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Mitigating the Incidence and Severity of Injuries and Other Harms

York v. Wellmark in d/b/a Wellmark Blue Cross and Blue Shield of Iowa

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Overview

York v. Wellmark in d/b/a Wellmark Blue Cross and Blue Shield of Iowa (U.S. Court of Appeals, Eighth Circuit, July 13, 2020): The court affirmed the dismissal of a lawsuit brought by women denied reimbursement for out-of-network providers of lactation services. The Affordable Care Act (ACA) requires no cost-sharing for preventative health services, including comprehensive lactation and support for counseling lactation services (CLS). The women brought breach of contract claims under Iowa law and breach of fiduciary duty claims under the Employee Retirement Income Security Act (“ERISA”). They alleged that Wellmark (1) violated ACA’s cost-sharing and “information and disclosure” requirements; and (2) failed to provide a list of in-network CLS providers which amounted to a failure to provide “coverage.” The court disagreed. Neither the ACA mandate nor its implementing regulation requires insurers to offer a list of providers. Requiring such a list would prescribe substantive disclosure requirements under the ACA and its regulations without proper rulemaking procedures. “‘[C]overage’ under the ACA,” noted the court, “refers to the type or amount of benefits or services covered under a plan, not the hassle associated with utilizing those services.” Read the full opinion here.

View all cases in the Judicial Trends in Public Health – August 11, 2020.

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