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 - In an unpublished May 5 opinion, a Minnesota appeals court affirmed a decision denying payment under Medicaid for a plaintiff's long-term care, saying that federal and state law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.
NEWARK, N.J. - A New Jersey board-certified orthopedic surgeon and the company he owns on April 16 sued a patient's health insurer and employer in federal court for allegedly paying the wrong amount for out-of-network services provided to the patient (Professional Orthopedic Associates, et al. v. Horizon Blue Cross Blue Shield of New Jersey, et al., No. 14-2438, D. N.J.).
WASHINGTON, D.C. - A District of Columbia federal judge on April 17 remanded one hospital's Medicare payment dispute to a review board, but granted the defendant's summary judgment motion as to a second hospital's dispute, saying the review board did not have jurisdiction to hear the challenge to the plaintiff's disproportionate share hospital adjustment (Emanuel Medical Center Inc., et al. v. Kathleen Sebelius, secretary of the United States Department of Health and Human Services, No. 12-1962, D. D.C.; 2014 U.S. Dist. LEXIS 52969).
WASHINGTON, D.C. - While the government tries to downplay its impact, the contraceptive mandate imposes a substantial burden on religious organizations that cannot be avoided through the self-certification process, plaintiffs told the District of Columbia Circuit U.S. Court of Appeals on April 11 (Priests for Life, et al. v. U.S. Department of Health and Human Services, et al., No. 113-5368; Roman Catholic Archbishop of Washington, et al. v. Kathleen Sebelius, et al., No. 13-5371, D.C. Cir.).
SAN DIEGO - A California physician on April 15 sued his health care provider in federal court for allegedly under-reimbursing his neurosurgeon for two surgeries he underwent for back and leg pain (Michael Keller v. Aetna Health and Life Insurance Co., No. 14-895, S.D. Calif.).
NEWARK, N.J. - A New Jersey federal judge on April 14 denied a renewed motion to certify two classes in a reimbursement lawsuit filed against a health care insurer, a database company and the database's parent company (Darlery Franco v. Connecticut General Life Insurance Co., et al., No. 07-6039, D. N.J.; 2014 U.S. Dist. LEXIS 51138).
WASHINGTON, D.C. - U.S. Secretary of Health and Human Services Kathleen Sebelius formally resigned April 11, and President Obama nominated Sylvia Matthew Burwell, now director of the Office of Management and Budget, to succeed her, according to the White House.