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Mealey's Health Care / ACA

  • November 21, 2018

    Health Care Provider Wants High Court Review Of ACA Section 1557 Case

    WASHINGTON, D.C. — An insurer and employer on Nov. 19 waived their right to respond to a U.S. Supreme Court petition alleging that they discriminated against African-Americans and women providers under the Patient Protection and Affordable Care Act (ACA) by selectively enforcing anti-assignment provisions (W.A. Griffin v. Verizon Communications Inc., et al., No. 18-523, U.S. Sup.).

  • November 15, 2018

    Health Care Providers, Patient See ERISA Case Against Insurer Dismissed

    TRENTON, N.J. — A valid anti-assignment provision dooms providers’ Employee Retirement Income Security Act claims, while the insured presents nothing suggesting that her insurer need to pay the providers more than it did, a federal judge in New Jersey held Oct. 31 (Atlantic Plastic & Hand Surgery, PA, et al. v. Anthem Blue Cross Life and Health Insurance Co., et al., No. 17-4599, D. N.J.).

  • November 15, 2018

    Federal Judge Finds Health Care Provider Lacks ERISA Standing

    PHILADELPHIA — Under recent Third Circuit precedent, a valid anti-assignment provision strips providers of standing to pursue ERISA claims, a federal judge in Pennsylvania held Oct. 25 (Howard Bloom, et al. v. Independence Blue Cross, et al., No. 14-2582, E.D. Pa., 2018 U.S. Dist. LEXIS 183023).

  • November 13, 2018

    Judge Gives Everyone Something In Expediting ACA Short-Term Plan Briefing

    WASHINGTON, D.C. — Neither plaintiffs nor defendants got their wish in a federal judge’s Nov. 12 minute order setting simultaneous and slightly expedited briefing of a challenge to a Patient Protection and Affordable Care Act (ACA) rule expanding the availability of short-term, limited coverage health plans (Association for Community Affiliated Plans, et al. v. United States Department of Treasury, et al., No. 18-2133, D. D.C.).

  • November 13, 2018

    Surgery Provider: Conversion Claim Against Insurer Supports Punitive Damages

    LOS ANGELES — An insurer never contests claims arising from its underpayment for medical services, and its unilateral and unlawful decision to simply reduce a bill by an amount it claimed it was owed evidences an “overt disregard” for the business and supports a punitive damages claim, a California out-of-network provider says Nov. 9 in a federal court in California (California Spine and Neurosurgery Institute v. Aetna Life Insurance Co., et al., No. 18-6829, C.D. Calif.).

  • November 13, 2018

    2nd Circuit Stays New York Risk-Adjustment Program During Insurers’ Appeal

    NEW YORK — New York may not confiscate tens of millions of dollars under its risk-adjustment program while two insurers appeal the program’s interaction with a similar Patient Protection and Affordable Care Act (ACA) provision, the Second Circuit U.S. Court of Appeals held Oct. 10 in granting a temporary injunction (UnitedHealthcare of New York Inc., et al. v. Maria T. Vullo, et al., No. 18-2583, 2nd Cir.).

  • November 12, 2018

    Anti-Assignment Provision Denies Standing, ERISA Preemptive Effect, Court Finds

    TRENTON, N.J. — A dispute over an insurer’s failure to fully pay a provider’s bill heads back to state court, after a federal judge on Nov. 9 partially adopted a report and recommendation finding that an anti-assignment provision precluded the provider from filing an ERISA action and prevented preemption (Tzvi Small v. Blue Cross Blue Shield of Michigan, et al., No. 18-11601, D. N.J., 2018 U.S. Dist. LEXIS 192415).

  • November 8, 2018

    Amici Urge Court Not To Kill ACA Association Health Insurance Rule

    WASHINGTON, D.C. — New rules allowing associations to offer large group market health insurance plans largely ungoverned by the Patient Protection and Affordable Care Act (ACA)’s protections would help provide quality, affordable health insurance to an underserved market and are within an agency’s power, two business interests and a handful of states told a federal court in the District of Columbia on Nov. 7 (New York, et al. v. U.S. Department of Labor, et al., No. 18-1747, D. D.C.).

  • November 8, 2018

    New Rules Further Expand Religious, Moral Exemptions To ACA Contraceptive Mandate

    WASHINGTON, D.C. — Employers with moral and religious objections to providing insurance coverage for contraceptives required by the Patient Protection and Affordable Care Act (ACA) would be exempts from the law’s mandate under a pair of rules announced Nov. 7.

  • November 7, 2018

    Divided Court Denies Insurers Rehearing In ACA Risk-Corridor Case

    WASHINGTON, D.C. — With two judges dissenting, a federal appeals court on Nov. 6 declined to rehear health care insurers’ case claiming that the government owes them billions of dollars in Patient Protection and Affordable Care Act (ACA) risk-corridor funds (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., 2018 U.S. App. LEXIS 31395).

  • November 7, 2018

    Health Care Allegations Don’t Rise To Level Of Discrimination, Judge Says

    SPOKANE, Wash. — While a deaf plaintiff need not plead the specific medical information she left uncommunicated as a result of a hospital’s alleged failure to provide an in-person interpreter, her “vague” and potentially “hyperbolic” allegations are insufficient to establish discrimination under the Patient Protection and Affordable Care Act (ACA) and other federal statutes, a federal judge in Washington state held Nov. 2 (Alissa Juech v. Children’s Hospital and Health System Inc., et al., No. 15-1482, E.D. Wash., 2018 U.S. Dist. LEXIS 188000).

  • November 6, 2018

    Federal Judge Enjoins Insurer At Heart Of ‘Massive’ ACA Insurance Scheme

    MIAMI — A federal judge in Florida issued an injunction and placed a health insurer into temporary receivership after the Federal Trade Commission alleged that the company sold limited benefit and medical discount memberships it misrepresented as providing comprehensive coverage under the Patient Protection and Affordable Care Act (ACA), according to a Nov. 2 release from the agency (Federal Trade Commission v. Simple Health Plans LLC, et al., No. 18-62593, S.D. Fla.).

  • November 2, 2018

    Judge: Insurer Can’t Escape Utah As Venue For Mental Health Coverage Case

    SALT LAKE CITY — A health insurer’s decision to have its insureds file claims and appeals with a Utah address provides sufficient basis for bringing a suit claiming that it improperly denied coverage for residential adolescent mental health treatment, a federal judge held Oct. 24 (D.K., et al. v. United Behavioral Health, et al., No. 17-1328, D. Utah, 2018 U.S. Dist. LEXIS 183341).

  • November 2, 2018

    With Trial Looming, Judge Continues Depression Treatment Insurance Coverage Case

    BRIDGEPORT, Conn. — Parties may explore a settlement before engaging in trial preparation, a federal judge in Connecticut said Oct. 16 in a docket entry granting a joint motion to continue only days after a summary judgment ruling allowed claims challenging denial of coverage for transcranial magnetic stimulation therapy (Christopher Meidl, et al. v. Aetna, Inc., et al., No. 15-1319, D. Conn.).

  • October 31, 2018

    Judge Expands Distribution Period In Mental Health Coverage Settlement Case

    CHICAGO — A federal judge in Illinois on Oct. 26 modified a settlement agreement resolving claims that an insurer improperly denied coverage for residential mental health treatments, granting a 45-day extension for distribution of hundreds of thousands of dollars in remaining funds despite the lack of any language in the agreement envisioning such a move (Elizabeth A. Craft, et al. v. Health Care Service Corp., No. 14-5853, N.D. Ill., 2018 U.S. Dist. LEXIS 184108).

  • October 30, 2018

    Judge Rejects UCL Claim For Insurer’s Alleged Failure To Pay For Services

    SAN FRANCISCO — After finding that claims for violation of California’s unfair competition law (UCL) in relation to an insurer’s alleged failure to pay hospitals for noncontracted services could not be based on the improper application of the California Code of Regulations, a California federal judge on Oct. 26 granted the insurer’s motion for partial summary judgment on the UCL claims (NorthBay Healthcare Group – Hospital Division v. Blue Shield of California Life & health Insurance, et al., No. 17-cv-02929, N.D. Calif., 2018 U.S. Dist. LEXIS 184180).

  • October 30, 2018

    Couple Tells 8th Circuit Insurer’s Air Transport Payment Unsupported By ERISA

    ST. LOUIS — A health insurer’s unsupported calculation of the allowable charge for air transport is a “radical view” of its powers under the Employee Retirement Income Security Act, would leave insureds with “virtually no coverage” and cannot withstand scrutiny, a couple tells the Eighth Circuit U.S. Court of Appeals in an Oct. 26 opening brief (Ivan Mitchell, et al. v. Blue Cross Blue Shield of North Dakota, et al., No. 18-2784, 8th Cir.).

  • October 29, 2018

    Health Care Provider Objects To Ruling Permitting Insurer’s Counterclaims

    SAN ANTONIO — An insurer’s counterclaim seeking offsets and alleging fraud are barred by a health care provider’s bankruptcy and the insurer’s failure to plead them with the required specificity, a hospital group told a federal court in Texas on Oct. 25 (Neil Gilmour III, et al. v. Aetna Health Inc., et al., No. 17-510, W.D. Texas).

  • October 24, 2018

    ACA Reinsurance Program Payments Not A Tax, 4th Circuit Rules

    RICHMOND, Va. — A health care plan’s payments under the Patient Protection and Affordable Care Act (ACA) reinsurance program do not constitute a tax, a panel of the Fourth Circuit U.S. Court of Appeals said Oct. 23 (The Electrical Welfare Trust Fund, et al. v. United States, et al., No. 17-1937, 4th Cir., 2018 U.S. App. LEXIS 29856).

  • October 24, 2018

    Court Seeks Evidence In Insurance Case Involving Assignment, Sovereignty Issues

    HOUSTON — A more thorough record must be developed before a court rules on how an anti-assignment clause and sovereign immunity impact an Employee Retirement Income Security Act case brought by a home dialysis company, a federal judge in Texas held Oct. 22 (Houston Home Dialysis v. Blue Cross and Blue Shield of Texas, et al., No. 17-2095, S.D. Texas).