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Paul Zimmerman
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Showing 14 posts in Affordable Care Act.

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Courts Read Network Adequacy Requirements into Federal Lactation Counseling Mandates

The ACA and federal regulations require health insurers and plans to cover lactation counseling without cost-sharing (deductibles and co-pays). Under the regulations, an insurer or plan can meet this obligation by either including “a provider” in its network who can provide the service, or by permitting its members to use an out-of-network provider free of any cost. In two recent cases, courts appear to be reading some level of network adequacy and disclosure requirements into the mandates for insurers and plans that take the in-network route. (Read More)

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Two Courts Reject § 1557 and Title VII Healthcare Discrimination Claims Against Insurance Companies Acting as Third-Party Administrators

In two recent decisions, courts have refused to hold insurers acting as third-party administrators (TPAs) liable under ACA § 1557 or Title VII for carrying out allegedly discriminatory terms of self-funded employer health plans. In both cases, the TPAs did not appear to have any role in setting the terms of the employer-sponsored plans, but only in approving and denying claims under their terms. (Read More)

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Will Disparate Impact Claims Be Permitted in ACA Section 1557 Healthcare Cases?

Civil rights act claimants have long sought to use the “disparate impact” theory to prove discrimination. Under this theory, a policy or action that is neutral on its face and is not intentionally discriminatory can still be deemed to violate the law if it has an especially adverse effect on a disability, sex, age or ethnic group. This theory, however, is difficult to apply to healthcare benefits. Unless resources are unlimited, governmental and private sponsors of health plans must make choices on which physical conditions to cover. But any decision not to cover a condition can seemingly be framed as having an adverse impact on a protected group. (Read More)

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New Proposed Regulations for Short-Term Health Insurance Are a Modest Step on the Road to Cheaper Coverage for Individuals

Federal regulators just announced new proposed rules that will make it easier to sell short-term, limited duration individual health insurance. Short-term insurance can be less costly because it is exempt by statute from most Affordable Care Act (ACA) mandates. In late 2016, to curtail its sale, federal regulators changed the rules to require that such insurance have a term of no more than 90 days, and that it not be renewable without the consent of both the insurer and the insured. The new rules alter these restrictions and permit short-term policies with a term of less than 12 months that are renewable with just the insurer’s consent. The net effect: insurers will be able to sell short-term individual policies with terms of up to 364 days that are essentially automatically renewable. (Read More)

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Closing the Health Insurance Gap for Small Business: The Potential and Pitfalls in the Proposed Rules for Association Health Plans

For years, the percentage of small businesses offering group health insurance coverage has been dropping. This hard fact of life accelerated with the advent of the Affordable Care Act (ACA), which put steep coverage mandates on insurance sold to small employers with 50 or less employees, causing corresponding increases in premiums. Many of these mandates did not apply to large employers. When small employers wanted to band together and form associations that would exceed the 50 employee threshold, they ran into federal rules that simply disregarded the existence of the association and treated its members based on their individual sizes. (Read More)

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Medicare Data Not Indicative of Overall Healthcare Spending Costs

In December 2015, a  research team at Carnegie Mellon published a paper titled “Examining the Variation in Health Spending and in Hospitals’ Transaction Prices” after receiving access to insurance claims data from Aetna, Humana, and United. (Read more)

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ACA Survives a Second Legal Challenge

The Affordable Care Act is frequently referred to as ACA or Obamacare.

  • “ACA” is an acronym based on its initials.
  • Obamacare started out as a pejorative label coined by political rivals, but the President famously noted during a 2012 debate that he liked the name.

If it keeps fending off political and court-based challenges, the infamous Molly Brown may not be the only one known as “unsinkable.” (Read More)

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Anthem-Cigna Mega Merger Likely Problematic for Providers

Anthem announced on July 24, 2015 that it would purchase Cigna, just three weeks after Aetna agreed to buy Human for $37 billion. The deal is valued at $54.2 billion, and would create the United States’ largest health insurer by membership, with a combined 53 million members. The merger will close sometime in 2016, pending regulatory approval. (Read more)

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Supreme Court Upholds Obamacare’s Federal Subsidies for Health Insurance

Supporters of the Obamacare are celebrating today as the Supreme Court in King v. Burwell rejected a lawsuit against the Affordable Care Act (ACA). In a 6-3 decision, the Supreme Court held that the federal government may continue to subsidize health insurance in those states that have not set up their own exchanges.  (Read more)

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California Department of Managed Care Denies CAPG’s Petition for Rulemaking Amendments Regarding Reimbursements

On August 12, 2014, the California Association of Physician Groups (CAPG) petitioned the Department of Managed Care (Department). On the action requested by CAPG, it was concerned with the considerations relevant to the reasonable and customary value of services performed by non-contracted providers. CAPG requested (for the third time – its previous two times had been rejected) amendment or repeal of subdivision (a) (3) (B) of Title 28, section 1300.71, known as the “Gould factors,” contending: (Read more)