Health Plan & Provider Report Index Summary

SAFETY OF PATIENTS

– Celebrex and Bextra, global class action settlement approved (N.D. Cal.), 380
– Information technology, increased use improves outcomes and saves money, study, 133

SCHIP

See STATE CHILDREN'S HEALTH INSURANCE PROGRAM (SCHIP)

SCREENING

See TESTS AND SCREENING

SECURITIES

– Aetna underpricing to gain market share, class action alleging misrepresentation dismissed (E.D. Pa.), 742
– Stock benefits not deferred until retirement, plan not governed by ERISA (D. Idaho), 826

SELF-REFERRALS

– Hospital sues over Scripps Health practices (Cal. Super Ct.), 712

SETTLEMENTS

– HMO underpayment for services alleged in class action, sanction order vacated (3d Cir.), 1061

SEX DISCRIMINATION

– Cal. bills passed barring gender-based discrimination in individual insurance policies, 592
– Suit filed to end higher premiums for women (Cal. Super. Ct.), 129

SEXUAL ORIENTATION DISCRIMINATION

– Domestic partners

See generally DOMESTIC PARTNERS

SKILLED NURSING FACILITIES (SNFs)

– Part A payments, most improper, IG report, 674

SMALL BUSINESSES

– Electronic health records, Highmark funding for some primary care practices, 571
– Health insurance

– – Benefit cuts planned by many firms, studies, 748
– – COBRA, N.Y. eligibility extended under economic stimulus package, 349
– – Colo., number of covered workers drops, report, 777
– – Eligibility rules under ERISA not established when insurer withdrew specific policy from market (S.D.N.Y.), 891
– – Median market share, largest small group carriers increased in 2008, GAO study, 391
– – Purging of policies by insurance companies

– – – CIGNA, Rockefeller (D-WVa) seeks response to allegations, 941
– – – House panel investigates, 1056

– – R.I., bill passed limiting premium increases, 745
– – Risk pooling and competitive markets would cut costs, Senate leaders say, 917
– – Taxation

– – – Cooperatives with tax credits

See LEGISLATION, FEDERAL, HR 850

– – – Incentives for state reform

See LEGISLATION, FEDERAL, S 979

– – Tenn. insurance coverage limit raised, 162

– “Play-or-pay” mandates in health care reform legislation, CRS report, 1179

SMOKING

– Cessation, mandated Or. benefit, In Brief, 803
– N.C. health plan, smokers and overweight workers will pay more, 534

SNFs

See SKILLED NURSING FACILITIES (SNFs)

SOUTH DAKOTA

– High-risk pools, children with preexisting conditions eligible for coverage under new law, 680
– Mergers, MeritCare Health Sys. of N.D./Sanford Health of S.D., 871

SPECIAL REPORTS

– America's Healthy Future Act, summary of pertinent provisions, 2031
– Bipartisan Affordable Health Choices Act, proposed draft bill imposes major employer requirements, 984
– COBRA subsidies, American Recovery and Reinvestment Act provisions raise questions for employers and insurers, 270
– Costs of U.S. health care system high, analysts discuss various factors, 1079
– Employer mandates in health care reform proposals, critics and supporters continue debate, 1196
– Health insurance cooperatives as possible solution to rising costs, critics and supporters continue debate, 1163
– Hospital pay-for-performance programs, provider negotiations and shared responsibility essential, 539
– LSCs, services expand as state regulatory efforts wane, 468
– Medical tourism industry, possible risks and legal issues discussed, 354
– Medicare Advantage and Part D plan programs, CMS proposed changes would boost oversight and accountability, 2028
– Outlook 2009, top health insurer and provider issues discussed, 18
– San Francisco fair share ordinance requiring employer-paid health coverage, employers adopting to pay-or-play rules, 629

SPECIALISTS

– Cardiologist, multiple-count fraud conviction for improper billing of private insurers and federal programs (W.D. La.), 71
– OB/GYN group reimbursement, ERISA does not preempt Tex. law claims challenging pay rate (5th Cir.), 1002

STANDING

– Derivative, provider receiving assignment of benefits from ERISA participant entitled to copies of plan documents (E.D. La.), 99
– Emergency services, physicians' challenge to contracts barred (Tex. Ct. App.), 162
– Hospitals, sanctions imposed on individual who did not receive Medicare Secondary Payer Act benefits and therefore could not bring qui tam suit (U.S., rev sought), 70
– Misrepresentation, spouse cannot sue insurer over terms of policy covering late wife (Cal. Ct. App.), 500

STATE AND LOCAL GOVERNMENT

– BCBS, legislative efforts will shift from coverage expansion to SCHIP, report, 220
– Employee benefits, 75 percent considering changes, survey, 723
– Health Information Tech. for Economics and Clinical Health (HITECH) Act, guide for states seeking to advance adoption, report, 954
– High-risk pools

See HIGH-RISK POOLS

– Public sector employers favor disease management and wellness programs over consumer-directed plans, report, 108
– Retiree benefits cannot be sustained, report, 869
– Telemedicine, federal funding approved for 6 regional networks, 507

STATE CHILDREN'S HEALTH INSURANCE PROGRAM (SCHIP)

– BCBS, legislative health reform efforts will shift from coverage expansion to children, report, 220
– Improved access and affordability data needed, GAO reports, 336
– Reauthorization

– – Bill

See LEGISLATION, FEDERAL, HR 2

– – Dental coverage requirements, CMS issues guidelines to states, 2018
– – Expansion as signed into law amends ERISA to promote coordination with employer plans, 147

STATUTES OF LIMITATIONS

– No-fault automobile insurer bound by 2-year period in ERISA plan contract (E.D. Mich.), 158

SUBROGATION

– BCBS of Mont. insurance forms exclude coverage of injuries covered by other policies, prohibition on use affirmed (Mont.), 1160
– Make whole doctrine, plan's reimbursement rights to medical expenses paid for participant limited (D. Or.), 344
– Third-party settlement proceeds, ERISA no bar to insurer suit to state law recovery of amount paid for insured's medical care (W.D. Ky.), 263

SUBSTANCE ABUSE

– Mental health parity law revision

See PAUL WELLSTONE AND PETE DOMENICI MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT (MHPAEA)

– Residential treatment, plan does not cover costs at facility without contract (9th Cir.), 923

SUPREME COURT, U.S.

– FEHBA preemption of state law claims against FEHBP insurer and removal of case to federal court under federal officer removal statute (rev grant), 2005
– Hospitals, sanctions imposed where individual did not receive Medicare Secondary Payer Act benefits and therefore lacked qui tam suit standing (rev sought), 70
– Medical benefits denied, arbitration provision enforceable despite ERISA violations in agreement (rev den), 1186
– Nominee Sotomayor, Second Circuit ERISA decisions scrutinized, 646
– Out-of-network care, denial proper where beneficiary did not prove medical necessity or superiority of surgery plan covered (rev sought), 1157; rev den, 2020
– Prescription data mining, First Circuit ruling upholding N.H. ban on sale of physicians' information upheld (rev sought), 412; (rev den), 800
– RICO, provider reimbursement suit over alleged insurer mailing of fraudulent explanations of benefits properly dismissed (8th Cir.), 290; (rev sought), 922; (rev den), 1189
– San Francisco fair share ordinance requiring employer-paid health coverage, no ERISA preemption (9th Cir., en banc rev sought), 39; restaurant group seeks stay from Justice Kennedy as Circuit Justice (application filed), 342; (stay denied), 375; (rev sought), 704; (amicus brief filed), 825; (brief filed), 1023; Solicitor General Kagan invited to file briefs, 1185
– Speech therapy coverage, plan administrator violated ERISA by failing to provide participant with internal guidelines (rev den), 1186

SURGICAL SERVICES

– Children's health care, new Wis. law requires hearing aid and cochlear implant coverage, 653
– Congenital jaw deformity, corrective surgery may be mandated by state law despite lack of coverage under ERISA plan (D. Or.), 1029
– Fraud, guilty plea entered by recruiter of healthy patients for unnecessary procedures (Cal. Super. Ct.), 264
– Full and fair review, BCBS did not afford where new grounds were raised for denying benefits for bypass patient (5th Cir.), 379
– Medical errors, 3 CMS national coverage decisions deny Medicare payment for some mistakes, 98
– Medicare coverage for liver resection performed out of plan without prior authorization, denial affirmed (D. Haw.), 1099
– Minimally invasive, incentives key to reducing health care costs, BNA Analysis, 806
– Obese patients

See generally OBESITY

– Out-of-network care, denial proper where Medicare beneficiary did not prove medical necessity or superiority of procedure plan covered (9th Cir.), 261; subpoenas ruling by administrative law judge (U.S., rev sought), 1157; (rev den), 2020
– Reconstructive surgery, Cal. passes health insurance coverage mandate bill, 1102
– Transplants

See ORGAN TRANSPLANTS

– Wrongful discharge, some claims proceed against employer who fired worker after surgery to prevent future benefits use but ERISA claims over promotion denial barred (E.D. Pa.), 623