prevail on the merits of its challenge to Patient Protection and Affordable Care Act (ACA) rules expanding religious and moral exclusions to the law’s birth control mandate, the government tells the Third Circuit U.S. Court of Appeals in a brief filed Sept. 24 (Commonwealth of Pennsylvania, et al. v. Donald J. Trump, et al., Nos. 17-3752, 18-1253, 3rd Cir.).

  • September 26, 2018

    Panel Finds Error In Remand Of Dispute Between Insolvent Insurer, U.S. Government

    CHICAGO — A federal court erred in remanding to a state court a dispute between the U.S. Department of Health and Human (HHS) and an insolvent insurer’s liquidator over the government’s setoff of its own debt payments by first paying down the insolvent insurer’s debt, the Seventh Circuit U.S. Court of Appeals ruled Sept. 25 (Jennifer Hammer v. U.S. Department of Health and Human Services, No. 18-2523, 7th Cir., 2018 U.S. App. LEXIS 27368).

  • September 26, 2018

    ACA Discrimination Claims Over Transgender Surgery Exclusion Head To Trial

    MADISON, Wis. — A federal judge on Sept. 24 cut some damage claims from an upcoming trial on an insurance policy’s prohibition on gender reassignment treatments after finding that the plaintiffs could proceed on allegations that the exclusion violated the Patient Protection and Affordable Care Act (ACA) and other federal law (Alina Boyden and Shannon Andrews v. Wisconsin Department of Employee Trust Funds, et al., No. 17-264, W.D. Wis.).

  • September 24, 2018

    Employer Can’t Escape Mother’s ACA Suit Over Gender Dysphoria

    MINNEAPOLIS — An employer and third-party administrator cannot escape a former employee’s Patient Protection and Affordable Care Act (ACA) lawsuit claiming that they discriminated against her son by denying coverage for gender reassignment surgery, a federal judge in Minnesota held Sept. 20 (Brittany R. Tovar v. Essentia Health, Innovis Health LLC d/b/a Essentia Health West and HealthPartners Inc., No. 16-100, D. Minn.).

  • September 18, 2018

    Health Insurer Says ERISA Preempts, Pleading Deficiencies Defeat UCL Claim

    LOS ANGELES — An out-of-network substance abuse services provider’s claims are preempted by the Employee Retirement Income Security Act, and the provider fails to adequately plead its California unfair competition law (UCL) claim, an insurer tells a California federal judge in a reply Sept. 14 (Miriam Hamideh Ph.D., et al. v. Anthem Blue Cross Life and Health Insurance Co., et al., No. 18-3044, C.D. Calif.).

  • September 18, 2018

    Hearing Treatments Exclusion Isn’t Discriminatory, Federal Judge Says

    SEATTLE — A pair of individuals with hearing loss have not shown that a health insurer’s exclusion for most hearing-related treatments constitutes discrimination under the Patient Protection and Affordable Care Act (ACA), a federal judge in Washington held Sept. 14 (Andrea Schmitt, et al. v. Kaiser Foundation Health Plan of Washington, et al., No. 17-1611, W.D. Wash., 2018 U.S. Dist. LEXIS 157308).

  • September 18, 2018

    Washington Top Court Deciding If Proton Beam Therapy Is ‘Medically Necessary’

    SEATTLE — Whether a health insurance policy’s “medically necessary” language required coverage of a man’s proton beam therapy confronts the Washington Supreme Court after it recently received supplemental briefing (John Strauss, et al. v. Premera Blue Cross, No. 74600-6-I, Wash. Sup.).

  • September 17, 2018

    Newly Created Short-Term Health Plan Rule Violates ACA, APA, Advocates Claim

    WASHINGTON, D.C. — The federal government’s attempt to create a loophole creating a “parallel individual insurance market” finds no support in the text, structure or purpose of the Patient Protection and Affordable Care Act (ACA), a coalition of health care advocates alleges in Sept. 14 complaint in District of Columbia federal court (Association for Community Affiliated Plans, et al. v. United States Department of Treasury, et al., No. 18-2133, D. D.C.).

  • September 17, 2018

    Maryland Seeks Ruling That Recent Changes Didn’t Invalidate ACA

    BALTIMORE — Illegal administrative actions seeking to undermine the Patient Protection and Affordable Care Act (ACA) threaten Maryland with “immediate and long-term harm,” the state alleges in a Sept. 13 complaint seeking a declaration that the law remains constitutional (Maryland v. United States, et al., No. 18-2849, D. Md.).

  • September 13, 2018

    Judge Finds Woman Lacks Standing To Challenge ACA Mandate Rules

    DENVER — A woman never alleges that her employer has or is likely to invoke newly issued rules broadening exemptions to the Patient Protection and Affordable Care Act (ACA)’s contraceptive mandate and, thus, lacks standing to pursue her action, a federal judge in Colorado held Sept. 11 (Jessica Campbell v. Donald Trump, et al., No. 17-2455, D. Colo., 2018 U.S. Dist. LEXIS 154593).

  • September 13, 2018

    Judge: Fiduciary Duty Claim In Wilderness Therapy ERISA Case Survives, Judge Says

    NEW YORK — An insurer’s alleged coverage for skilled nursing and rehabilitation while imposing a blanket exclusion on wilderness therapy adequately pleads a violation of the mental health parity law, a federal judge in New York held Sept. 11 while denying a motion to dismiss an ERISA breach of fiduciary duty claim (William Gallagher, et al. v. Empire Healthcare Assurance Inc., et al., No. 16-9105, S.D. N.Y.).

  • 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).