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

Mealey's Health Care / ACA

April 12, 2023
Washington High Court Agrees To Hear ACA Breach Of Contract Case

SEATTLE — The Washington Supreme Court agreed to hear issues raised in an insurer’s petition for review and an insured’s answer, wading into a case where the appellate court found that a violation of the Patient Protection and Affordable Care Act (ACA) could form the basis of a state law breach of contract claim.
April 12, 2023
Judge Sends Emergency Care Payment Suit Back To Florida State Court

TAMPA, Fla. — Because an insurer has not shown that a hospital has assignment of rights that would permit it to bring its claims under the Employee Retirement Income Security Act, state court is the proper place for the dispute over payment for emergency services, a federal judge in Florida said.
April 11, 2023
Judge Dismisses AIDS Group’s UCL Suit For Vendor’s Failure To Get Low Drug Prices

LOS ANGELES — A California federal judge on April 10 dismissed with prejudice a nonprofit AIDS health care provider’s lawsuit accusing one of its vendors of violating California’s unfair competition law (UCL) for allegedly failing to negotiate “sub-ceiling” prices on its behalf, finding that the provider as a member of a federal health care program has no “private right of action” against the vendor.
April 11, 2023
Amici Urge Reversal Of ACA Section 1557 Case Dismissal

CINCINNATI — Two medical associations may bring a pre-enforcement action because their members are threatened by Patient Protection and Affordable Care Act Section 1557’s ban on discriminating based on gender identity and face having to violate medical and religious beliefs in service to an administration seeking political wins despite the paucity of medical evidence for gender dysphoria treatments, three amicus curiae parties tell the Sixth Circuit U.S. Court of Appeals in support of the associations.
April 10, 2023
Government: Providers’ No Surprises Act Fee Hike Suit Should Be Barred

TYLER, Texas — Having failed to raise their current concerns about the No Surprises Act procedures in four previous lawsuits, medical providers should be estopped from bringing them now, the government told a federal judge in Texas in an April 7 reply in support of its cross-motion for summary judgment.
April 06, 2023
Hospital Downplays Need For Review Of Managed Care Timely Payment Dispute

WASHINGTON, D.C. — There is no conflict over the private enforceability of the spending clause, and a case involving largely hypothetical situations unlikely to ever occur would not be the vehicle to address the issue if there were, a hospital seeking to hold an Illinois agency responsible for not ensuring that managed care organizations made timely payments tells the U.S. Supreme Court in opposing a petition for review.
April 06, 2023
Provider, Insurer Debate Need For Review Of Texas Arbitration Payment Dispute

FORT WORTH, Texas — A medical provider told the Texas Supreme Court that nothing in the state’s out-of-network dispute process required or even permitted an arbitrator to look outside the 10 factors laid out by the law after an insurer told the court that the case presents only a question of “routine judicial deference.”
April 03, 2023
Out-Of-Network Providers, Government Square Off Over No Surprises Act Fee Hike

TYLER, Texas — The government and out-of-network medical providers filed dueling motions for summary judgment in a Texas federal court about whether a sevenfold increase in the No Surprises Act (NSA) administrative fee constituted guidance or a rule and whether such an increase was lawful.
March 31, 2023
Judge Finds Standing, Vacates ACA’s Preventive Care Mandate

DALLAS — Religious objectors have standing to challenge the Affordable Care Act’s preventive care HIV/AIDS drug mandate and are entitled to vacatur of the preventive care rule, a federal judge in Texas said March 30 in granting summary judgment to the challengers.
March 31, 2023
Federal Judge Found That POA Not Sufficient To Bring ERISA Suit Against Insurer

CENTRAL ISLIP, N.Y. — A New York federal judge on March 30 granted Cigna’s motion to dismiss an ERISA suit filed against it by a physician acting as an agent for his patient pursuant to a power of attorney (POA), finding that “without a valid assignment of Patient’s claim, he lacks a cause of action under ERISA Section 1132(a)(1)(B).”
March 30, 2023
Health Insurer Defends ERISA Substantial Compliance Standard At 10th Circuit

DENVER — Insureds offer no evidence of the type of procedural errors required for the court to even consider abandoning the substantial compliance standard and the record shows that the insurer considered all the factors in denying coverage for residential treatment, UnitedHealthcare Insurance Co. tells the 10th Circuit U.S. Court of Appeals.
March 30, 2023
ACA Discrimination Ruling Stands As Court Denies Dueling Rehearing Petitions

ST. LOUIS — The Eighth Circuit U.S. Court of Appeals issued a formal mandate after denying dueling motions for rehearing involving questions of associational standing and whether challenges to rules interpreting Patient Protection and Affordable Care Act (ACA) Section 1557 were premature before enforcement.
March 30, 2023
Government Says Standing, Merits Doom Providers’ ACA Section 1557 Challenge

NEW ORLEANS — Medical providers who do not discriminate on the basis of sexual orientation face no threat of an enforcement action under Patient Protection and Affordable Care Act Section 1557 and lack both standing to pursue their suit and the ability to prevail on the merits in the wake of Bostock v. Clayton County, 140 S. Ct. 1731 (2020), the government tells a Fifth Circuit U.S. Court of Appeals panel.
March 28, 2023
Judge Says Subacute Care Allegations Save Residential Treatment Case

LOUISVILLE, Ky. — Allegations that an insurer covers sub-acute residential treatment for mental health differently than it does similar sub-acute care in the medical and surgical setting meets the requirements for a Parity Act claim given the trend in deciding such cases, a federal judge in Kentucky said in denying a motion to dismiss.
March 24, 2023
Air Transport Company Says School District Isn’t Immune From Compensation Suit

FRESNO, Calif. — A school district operating a self-insured health plan is not entitled to immunity as a public entity from claims that it undercompensated for emergency air transport, a company tells a California appeals court.
March 24, 2023
Substance Abuse Providers See ERISA, UCL, Contract Claims Largely Fail

SANTA ANA, Calif. — A dozen substance abuse providers’ reimbursement claims lack any evidence that relevant Employee Retirement Income Security Act plans require payment at the levels they suggest, and the California unfair competition law (UCL) claim lacks any tie to a statutory basis on which the claims could be brought, leaving only oral contract claims remaining, a federal judge in California said in granting a motion to dismiss.
March 23, 2023
Hospital Largely Escapes Damages In ACA Deafness Discrimination Case

CENTRAL ISLIP, N.Y. — Evidence that a hospital at times provided an interpreter for a deaf woman and her allegations that the law requires one at every critical encounter raise more questions about her case than it answers, and under recent precedent, she can seek only nominal damages, a federal judge in New York said in denying her summary judgment and partially granting the provider’s motion.
March 22, 2023
Assignee Says Bristol Provides Standing To Sue Insurers Under ERISA

PASADENA, Calif. — The Ninth Circuit U.S. Court of Appeals should ignore insurers’ “novella about the history of standing” and instead follow the clear precedent giving an assignee the power to pursue them under the Employee Retirement Income Security Act, a debt collector tells the Ninth Circuit U.S. Court of Appeals in a reply brief.
March 21, 2023
Insurer Downplays Need For Review Of Texas Arbitration Payment Dispute

FORT WORTH, Texas — An insurer told the Texas Supreme Court on March 20 that it could reject a petition for review challenging an appellate court’s reinstatement of an out-of-network dispute arbitrator’s award, saying the case presents only a question of “routine judicial deference.”
March 20, 2023
Government Says Flexible Drug Program Rule Doesn’t Run Afoul Of ACA Cost Sharing

WASHINGTON, D.C. — Because a rule grants states and insurers flexibility in determining whether manufacturers’ drug assistance programs fall under the cost-sharing requirements of the Patient Protection and Affordable Care Act (ACA) and doesn’t determine substantive rights, a legal challenge to it fails, the government tells a federal judge in a cross-motion for summary judgment and opposition.
March 20, 2023
Judge: Hearing Loss Coverage Exclusion Doesn’t Constitute Proxy Discrimination

SEATTLE — Two individuals have not shown that a blanket exclusion on hearing loss treatments targets those with a hearing disability or that the exclusion falls mostly on disabled individuals, a federal judge in Washington said in granting a motion to dismiss.
March 16, 2023
Judge Seeks Briefing About Staying Section 1557 Discrimination Case

TACOMA, Wash. — A federal judge in Washington pondering a motion to decertify a class alleging transgender discrimination under the Patient Protection and Affordable Care Act (ACA) issued an order to show cause asking for briefing on whether he should stay the case pending the outcome of a motion for rehearing in the wake of Wit v. United Behavioral Health.
March 16, 2023
Panel Deems Arbitration Agreement Unenforceable In Pharmacies’ UCL Suit

SAN FRANCISCO — A California appellate panel on March 15 held that an arbitration agreement between a pharmacy benefits manager (PBM) and 22 independent pharmacies was “unconscionable” and affirmed a trial court’s ruling allowing the pharmacies to sue the PBM for violating California’s unfair competition law (UCL) and other statutes for conduct allegedly including price-fixing and diverting their business to its own mail-order pharmacy.
March 16, 2023
Blanket Wilderness Therapy Exclusion Doesn’t Violate Parity Act, Judge Says

SALT LAKE CITY — A health insurance plan’s blanket exclusion on wilderness therapy does not violate the Parity Act, an outcome that is not avoided by a claimant’s arguments about licensing or how an independent reviewer reached a conclusion affirming the benefits decision, a federal judge in Utah said.
March 15, 2023
Class Wants 9th Circuit To Take Another Look At ERISA Claim Reprocessing Ruling

SAN FRANCISCO — The Ninth Circuit U.S. Court of Appeals deviated from a “unanimous chorus of authority” when it determined that claims reprocessing is a means to an end rather than a remedy itself in an Employee Retirement Income Security Act case, a ruling that will produce “nightmarish” results for courts, a class argues in a petition for rehearing.