Elevance Health<\/a> is facing a class-action lawsuit in Maine for allegedly discriminating against individuals with obesity by excluding prescription medications for obesity treatment in its health plans. The lawsuit argues that this exclusion violates the Affordable Care Act\u2019s (ACA) prohibition against discrimination based on disability. Medications like semaglutide and tirzepatide, typically covered for other conditions, are excluded when prescribed for obesity.<\/p>\r\n\r\n\r\n\r\nImpact on Obesity Treatment<\/h3>\r\n\r\n\r\n\r\n
The lawsuit highlights a broader issue of access to obesity medications, which have gained popularity for their effectiveness. Anti-obesity treatments are crucial for individuals suffering from obesity-related conditions, and the exclusion of these medications from health plans raises questions about healthcare equity and discrimination.<\/p>\r\n\r\n\r\n\r\n
Minnesota Health Systems vs. Humana and UnitedHealthcare<\/h2>\r\n\r\n\r\n\r\nEssentia Health and Sanford Health’s Stand<\/h3>\r\n\r\n\r\n\r\n
In Minnesota, Essentia Health announced that it would no longer accept Medicare Advantage plans from UnitedHealthcare and Humana starting in January. The health system cited delays caused by prior authorization processes as a key reason for this decision. Sanford Health, another Minnesota-based system, followed suit, announcing it would drop Humana\u2019s Medicare Advantage plans by year-end. These decisions could have significant implications for Medicare Advantage beneficiaries, who may need to find new providers or insurance options.<\/p>\r\n\r\n\r\n\r\n
LMH Health and Medicare Advantage Plans<\/h3>\r\n\r\n\r\n\r\n
Kansas-based LMH Health joined the trend by cutting ties with Humana and Aetna\u2019s Medicare Advantage plans, also due to issues related to prior authorization delays. This growing rift between health systems and Medicare Advantage insurers highlights ongoing frustrations within the healthcare industry regarding administrative burdens and delays in patient care.<\/p>\r\n\r\n\r\n\r\n
Legislation Updates Across the U.S.<\/h2>\r\n\r\n\r\n\r\nAlaska\u2019s PBM Bill<\/h3>\r\n\r\n\r\n\r\n
Alaska recently signed a bill into law that requires pharmacy benefit managers to pass on negotiated discounts to the state and disclose conflicts of interest. This bill is aimed at combating the monopolistic practices of PBMs that have driven independent pharmacies out of business and contributed to rising prescription drug costs.<\/p>\r\n\r\n\r\n\r\n
Competing IVF Bills in the Senate<\/h3>\r\n\r\n\r\n\r\n
Two competing bills regarding in vitro fertilization (IVF) failed to advance in the Senate. The Democratic-backed bill sought to protect access to IVF while Republican lawmakers pushed for a version they claimed would provide better protections. Both bills failed to garner the necessary votes, leaving IVF access rights unresolved for the time being.<\/p>\r\n\r\n\r\n\r\n
No Surprises Act Amendments<\/h3>\r\n\r\n\r\n\r\n
A new bill has been introduced in Congress to amend the No Surprises Act, with the aim of closing loopholes and enhancing protections for patients against surprise medical bills. The proposed legislation seeks to increase penalties for health plans that violate balance billing requirements and improve enforcement mechanisms.<\/p>\r\n\r\n\r\n\r\n
Legal Actions and Industry Developments<\/h2>\r\n\r\n\r\n\r\nKentucky\u2019s Lawsuit Against Express Scripts<\/h3>\r\n\r\n\r\n\r\n
Kentucky has filed a lawsuit against Express Scripts, accusing the PBM of being complicit in the opioid crisis by allegedly colluding with manufacturers to increase opioid sales. The lawsuit mirrors a similar case filed in Arkansas, where state officials claim that PBMs played a role in exacerbating the opioid epidemic.<\/p>\r\n\r\n\r\n\r\n
Blue Cross Blue Shield of Louisiana’s $421M Fraud Case<\/h3>\r\n\r\n\r\n\r\n
A jury has ordered Blue Cross Blue Shield of Louisiana to pay $421 million in damages after finding that the insurer committed fraud by only paying a fraction of the costs for breast reconstruction surgeries over the past seven years. The ruling is one of the largest penalties ever imposed on a health insurer for fraudulent billing practices.<\/p>\r\n\r\n\r\n\r\n
Aetna\u2019s Class Action Lawsuit Over Gender-Affirming Care<\/h3>\r\n\r\n\r\n\r\n
Aetna is facing a class-action lawsuit for allegedly denying coverage for gender-affirming facial reconstructive surgeries. The lawsuit argues that Aetna\u2019s refusal to cover these surgeries, while providing coverage for other facial reconstructive procedures, constitutes discrimination based on gender identity.<\/p>\r\n\r\n\r\n\r\n
Conclusion<\/h2>\r\n\r\n\r\n\r\n
The healthcare landscape continues to be shaped by significant legislative, legal, and industry developments. From Governor Newsom\u2019s vetoes of key healthcare bills in California to lawsuits against major insurers like Elevance Health and Aetna, the payer and provider landscape is constantly evolving. These developments not only affect the way healthcare is administered but also highlight the ongoing challenges surrounding access, affordability, and equity in healthcare.<\/p>\r\n\r\n\r\n\r\n
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