Court decisions on ACA marketplace rules affect key coverage provisions
As CMS moves ahead with Medicaid funding limits for gender-affirming care in minors, Democratic state leaders used litigation to block restrictions in the Affordable Care Act (ACA) insurance marketplaces. The ACA policy, established in 2025 regulations, would remove the essential health benefit (EHB) designation from gender-affirming care. EHB status allows ACA consumer protections, such as…
No Surprises Act QPA calculations set to change after appeals court ruling
An appeals court sided with providers in a case about the No Surprises Act’s qualifying payment amount (QPA), a key benchmark in out-of-network payment determinations. The U.S. Court of Appeals for the Fifth Circuit issued a ruling that QPA calculations must not include ghost rates, referring to non-negotiated rates listed in contracts for services a…
MultiPlan antitrust litigation gains momentum after rulings for providers
Healthcare providers obtained two favorable rulings over the last month in their massive antitrust litigation against a vendor’s repricing algorithm. The case entails allegations that MultiPlan — which since has rebranded as Claritev — conspired to set out-of-network (OON) payment rates by gathering competitively sensitive information from roughly 700 health plans and using that information…
HHS concedes defeat in litigation over providers’ use of tracking technologies on websites
The hospital lobby cemented its victory in litigation about online tracking tools after HHS canceled its planned appeal. In June, the American Hospital Association (AHA) and co-plaintiffs won a decision in a Texas federal court about 2022 guidance (revised and somewhat softened in 2024) instructing hospitals and other HIPAA-covered entities to avoid using online tracking…
Appeals court eliminates Medicare supplemental payments for low-wage hospitals (updated-2)
Note: This article was updated most recently Oct. 4 with news that CMS has ended the low-wage-index policy. See that update below. Plaintiff hospitals won litigation last week at the federal appellate level that will adversely affect Medicare payment for some rural hospitals. The U.S. Court of Appeals for the D.C. Circuit backed a district…
Supreme Court ruling on Chevron makes regulations in healthcare (and other industries) more vulnerable to legal challenges
The U.S. Supreme Court issued a decision Friday that has dramatic implications for the regulatory infrastructure in healthcare, among many other industries. Since it was established in a 1984 case, Chevron deference has served as guidance to courts that regulatory authorities such as CMS and dozens of others across the federal government have license to…
Preventive-services coverage mandate for Affordable Care Act plans remains intact following appeals court ruling
In a decision that could have been consequential for health insurance coverage offered through the Affordable Care Act (ACA) marketplaces, an appeals court limited the immediate impact. The U.S. Court of Appeals for the Fifth Circuit upheld a lower-court ruling that preventive-care mandates for ACA health plans are unconstitutional. But the appeals court said the…
Hospitals can bring their case on disproportionate share hospital payments to the Supreme Court
The Supreme Court granted hospitals’ request that it hear their appeal about the formula for determining Medicare disproportionate share hospital (DSH) payments, landing the case on the docket for the 2024-25 term. More than 200 hospitals are plaintiffs in the case. A federal district court ruled for HHS and against the hospitals in 2022, and…
340B providers are at a disadvantage after the latest court ruling on contract pharmacies
A decision issued by an appeals court represents the latest setback for 340B providers hoping to secure widespread access to price discounts on Medicare Part B drugs. The U.S. Court of Appeals for the District of Columbia Circuit on May 21 upheld a district-court ruling that drug manufacturers can impose restrictions on the 340B discounts…
A new 340B dispute resolution process could create more opportunities for providers
Regulatory updates to the administrative dispute resolution (ADR) process in the 340B Drug Pricing Program seem likely to expedite the filing of claims over manufacturers’ refusal to offer discounts on drugs distributed at contract pharmacies. HHS and the Health Resources and Services Administration (HRSA), which administers the 340B program, published a final rule that modifies…