Insurance Coverage and Medical Care

Indiana has received federal approval of a first-of-its-kind program that helps individuals transition from Medicaid to employer-based health coverage or a plan in the individual marketplace. The new “workforce bridge” builds on the Healthy Indiana Plan (HIP), which is used by the state to expand Medicaid to cover low-income adults.

Each HIP participant has $2,500 placed in an account each year to use for health care expenses. But what happens when someone no longer qualifies for HIP, due to a new job or other factors that cause his or her income to rise above eligibility thresholds?

Previously, participants lost the ability to use any funds in their state-funded account. However, with implementation of the HIP Workforce Bridge, members leaving the Healthy Indiana Plan can continue to use up to $1,000 from their account for up to 12 months in order to pay premiums, deductibles, co-payments and co-insurance during their transition to other types of coverage.

Amy Howe at SCOTUSblog aptly describes Maine Community Health Options v. United States as “relatively low-profile but super-high dollar!” In this case the Supreme Court held 8-1 that health insurance plans can sue the federal government to recover unpaid Risk Corridors payments under the Affordable Care Act (ACA).

The Risk Corridors program was designed to...

Screening mammograms are used to check for breast cancer in women who have not yet shown any signs or symptoms of the disease. Diagnostic mammograms, on the other hand, are used when additional images are needed after the screening mammogram discovers possible indicators of breast cancer.

These indicators include lumps and dense breast tissue; the latter is an important indicator because women with extremely dense breasts are four to six times more likely to develop cancer than women with fatty breasts, according to Densebreast-info, Inc., an online educational resource. Additionally, it is often hard to detect cancer via routine screening mammograms in higher-density breasts, thus necessitating further tests.

Beyond more in-depth X-ray diagnostic mammograms, other detection tests include ultrasounds (sonograms) and magnetic resonance imaging (MRIs). Since 2010, under the Affordable Care Act, insurance providers must cover screening mammograms once a year for women ages 40 to 74 with average risk for breast cancer, and once every two years for all other women. However, insurance providers are not required to cover diagnostic tests under federal law.

Today the Supreme Court heard oral argument in its first abortion case since Justice Kennedy left the bench and was replaced by Justice Kavanaugh. The outcome of this case is likely to come down to Chief Justice Roberts and Justice Kavanaugh.  

In June Medical Services v. Russo the Supreme Court will decide whether Louisiana’s law requiring physicians performing abortions to have admitting privileges at a local hospital is...

In Texas v. California and California v. Texas the Supreme Court will decide whether the Affordable Care Act’s (ACA) individual mandate is unconstitutional. More importantly, if the Court holds that it is, it will decide whether the individual mandate is severable from the ACA. It is possible the Court will conclude it isn’t and that the entire law is...

Trump v. Pennsylvania and Little Sister of the Poor Saints Peter and Paul Home v. Pennsylvania are complicated cases. The most prominent legal issue in them is whether the Trump administration has the statutory authority to expand the Affordable Care Act (ACA) contraceptive mandate’s conscience exemption....

In Rutledge v. Pharmaceutical Care Management Association the Supreme Court will decide whether states’ attempts to regulate pharmacy benefit managers’ (PBMs) drug-reimbursement rates are preempted by the Employee Retirement Income Security Act (ERISA).

PBMs are an intermediary between health plans and pharmacies. Among other things, they set reimbursement rates to pharmacies dispensing generic drugs. Contracts between PBMs and pharmacies create pharmacy networks. According to the Eighth Circuit, “[b]ased upon these contracts and in order to participate in a preferred network, some pharmacies choose to accept lower reimbursements for dispensed prescriptions.” So, in some instance pharmacies lose money.

Arkansas passed a law requiring that pharmacies “be reimbursed for generic drugs at a price equal to or higher than the pharmacies’ cost for the drug based on the invoice from the wholesaler.”

In a long-awaited decision in Texas v. Azar the Fifth Circuit held that the Affordable Care Act’s (ACA) individual mandate is unconstitutional. This decision has no practical effect because no one is currently required to pay the shared-responsibility payment. A year ago, a federal district court held the individual mandate is inseverable from the ACA rendering the entire law unconstitutional. The Fifth Circuit sent the case back to the lower court...