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Mealey's Health Care / ACA

  • March 22, 2019

    Insurer Cites Individual Issues In Opposing Certification In ACA Lactation Spat

    SAN FRANCISCO — Plaintiffs seeking class certification in a challenge to the availability of in-network lactation services under the Patient Protection and Affordable Care Act (ACA) ignore that any such determination requires individualized evidence and defenses, an insurer told a federal judge in California March 21 (Rachel Condry, et al. v. UnitedHealth Group Inc., et al., No. 17-183, N.D. Calif.).

  • March 21, 2019

    Citing Abuse Of Discretion By Insurer, 5th Circuit Affirms In ERISA Case

    NEW ORLEANS — A Texas federal judge did not abuse her discretion in finding, following a bench trial, that Blue Cross & Blue Shield of Louisiana (BCBSLA) violated the Employee Retirement Income Security Act when it arbitrarily denied claims for covered services submitted by a company that facilitates in-office surgical procedures, a divided Fifth Circuit U.S. Court of Appeals ruled March 19 (Encompass Office Solutions Inc. v. Louisiana Health Service & Indemnity Company, d/b/a Blue Cross & Blue Shield of Louisiana, 17-10736, 5th Cir., 2019 U.S. App. LEXIS 8165).

  • March 20, 2019

    9th Circuit: Settlement Properly Included In ACA Medical Loss Ratio Calculation

    LOS ANGELES — An insurer’s categorization of settlement funds it paid in settling claims that it misstated the size of its network coverage as incurred claims under the medical loss ratio (MLR) calculation did not violate the Patient Protection and Affordable Care Act (ACA), a Ninth Circuit U.S. Court of Appeals panel held March 18 (Rebecca Morris, et al. v. Blue Shield of California, et al., No. 17-55878, 9th Cir., 2019 U.S. App. LEXIS 7994).

  • March 19, 2019

    Both Parties Granted Judgment In ERISA Mental Health Treatment Case

    CHICAGO — One of an insured’s providers falls outside the guise of a residential treatment program and is excluded by her health insurance, but her treatment at a second health care facility clearly constituted medically necessary care, a federal judge in Illinois held March 18 in partially granting judgment in an Employee Retirement Income Security Act case for both the insured and insurer (Alice F. v. Health Care Service Corp., et al., No. 17-3710, N.D. Ill., 2019 U.S. Dist. LEXIS 43150).

  • March 19, 2019

    Health Care Provider Secures Remand Of Insurer Underpayment Case

    TRENTON, N.J. — A health care provider is not the type of entity able to bring an Employee Retirement Income Security Act claim, and his claims are not preempted, a federal judge in New Jersey held March 15 in adopting a magistrate judge’s recommendation that the case be remanded (Tzvi Small, M.D. v. Anthem Blue Cross Blue Shield, et al., No. 18-399, D. N.J., 2019 U.S. Dist. LEXIS 42450).

  • March 19, 2019

    Hospital May Continue Pursuit Of Insurer Over Unpaid Bills, Judge Says

    SALT LAKE CITY — An alleged assignment of benefits gives a hospital standing to sue an insurer, and its allegation that the insurer improperly calculated the reasonable and customary rate for treatment provides grounds for its Employee Retirement Income Security Act suit, a federal judge in Utah held March 15 (IHC Health Service d/b/a McKay-Dee Hospital v. Central States, et al., No. 17-1327, D. Utah, 2019 U.S. Dist. LEXIS 42786).

  • March 18, 2019

    Parties File Oppositions In ACA Short-Term Plan Rule Challenge

    WASHINGTON, D.C. — The federal government and plaintiffs challenging a rule expanding the availability of Patient Protection and Affordable Care Act (ACA) short-term, limited duration insurance (STLDI) health insurance plans on March 15 filed dueling oppositions to motions for summary judgment in the 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.).

  • March 15, 2019

    Amici Parties Urge Reversal Of Injunction Barring ACA Birth-Control Rules

    HARRISBURG, Pa. — Both the Patient Protection and Affordable Care Act (ACA) and the Religious Freedom Restoration Act (RFRA) provide grounds for the U.S. Department of Health and Human Services (HHS) to issue rules addressing constitutional issues in the contraceptive mandate, three amicus curiae parties tell the Third Circuit U.S. Court of Appeals in Feb. 22 briefs (Pennsylvania, et al. v. President, United States of America, et al., Nos. 17-3752, 18-1253,19-1129, 19-1189, 3rd Cir.).

  • March 14, 2019

    Judge: Precedent Provides Room For Provider’s Suit Against ERISA Insurer

    BRIDGEPORT, Conn. — There is room for out-of-network health care providers to bring claims against Employee Retirement Income Security Act plan insurers, as long as the claims in no way implicate the plan contract, a federal judge in Connecticut held March 12 (Aesthetic and Reconstructive Breast Center LLC v. United Healthcare Group Inc., No. 18-608, D. Conn., 2019 U.S. Dist. LEXIS 39284; Taylor Theunissen, M.D. LLC v. United Healthcare Group Inc., et al., No. 18-606, D. Conn., 2019 U.S. Dist. LEXIS 39284).

  • March 14, 2019

    Female Athletes Level ACA Discrimination Claims Against Olympic Committee

    DENVER — Allegations that the U.S. Olympic Committee (USOC) and related individuals discriminated against women in violation of Patient Protection and Affordable Care Act (ACA) Section 1557 by permitting the sexual abuse of female athletes under its care are among the bevy of claims brought by 51 female athletes in a March 12 lawsuit in Colorado federal court (Jane L.B. DOE 1, et al. v. United States Olympic Committee, et al., No. 19-737, D. Colo.).

  • March 13, 2019

    ACA Doesn’t Preempt Marketplace Breach Of Contract Suit, Judge Finds

    CINCINNATI — The Patient Protection and Affordable Care Act (ACA) does not preempt a class’s state law claims alleging that their marketplace insurer breached its contract with insureds by misrepresenting the size of its provider network, a federal judge in Ohio said March 11 in remanding the case (Neha Desai, et al. v. CareSource Inc., No. 18-118, S.D. Ohio, 2019 U.S. Dist. LEXIS 38172).

  • March 13, 2019

    North Carolina Health Plan Discriminates Against Transgendered, Employees Say

    GREENSBORO, N.C. — A state employer health plan violates the Patient Protection and Affordable Care Act (ACA) by discriminating against transgendered individuals by denying coverage for related procedures and medicines, plaintiffs allege in a March 11 suit filed in North Carolina federal court (Maxwell Kadel, et al. v. Dale Folwell, et al., No. 19-272, M.D. N.C.).

  • March 12, 2019

    Iowa High Court: Medicaid Must Cover Transgender Surgery

    DES MOINES, Iowa — An administrative rule prohibiting Iowa’s Medicaid program from covering transgender surgery conflicts with state law adding gender identity as a protected class and cannot stand, the Iowa Supreme Court held March 8 (Eerieanna Good, et al. v. Iowa Department of Human Services, No. 18-1158, Iowa Sup.).

  • March 11, 2019

    Amici: Government Pulled Risk Corridor Rug Out From Under ACA Insurers

    WASHINGTON, D.C. — The government should not be permitted to incentivize private companies to participate in its Patient Protection and Affordable Care Act (ACA)  risk corridor program and then retroactively revoke its promises in vague riders, eight amicus curiae parties tell the U.S. Supreme Court in March 8 briefs (Land of Lincoln Mutual Health Insurance Co. v. United States, No. N/A, Moda Health Plan Inc. v. United States, No. 18-1028, Blue Cross and Blue Shield of North Carolina v. United States, No. 17-2154, Maine Community Health Options v. United States, No. 18-1023, U.S. Sup.).

  • March 8, 2019

    Judge: Discrimination Suit Against Wal-Mart, Eye Care Provider May Proceed

    PORTLAND, Ore. — A deaf man adequately alleges that Wal-Mart and its vision center partner violated the Patient Protection and Affordable Care Act (ACA) and various anti-discrimination laws by promising but failing to provide an adequate sign language interpreter, a federal judge in Oregon held March 6 in adopting a magistrate judge’s findings (Larry R. Spiva Jr. v. Walmart, et al., No. 18-1024, D. Ore.).

  • March 7, 2019

    Judge: Drug Abuse Treatment Provider Adequately Alleges Breach Of Contract

    LOS ANGELES — Substance abuse treatment providers adequately plead breach of contract claims against an insurer, but the remainder of their action fails, a California federal judge held March 4 (TML Recovery v. Humana Inc., No. 18-462, MMR Services LLC v. Humana Inc., et al, No. 18-463, C.D. Calif.).

  • March 7, 2019

    2nd Circuit Grants HHS Extension In New York-ACA Risk-Adjustment Program Spat

    NEW YORK — The Second Circuit U.S. Court of Appeals on March 5 gave the U.S. Department of Health and Human Services until June to respond to its request for an opinion on how the Patient Protection and Affordable Care Act (ACA)’s risk-adjustment program interacts and impacts a similar New York program in two insurers’ case challenging whether the state can take proceeds to which the companies were entitled under the federal law (UnitedHealthcare of New York Inc., et al. v. Maria T. Vullo, et al., No. 18-2583, 2nd Cir.).

  • March 6, 2019

    Health Insurer Violated Standard Of Care, Judge Says In ERISA Case

    SAN FRANCISCO — An insurer’s denial of coverage for intensive residential health care and substance abuse treatments violated generally accepted standards of care, a federal magistrate judge in California held March 5 in a pair of Employee Retirement Income Security Act class actions (David and Natasha Wit, et al. v. United Behavioral Health, No. 14-02346, Gary Alexander, et al. v. United Behavioral Health, No. 14-5337, N.D. Calif.).

  • March 4, 2019

    AARP Says Court Must Vacate ACA Skirting Short-Term Plan Rule

    WASHINGTON, D.C. —  n agency rule extending how long individuals can receive coverage under threadbare health insurance plans threatens the very communities the Patient Protection and Affordable Care Act (ACA) sought to protect, an amicus curiae told a District of Columbia federal judge on March 1 (Association for Community Affiliated Plans, et al. v. United States Department of Treasury, et al., No. 18-2133, D. D.C.).

  • February 28, 2019

    Judge Largely Dismisses Surgery Provider’s ERISA Action

    LOS ANGELES — A medical provider’s claim that plan documents in its Employee Retirement Income Security Act case may differ from other, undisclosed plan documents, does not survive a motion to dismiss, a federal judge in California held Feb. 27 (Beverly Oaks Physicians Surgical Center LLC, et al. v. Blue Cross Blue Shield of Illinois, et al., No. 18-3866, C.D. Calif., 2019 U.S. Dist. LEXIS 31450).