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

Mealey's Health Care / ACA

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.
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.