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.).
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).
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.).
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.).
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.).
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).
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.).
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).
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).
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.).
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.).
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.).
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).
WASHINGTON, D.C. — Despite fears that certain changes could undermine Patient Protection and Affordable Care Act (ACA) enrollment, the number of uninsured individuals remained steady at 8.8 percent through the first three months of 2018, according to a new government report.
SALT LAKE CITY — Any irregularities in a health insurer’s handling of two residential treatment claims do not warrant de novo review, and the record does not support the conclusion that the insurer abused its discretion in denying coverage for treatment two children received, a federal judge in Utah held Aug. 27 (Sandy Jo H., et al. v. Cigna Behavioral Health, et al., No. 17-110, D. Utah, 2018 U.S. Dist. LEXIS 146065).
TRENTON, N.J. — A medical provider’s claim that an Employee Retirement Income Security Act plan’s anti-assignment provision involves only the insured’s right to assign benefits, not the power to do so, is contrary to district and circuit precedent, a federal judge in New Jersey said Aug. 27 (University Spine Center, et al. v. United Healthcare, No. 17-8575, D. N.J.).
SACRAMENTO, Calif. — A district court judge erred in concluding that crisis pregnancy centers (CPCs) were unlikely to prevail on their free speech claims challenging a California abortion-disclosure law and on remand should reconsider in light of more recent precedent, the Ninth Circuit U.S. Court of Appeals held Aug. 28 (A Woman’s Friend Pregnancy Resource Clinic, et al. Xavier Becerra, et al., No. 15-17517, 9th Cir., 2018 U.S. App. LEXIS 24327).
SEATTLE — Allegations that an insurer imposes a formulaic policy in determining what constitutes reasonable medical costs in a given geographic area form the basis of a Washington state consumer protection act claim, a state appellate court held Aug. 24 (Folweiler Chiropractic, et al. v. American Family Insurance Co., No. 76448-9-I, Wash. App., Div. 1, 2018 Wash. App. LEXIS 2029).
LOS ANGELES — Attorneys’ failure to investigate whether their health insurance client’s administrative appeals process applied to a contracted provider prior to arguing that the plaintiff failed to exhaust such remedies warrants imposing sanctions, a federal judge in California held Aug. 22 (Prime Healthcare Services Inc. v. Humana Insurance Co., et al., No. 16-1097, C.D. Calif.).
ATLANTA — Regardless of the standard applying in Patient Protection and Affordable Care Act (ACA) Section 1557 cases, the law at the very least requires evidence of discrimination an African-American dermatologist cannot produce in support of her allegation that a company selectively enforces its anti-assignment provision against women and minorities, a panel of the 11th Circuit U.S. Court of Appeals held Aug. 20 (W.A. Griffin v. Verizon Communications Inc., et al., No. 17-14761, 11th Cir., 2018 U.S. App. LEXIS 23146).