Justia Health Law Opinion Summaries

The Ninth Circuit affirmed the district court's dismissal of plaintiffs' claim that their insurer, Blue Shield, violated the Medical Loss Ratio (MLR) provision of the Patient Protection and Affordable Care Act (ACA). The MLR is the ratio between what an insurer pays out in claims for medical services and the revenue it takes in.The panel held that there was no basis in the language, history, intent or spirit of the ACA to narrow the MLR by excluding payments for services rendered by out-of-network physicians. In this case, the MLR was properly calculated under federal law by including the settlement reimbursements for medical services by nonnetwork providers. Therefore, the district court correctly recognized the services were covered by the plan and the payments were made. View "Morris v. California Physicians' Service" on Justia Law

After federal agencies issued two interim final rules (IFRs) exempting employers with religious and moral objections from the Affordable Care Act requirement that group health plans cover contraceptive care without cost sharing, states filed suit to enjoin the enforcement of the IFRs. The Ninth Circuit affirmed that venue was proper in the Northern District of California; affirmed that plaintiff states have standing to sue based on procedural injury where the states have shown with reasonable probability that the IFRs will first lead to women losing employer-sponsored contraceptive coverage, which will then result in economic harm to the states; affirmed the preliminary injunction insofar as it barred enforcement of the IFRs in the plaintiff states; but vacated the portion of the injunction barring enforcement in other states because the scope of the injunction was overbroad. View "California v. Azar" on Justia Law

The Ninth Circuit reversed the district court's grant of summary judgment for defendant in an action challenging an Employee Retirement Income Security Act (ERISA) plan's denial of a claim. The plan denied plaintiff's claim for the cost of an inpatient stay in a residential mental health treatment facility. The panel held that the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 did not require that the plan's coverage for stays at licensed inpatient residential treatment facilities had to be no more restrictive than stays at skilled nursing facilities. The panel explained that the Parity Act precluded the plan from deciding that it would provide room and board reimbursement at licensed skilled nursing facilities for medical and surgical patients, but not at residential treatment facilities for mental health patients. View "Danny P. v. Catholic Health Initiatives" on Justia Law

The Ninth Circuit affirmed the district court's grant of a preliminary injunction enjoining California Department of Public Health officials from enforcing the California Medical Waste Management Act (MWMA). The preliminary injunction enjoined Department officials from enforcing the Act on Daniels for the manner in which it disposed of medical waste at facilities outside of the State of California. The panel held that Daniels will likely succeed on the merits of its dormant Commerce Clause claim. Furthermore, the panel held that Department officials were entitled to qualified immunity because Daniels' constitutional rights under the dormant Commerce Clause were not clearly established at the time of the violation. Therefore, the panel reversed the denial of Department officials' motion to dismiss on the basis of qualified immunity. View "Daniels Sharpsmart, Inc. v. Smith" on Justia Law

Garrison, a licensed physician’s assistant, was convicted of conspiracy to distribute controlled substances, 21 U.S.C. 846. During the trial, the government offered evidence that Garrison and his co-conspirators had abused their positions as healthcare providers by intentionally prescribing OxyContin, a powerful opioid pain reliever, for no legitimate medical purpose as part of a scheme to sell the drug on the street. The Ninth Circuit affirmed, rejecting an argument that there was insufficient evidence to support his conviction. The court upheld the remedies the trial court crafted for the government’s late disclosures concerning two prosecution witnesses; the district court had advised the jury of the government’s failure to timely comply with its constitutional obligations, stating that the jury could draw adverse inferences from this failure, which could lead the jury to find reasonable doubt as to Garrison’s and his codefendants’ guilt. The court also upheld jury instructions regarding the abrupt departure of two co-defendants from the trial and the dismissal of charges against a third co-defendant. View "United States v. Garrison" on Justia Law

The Ninth Circuit reversed the district court's partial grant of summary judgment for the Department and held that the Department did not violate the dormant Commerce Clause in adopting Medi-Cal policies related to reimbursement to out-of-state hospitals. The panel held that when a state was acting as a market participant, rather than a market regulator, its decisions were exempted from the dormant Commerce Clause. In this case, the Department sets rates of reimbursement to hospitals for those who were essentially insured as beneficiaries under Medi-Cal in a manner much like that of a private insurer participating in the market. Therefore, the Department was acting as a market participant, rather than a regulator and was exempt from dormant Commerce Clause requirements. View "Asante v. California Department of Healthcare Services" on Justia Law

Solis alleged that his former employers violated the federal False Claims Act (FCA) by promoting dangerous off-label uses of a cardiovascular drug, Integrilin, and by paying physicians kickbacks to prescribe Integrilin and an antibiotic drug, Avelox. The district court found that Solis’s FCA claims were foreclosed by the public disclosure bar, which deprives federal courts of subject matter jurisdiction over FCA suits when the alleged fraud has already been publicly disclosed unless the relator is deemed an original source. The Ninth Circuit affirmed in part, holding that Solis’s Integrilin claims were substantially similar to those in prior public disclosures, and were close enough in kind and degree to have put the government on notice to investigate the alleged fraud before Solis filed his complaint. The court vacated the dismissal of Solis’s Integrilin claims and remanded for a determination of whether Solis qualified for the “original source” exception, 31 U.S.C. 3730(e)(4). Concerning Solis’s Avelox claims, the court held that the district court clearly erred in finding that the Avelox claims were publicly disclosed based on court complaints that never mentioned Avelox but affirmed the dismissal of Solis’s Avelox claims on the alternative ground of failure to plead with particularity as required by Fed.R.Civ.P. 9(b). View "Solis v. Millenium Pharmaceuticals, Inc." on Justia Law

The Ninth Circuit affirmed the district court's grant of summary judgment for the Department in an action brought by private ambulance companies challenging the reimbursement rate for their transportation of patients covered by Medi-Cal. The panel held that plaintiffs failed to carry their burden of producing evidence upon which a reasonable jury could return a verdict in their favor and thus the district court did not err in entering judgment in the Department's favor on the Takings Clause claim. The panel reasoned that the ambulance companies lacked a constitutionally protected property interest in a particular reimbursement rate, but the mandatory-care provision of Cal. Health & Safety Code 1317(d) implicated a constitutionally protected property right. The panel held that section 1317(d) did not effect a regulatory taking under the Penn Central test. The panel also held that the ambulance companies did not establish a due process claim regarding DHCS's failure to ensure that Medi-Cal reimbursement rates kept pace with their costs because they lacked a constitutionally protected interest in any particular reimbursement rate. View "Sierra Medical Services Alliance v. Kent" on Justia Law

The Ninth Circuit affirmed the district court's grant of summary judgment for the Department in an action brought by private ambulance companies challenging the reimbursement rate for their transportation of patients covered by Medi-Cal. The panel held that plaintiffs failed to carry their burden of producing evidence upon which a reasonable jury could return a verdict in their favor and thus the district court did not err in entering judgment in the Department's favor on the Takings Clause claim. The panel reasoned that the ambulance companies lacked a constitutionally protected property interest in a particular reimbursement rate, but the mandatory-care provision of Cal. Health & Safety Code 1317(d) implicated a constitutionally protected property right. The panel held that section 1317(d) did not effect a regulatory taking under the Penn Central test. The panel also held that the ambulance companies did not establish a due process claim regarding DHCS's failure to ensure that Medi-Cal reimbursement rates kept pace with their costs because they lacked a constitutionally protected interest in any particular reimbursement rate. View "Sierra Medical Services Alliance v. Kent" on Justia Law

The Ninth Circuit held that the Secretary erred in approving a state plan amendment (SPA) pursuant to 42 U.S.C. 1396(a)(30)(A), without requiring any evidence regarding the extent that such care and services were available to the general population in the geographic area. In this case, the Secretary's approval of the SPA absent considerations of some form of comparative-access data was arbitrary and capricious. Accordingly, the court reversed the district court's grant of summary judgment in favor of the Secretary and remanded. View "Hoag Memorial Hospital Presbyterian v. Price" on Justia Law