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

Mealey's Health Care / ACA

May 01, 2024
Gender-Affirming Care Exclusion Violates Law, 4th Circuit Affirms

RICHMOND, Va. — State health plan exclusions on otherwise covered care as a treatment for gender dysphoria facially discriminate on the basis of sex, a majority of the Fourth Circuit U.S. Court of Appeals said in a split en banc decision, affirming summary judgment for the insureds but with some judges stating in dissent that the ruling “oversteps the bounds of the law.”
May 01, 2024
Medicare Voluntary, Drug Price Law Survives Summary Judgment, Judge Says

TRENTON, N.J. — Because participation in Medicare is wholly voluntary, the Inflation Reduction Act (IRA) requirement that drug manufacturers negotiate the prices of certain drugs is not an unconstitutional taking and does not compel speech in violation of First Amendment rights, a federal judge in New Jersey said in an unpublished opinion.
May 01, 2024
Provider Tells Texas High Court Compensation Claim Is Dead, Appeal Is Moot

AUSTIN, Texas — A ruling eliminating the possibility of liability under Texas law moots an appeal and warrants rejecting a petition for review, but the ruling below finding that a health maintenance organization did not enjoy governmental immunity from a suit seeking additional compensation for care was the correct one, a medical provider told the Texas Supreme Court.
May 01, 2024
Government, Health Plans Brief Tolling Opt-In Class Cases In ACA Reinsurance Row

WASHINGTON, D.C. — In supplemental briefing in the U.S. Court of Federal Claims in consolidated cases over allegedly illegal exactions made under the Transitional Reinsurance Program (TRP) of the Patient Protection and Affordable Care Act (ACA), group health plans and the government agree that there’s a dearth of case law on American Pipe & Construction Co. v. Utah tolling for opt-in classes.
May 01, 2024
$42.1M Attorney Fees, Final Approval Sought In Class ACA Reinsurance Row

WASHINGTON, D.C. — None of the 357 class members has objected to a $169,022,397.28 settlement that would resolve part of a lawsuit over the Transitional Reinsurance Program (TRP) of the Patient Protection and Affordable Care Act (ACA) or a request that class counsel get 25% of that amount for attorney fees, the class representative told the U.S. Court of Federal Claims in a reply brief.
April 29, 2024
Multiplan Not Liable For Insurer’s Compensation, 3rd Circuit Affirms

CAMDEN, N.J. — A contract between a plastic surgery center and Multiplan Inc. does not guarantee any specific rate of reimbursement, and the latter cannot be held liable for an insurer’s failure to properly compensate for medical care, a Third Circuit U.S. Court of Appeals panel said April 26.
April 29, 2024
Special Master Won’t Reconsider Discovery Into Drug Savings Plan

NEWARK, N.J. — The special master overseeing a dispute in federal court in New Jersey between two drug payment assistance programs declined to reconsider or clarify her early ruling limiting discovery into the plaintiffs’ program or how Johnson & Johnson Health Care Systems Inc. prices certain drugs.
April 23, 2024
J&J Seeks Dismissal Of ERISA Fiduciary Breach Suit Over Drug Benefits

CAMDEN, N.J. — Arguing in part that the sponsor of the self-funded health plans at issue “has every incentive to negotiate the best overall deal,” Johnson and Johnson (J&J) and related defendants asked a New Jersey federal court to dismiss the complaint and strike the jury demand in a putative class case asserting Employee Retirement Income Security Act claims over alleged “mismanagement of prescription-drug benefits.”
April 23, 2024
Judge Dismisses Funds’ ERISA Suit Against Administrative Service Providers

NEW HAVEN, Conn. — Ruling that the trustees of two multiemployer, self-funded welfare benefit funds had standing to sue administrative service providers but “do not plausibly allege that Defendants exercise or possess[] discretionary authority required to be” fiduciaries under the Employee Retirement Income Security Act, a Connecticut judge dismissed the case without prejudice on April 22.
April 23, 2024
Intentional Discrimination Claims Survive In HIV/AIDS Medication Suit

SAN FRANCISCO — Individuals required by their insurer to use mail or pharmacy pickup to receive their HIV/AIDS medications rather than their preferred community pharmacy have shown intentional discrimination under the Patient Protection and Affordable Care Act (ACA) but not proxy discrimination or violation of the California unfair competition law (UCL), a federal judge in the state said in partly denying a motion to dismiss.
April 19, 2024
Judge Approves Settlement, Attorney Fees In ACA Hearing Discrimination Case

SEATTLE — Class counsel’s “excellent result” in obtaining a settlement compensating claimants who paid out-of-pocket for hearing aids and hearing-loss related services regardless of whether they submitted a claim to the insurer warrants 33.3% in attorney fees, a federal judge in Washington said April 18 in granting final approval to the settlement in a case involving claims that the insurer’s exclusion of coverage for certain hearing loss products and care constituted discrimination under the Patient Protection and Affordable Care Act.
April 17, 2024
Drug Pricing Suit Not Subject To Medicare Process, Appellants Tell 5th Circuit

SAN ANTONIO — The government holds a “constitutionally dubious” position in a challenge to the Medicare drug price negotiation law, and a federal judge erred in dismissing on the grounds that the claim is subject to the Medicare Act channeling provision, appellants tell the Fifth Circuit U.S. Court of Appeals in an appellant brief.
April 17, 2024
Judge Issues Limited Stay In Catholic Employment Groups’ Gender Transition Case

FARGO, N.D. — Because a forthcoming final rule governing Patient Protection and Affordable Care Act Section 1557 could impact some portions of religious employers’ case, the action can be stayed until May 1, after which if the rule is not yet finalized the government defendants must answer the complaint, a federal judge in North Dakota said April 16.
April 15, 2024
Blue Cross: Claim Denials Done With Plan In Mind, Not Discriminatory Intent

PASADENA, Calif. — A third-party administrator tells the Ninth Circuit U.S. Court of Appeals in an April 12 opening brief that it was simply fulfilling its fiduciary duty under the Employee Retirement Income Security Act when it denied claims for transgender care and cannot be held liable under the Patient Protection and Affordable Care Act for any allegedly discriminatory plan details.
April 15, 2024
U.S. Supreme Court Denies Review Bid Over 4th Circuit ERISA Surcharge Ruling

WASHINGTON, D.C. — The U.S. Supreme Court on April 15 declined to review a case over a heart transplant denial, which concerns whether surcharge is available under an Employee Retirement Income Security Act provision that allows equitable relief.
April 12, 2024
9th Circuit Discusses Parity Act Pleading Standard In Partly Reviving ERISA Case

PASADENA, Calif. — Addressing “what pleading standard applies to cases alleging an improper internal process” under the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA or Parity Act), a Ninth Circuit U.S. Court of Appeals panel on April 11 partly reversed dismissal of a putative class case over mental health and substance use disorder (MH/SUD) treatment coverage.
April 11, 2024
Insurer Accused Of Using AI Software To Deny Claims ‘En Masse’ In Class Suit

OAKLAND, Calif. — An insured filed a putative class action in California state court accusing his insurer of violating California’s insurance regulations and its unfair competition law (UCL) by using artificial intelligence (AI) software to deny claims for coverage.
April 08, 2024
Medical Coding, Damages Testimony Largely Admitted In Labs’ Compensation Case

BRIDGEPORT, Conn. — Experts may largely testify about medical coding practices and the resulting damages labs incurred from an insurer’s denials of the labs’ claims because they go beyond a layperson’s knowledge and are based on solid calculations, a federal judge in Connecticut said in excluding only portions based on flawed data provided to the damages expert and the medical coder’s testimony about whether the labs attempted to collect from patients.
April 08, 2024
Judge Allows Some Claims In ACA Hearing Loss Proxy Discrimination Case

SEATTLE — Proxy discrimination and injunctive relief claims based on exclusions or limitations in health insurance coverage for hearing aids that allegedly targeted people with disabilities in violation of the Patient Protection and Affordable Care Act (ACA) may proceed, but other claims appear to be barred by state law, a federal judge in Washington said in partially granting a motion to dismiss.
April 08, 2024
ACA Fertility Discrimination Claims Survive Dismissal, Federal Judge Says

NEW HAVEN, Conn. — A woman who claims that an insurer’s policy on what constitutes infertility discriminates against non-heterosexual individuals assigned female at birth enjoys standing under the Patient Protection and Affordable Care Act, but since she no longer participates in the plan, she cannot proceed on a declaratory relief claim, a federal judge in Connecticut said in partly granting the insurer’s motion to dismiss.
April 02, 2024
Judge Finds No Suprises Act Portal’s Reopening Moots Medical Provider’s Challenge

BROOKLYN, N.Y. — The reopening of the No Suprises Act (NSA) arbitration portal moots a case challenging the process because it now appears fully capable of handling any problems that arise, and a medical provider may not proceed based on “an entirely speculative possibility that complained-of conduct may occur in the future,” a federal judge in New York said.
April 02, 2024
Judge Sends Air Ambulances’ $5M Arbitration Award Cases To Connecticut

AUSTIN, Texas — Because two actions alleging that insurers failed to make timely payments required by the No Surprises Act’s arbitration process involve alleged conduct by the insurers in Connecticut, a Texas court is not the proper venue, a federal judge in Texas said in granting motions to dismiss but transferring the actions.
April 02, 2024
Judge ‘Appalled’ At AI’s Use In Research, Affirms Denial Of AD&D Claim

CHICAGO — A federal judge in Illinois said that despite an attorney’s clear violation of a court order prohibiting the use of artificial intelligence, she would assume that ChatGPT was not used to author the entire brief, while dismissing an Employee Retirement Income Security Act claim alleging that an insurer improperly denied an accidental death and dismemberment claim after a fatal car fire.
April 01, 2024
Railway Says Montana Asbestos Screener Stuck ‘Head In Sand’

MISSOULA, Mont. — Evidence introduced at trial showed a Libby, Mont., medical facility must have known the B-read-only and other claims it submitted to a special asbestos-related Patient Protection and Affordable Care Act (ACA) program were not a diagnosis and were fraudulent, and it cannot avoid liability by claiming it was simply doing its best when in reality it was sticking its head in the sand over the program’s requirements, a railway tells the Ninth Circuit U.S. Court of Appeals in a March 29 answering brief.
April 01, 2024
California Court Affirms Insurer’s Summary Judgment In Medical Air Transport Case

LOS ANGELES — Insureds seeking compensation for medical transport never produced evidence of disputed facts or sufficiently cited to the record, a California appellate court said March 29 in affirming summary judgment to the insurer.