965 F.3d 633
8th Cir.2020Background
- The ACA requires group health plans and issuers to cover certain preventive services without cost sharing, including comprehensive lactation support and counseling (CLS).
- Jillian York (UIChoice governmental plan) received in-network CLS at University of Iowa Hospitals & Clinics (UIHC), later paid $65 to an out-of-network lactation consultant (Pitkin); Wellmark denied reimbursement as Pitkin was not an in-network provider.
- Jody Bailey (Wellmark Alliance Select ERISA plan) received some in-network CLS at UIHC, later paid $115 to an out-of-network consultant (Hendricks); she did not file for reimbursement in time and Wellmark’s directory did not list lactation consultants.
- Plaintiffs sued alleging (a) violations of the ACA cost-sharing mandate and (b) failures to provide required information/disclosures (e.g., a separate list of in-network lactation providers); York asserted breach of contract (state law), Bailey asserted ERISA fiduciary/benefit-denial claims.
- The district court dismissed the information/disclosure claims and granted summary judgment to Wellmark on the cost-sharing claims, finding in-network providers capable of providing CLS were available and the ACA does not impose the alleged disclosure duties.
- The Eighth Circuit affirmed: no private ACA disclosure duty requiring a separate provider list, ERISA disclosure regulations did not impose the claimed categorical duty, and the regulation permits denying out-of-network claims if an in-network provider can provide the service.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether the ACA (or its regs) requires plans to publish a separate list of in-network lactation counseling providers or prohibits alleged "administrative barriers" to finding providers | ACA requires disclosure/availability of in-network CLS (separate list); failure to provide list or consistent information violates mandate | ACA requires coverage and no cost-sharing but does not impose separate disclosure or provider-listing obligations | Dismissal affirmed: ACA text/regulations do not create a private right to require a separate in-network CLS list; alleged "administrative barriers" do not state an ACA claim |
| Whether a plan must recognize/credential lactation consultants as a distinct in-network provider type before it may impose cost-sharing or deny out-of-network CLS claims | Wellmark must expand networks or separately credential lactation consultants so insureds have in-network access | Regulation permits denying out-of-network coverage if plan already has an in-network provider who can provide the service; no requirement to create a separate lactation-consultant network | Summary judgment affirmed for Wellmark: undisputed record showed in-network providers (IBCLCs at UIHC) provided CLS without charge, so Wellmark could properly deny out-of-network claims |
| Whether ERISA imposes an independent fiduciary duty to publish a separate list of CLS providers | (Bailey) ERISA fiduciary duties require specific disclosures about which network providers offer CLS | ERISA disclosure regulations require accurate, comprehensive notices but do not require specifying which providers offer particular services like CLS | Dismissal affirmed: ERISA disclosure rules do not impose the categorical "separate list" duty alleged; Bailey did not plead the statutory disclosure claim that would survive her untimely filing defense |
Key Cases Cited
- Eckelkamp v. Beste, 315 F.3d 863 (8th Cir. 2002) (standard of review for district court orders on dismissal and summary judgment)
- Ashcroft v. Iqbal, 556 U.S. 662 (2009) (plausibility standard for Rule 12(b)(6) complaints)
- Bell Atlantic Corp. v. Twombly, 550 U.S. 544 (2007) (pleading requirements for plausibility)
- King v. Burwell, 135 S. Ct. 2480 (2015) (statutory text controls over generalized purposes in interpretation)
- CIGNA Corp. v. Amara, 563 U.S. 421 (2011) (ERISA fiduciary duty to provide accurate, comprehensive plan notices)
- Geddes v. United Staffing All. Emp. Med. Plan, 469 F.3d 919 (10th Cir. 2006) (definition and customary meaning of an insurer's provider network)
- Children’s Health Care v. Centers for Medicare & Medicaid Servs., 900 F.3d 1022 (8th Cir. 2018) (agency must use notice-and-comment rulemaking to impose substantive requirements beyond statute/regulation)
- Children’s Hosp. of the King’s Daughters, Inc. v. Azar, 896 F.3d 615 (4th Cir. 2018) (same principle on APA rulemaking and substantive duties)
- Great-West Life & Annuity Ins. Co. v. Knudson, 534 U.S. 204 (2002) (cannot rely on statutory purpose to override clear statutory text)