A federal trial court docket has determined the newest installment of a case during which a big dialysis supplier sued a bunch well being plan and its TPA for classifying all dialysis suppliers as “out-of-network,” leading to a decrease reimbursement fee for them than for suppliers of different medical companies. The case lately made its strategy to the U.S. Supreme Courtroom, which dominated {that a} group well being plan doesn’t violate the Medicare Secondary Payer (MSP) guidelines by limiting protection for outpatient dialysis, regardless that the therapy is used virtually solely for sufferers with end-stage renal illness (ESRD) (see our Checkpoint article). The case was despatched again to the trial court docket for additional proceedings.

The trial court docket has now dismissed the supplier’s declare that the out-of-network categorization violated the MSP guidelines, citing the Supreme Courtroom’s conclusion that the plan’s phrases didn’t “differentiate in the advantages it offers to people with [ESRD] or consider whether or not a person is entitled to or eligible for Medicare.” Nonetheless, the court docket has allowed two separate claims to proceed to trial. First, the supplier alleged that the plan discriminates towards contributors with ESRD—in violation of HIPAA’s well being standing nondiscrimination guidelines—by eliminating community protection for dialysis and exposing the contributors to larger prices. The court docket has allowed that declare to proceed, stating that the Supreme Courtroom’s MSP ruling doesn’t foreclose a declare primarily based on an unrelated anti-discrimination statute. The court docket additionally declined to dismiss the supplier’s declare for advantages beneath ERISA § 502, to the extent it was primarily based on the plan’s alleged HIPAA violation and corresponding ERISA breach.

EBIA Remark: Though the Supreme Courtroom could have given the inexperienced gentle for plans to scale back protection for outpatient dialysis with out worry of violating the MSP guidelines, plan sponsors and directors needs to be conscious that dialysis suppliers could produce other authorized avenues, together with HIPAA and ERISA, by which to problem such limitations. It is going to be fascinating to comply with this case because it strikes towards decision. For extra info, see EBIA’s HIPAA Portability, Privateness & Safety handbook at Part XI.C (“Well being Standing and Genetic Data Nondiscrimination Guidelines: Nondiscrimination Guidelines for Eligibility and Advantages”), EBIA’s Group Well being Plan Mandates handbook at Part XXIV.H (“MSP Necessities: ESRD-Based mostly Medicare Eligibility or Entitlement”), and EBIA’s ERISA Compliance handbook at Part XXXVI (“ERISA Litigation”).

Contributing Editors: EBIA Workers.