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89 Matching News Items
1.
Text of Agency FAQs, Part 62: Implementation of No Surprises Act in Light of the Recent Court Decision in Texas Medical Association v. HHS (PDF)
Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS]
Oct. 6, 2023
Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS]
Oct. 6, 2023
10 pages. "Q1: How should plans and issuers calculate a QPA for purposes of patient cost sharing, disclosures with an initial payment or notice of denial of payment, and disclosures and submissions required under the Federal IDR process following the decision in TMA III? ... Q2: What is the Departments' and OPM's general approach to implementation of the No Surprises Act with respect to the methodology for calculating a QPA following the decision in TMA III? ... Q3: Must plans and issuers continue to make disclosures about the QPA to nonparticipating providers, facilities, and providers or air ambulance services with an initial payment or notice of denial of payment, and in a timely manner upon request of the provider or facility? ... Q4: In light of the district court's decision in TMA III, how can certified IDR entities proceed in considering a QPA submitted to a Federal IDR payment dispute? ... Q5: In light of the district court's decision in TMA III, how should a plan or issuer proceed when the plan or issuer does not have the information necessary to decide a claim for payment within 30 calendar days after a bill for air ambulance services is transmitted by a nonparticipating provider of air ambulance services? ... Q6: Does the No Surprises Act continue to prohibit balance billing for air ambulance services provided by a nonparticipating provider of air ambulance services? ... Q7: May nonparticipating providers of air ambulance services balance bill participants, beneficiaries, and enrollees if a claim for air ambulance services is denied for lack of sufficient information (in other words, because it is not a 'clean claim')?"
2.
CRS Legal Sidebar: Preventive Services Access on the Docket in Braidwood v. Becerra
Congressional Research Service [CRS]
Sept. 13, 2023
Congressional Research Service [CRS]
Sept. 13, 2023
"In September 2022, a Texas district court dismissed most of the plaintiffs' constitutional claims, but concluded in part that covered services based on certain U.S. Preventive Service Task Force recommendations were invalid.... This Legal Sidebar provides background on the preventive services requirement, examines the Braidwood case, and discusses legal considerations for Congress." [Braidwood Management, Inc. v. Becerra, No. 20-0283 (N.D. Tex. Sep. 7, 2022; on appeal to 5th Cir. No. 23-10326)] [LSB11040 Sep. 12, 2023]
3.
Understanding Recent Litigation on Medication Abortion: A Guide for Health Plan Sponsors
Proskauer
Apr. 24, 2023
Proskauer
Apr. 24, 2023
"With the January 2023 changes to the FDA protocol, many group health plan sponsors began exploring adding mifepristone to the plan's pharmacy benefit, since it no longer had to be dispensed in-person by a health care provider.... [It] is unclear whether pharmacies will continue to pursue certification to dispense mifepristone while the Texas case proceeds through the appellate process." [Alliance for Hippocratic Med. v. U.S. Food & Drug Admin., No. 22-0223 (N.D. Tex. Apr. 7, 2023; S. Ct. No. 22A902 grant of application for stay of District Court order Apr. 21, 2023)
4.
Competing Texas and Washington State Rulings Place Coverage of Medication Abortion in Question
Thomson Reuters Practical Law
Apr. 12, 2023
Thomson Reuters Practical Law
Apr. 12, 2023
"[A] Texas district court ruled to stay the [FDA's] administrative approval of mifepristone (a medication abortion drug) ... On the same day, a Washington State district court preliminarily enjoined the FDA from 'altering the status quo' regarding the availability of mifepristone ... The Texas ruling in particular, if it goes into effect, will have a significant impact on employer-sponsored health plans that currently cover mifepristone for medication abortion." [Alliance for Hippocratic Med. v. U.S. Food & Drug Admin., No. 22-0223 (N.D. Tex. Apr. 7, 2023); Washington v. U.S. Food & Drug Admin., No. 23-3026 (E.D. Wash. Apr. 7, 2023)]
5.
Many Preventive Medical Services Cost Patients Nothing, But a Federal District Court Decision Could Change That
Kaiser Health News
Sept. 9, 2022
Kaiser Health News
Sept. 9, 2022
"A key part of the ruling by Judge Reed O'Connor of the U.S. District Court for the Northern District of Texas says one way that preventive services are selected for the no-cost coverage is unconstitutional. Another portion of his ruling says a requirement that an HIV prevention drug therapy be covered without any cost to patients violates the religious freedom of an employer who is a plaintiff in the case. It is not yet clear what all this means for insured patients. A lot depends on what happens next." [Braidwood Management, Inc. v. Becerra, No. 20-0283 (N.D. Tex. Sep. 7, 2022)]
6.
U.S. Chamber of Commerce Urges Court to Nix 'Multi-Plan' Benefits Class Action
Reuters; free registration may be required
Aug. 8, 2022
Reuters; free registration may be required
Aug. 8, 2022
"Plan Benefit Services and its parent, Fringe Benefit Group, are appealing the certification of a class in a 2017 lawsuit accusing the company of charging excessive administration fees. The class members are employed by more than 2,000 companies, but the three named plaintiffs all work for the same Texas construction company and are participants in a single benefit plan. The Chamber said that under [ERISA], plaintiffs only have standing to sue over fees charged by plans in which they participate." [Chavez v. Plan Benefit Services, Inc., No. 22-50368 (5th Cir. amicus brief filed Aug. 2, 2022)]
7.
Texas District Court Sacks NFL Retirement Plan Procedures for Disability Claims (PDF)
U.S. District Court for the Northern District of Texas
June 23, 2022
U.S. District Court for the Northern District of Texas
June 23, 2022
"The curtain has been pulled back as to the inner workings of Defendant The Bert Bell/Pete Rozelle NFL Player Retirement Plan. And what lies behind it is far from pretty with respect to how it handles disability benefit claims sought by former players ... What has become clear over the course of this litigation is that Plaintiffs claim for disability benefits was wrongfully and arbitrarily denied in a process that lacked the procedural safeguards both promised by the benefits plan and required by law." [Cloud v. The Bert Bell/Pete Rozelle NFL Player Retirement Plan, No. 20-1277 (N.D. Tex. Jun. 21, 2022)]
8.
Text of Memorandum from Agencies Regarding Continuing Surprise Billing Protections for Consumers
U.S. Department of Health and Human Services [HHS]; U.S. Department of Labor [DOL]; and U.S. Treasury Department
Feb. 28, 2022
U.S. Department of Health and Human Services [HHS]; U.S. Department of Labor [DOL]; and U.S. Treasury Department
Feb. 28, 2022
"On February 23, 2022, the United States District Court for the Eastern District of Texas ... invalidated portions of an interim final rule ... issued by the Departments of Health and Human Services, Labor, and the Treasury governing aspects of the federal independent dispute resolution (IDR) process under the No Surprises Act.... This announcement serves as a notification to health care providers, emergency facilities, providers of air ambulance services, group health plans, health insurance issuers, Federal Employees Health Benefits (FEHB) Carriers, and certified IDR entities of steps the Departments are taking to conform to the court's order." [Texas Medical Assoc. v. HHS, No. 21-0425 (E.D. Tex. Feb. 23, 2022)]
9.
District Court Finds Provider Can Bring Suit to Enforce COVID Test Coverage Requirement (PDF)
U.S. District Court for the Northern District of Texas
Jan. 31, 2022
U.S. District Court for the Northern District of Texas
Jan. 31, 2022
"The terms of the FFCRA and CARES Act support finding an implied private right of action to enforce the right to reimbursement for COVID-19 testing against [group health plans] and administrators ... A private right of action to recover the mandated reimbursement is fully consistent with the legislative scheme ... Diagnostic Affiliates has pled sufficient factual allegations to support its standing to assert ERISA claims on behalf of the patients it served by pleading that it has obtained many assignments from patient members of the plans." [Diagnostic Affiliates of Northeast Houston, LLC v. United Healthcare Services, Inc., No. 21-0131 (N.D. Tex. Jan. 18, 2022)]
10.
Fifth Circuit Is Right To Question ERISA Review Norms
DeBofsky Sherman Casciari Reynolds P.C.
Oct. 7, 2021
DeBofsky Sherman Casciari Reynolds P.C.
Oct. 7, 2021
"The court maintained that under a deferential standard of review, none of the plaintiff's arguments proved that the determination was arbitrary and capricious. While the court's ruling was unanimous, U.S. Circuit Judge Andy Oldham wrote a concurrence addressing the scope of review applied by the court in this case and questioning its use in other ERISA cases. What Judge Oldham wrote was an indictment of the way federal judges decide ERISA cases and has the potential to dramatically change all future ERISA litigation involving benefit claim denials." [Michael J. P. v. Blue Cross and Blue Shield of Texas, No. 20-30361 (5th Cir. Sep. 22, 2021; unpub.)]
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