HOUSTON - A health benefits plan is entitled to an equitable lien over funds that a participant received in a third-party settlement pursuant to the plan's reimbursement/subrogation provision under the Employee Retirement Income Security Act, a federal judge in Texas ruled May 2 in granting the plan's motion for summary judgment (Humana Health Plan, Inc. v. Patrick Nguyen, et al., No. H-13-1793, S.D. Texas; 2014 U.S. Dist. LEXIS 61239).
NEW YORK - The Second Circuit U.S. Court of Appeals on May 6 affirmed that a lower court correctly remanded to state court a dispute over the failure to return surplus distributions to a not-for-profit corporation that provided comprehensive health services to individuals primarily made up of Medicaid patients, holding that the defendant failed to demonstrate that removal was proper (James J. Veneruso, as temporary receive for Community Choice Health Plan of Westchester Inc., v. Mount Vernon Neighborhood Health Center, No. 13-1572, 2nd Cir.; 2014 U.S. App. LEXIS 8449).
NEW ORLEANS - In an unpublished opinion, the Fifth Circuit U.S. Court of Appeals on May 6 affirmed that the State of Louisiana must return to the federal government an excess of nearly $240 million it received in Medicaid funds for charity care (State of Louisiana Department of Health and Hospitals v. U.S. Department of Health and Human Services, et al., No. 13-30240, 5th Cir.; 2014 U.S. App. LEXIS 8520).
PHILADELPHIA - In reversing a lower court, a Third Circuit U.S. Court of Appeals panel on May 6 held that health care providers' direct and derivative claims fall outside the scope of an arbitration agreement with a health insurance provider and thus the claims at issue are not subject to arbitration (CardioNet Inc., et al. v. CIGNA Health Corp., No. 13-2496, 3rd Cir.; 2014 U.S. App. LEXIS 8468).
NEW YORK - A health benefits plan that excludes benefits for same sex and domestic partners does not violate Employee Retirement Income Security Act Section 510's prohibition of interference with the attainment of benefits, a federal judge in New York ruled May 1 (Jane Roe, et al. v. Empire Blue Cross Blue Shield, et al., No. 12-cv-04788, S.D. N.Y.; 2014 U.S. Dist. LEXIS 61345).
BOSTON - Massachusetts will abandon its Patient Protection and Affordable Care Act (ACA) health insurance exchange and purchase an "off-the-shelf" exchange or default to the federal exchange, according to a May 5 press release.
ST. PAUL, Minn. - In an unpublished May 5 opinion, a Minnesota appeals court affirmed a decision denying payment under Medicaid for a plaintiff's long-term care, saying that federal and state law provided coverage only for emergency medical conditions for unqualified "aliens" (Sekou Bamba v. Minnesota Department of Human Services, et al., No. A13-1717, Minn. App.; 2014 Minn. App. Unpub. LEXIS 423).
MOBILE, Ala. - An Alabama federal judge on May 5 granted summary judgment in favor of the defendants in a breach of fiduciary duty and wrongful denial of health care benefits suit, finding that the plaintiff failed to sue the proper parties (Melisa Courtney v. ART Applied Reimbursement Techniques Inc., et al., No. 12-311, S.D. Ala.; 2014 U.S. Dist. LEXIS 61624).
WASHINGTON, D.C. - The Internal Revenue Service on May 2 issued final regulations governing information reporting related to enrollment in health insurance exchanges.
WASHINGTON, D.C. - Only 67 percent of those who enrolled in insurance through the Patient Protection and Affordable Care Act (ACA)'s federal exchange paid the first month premium, and 25 percent were between the ages of 18 and 34, according to a report released by the U.S. House of Representatives Energy and Commerce Committee.
TRENTON, N.J. - A pharmaceutical manufacturer that alleged that its competitor violated federal and state antitrust laws by using market-share discounting practices and exclusionary contracts with hospitals filed a notice of appeal on April 23 to the Third Circuit U.S. Court of Appeal of the trial court's order granting summary judgment against it (Eisai Inc. v. Sanofi-Aventis U.S., LLC, et al., No. 08-4168, D. N.J.).
ST. LOUIS - A Missouri federal judge on April 25 granted summary judgment in favor of a prescription benefit management company accused of violating the Telephone Consumer Protection Act (TCPA) and a do-not-call law, saying that the plaintiff had consented to the calls when she provided her phone number on the enrollment form for health care benefits (Suzy Elkins v. Medco Health Solutions Inc., No. 12-2141, E.D. Mo.; 2014 U.S. Dist. LEXIS 57633).
MIAMI - A Florida federal judge on April 25 held that an external appeal upholding a plaintiff's denial of medical benefits is conclusive to the issue of medical necessity but said she would allow the plaintiff to conduct discovery as to whether the external reviewer had any conflict of interest that may have biased the decision (Alexandra H. v. Oxford Health Insurance Inc., et al., No. 11-23948, S.D. Fla.; 2014 U.S. Dist. LEXIS 57863).
LOS ANGELES - A divided California appeals court on April 23 reversed a trial court's decision in part and modified it to enjoin the California Department of Managed Health Care (DMHC) from upholding a plan's denial of applied behavioral analysis (ABA) therapy on the grounds that a Behavior Analyst Certification Board (BACB)-certified provider is not licensed. The court further held that even when a health plan is exempted from the ABA statute, the DMHC may not uphold a denial of coverage for ABA performed or supervised by therapists who are BACB certified on the basis the provider is not licensed (Consumer Watchdog, et al. v. Department of Managed Health Care, et al., No. B232338, Calif. App., 2nd Dist. Div. 3; 2014 Cal. App. LEXIS 352).
WASHINGTON, D.C. - The District of Columbia U.S. Circuit Court of Appeals on April 28 denied a petition seeking rehearing in a case challenging the Patient Protection and Affordable Care Act (ACA) individual mandate (Association of American Physicians & Surgeons Inc., et al. v. Kathleen G. Sebelius, et al., No. 13-5003, D.C. Cir.).
HOUSTON - A Texas federal judge on April 23 partially granted a health insurance company's motion to dismiss a reimbursement suit brought by a health care provider related to the payment of out-of-network services (Mid-Town Surgical Center v. Humana Health Plan of Texas Inc., No. 13-2620, S.D. Texas; 2014 U.S. Dist. LEXIS 56260).
DURHAM, Ore. - Oregon dumped its failed Patient Protection and Affordable Care Act (ACA) state exchange at an April 25 agency board meeting, with the governing body unanimously adopting a technology workgroup suggestion that the federal exchange provided the most reliable and least costly option going forward.
JEFFERSON CITY, Mo. - An insurance agents' group fails to demonstrate standing to intervene in a Patient Protection and Affordable Care Act (ACA) exchange regulation case or that the existing parties cannot adequately litigate the interest involved, a Missouri judge held April 24 (St. Louis Effort for Aids, et al. v. John Huff, director of the Missouri Department of Insurance, Financial Institutions and Professional Registration, No. 13-4246, W.D. Mo.).
DURHAM, Ore. - Oregon officials will vote April 25 on whether to abandon the state's failed health insurance exchange in favor of the federal Patient Protection and Affordable Care Act (ACA) exchange.
WASHINGTON, D.C. - No legal support exists for a man's claim that the Patient Protection and Affordable Care Act (ACA) exempts independent contractors of grant recipients from self-employment taxes, and the law is "devoid" of any language to that affect, a tax court judge held April 22 (Harris He Wang v. Commissioner of Internal Revenue, No. 4306-13S, U.S. Tax; 2014 Tax Ct. Summary LEXIS 42).
CINCINNATI - The Sixth Circuit U.S. Court of Appeals on April 22 upheld a Federal Trade Commission order requiring ProMedica Health System to divest St. Luke's Hospital to an FTC-approved buyer within 180 days, concluding that the FTC properly found that the acquisition was likely to substantially lessen competition and increase prices for general acute-care inpatient hospital services and inpatient obstetric services sold to commercial health plans in the Toledo, Ohio, area (ProMedica Health System, Inc. v. Federal Trade Commission, No. 12-3583, 6th Cir.; 2014 U.S. App. LEXIS 7500).
DENVER - A Colorado federal judge on April 17 enjoined Patient Protection and Affordable Care Act (ACA) regulations mandating that a group health plan provide post-fertilization contraceptive coverage (Dr. James C. Dobson and Family Talk v. Kathleen Sebelius, et al., No. 13-3326, D. Colo.; 2014 U.S. Dist. LEXIS 54585).
ALEXANDRIA, La. - A Louisiana federal judge on April 21 concurred with a magistrate judge's finding that a reimbursement dispute over the payment of health care benefits should be dismissed for failure of the plaintiff to exhaust administrative remedies (Sanat V. Sanghani, M.D. v. Aetna Life Insurance Co., No. 12-632, W.D. La.; 2014 U.S. Dist. LEXIS 55747).
SEATTLE - Two families who have had coverage for applied behavioral analysis (ABA) therapy to treat their children's autism spectrum disorders (ASD) denied filed a class action lawsuit in a Washington federal court against the plan and plan administrator on April 17 (C.S., et al. v. The Boeing Company Master Welfare Plan, et al., No. 14-574, W.D. Wash.).
ATLANTA - Less than half of the 221,604 Georgia residents who signed up for insurance through the Patient Protection and Affordable Care Act (ACA)'s federal exchange paid their premium by the close of enrollment, Georgia Insurance Commissioner Ralph Hudgens announced April 17.