Mealey's Health Care / ACA

  • January 16, 2020

    Judge Remands Insolvent Insurer’s Liquidator’s Breach Of Fiduciary Duty Case

    SALT LAKE CITY — A federal judge in Utah on Jan. 13 remanded to the liquidation court an insolvent health insurer’s liquidator’s breach of fiduciary and negligence lawsuit against the insurer’s executives because the executives failed to establish that the case necessarily raises or involves a substantial issue of federal law for purposes of jurisdiction (Stillman Consulting Services, LLC v. Shaun Greene, et al., No. 19-668, D. Utah, 2020 U.S. Dist. LEXIS 6274).

  • January 14, 2020

    U.S. Supreme Court Told Not To Rush To Judgment In ACA Individual Mandate Case

    WASHINGTON, D.C. — Rulings that found the Patient Protection and Affordable Care Act (ACA) individual mandate unconstitutional present no immediate impact and do not need to be addressed in an expedited fashion, a trio of Supreme Court respondents told the court Jan. 10 (California, et al. v. Texas, et al, No. 19-840, United States House of Representatives v. Texas, et al., No. 19-841, U.S. Sup.).

  • January 13, 2020

    Court: California Law Sets Reimbursement Rate In Medicaid Payment Spat

    LOS ANGELES — California law setting diagnosis-based payment rates applies to out-of-network care provided in an inpatient post-stabilization setting, a state appeals court held Jan. 9 (Dignity Health, et al. v. Local Initiative Health Care Authority of Los Angeles County, No. B288886, Calif. App., 2nd Dist.).

  • January 06, 2020

    U.S. Supreme Court Asked To Take Up ACA Individual Mandate Case

    WASHINGTON, D.C. — A pair of Jan. 3 petitions for writ of certiorari seek U.S. Supreme Court review of a decision finding the Patient Protection and Affordable Care Act (ACA) individual mandate unconstitutional (The States of California, et al. v. The State of Texas, et al, No. 19-840, United States House of Representatives v. State of Texas, et al., No. 19-841, U.S. Sup.).

  • January 03, 2020

    Plaintiff States Urge Supreme Court To Stay Away From ACA Mandate Question

    WASHINGTON, D.C. — A handful of amicus curiae parties on Nov. 1 urged the U.S. Supreme Court to take up the Patient Protection and Affordable Care Act (ACA) contraceptive mandate case (Little Sisters of the Poor Saints Peter and Paul Home v. Pennsylvania, et al., Donald J. Trump, et al. v. Pennsylvania, Nos. 19-431, 19-454, U.S. Sup.).

  • January 02, 2020

    Appeals Panel Reverses Judgment For Insurer In ACA Risk-Adjustment Case

    ALBUQUERQUE, N.M. — The government could not have acted in an arbitrary and capricious manner because it properly evaluated and investigated methods of imposing Patient Protection and Affordable Care Act (ACA) risk-adjustment charges, a 10th Circuit U.S. Court of Appeals panel held Dec. 31 (N.M. Health Connections v. United States HHS, No. 18-2186, 10th Cir., 2019 U.S. App. LEXIS 38739).

  • January 02, 2020

    Judge Dismisses Conclusory, ‘Stunning’ Health Coverage Allegations

    HARRISBURG, Pa. — A claim by a man with cancer that his health insurer misrepresented coverage lacks support and his claim that he didn’t know his health maintenance organization limited his coverage “is stunning,” a federal judge in Pennsylvania said in dismissing claims on Dec. 27 (Adam Brown v. Kaiser Foundation Health Plan of the Mid-Atlantic States Inc., No. 19-1190, M.D. Pa., 2019 U.S. Dist. LEXIS 221471).

  • January 02, 2020

    Liquidators Appeal Dismissal Of Claims Over Offset Under ACA Reinsurance Program

    WASHINGTON, D.C. — The liquidators for an insolvent insurer gave notice on Dec. 23 that they are appealing a U.S. Court of Federal Claims judge’s dismissal of their state law claims against the U.S. government over violation of South Carolina insurance law following the government’s offset of $36 million under the reinsurance program of the Patient Protection and Affordable Care Act (ACA) (Raymond G. Farmer, et al. v. The United States, No. 18-1484, Fed. Clms.).

  • December 20, 2019

    U.S. Government Appeals Ruling On Offsetting Insolvent Insurer’s Debt Under ACA

    WASHINGTON, D.C. — The U.S. government said on Dec. 19 that it is appealing to the Federal Circuit U.S. Court of Appeals a federal judge’s finding that Colorado insurance liquidation law bars its health agency from using money owed to an insolvent Colorado insurer to pay debts owed under the Patient Protection and Affordable Care Act’s (ACA) reinsurance and risk-adjustment programs (Michael Conway v. The United States, No. 18-1623, Fed. Clms., 2019 U.S. Claims LEXIS 1306).

  • December 19, 2019

    Class Survives UnitedHealth’s Facility-Fee Certification Challenge

    NEW YORK — A federal judge in New York on Dec. 18 denied a motion for reconsideration, saying that a certified class did not include patients who assigned their Employee Retirement Income Security Act rights to health care providers and that the issue involved predominance more than commonality (The Medical Society of the State of New York, et al. v. UnitedHealth Group Inc., et al., No. 16-5265, S.D. N.Y.).

  • December 19, 2019

    5th Circuit Finds ACA Individual Mandate Unconstitutional

    NEW ORLEANS — The Patient Protection and Affordable Care Act (ACA) individual mandate is unconstitutional with its payment set at zero, a majority of a Fifth Circuit U.S. Court of Appeals panel held Dec. 18, but it remanded the case for a closer inspection of whether the provision could be severed from the entire law (Texas, et al. v. United States, et al., No. 19-10011, 5th Cir.).

  • December 16, 2019

    Government Will Appeal $1.58B ACA Cost-Sharing Class Judgment

    WASHINGTON, D.C. — In a Dec. 16 filing, the federal government indicated that it will appeal a nearly $1.6 billion judgment for its failure to make Patient Protection and Affordable Care Act (ACA) cost-sharing payments for 2017 and 2018 (Common Ground Healthcare Cooperative v. The United States, No. 17-877, Fed. Clms.).

  • December 11, 2019

    Lipedema Sufferer’s Liposuction Coverage Claims Proceed, Judge Says

    SAN FRANCISCO — A woman adequately alleges that her insurer denies coverage for liposuction treatments for lipedema, despite covering surgeries needed to reduce pain and improve functionality in other settings, a federal judge in California said in declining to dismiss her case Dec. 10 (Michala Kazda v. Aetna Life Insurance Co., No. 19-2512, N.D. Calif.).

  • December 11, 2019

    Utah Federal Judge Considers Wilderness Therapy Parity Act Claim

    SALT LAKE CITY — A federal judge in Utah on Dec. 10 heard arguments about whether a family adequately pleaded that an insurer improperly denied coverage for wilderness therapy and withheld judgment on the insurer’s motion to dismiss the Mental Health Parity and Addiction Act claim (Candace B., et al. v. Blue Cross and Blue Shield of Rhode Island, No. 19-39, D. Utah).

  • December 10, 2019

    Insurers, Government Battle Over ACA Risk-Corridor Payments

    WASHINGTON, D.C. — The U.S. Supreme Court heard arguments on Dec. 10 about whether the Patient Protection and Affordable Care Act (ACA)’s “shall pay” language created a financial obligation for the government or at all times remained contingent on later congressional funding (Land of Lincoln Mutual Health Insurance Co. v. United States, No. 18-1038, Moda Health Plan Inc., et al. v. United States, No. 18-1028, Maine Community Health Options v. United States, No. 18-1023, U.S. Sup.).

  • December 10, 2019

    Surgery Provider’s Suit Seeking Payment From Insurers Survives Dismissal

    ALAMEDA, Calif. — A surgery provider’s preauthorization conversations with insurers led it to believe it that would be paid its usual and customary rates, a federal judge in California said Nov. 20 in denying a motion to dismiss (California Spine and Neurosurgery Institute v. Oxford Health Insurance Inc., et al., No. 19-3533, N.D. Calif., 2019 U.S. Dist. LEXIS 202556).

  • December 10, 2019

    Magistrate Judge Says Medical Provider’s Suit Belongs In State Court

    TRENTON, N.J. — The record is largely silent as to whether a medical provider has valid assignments from insureds, and even if it had standing under the Employee Retirement Income Security Act, its claims do not directly involve such a plan, a federal magistrate judge in New Jersey said Nov. 25 in recommending remand (North Jersey Brain & Spine Center v. United Healthcare Insurance Co., et al., No. 18-15631, D. N.J.).

  • December 10, 2019

    Judge: Medical Transport Prevails Against Authorization, Necessity Arguments

    CHICAGO — Only a health plan’s participating providers must obtain preauthorization for nonemergency transport, and absent evidence of a closer qualified provider, there exists no reason to conclude that air transport to the facility in question was not medically necessary, a federal judge in Illinois held Nov. 26 (Aviation West Charters LLC v. Health and Welfare Plan for Employees of Anjinomoto USA Inc., et al., No. 18-7431, N.D. Ill., 2019 U.S. Dist. LEXIS 204908).

  • December 05, 2019

    Judge Orders Insurer To Turn Over Documents In Mental Health Coverage Spat

    SALT LAKE CITY — A health insurer and plan must produce documents related to an insured’s mental health treatments and how they determine medical necessity in that setting as well as surgical settings, a federal judge in Utah said Dec. 2 in reserving rulings on motions to dismiss and to amend a complaint (James C., et al. v. Anthem Blue Cross and Blue Shield, No. 19-38, D. Utah).

  • November 26, 2019

    Judge Finds Standing But Not Sufficient Allegations In Parity Act Case

    SALT LAKE CITY — Debts incurred when a health insurer denied coverage for a child’s treatments provide the parents with standing, but their attempts to recover the amount through the Mental Health Parity and Addiction Act rely on conclusory statements and are better addressed by the Employee Retirement Income Security Act, a federal judge in Utah said Nov. 21 (John R., et al. v. United Behavioral Health, et al., No. 18-35, D. Utah).