In the United States, a health maintenance organization (HMO) is a medical insurance group that provides health services for a fixed annual fee. It is an organization that provides or arranges managed care for health insurance, self-funded health care benefit plans, individuals, and other entities, acting as a liaison with health care providers on a prepaid basis. The Health Maintenance Organization Act of 1973 required employers with 25 or more employees to offer federally certified HMO options if the employer offers traditional healthcare options. Unlike traditional indemnity insurance, an HMO covers care rendered by those doctors and other professionals who have agreed by contract to treat patients in accordance with the HMO's guidelines and restrictions in exchange for a steady stream of customers. HMOs cover emergency care regardless of the health care provider's contracted status.
The Commerce Clause describes an enumerated power listed in the United States Constitution. The clause states that the United States Congress shall have power "To regulate Commerce with foreign Nations, and among the several States, and with the Indian Tribes." Courts and commentators have tended to discuss each of these three areas of commerce as a separate power granted to Congress. It is common to see the individual components of the Commerce Clause referred to under specific terms: the Foreign Commerce Clause, the Interstate Commerce Clause, and the Indian Commerce Clause.
The Employee Retirement Income Security Act of 1974 (ERISA) is a federal United States tax and labor law that establishes minimum standards for pension plans in private industry. It contains rules on the federal income tax effects of transactions associated with employee benefit plans. ERISA was enacted to protect the interests of employee benefit plan participants and their beneficiaries by:
Chevron U.S.A., Inc. v. Natural Resources Defense Council, Inc., 467 U.S. 837 (1984), was a landmark case in which the United States Supreme Court set forth the legal test for determining whether to grant deference to a government agency's interpretation of a statute which it administers. Chevron is the Court's clearest articulation of the doctrine of "administrative deference", to the point that the Court itself has used the phrase "Chevron deference" in more recent cases. The fundamental test applied by the court, when appropriate, is deferential: "whether the agency's answer is based on a permissible construction [emphasis added] of the statute", so long as Congress has not spoken directly to the precise issue at question.
The McCarran–Ferguson Act, 15 U.S.C. §§ 1011-1015, is a United States federal law that exempts the business of insurance from most federal regulation, including federal antitrust laws to a limited extent. The McCarran–Ferguson Act was passed by the 79th Congress in 1945 after the Supreme Court ruled in United States v. South-Eastern Underwriters Association that the federal government could regulate insurance companies under the authority of the Commerce Clause in the U.S. Constitution and that the federal antitrust laws applied to the insurance industry.
National League of Cities v. Usery, 426 U.S. 833 (1976), was a case in which the Supreme Court of the United States held that the Fair Labor Standards Act could not constitutionally be applied to state governments. The decision was overruled by the U.S. Supreme Court in Garcia v. San Antonio Metropolitan Transit Authority.
Egelhoff v. Egelhoff, 532 U.S. 141 (2001), is a major decision of the Supreme Court of the United States on federalism, specifically with regards to the preemption powers of federal law over state laws. It sets the precedent that any state statutes having a "connection with" ERISA plans are superseded by ERISA, or any future substantially similar law that takes its place. In essence, this decision is a reaffirmation of the right and ability of the federal government to, at least in some instances, pre-empt state laws.
Gonzaga University v. Doe, 536 U.S. 273 (2002), was a case in which the Supreme Court of the United States ruled that the Family Educational Rights and Privacy Act of 1974, which prohibits the federal government from funding educational institutions that release education records to unauthorized persons, does not create a right which is enforceable under 42 U.S.C. § 1983.
Paul v. Virginia, 75 U.S. 168 (1869), is a U.S. corporate law case, of the United States Supreme Court. It held that a corporation is not a citizen within the meaning of the Privileges and Immunities Clause. Of greater consequence, the Court further held that "issuing a policy of insurance is not a transaction of commerce," effectively removing the business of insurance beyond the United States Congress's legislative reach.
Aetna Health Inc. v. Davila, 542 U.S. 200 (2004), was a United States Supreme Court case in which the Court limited the scope of the Texas Healthcare Liability Act (THCLA). The effective result of this decision was that the THCLA, which held Case Management and Utilization Review decisions by Managed Care entities like CIGNA and Aetna to a legal duty of care according to the laws of The State of Texas could not be enforced in the case of Health Benefit plans provided through private employers, because the Texas statute allowed compensatory or punitive damages to redress losses or deter future transgressions, which were not available under ERISA § 1132. The ruling still allows the State of Texas to enforce the THCLA in the case of Government-sponsored (Medicare, Medicaid, Federal, State, Municipal Employee, etc., Church-sponsored, or Individual Health Plan Policies, which are saved from preemption by ERISA. The history that allows these Private and Self-Pay Insurance to be saved dates to the "Interstate Commerce" power that was given the federal Government by the Supreme Court. ERISA, enacted in 1974, relied on the "Interstate Commerce" rule to allow federal jurisdiction over private employers, based on the need of private employers to follow a single set of paperwork and rules for pensions and other employee benefit plans where employers had employees in multiple states. Except for private employer plans, insurance can be regulated by the individual states, and Managed Care entities making medical decisions can be held accountable for those decisions if negligence is involved, as allowed by the Texas Healthcare Liability Act.
Brown v. Hotel and Restaurant Employees, 468 U.S. 491 (1984), is a 4-to-3 ruling by the United States Supreme Court which held that a New Jersey state gaming law requiring union leaders to be of good moral character was not preempted by the National Labor Relations Act (NLRA).
CIGNA v. Calad was a Supreme Court of the United States appeal and ruling, where CIGNA Healthcare, Inc. challenged a United States Court of Appeals for the Fifth Circuit ruling in favor of Mrs. Ruby Calad, who was insured under her husband's employer's self-funded medical insurance plan in the State of Texas. This was a Landmark Supreme Court Case.
To determine whether the Sherman Antitrust Act preempts a state law, courts will engage in a two-step analysis, as set forth by the Supreme Court in Rice v. Norman Williams Co..
The Supremacy Clause of the United States Constitution establishes that the Constitution, federal laws made pursuant to it, and treaties made under its authority, constitute the supreme law of the land. It provides that state courts are bound by the supreme law; in case of conflict between federal and state law, the federal law must be applied. Even state constitutions are subordinate to federal law. In essence, it is a conflict-of-laws rule specifying that certain federal acts take priority over any state acts that conflict with federal law. In this respect, the Supremacy Clause follows the lead of Article XIII of the Articles of Confederation, which provided that "Every State shall abide by the determination of the United States in Congress Assembled, on all questions which by this confederation are submitted to them." A constitutional provision announcing the supremacy of federal law, the Supremacy Clause assumes the underlying priority of federal authority, at least when that authority is expressed in the Constitution itself. No matter what the federal government or the states might wish to do, they have to stay within the boundaries of the Constitution. This makes the Supremacy Clause the cornerstone of the whole American political structure.
O'Gorman & Young, Inc. v. Hartford Fire Ins. Co., 282 U.S. 251 (1931), was a case in which the United States Supreme Court held that a state statute limiting the commissions allowable by insurers against loss by fire to local agents will be deemed a valid exercise of the police power in the absence of facts showing it to be unreasonable.
Nationwide Mutual Insurance Co. v. Darden, 503 U.S. 318 (1992), is a US labor law case, concerning the scope of protection for employees, under the Employee Retirement Income Security Act of 1974 (ERISA). The Court held that principles of agency were relevant to interpreting the concept of "employee".
Gobeille v. Liberty Mutual Insurance Company, 577 U.S. ___ (2016), was a United States Supreme Court case in which the Court held that a Vermont state law requiring the disclosure of certain information relating to health care services was preempted by the Employee Retirement Income Security Act (ERISA) to the extent that the state law applied to ERISA plans. Writing for a majority of the Court, Justice Anthony Kennedy held that the Vermont law "impose[d] duties that are inconsistent with the central design of ERISA, which is to provide a single uniform national scheme for the administration of ERISA plans without interference from laws of the several States".
Ingersoll-Rand Co. v. McClendon, 498 U.S. 133 (1990), is a US labor law case, concerning the scope of labor rights in the United States.
