Health Reform WK-EDGE Question of fact over whether dialysis was an essential health benefit under the ACA
Monday, September 18, 2017

Question of fact over whether dialysis was an essential health benefit under the ACA

By Paige Arnold, J.D.

An insurer may be liable for reimbursement of claims for dialysis treatment in 2013 beyond the capped benefit under its plan, because the cap may not have been in compliance with the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), a federal district court in Wisconsin ruled. The court found that both parties failed to provide evidence as to whether dialysis was an essential health benefit, thus barred from any benefit limits, under the ACA, (Fresenius Medical Care et. al. v Humana Insurance Co., September 5, 2017, Duffin, W.).

Background: Patients insured by Humana Insurance Company received dialysis treatments from a dialysis provider under various health care plans. The provider administered the dialysis to patients who each suffered from end stage renal disease, a chronic kidney disease. The covered health plans included an annual limit of $30,000 per person on dialysis benefits, and the insurer reimbursed the provider according to this limit. As of September 23, 2012, the annual or lifetime limit on essential health benefits under the ACA was no less than 2 million dollars, and the limit was eliminated entirely for plan years beginning in 2014. The determination of what was an essential health benefit was determined by each state through benchmark plans. Wisconsin adopted a benchmark plan, which included coverage of dialysis as an essential health plan benefit.

The insurer continued to apply the annual limit under the plan to dialysis claims in 2013 and claimed that dialysis was not an essential health benefit. The provider filed a cause of action alleging that the annual limit on dialysis benefits violated the ACA. The parties filed cross motions for partial summary judgment.

Dialysis as an essential health benefit. The court found that both parties failed to provide sufficient evidence to determine if dialysis was an essential health benefit in 2013 under the ACA. The determination of dialysis as an essential health benefit was fundamental to the issue of whether a cap on dialysis treatment benefits was permitted under the ACA in 2013. The court rejected the insurer’s argument that dialysis was not an essential health benefit in 2013 because 12 states did not include dialysis in proposed benchmark plan. The insurer relied on the summary of states Benchmark Plan benefits listed on the CMS website as its only evidence of this fact. The court reasoned that information contained on a website was merely a summary, unsubstantiated by means or methods of compilation, and was insufficient and unreliable to support the insurer’s argument.

The court determined that the provider did not submit any information or evidence as to how an insurer in 2013 would reasonably understand the meaning or scope of the term essential health benefit. Not every item and service falls within the ten categories of essential benefits mentioned under section 10822(b)(1) of the ACA. The court further rejected the provider’s argument that dialysis was essential because a patient with chronic kidney disease could die without it. The court reasoned that the word "essential" as a health benefit was not necessarily indicative to the service provided in relation to a person’s health or wellbeing, but referred to being something necessary to a health plan.

Both parties’ motions for partial summary judgment were denied.

The case number is No. 16-CV-711.

Cases: CaseDecisions AccessNews AgencyNews EssentialBenefitNews InsurerNews ProviderPaymentNews WisconsinNews NewsFeed

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