Mealey's Health Care / ACA : Mealey's : Legal News & Analysis

Mealey's Health Care / ACA

May 15, 2023
$185.2M Judgment Entered For Plans In ACA Reinsurance Row; 9 Similar Cases Refiled

WASHINGTON, D.C. — Noting that the government’s earlier objection was withdrawn, a U.S. Court of Federal Claims judge on May 12 entered partial judgment under which the government will pay a class of 357 self-insured, self-administered employee health and welfare benefit plans (SISAs) a combined $185,230,024.42 in a suit over the Transitional Reinsurance Program (TRP) of the Patient Protection and Affordable Care Act (ACA).
May 11, 2023
Insurer Granted Summary Judgment In Autism Evidence-Based Insurance Coverage Case

MADISON, Wis. — A couple has not shown that an insurer’s decision not to cover certain autism spectrum disorder (ASD) treatments deviated from a plan’s evidence-based approach, that its standards were outdated or that it treated mental health treatments differently from similar medical or surgical treatments, a federal judge in Wisconsin said in granting summary judgment to the insurer.
May 08, 2023
Judge: Plaintiffs In ERISA Row Over Cross-Plan Offsetting Lack Standing

MINNEAPOLIS — Dismissing the first amended complaint (FAC) in an Employee Retirement Income Security Act case without prejudice, a Minnesota federal judge ruled that the plaintiffs failed to plead an injury in fact in the putative class suit over the practice known as “cross-plan offsetting.”
May 05, 2023
Medical Insurers Seek Dismissal Of COVID-Testing Lab’s Reimbursement Claims

NEWARK, N.J. — In a lawsuit brought by a medical testing laboratory seeking reimbursement for COVID-19 testing from a group of health insurers, the insurers moved to dismiss the laboratory’s amended complaint, contending that the laboratory insufficiently pleaded a cause of action under the Employment Retirement Income Security Act and failed to allege that a valid contract existed between the parties so as to provide for state law causes of action.
May 05, 2023
5th Circuit Affirms Proton Therapy Ruling In Favor Of Throat Cancer Patient

NEW ORLEANS — Affirming a ruling requiring a health insurer to pay for a throat cancer patient’s proton beam therapy (PBT), a Fifth Circuit U.S. Court of Appeals panel said in an unpublished per curiam opinion that a lower court used the right standard of review and the insurer’s denial of coverage was not supported by substantial evidence.
May 04, 2023
3rd Circuit Affirms Dismissal Of FCA Claims Against AmeriHealth In ACA Dispute

PHILADELPHIA — The Third Circuit U.S. Court of Appeals on May 3 affirmed a district court’s dismissal of a relator’s suit alleging that AmeriHealth defrauded the federal government in violation of the federal False Claims Act (FCA) by falsely certifying compliance with New Jersey regulations, finding that certifying compliance was not required to receive payment for health insurance plans listed on New Jersey’s federally operated exchange pursuant to the Patient Protection and Affordable Care Act (ACA).
May 03, 2023
Judge Remands Insurance Payment Spat For Clarification Of Methodology

TRENTON, N.J. — An insurance company never referenced the gap methodology it now claims it used in determining an autism-care provider’s reimbursement, leaving the court “at a loss” for how it could conclude that the rate was reasonable, a federal judge in New Jersey said in remanding the Employee Retirement Income Security Act case to the administrator for clarification.
May 02, 2023
ACA Asbestos Program Suit Parties Parry Bid To Quash Subpoenas To U.S. Agencies

MISSOULA, Mont. — The United States says in a motion to quash that an agency already produced almost all the information two subpoenas seek and that further searches into whether a medical facility meets the criteria for “qualified physicians” under a special Patient Protection and Affordable Care Act program involving Libby, Mont., asbestos exposures “will simply waste time while yielding ever diminishing returns.” But in a joint response, the parties in the federal litigation in Montana say the subpoenas are not burdensome and that to the extent the answers to the subpoena questions are self-evident, the questions should be easy to answer.
May 02, 2023
HIV Group Says Copayment Drug Program Challenge Justiciable

WASHINGTON, D.C. — A government notice legalizing insurers’ copayment accumulator programs rescinded an existing prohibition on including them in Patient Protection and Affordable Care Act (ACA) copay calculations and “flatly guts” the argument that the issue is not justiciable, a group of plaintiffs told a federal judge in the District of Columbia on May 1.
May 01, 2023
Texas Court: Insurance Arbitration Doesn’t Mandate Data, Detailed Ruling

FORT WORTH, Texas — Nothing in the arbitration statute governing out-of-network insurance payment disputes mandates that the state database include any specific evidence or that the arbitrator provide a detailed explanation of a decision, a Texas appeals court said in affirming an award.
May 01, 2023
Panel Reverses Dismissal Of UCL Suit For ‘Hidden’ Fee Charged After ER Visit

FRESNO, Calif. — A California appellate panel on April 28 reversed a trial court’s dismissal of a patient’s putative class action against a medical services provider, which he accused of violating California’s unfair competition law (UCL) for charging him a more than $8,000 undisclosed emergency room fee after finding that the trial court’s dismissal improperly created a “safe harbor” protecting the provider from conduct that was not mandated by state and federal pricing disclosure requirements.
May 01, 2023
Government Seeks Stay Of ACA Preventive Care Ruling Pending Appeal

NEW ORLEANS — Various U.S. government officials and a group of amici curiae asked the Fifth Circuit U.S. Court of Appeals to stay the nationwide vacatur of the Patient Protection and Affordable Care Act (ACA)’s preventive care mandate pending appeal, saying undoing more than a decade’s worth of action ensuring cost-effective access to health care lacks legal justification and threatens public health.
April 28, 2023
Joint Status Report Filed In Risk-Corridor Dispute Involving Insolvent Insurers

WASHINGTON, D.C — The federal government and a subclass member filed a joint status report in liquidated insurers’ suit seeking a declaratory judgment that the government owes insurers millions of dollars under the Patient Protection and Affordable Care Act (ACA) risk-corridor program, with the parties not disputing the amounts owed but the type of judgment to be entered against the subclass member.
April 26, 2023
Justice: Insurer’s Undisclosed Coverage Standards Permit Breach Of Contract Claim

ROCHESTER, N.Y. — Allegations that an insurer essentially eliminated the possibility of receiving medically necessary care at an otherwise approved residential treatment center by relying on undisclosed standards supports a breach of contract claim, a justice in New York said in denying the insurer’s motion.
April 26, 2023
1st Circuit Affirms That TPA Is Not A Functional Fiduciary, Avoids Assets Question

BOSTON — In an April 25 opinion upholding a ruling that the third-party administrator (TPA) of a self-funded health plan was not a functional fiduciary under the Employee Retirement Income Security Act, a First Circuit U.S. Court of Appeals panel did not decide a question it said “the parties and their amici vigorously dispute” — “whether the working capital amount remained a Plan asset once paid to” the TPA.
April 26, 2023
California Court Revives UCL Mental Health Coverage Claims Against Kaiser

SAN FRANCISCO — Allegations that individuals paid for mental health insurance coverage they couldn’t access as a result of Kaiser Foundation Health Plan Inc.’s policy of underfunding its integrated providers successfully establishes a nontrivial injury sufficient for standing under the California unfair competition law (UCL), a state appellate court said in also reversing summary judgment on April 25 on Parity Act and Unruh Act claims.
April 24, 2023
Advocacy Group Defends Drug Co-Pay Programs As Balancing Marketplace

WASHINGTON, D.C. — Co-pay accumulator programs mitigate the marketing and profits effects drug manufacturers reap from co-pay coupons and return the market to status quo, America’s Health Insurance Plans says in an amicus curiae brief to a federal court in the District of Columbia.
April 24, 2023
Insurer: ERISA Rehearing Arguments ‘Overblown,’ Reprocessing Ruling Proper

SAN FRANCISCO — An insurer told a Ninth Circuit U.S. Court of Appeals panel that the plan required only that any covered procedure qualify as a generally accepted level of medical care and did not require coverage of all such procedures and that the court’s rejection of reprocessing of claims as futile recognized existing law and did not eliminate reprocessing as a remedy under the Employee Retirement Income Security Act.
April 20, 2023
Assignee: Contract Claims Survive Preemption; Fee Forgiveness Evidence Lacking

SANTA ANA, Calif. — State law claims alleging that an insurer made payment promises escape preemption under the Employee Retirement Income Security Act, the insurer produced next to no evidence for why it believed the provider was conducting a fee forgiveness scheme and the company’s contention that the majority of the 106 plans at issue were self funded suggests that at least some were fully funded, an assignee tells the Ninth Circuit U.S. Court of Appeals in an opening brief.
April 19, 2023
Insurer Says Insured Has No Grounds To Challenge Mental Health Claim Denials

PASADENA, Calif. — An insurer told the Ninth Circuit U.S. Court of Appeals that a man never alleged improper denial of benefits because he cannot point to any plan provision requiring coverage of his mental health and substance abuse claims and so instead recast his case as one seeking equitable relief.
April 19, 2023
Parties Discuss 8 Cases, Advance Arguments In ACA Reinsurance Row

WASHINGTON, D.C. — Notable filings in a U.S. Court of Federal Claims case over the Transitional Reinsurance Program (TRP) of the Patient Protection and Affordable Care Act (ACA) include a status report outlining the parties’ positions on eight similar suits commenced in the last few months by entities that say they are SISAs — self-insured, self-administered employee health and welfare benefit plans.
April 19, 2023
Insurer’s Eating Disorder Coverage Denial Complied With Plan Terms, Judge Says

AUSTIN, Texas — An insurer’s decision to stop covering a child’s eating disorder treatments after concluding that they were not medically necessary complied with plan guidelines, and the plan permitted payment at the rate the insurer chose rather than the one negotiated by its contractor, a federal judge in Texas said in finding for the insurer after a bench trial.
April 17, 2023
Judge Stays ACA Discrimination Case Pending 9th Circuit Reprocessing Ruling

TACOMA, Wash. — A federal judge in Washington on April 17 said he would withhold ruling on motions for declaratory and permanent injunctive relief, as well as on a motion to decertify a class alleging that their insurer discriminates against transgender individuals, until the Ninth Circuit U.S. Court of Appeals issues its ruling addressing the appropriateness of reprocessing as a remedy in Wit v. United Behavioral Health.
April 13, 2023
Authorization Letters Don’t Save Providers’ Case From Preemption, Judge Says

NEW ORLEANS — Letters authorizing a trio of surgeries were “inextricably linked” to the insured’s Employee Retirement Income Security Act plan and do not create an independent duty, a federal judge in Louisiana said April 12 in finding state law claims preempted.
April 12, 2023
Kaiser, Insureds Square Off In Parity Act Case

SAN FRANCISCO — A California appeals court heard arguments on insureds’ allegation that Kaiser health plan games the state’s parity act’s medically necessary coverage mandate by restricting funding for behavioral health treatments to the point that care becomes unavailable from in-network Kaiser providers.