Justia Health Law Opinion Summaries

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The parents were domiciled in Nassau, the Bahamas. Mother traveled to the U.S. five times while pregnant. A.R. was born in November 2015, in Nassau, and lived in Nassau for six months. He received his first two sets of vaccinations in Nassau, with no apparent adverse consequences. During his six-month well-child visit in Nassau, A.R. received his third set of eight vaccinations that are listed in the Vaccine Injury Table and were manufactured by companies with a U.S. presence. Days later, A.R. became ill. A.R. was flown to Nicklaus Children’s Hospital in Miami, Florida, where he was diagnosed with hemophagocytic lymphohistiocytosis, an autoimmune disease of the blood. He remained in Florida as an outpatient, returning to Nassau for Christmas, and months later, was diagnosed with acute myeloid leukemia. A.R. underwent treatment, at Cincinnati Children’s Hospital and at Johns Hopkins before he died.The Federal Circuit affirmed the dismissal of the parents’ Vaccine Act claim (42 U.S.C. 300aa). The parents asserted that the condition that caused A.R.’s death was a complication resulting from the treatment he had received for his vaccine-induced condition. The Act grants standing to a person who “received [a covered] vaccine outside the” U.S. if “such person returned" to the U.S. not later than 6 months after the vaccination. A.R., while living outside of his mother’s body, was never present in the U.S. before his vaccinations such that his entrance for medical treatment could be a “return.” View "Dupuch-Carron v. Secretary of the Department of Health & Human Services" on Justia Law

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SmileDirect filed suit against the Georgia Board of Dentistry, including the Board’s members in their individual capacities, alleging inter alia, antitrust, Equal Protection, and Due Process violations related to the amendment of Ga. Bd. of Dentistry R. 150-9-.02. On appeal, the Board members challenged the denial of their motion to dismiss the complaint with respect to the alleged antitrust violations.After determining that it does have appellate jurisdiction under the collateral order doctrine, the Eleventh Circuit affirmed, holding that, based on the facts alleged in SmileDirect's complaint, the Board members are not entitled to state-action immunity under Parker v. Brown, 317 U.S. 341 (1943), at this point in the litigation, and the district court properly denied their motion to dismiss. In this case, the Board members have failed to satisfy the Midcal test by failing to meet the "active supervision" prong of the test and both prongs are necessary to satisfy the test. Furthermore, the court rejected the Board members' argument that ipso facto state-action immunity is available merely because of the Governor's power and duty, and without regard to his actual exercise thereof. The court explained that the Board members have established no more than the mere potential for active supervision on the part of the Governor, and thus they have fallen far short of establishing that the amended rule was "in reality" the action of the Governor. View "SmileDirectClub, LLC v. Battle" on Justia Law

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Four consolidated appeals presented a question of whether medical providers who provided services under California’s Medi-Cal program were entitled to reimbursement for the costs of providing in-house medical services for their own employees through “nonqualifying” self-insurance programs. Even for nonqualifying self-insurance programs, however, the Provider Reimbursement Manual allowed providers to claim reimbursement for reasonable costs on a “claim-paid” basis. Oak Valley Hospital District (Oak Valley) and Ridgecrest Regional Hospital (Ridgecrest) had self-insurance programs providing health benefits to their employees. Claims for in-house medical services to their employees were included in cost reports submitted to the State Department of Health Care Services (DHS). DHS allowed the costs when Oak Valley and Ridgecrest employees received medical services from outside providers but denied costs when the medical services were provided in-house. DHS determined claims paid to Oak Valley and Ridgecrest out of their self-insurance plan for in-house medical services rendered to their employees were not allowable costs. The trial court granted Oak Valley and Ridgecrest's the writ petitions on grounds that costs of in-house medical services were reimbursable so long as they were “ ‘reasonable’ ” as defined by the Provider Reimbursement Manual. DHS appealed in each case. After review, the Court of Appeal concluded Oak Valley’s and Ridgecrest’s self-insurance programs did not meet the requirements of a qualified plan under CMS guidelines and Provider Reimbursement Manual. The Court of Appeal rejected DHS’s contention that Oak Valley and Ridgecrest costs relating to in-house medical services for their employees were inherently unreasonable. To the extent DHS argued the cost reports were not per se unreasonable, but unreasonable under the circumstances of the actual treatments of Oak Valley and Ridgecrest employees, the Court determined the evidence in the record supports the trial court’s findings that expert testimony established Oak Valley and Ridgecrest incurred actual expenses in providing in-house medical services for their employees that were not otherwise reimbursed. Accordingly, the Court affirmed the trial court’s granting of the petitions for writs of administrative mandate. View "Oak Valley Hospital Dist. v. Cal. Dept. of Health Care Services" on Justia Law

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Plaintiffs Rafi Ghazarian and Edna Betgovargez had a son, A.G., with autism. A.G. received applied behavior analysis (ABA) therapy for his autism under a health insurance policy (the policy) plaintiffs had with defendant California Physicians’ Service dba Blue Shield of California (Blue Shield). Mental health benefits under this policy are administered by defendants Magellan Health, Inc. and Human Affairs International of California (collectively Magellan). By law, the policy had to provide A.G. with all medically necessary ABA therapy. Before A.G. turned seven years old, defendants Blue Shield and Magellan approved him for 157 hours of medically necessary ABA therapy per month. But shortly after he turned seven, defendants denied plaintiffs’ request for 157 hours of therapy on grounds only 81 hours per month were medically necessary. Plaintiffs requested the Department of Managed Health Care conduct an independent review of the denial. Two of the three independent physician reviewers disagreed with the denial, while the other agreed. As a result, the Department ordered Blue Shield to reverse the denial and authorize the requested care. Plaintiffs then filed this lawsuit against defendants, asserting breach of the implied covenant of good faith and fair dealing against Blue Shield, and claims for intentional interference with contract and violations of Business and Professions Code section 17200 (the UCL) against defendants. Defendants each successfully moved for summary judgment. As to the bad faith claim, the trial court found that since one of the independent physicians agreed with the denial, Blue Shield acted reasonably as a matter of law. As to the intentional interference with contract claim, the court found no contract existed between plaintiffs and A.G.’s treatment provider with which defendants could interfere. Finally, the court found the UCL claim was based on the same allegations as the other claims and thus also failed. After its review, the Court of Appeal concluded summary judgment was improperly granted as to the bad faith and UCL claims. "[I]t is well established that an insurer may be liable for bad faith if it unfairly evaluates a claim. Here, there are factual disputes as to the fairness of defendants’ evaluation. . . .There are questions of fact as to the reasonability of these standards. If defendants used unfair criteria to evaluate plaintiffs’ claim, they did not fairly evaluate it and may be liable for bad faith." Conversely, the Court found summary judgment proper as to the intentional interference with contract claim because plaintiffs failed to show any contract with which defendants interfered. View "Ghazarian v. Magellan Health" on Justia Law

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Defendants Silverado Senior Living Management, Inc., and Subtenant 350 W. Bay Street, LLC dba Silverado Senior Living – Newport Mesa appealed a trial court's denial of its petition to compel arbitration of the complaint filed by plaintiffs Diane Holley, both individually and as successor in interest to Elizabeth S. Holley, and James Holley. Plaintiffs filed suit against defendants, who operated a senior living facility, for elder abuse and neglect, negligence, and wrongful death, based on defendants’ alleged substandard treatment of Elizabeth. More than eight months after the complaint was filed, defendants moved to arbitrate based on an arbitration agreement Diane had signed upon Elizabeth’s admission. At the time, Diane and James were temporary conservators of Elizabeth’s person. The court denied the motion, finding that at the time Diane signed the document, there was insufficient evidence to demonstrate she had the authority to bind Elizabeth to the arbitration agreement. Defendants argued the court erred in this ruling as a matter of law, and that pursuant to the Probate Code, the agreement to arbitrate was a “health care decision” to which a conservator had the authority to bind a conservatee. Defendants relied on a case from the Third District Court of Appeal, Hutcheson v. Eskaton FountainWood Lodge, 17 Cal.App.5th 937 (2017). After review, the Court of Appeal concluded that Hutcheson and other cases on which defendants relied are distinguishable on the facts and relevant legal principles. "When the Holleys signed the arbitration agreement, they were temporary conservators of Elizabeth’s person, and therefore, they lacked the power to bind Elizabeth to an agreement giving up substantial rights without her consent or a prior adjudication of her lack of capacity. Further, as merely temporary conservators, the Holleys were constrained, as a general matter, from making long-term decisions without prior court approval." Accordingly, the trial court was correct that the arbitration agreement was unenforceable as to Elizabeth. Furthermore, because there was no substantial evidence that the Holleys intended to sign the arbitration agreement on their own behalf, it could not be enforced against their individual claims. The Courttherefore affirmed the trial court’s order denial to compel arbitration. View "Holley v. Silverado Senior Living Management" on Justia Law

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PCMA filed suit claiming that the Employee Retirement Income Security Act of 1974 (ERISA) and the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Medicare Part D), preempt two sections of the North Dakota Century Code regulating the relationship between pharmacies, pharmacy benefits managers (PBMs), and other third parties that finance personal health services. The district court determined that only one provision in the legislation was preempted by Medicare Part D and entered judgment in favor of North Dakota on the remainder of PCMA's claims.The Eighth Circuit held that it need not address the "connection with" element of the analysis because the legislation is preempted due to its impermissible "reference to" ERISA plans. In this case, the legislation is preempted because its references to "third-party payers" and "plan sponsors" impermissibly relate to ERISA benefit plans. Therefore, the court held that the North Dakota legislation is preempted because it "relates to" ERISA plans "by regulating the conduct of PBMs administering or managing pharmacy benefits." Finally, the court held that North Dakota waived its savings clause argument. Accordingly, the court affirmed in part, reversed in part, and remanded. View "Pharmaceutical Care Management Ass'n v. Tufte" on Justia Law

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A juvenile court has the authority to order vaccinations for dependent children under its jurisdiction. Recently enacted Health and Safety Code section 120372, subdivision (d)(3)(C) provides that a state public health officer (SPHO) or a doctor designated by a SPHO "may revoke the medical exemption." The Court of Appeal held that section 120372, subdivision (d)(3)(C) does not deprive the juvenile court of that authority.After determining that this case was not moot, the court rejected father's contention that the juvenile court had no legal authority to revoke the vaccination exemptions from a past treating physician and to order that the children be vaccinated. The court held that evidence in the record supported the juvenile court's finding that the children needed vaccinations. The court also held that there is no statutory bar to preclude the juvenile court from ordering dependent children to receive medically necessary vaccinations. Finally, the court held that the juvenile court could reasonably find that the past treating physician did not know the children's current need for vaccinations and father's remaining contentions do not show grounds for reversal. View "In re S.P." on Justia Law

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Petitioners PeaceHealth St. Joseph Medical Center and PeaceHealth St. John Medical Center (PeaceHealth) argued that, under RCW 82.04.4311’s plain language, qualifying Washington hospitals were entitled to a business and occupation (B&O) tax refund and deduction on compensation they receive from any state’s Children’s Health Insurance Programs (CHIP) or Medicaid programs, not just Washington’s. Alternatively, PeaceHealth contended that by excluding compensation that qualifying Washington hospitals receive from other states’ CHIP and Medicaid programs, the Washington Department of Revenue (Department) unlawfully penalized those hospitals that served out-of-state patients, thus violating the dormant Commerce Clause of the United States Constitution. In holding that RCW 82.04.4311’s deduction excluded compensation that qualifying hospitals receive from other states’ CHIP and Medicaid programs, the Court of Appeals used the "series-qualifier" rule of statutory construction in lieu of the last antecedent rule. To this, the Washington Supreme Court held the Court of Appeals properly applied the series-qualifier rule to delimit the scope of RCW 82.04.4311’s deduction, thus affirming the Court of Appeals’ reasoning on this issue. Additionally, because the Supreme Court found that RCW 82.04.4311 supported a traditional government function without any differential treatment favoring local private entities over similar out-of-state interests, the Supreme Court held that RCW 82.04.4311 was constitutional under the government function exemption to the dormant Commerce Clause. View "Peacehealth St. Joseph Med. Ctr. v. Dep't of Revenue" on Justia Law

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Vaughn, a quadriplegic, has received home‐based care for over 30 years. She requires help with personal care, household maintenance, mobility exercises, transportation, medications, suctioning secretions from her tracheostomy, and use of the ventilator. When nursing shifts cannot be staffed, Vaughn has relied on friends. Indiana funded her care through two federally-reimbursed Medicaid programs: A&D waiver and core Medicaid. Vaughn could select her own caregivers to receive A&D waiver funds but could not personally direct nursing care funded through core Medicaid. In 2016, Vaughn was hospitalized with pneumonia. She was cleared to be discharged but the state could not find nurses to provide round‐the‐clock care at home at Medicaid rates Vaughn was transferred to a nursing home and filed suit under the Americans with Disabilities Act, 42 U.S.C. 12132; the Rehabilitation Act, 29 U.S.C. 794; and the Medicaid Act, 42 U.S.C. 1396a(a)(8). The court granted Vaughn summary judgment with an injunction requiring the state to “do whatever is necessary to achieve” round‐the‐clock home‐based care, fully paid for by the state.The Seventh Circuit vacated. Vaughn is not entitled to the services she has requested under Indiana’s version of the Medicaid program, as the program was structured before the state adopted a new pilot program. The state is not obligated to reimburse Vaughn’s providers at rates above the approved Medicaid caps, nor must it use funds outside the Medicaid program to comply with a rule about accommodation within the program. View "Vaughn v. Walthall" on Justia Law

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The Department of Health and Human Services disallowed roughly $30 million in Medicaid reimbursements for payments Virginia made to two state hospitals. HHS determined that Virginia had materially altered its payment methodology without notifying HHS or obtaining approval and that the new methodology resulted in payments that overstepped applicable federal limits. Virginia had allocated disproportionate share hospitals (DSH) payments for the two hospitals to fiscal years other than “the actual year in which [related] DSH costs were incurred” by those hospitals for purposes of complying with the annual statewide DSH allotment and hospital-specific limit. The district court and D.C. affirmed. A comparison between Virginia’s previous operation of its plan—as manifested in the state’s prior representations about the plan’s operation—and its later operation of the same plan shows that there was a “[m]aterial change” in “the State’s operation of the Medicaid program,” so that the state was required to amend its plan and present the amendment for approval, 42 C.F.R. 430.12(c)(1)(ii). View "Department of Medical Assistant Services of the Commonwealth of Virginia v. United States Department of Health and Human Services" on Justia Law