Category Archives: Health Insurers & Managed Care Organizations

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Will President Trump’s Supreme Court Pick Have an Influence on The Healthcare Industry?

On July 9, 2018, President Trump announced his intention to nominate D.C. Circuit Court Judge Brett Kavanaugh to replace retiring Justice Anthony Kennedy on the Supreme Court. Since the announcement, there has been considerable discussion about what Judge Kavanaugh’s views are on several “hot button” issues, including free speech, religious-rights and abortion, and how Judge … Continue Reading

Per se versus ‘Rule of Reason’ Standard: Judge in Blue Cross Antitrust MDL Proceeding Certifies His Decision For Interlocutory Appeal

In a somewhat unexpected but highly significant move, United States District Judge David Procter (Northern District of Alabama), who is presiding over the In re Blue Cross Blue Shield Antitrust Litigation (Case No. 2:13-cv-20000, N.D. Alabama), has granted defendants’ request that he certify his ruling that the defendants’ alleged conduct should be assessed under a … Continue Reading

Pharmacies Accuse Drug Maker of Anticompetitive Contracting to Restrict Biosimilar Market

Walgreens and Kroger have filed an antitrust action in the United States District Court for the Eastern District of Pennsylvania accusing Johnson & Johnson (J&J) of engaging in anticompetitive conduct designed to stymie the growth of biosimilar alternatives to J&J’s Remicade, a biologic drug used to treat certain chronic immune disorders (Walgreen Co. v. Johnson … Continue Reading

The 2018 SMMC Proposed Contract Awards: Where Do You Go From Here?

On April 24 the Agency for Health Care Administration (“AHCA”) released its proposed contract awards for the Statewide Medicaid Managed Care (“SMMC”) Program.  The determinations that AHCA made for this 5 year, $90 billion re-procurement were surprising to many and are likely to result in a significant reshaping of the program that currently exists.  First, … Continue Reading

Health Insurers Contend Allergy Test Maker’s Antitrust Claims Make No Economic Sense – Seek Early Dismissal on that Basis

Three health insurers accused of having violated the antitrust laws in Academy of Allergy & Asthma in Primary Care v. Blue Cross Blue Shield of Louisiana, et al. (Eastern District of Louisiana), have filed motions seeking a swift win in the matter prior to the commencement of discovery. In support of their request, Humana, Blue … Continue Reading

GDPR: What You Need to Know Now

It is safe to say that there has been much fear and confusion over the European Union (EU) General Data Protection Rule, or GDPR. With an effective date of May 25, 2018, and little guidance as to how the GDPR applies to organizations that do not have a physical presence in the EU or do … Continue Reading

Reversal of Fortune: Rhode Island Court Withdraws “Tentative” Decision to Grant Summary Judgment to Health Insurer in Health System Antitrust Case and Sets Matter for Trial

In what was a surprise result, on April 23, Judge William Smith (Chief Judge of the District of Rhode Island) reversed the “tentative” decision he had announced last November, in Steward Health v. Blue Cross & Blue Shield of Rhode Island, which would have granted defendant Blue Cross & Blue Shield of Rhode Island (BCBS-RI) … Continue Reading

Partial Summary Judgment Granted to Plaintiffs in the In re Blue Cross Blue Shield Antitrust Litigation MDL Proceeding

On April 5, United States District Judge David Proctor (N.D. Alabama) granted partial summary judgment to the plaintiffs in the In re Blue Cross Blue Shield Antitrust Litigation, ruling that a network of trademark licensing agreements between the Blue Cross Blue Shield Association and its member insurance companies (referred to as the ‘Blues’), which plaintiffs … Continue Reading

New Jersey Congressman Calls for a Hearing on the Proposed Cigna/Express Scripts Merger

Recently, Cigna announced its plan to purchase pharmacy benefit manager (“PBM”) Express Scripts. In a March 14, 2018 letter to the chair of the House Committee on Energy and Commerce, Gregory Walden (R-Oregon), Congressman Frank Pallone (D-New Jersey) called for a hearing on the proposed merger. In the letter, Congressman Pallone notes that the combination … Continue Reading

Cigna Announces Proposed Acquisition of Express Scripts, Quickening the Pace of Vertical Mergers in the Healthcare Industry

Late last year, CVS and Aetna announced a merger, combining one of the nation’s largest health insurance companies and a large pharmacy benefits management company (a “PBM”), that being CVS’ Caremark division. The trend continues, as on March 8, Cigna announced its intention to acquire Express Scripts, another PBM, in a deal reportedly valued at … Continue Reading

2018 Legislative Session –A Sampling of Health Related Bills Filed

The 2018 Florida Legislative Session began its 60 day trek to completion on Tuesday, January 9, 2018.  Both House and Senate will be debating various health related bills which may be of interest to healthcare providers in the State.  The following is a sample of those bills which we feel are pertinent to our clients’ … Continue Reading

Issues and Analysis of the State’s Medicaid Managed Assistance ITN

The recently released Invitations to Negotiate (ITN) for Florida’s Statewide Medicaid Managed Care program (SMMC) parallels in large part the State’s initial procurements that were released in 2012 and 2013. Where the current ITN differs, however, should be of interest to all applicants and associated parties. This blog post addresses several of the more significant … Continue Reading

State Releases Medicaid Managed Care Invitation to Negotiate

Last Friday, July 14, 2017, the Florida Agency for Health Care Administration (AHCA) released its long awaited Invitation to Negotiate (ITN) for State Wide Medicaid Managed Care services. The ITN, one for each of the 11 regions within the state, may be found on the state Vendor Bid System (VBS), the link for which is … Continue Reading

Senate Healthcare Bill Released for Public Review

Just over four weeks after the Congressional Budget Office (CBO) released its score of the American Healthcare Act (AHCA), the bill passed by a narrow margin in the U.S. House of Representatives, the U.S. Senate released ‘The Better Care Reconciliation Act of 2017’. Upon initial review, we are providing a quick overview of this proposed … Continue Reading

Repeal of the Affordable Care Act Will Not Include Changes to Tax Exempt Hospitals’ 501(r) Charitable Care Obligations

While the Senate Budget Committee works to draft legislation to reconcile the American Health Care Act, the repeal and replace bill passed by the House, there is no expectation of a repeal of the charitable care obligations imposed on tax exempt hospitals under Section 501(r) of the Internal Revenue Code as part of the Affordable … Continue Reading

The American Health Care Act, the Sequel Receives Its CBO Grade

Perhaps the high fives in the Rose Garden of the White House a few weeks ago may have been a bit premature. On Wednesday, May 24, 2017, the non-partisan Congressional Budget Office (CBO) released its analysis of the revised American Health Care Act (AHCA), and the review contained positive budgetary news, but the overall impact of … Continue Reading

The American Health Care Act: Now What Happens?

To great fanfare by both the leadership of the Republican caucus in the House of Representatives (the House) and President Trump, on May 4, 2017, the American Health Care Act (AHCA), the proposed successor/replacement to the Affordable Care Act (ACA), passed the House by a narrow vote of 217-213. Unsurprisingly, no member of the Democratic … Continue Reading

Medicare Advantage 2018 Rate Announcement

The Centers for Medicare and Medicaid Services (CMS) announced its 2018 Medicare Advantage (MA) capitation rates, with an expected increase of .45 percent, slightly higher than proposed in the advance notice. CMS estimates that MA health plans will realize an increase in revenue of 2.95 percent, reflecting increases in coding acuity and risk adjustment payments. … Continue Reading

House Republican Health Care Bill: Good News for Health Insurance Executives

An Affordable Care Act (ACA) provision that is often-overlooked by the media, but has impacted the ability of insurers and their non-insurance related entities, in their role as employers, to take tax deductions for certain compensation paid to their highly paid employees may be ending at the end of the year. If passed, the House … Continue Reading

Potential Implications to the ACA Under the Incoming Republican Administration – Part I: the Insurance Industry

In the uncertain atmosphere surrounding the process of ‘repealing’ and replacing the Affordable Care Act (ACA), there are some clues as to what we can expect to come next, at least with regard with the health insurance industry. Obviously, one place to look is to President-Elect Trump himself. During his campaign, then-candidate Trump published a … Continue Reading

HHS Publishes a New Rule to Protect Dialysis Patients From Being “Steered” into Private Coverage for the Benefit of Dialysis Centers

On implementing significant, new requirements for Medicare-certified dialysis facilities that make payment of premiums for individual health coverage, on December 14, 2016, the Department of Health and Human Services (HHS) published an Interim final rule with comment period. The regulations become effective 30 days after the date of publication – January 13, 2017, and comments … Continue Reading

11th Circuit Awards Humana Double Damages Under Medicare Secondary Payer Act

Humana Medical Plan, Inc. v. Western Heritage Insurance Co., case number 15-11436. Liability insurers beware, as the 11th Circuit held that Medicare Advantage Organizations (MAO) are entitled to the same rights Medicare itself would have in actions against primary payers for reimbursement of conditional healthcare treatment costs. … Continue Reading

Anti-Discrimination, Language Access Rules Compliance Deadline Fast Approaching for Health Insurers

Health insurers and HMOs have a limited time to review the new federal meaningful access rules and amend plan documents accordingly. However, many payors still have not revised their plans to include the required language, and others might not be aware the rules apply to them.… Continue Reading

Insurers Challenge Retroactive Application of New Florida Law that Requires Comparison of Names of Accounts to Death Master File

Amendments to the Florida Disposition of Unclaimed Property Act in 2016 made significant changes to unclaimed property presumptions and insurance company obligations. See § 717.107, Fla. Stat. (2016) (the Act). Among other things, the Act: (a) revises conditions of when certain insurance policies or annuity contracts are deemed matured and the proceeds are due and … Continue Reading
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