Court Cases

News Briefs: AMA, AHA Scrap Surprise Billing Lawsuit

The American Medical Association (AMA) and American Hospital Association (AHA) on Sept. 20 both pulled lawsuits challenging rulemaking related to the No Surprises Act (NSA), the federal law that banned most balance billing. In a joint statement, the country’s two largest provider trade groups said that “the lawsuit became moot when the Administration released a revised final rule on Aug. 26. However, the AHA and AMA remain concerned that the final rule continues to favor insurers and does not line up with what Congress intended when it passed the law.” A broad group of providers objected to the Biden administration’s guidance on Independent Dispute Resolution (IDR), the HHS-managed arbitration process that will resolve balance billing disputes. Payers and providers have viewed IDR regulations as a zero-sum issue. Providers have argued that rulemaking favored insurers at their expense. The Biden administration recently released new guidance designed to address providers’ concerns and head off legal challenges; while that has worked in the AMA and AHA’s cases, several other lawsuits from providers are still in progress.

0 Comments

News Briefs: Walgreens to Complete Acquisition of Specialty Pharmacy

Walgreens Boots Alliance, Inc. (WBA) will assume full control of specialty pharmacy Shields Health Solutions for approximately $1.37 billion cash, the firm said Tuesday. Walgreens already controlled the pharmacy, holding 71% of the company’s stock thanks to a $970 million deal that closed last year. WBA CEO Roz Brewer said in a press release that the deal will allow “further progress on our strategy through Shields’ integrated model, increasing our value to health systems, expanding access to payor partners and supporting improved outcomes and lower costs.”

Centene Corp. agreed to pay $165.6 million to the state of Texas over the state's contention that the insurer overcharged the state's Medicaid program for PBM services, according to legal documents obtained by Kaiser Health News (KHN). The settlement is the largest of a series of settlements from at least a dozen states over similar charges. The Texas settlement is the largest such arrangement, with Centene paying out at least $475 million so far to the states of Arkansas, Illinois, Kansas, Mississippi, New Hampshire, New Mexico, Ohio, Texas, and Washington; three other states have not released the value of their settlements with the Medicaid-focused insurer, per KHN. Centene has divested most of its PBM assets over the past year, and told investors in 2021 that it set aside $1.25 billion to wind down its liability to states in this area.

News Briefs: Home Depot Appeals Settlement With BCBSA

The Home Depot, Inc. and two other employers — Topographic and Employee Services Inc. — have appealed a $2.67 billion settlement reached in connection with a class-action lawsuit against the Blue Cross Blue Shield Association (BCBSA). The litigation, which has been ongoing since 2012, challenges Blues plans’ agreement to divide the country among the association’s 36 members and to restrict members’ ability to offer non-Blues products, alleging that constitutes anticompetitive behavior. The decision to appeal the settlement could delay the disbursement of funds as well as the changes expected to come about from the settlement, which could give Blues plans more freedom to collaborate and consolidate, experts told AIS Health in 2020. A federal judge signed off on the settlement in August.

0 Comments

AHIP Cheers Ruling in Dialysis Payment Case, but Congress Could Step In

Recently, health insurance trade group AHIP highlighted an under-the-radar Supreme Court ruling that centered on who should pay the bulk of the costs associated with treating some of the sickest patients: those with end-stage renal disease (ESRD). However, industry experts tell AIS Health, a division of MMIT, that what seems to be a victory for employer-based plans may be short-lived if Congress weighs in on the issue.

The case, Marietta Memorial Hospital Employee Health Benefit Plan v. DaVita Inc., concerned whether an employer-based health plan violated the Medicare Secondary Payer Statute (MSPS) by offering limited outpatient dialysis benefits to its enrollees. Specifically, the health plan in question had no in-network dialysis providers, capped reimbursement at 87.5% of the Medicare rate, and “imposed utilization management restrictions, such as claims audits and reviews,” health law attorney and Georgetown University research professor Katie Keith noted in a June article for Health Affairs.

0 Comments

New Suit Claims Copay Accumulators Violate ACA, but Will Judge Agree?

In a newly filed lawsuit, three patient groups are challenging a federal regulation that allows what they call an “evil money grab” by health insurers and PBMs: copay accumulator adjustment programs. The lawsuit contends that the rule violates both the Affordable Care Act and the Administrative Procedure Act, and legal experts tell AIS Health that it’s still an open question whether those claims will prevail.

The rule in question is the 2021 Notice of Benefit and Payment Parameters (NBPP), an omnibus regulation issued annually that chiefly sets ground rules for the ACA marketplaces. It drew the ire of groups that represent patients with chronic conditions by allowing individual and group health plans to implement copay accumulator adjustment programs, which prevent patients from counting the value of drug manufacturer coupons toward their deductibles or out-of-pocket payment limits. Drugmakers often offer coupons for pricey branded drugs — a practice that they say helps increase access to vital medications. But insurers contend that such coupons push consumers toward high-priced medicines, forcing health plans to raise premiums across the board to compensate.

News Briefs: UnitedHealth, Walmart Ink Medicare Advantage Deal

UnitedHealth Group on Sept. 7 unveiled a “10-year, wide-ranging collaboration” with Walmart Inc., which will start in 2023 with 15 Walmart Health locations in Florida and Georgia. UnitedHealth’s Optum division will provide Walmart Health clinicians with “analytics and decision support tools” to help them improve outcomes for Medicare beneficiaries, and the two firms will offer a co-branded Medicare Advantage plan starting in January called UnitedHealthcare Medicare Advantage Walmart Flex (HMO-POS). Commercial health plan members with UnitedHealthcare’s Choice Plus PPO plan will also have in-network access to Walmart Health Virtual Care, effective in January. “Eventually, the collaboration aims to serve even more people, including those across commercial and Medicaid plans, by providing access to fresh food and enhancing current initiatives to address social determinants of health, over-the-counter and prescription medications, and dental and vision services,” stated a UnitedHealth press release.

0 Comments

Johnson & Johnson Files Lawsuit Against Copay Maximizer Company SaveOnSP

Multiple companies that provide alternate funding options for patients have been launching over the last several years. But one maximizer company has found itself the target of a legal battle with manufacturer Johnson & Johnson over its strategy to reclassify drugs and maximize the copay assistance it gets from pharma manufacturers.

Copay maximizers have companies classify some drugs as “non-essential health benefits” (NEHBs) as outlined in the Affordable Care Act (ACA). They then secure patient assistance for these drugs through manufacturers’ or charitable foundations’ patient assistance programs, taking the full annual amount of assistance per drug and spreading out that money over the course of the year (see story). The programs are seen as follow-on offerings to copay accumulators, which take the maximum assistance up front and deplete the contribution before the end of the year.

Federal Judge Strikes Down ACA’s Coverage Mandate for PrEP Drugs

A federal judge on Sept. 7 ruled that the Affordable Care Act’s requirement that individual and group health plans must cover pre-exposure prophylaxis (PrEP) medications to prevent HIV violates the religious freedom of objecting employers. The ruling is not likely the final salvo in a case that challenged the ACA’s entire preventive service coverage mandate, but it did spark outcry from one advocacy group representing HIV-positive patients.

The case in question, now known as Braidwood Management Inc., et al v. Becerra, argues that Section 2713 of the ACA — which mandates coverage of preventive services recommended by the U.S. Preventive Services Task Force (USPSTF), the Advisory Committee on Immunization Practices and the Health Resources and Services Administration — is unconstitutional. It also challenges coverage mandates for specific preventive care, namely PrEP and some contraceptive methods, on religious freedom grounds.

New Suit Claims Copay Accumulators Violate ACA, but Will Judge Agree?

In a newly filed lawsuit, three patient groups are challenging a federal regulation that allows what they call an “evil money grab” by health insurers and PBMs: copay accumulator adjustment programs. The lawsuit contends that the rule violates both the Affordable Care Act and the Administrative Procedure Act, and legal experts tell AIS Health that it’s still an open question whether those claims will prevail.

The rule in question is the 2021 Notice of Benefit and Payment Parameters (NBPP), an omnibus regulation issued annually that chiefly sets ground rules for the ACA marketplaces. It drew the ire of groups that represent patients with chronic conditions by allowing individual and group health plans to implement copay accumulator adjustment programs, which prevent patients from counting the value of drug manufacturer coupons toward their deductibles or out-of-pocket payment limits. Drugmakers often offer coupons for pricey branded drugs — a practice that they say helps increase access to vital medications. But insurers contend that such coupons push consumers toward high-priced medicines, forcing health plans to raise premiums across the board to compensate.

FTC Fines Broker for Pushing ‘Sham’ Health Insurance Plans

Benefytt Technologies, Inc., a health insurance brokerage controlled by private equity firm Madison Dearborn Partners, LLC, will refund its customers $100 million after the Federal Trade Commission (FTC) found Benefytt knowingly defrauded consumers shopping for Affordable Care Act marketplace plans. Health care experts tell AIS Health, a division of MMIT, that similar schemes involving deceptive and exploitative sales tactics are now a common problem.

The FTC said in a press release that Benefytt misrepresented bundles of short-term, limited duration (STLD) plans and supplemental health insurance products as comprehensive plans that meet the ACA’s standard benefits requirements. Benefytt’s marketing practices were misleading, the FTC said, and involved “lying to consumers about their sham health insurance plans and using deceptive lead generation websites to lure them in.” According to the FTC complaint, Benefytt also “illegally charged people exorbitant junk fees for unwanted add-on products without their permission.”

0 Comments