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 US 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 Takeda Pharmaceutical Company Limited is a Japanese multinational pharmaceutical company. It is the third largest pharmaceutical company in Asia, behind Sinopharm and Shanghai Pharmaceuticals, and one of the top 20 largest pharmaceutical companies in the world by revenue. The company has over 49,578 employees worldwide and achieved US$19.299 billion in revenue during the 2018 fiscal year. The company is focused on oncology, rare diseases, neuroscience, gastroenterology, plasma-derived therapies and vaccines. Its headquarters is located in Chuo-ku, Osaka, and it has an office in Nihonbashi, Chuo, Tokyo. In January 2012, Fortune Magazine ranked the Takeda Oncology Company as one of the 100 best companies to work for in the United States. As of 2015, Christophe Weber was appointed as the CEO and president of Takeda.
The Employee Retirement Income Security Act of 1974 (ERISA) is a U.S. federal 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:
United States labor law sets the rights and duties for employees, labor unions, and employers in the US. Labor law's basic aim is to remedy the "inequality of bargaining power" between employees and employers, especially employers "organized in the corporate or other forms of ownership association". Over the 20th century, federal law created minimum social and economic rights, and encouraged state laws to go beyond the minimum to favor employees. The Fair Labor Standards Act of 1938 requires a federal minimum wage, currently $7.25 but higher in 29 states and D.C., and discourages working weeks over 40 hours through time-and-a-half overtime pay. There are no federal laws, and few state laws, requiring paid holidays or paid family leave. The Family and Medical Leave Act of 1993 creates a limited right to 12 weeks of unpaid leave in larger employers. There is no automatic right to an occupational pension beyond federally guaranteed Social Security, but the Employee Retirement Income Security Act of 1974 requires standards of prudent management and good governance if employers agree to provide pensions, health plans or other benefits. The Occupational Safety and Health Act of 1970 requires employees have a safe system of work.
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.
An independent medical review (IMR) is the process where physicians review medical cases in order to provide claims determinations for health insurance payers, workers compensation insurance payers or disability insurance payers. Peer review also is used in order to define the review of sentinel events in a hospital environment for quality management purposes such as to look at bad outcomes and determine whether there was any mis-diagnosis, mistreatment or any systemic problems involved which led to the sentinel event.
Utilization management (UM) or utilization review is the use of managed care techniques such as prior authorization that allow payers, particularly health insurance companies, to manage the cost of health care benefits by assessing its medical appropriateness before it is provided, by using evidence-based criteria or guidelines.
IQVIA, formerly Quintiles and IMS Health, Inc., is an American Fortune 500 and S&P 500 multinational company serving the combined industries of health information technology and clinical research. IQVIA is a provider of biopharmaceutical development, professional consulting and commercial outsourcing services, focused primarily on Phase I-IV clinical trials and associated laboratory and analytical services, including investment strategy and management consulting services. It has a network of more than 88,000 employees in more than 100 countries and a market capitalization of US$49 billion as of August 2021. As of 2023, IQVIA was reported to be one of the world's largest contract research organizations (CRO).
Mertens v. Hewitt Associates, 508 U.S. 248 (1993), is the second in the trilogy of United States Supreme Court ERISA preemption cases that effectively denies any remedy for employees who are harmed by medical malpractice or other bad acts of their health plan if they receive their health care from their employer.
The Employee Benefits Security Administration (EBSA) is an agency of the United States Department of Labor responsible for administering, regulating and enforcing the provisions of Title I of the Employee Retirement Income Security Act of 1974 (ERISA). At the time of its name change in February 2003, EBSA was known as the Pension and Welfare Benefits Administration (PWBA). Prior to January 1986, PWBA was known as the Pension and Welfare Benefits Program. Originally the Program was established as an Office within the Labor Management Services Administration reporting the then Assistant Secretary Paul Fasser and his successors from 1974 through 1986.
In the United States, a pharmacy benefit manager (PBM) is a third-party administrator of prescription drug programs for commercial health plans, self-insured employer plans, Medicare Part D plans, the Federal Employees Health Benefits Program, and state government employee plans. PBMs operate inside of integrated healthcare systems, as part of retail pharmacies, and as part of insurance companies.
Self-funded health care, also known as Administrative Services Only (ASO), is a self insurance arrangement in the United States whereby an employer provides health or disability benefits to employees using the company's own funds. This is different from fully insured plans where the employer contracts an insurance company to cover the employees and dependents.
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.
Leslie Carol Rutledge is an American attorney and politician who has served as the 21st lieutenant governor of Arkansas since 2023. A member of the Republican Party, she was previously the 56th attorney general of Arkansas from 2015 to 2023.
Montanile v. Board of Trustees of the National Elevator Industry Health Benefit Plan, 577 U.S. ___ (2016), was a case in which the Supreme Court of the United States clarified subrogation procedures under the Employee Retirement Income Security Act ("ERISA"). The Court held that healthcare plan fiduciaries cannot demand reimbursement for medical benefits from a plan member's general assets if the beneficiary's general assets cannot be traced back to the original payment from the fiduciary. Although some scholars suggested that the court's ruling would have little impact, others suggested the case places "significant restrictions" on the rights of ERISA benefit plan providers.
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.
Fifth Third Bancorp v. Dudenhoeffer, 573 U.S. 409 (2014), was a United States Supreme Court case in which the court found Employee stockownership (ESOP) fiduciaries have the same prudential duties as non-ESOP fiduciaries, as set by ERISA, except that they are not required to diversify their investments beyond shares of the employer's stock.
American Legion v. American Humanist Association, 588 U.S. 19 (2019), was a United States Supreme Court case dealing with the separation of church and state related to maintaining the Peace Cross, a World War I memorial shaped after a Latin cross, on government-owned land, though initially built in 1925 with private funds on private lands. The case was a consolidation of two petitions to the court, that of The American Legion who built the cross, and of the Maryland-National Capital Park and Planning Commission who own the land and maintain the memorial. Both petitions challenged the Fourth Circuit's ruling that, regardless of the secular purpose the cross was built for in honoring the deceased soldiers, the cross emboldened a religious symbol, and had ordered it altered or razed. The Supreme Court reversed the Fourth Circuit's ruling in a 7–2 decision, determining that since the Cross had stood for decades without controversy, it did not violate the Establishment Clause and could remain standing.
The Supreme Court of the United States handed down fourteen per curiam opinions during its 2020 term, which began October 5, 2020 and concluded October 3, 2021.
