Justia Public Benefits Opinion Summaries

by
Plaintiff Family Health Centers of San Diego operated a federally qualified health center (FQHC) that provided various medical services to its patients, some of whom are Medi-Cal beneficiaries. Section 330 of the Public Health Service Act authorized grants to be made to FQHC’s. In addition, FQHC’s could seek reimbursement under Medi-Cal for certain expenses, including reasonable costs directly or indirectly related to patient care. Plaintiff appealed a trial court’s order denying its petition for writ of mandate seeking to compel the State Department of Health Care Services (DHCS) to reimburse plaintiff for money it expended for outreach services. The Court of Appeal rejected plaintiff’s contention that the trial court and the DHCS improperly construed and applied applicable guidelines in the Centers for Medicare & Medicaid Services Publication 15-1, The Provider Reimbursement Manual (PRM). The Court concluded that the monies spent by plaintiff were not an allowable cost because they were akin to advertising to increase patient utilization of plaintiff’s services. View "Family Health Centers of S.D. v. State Dept. of Health Care Services" on Justia Law

by
The 2017 Veterans Appeals Improvement and Modernization Act (AMA) reforms the VA's administrative appeals system, 131 Stat. 1105, replacing the existing system, which had shepherded all denials of veteran disability claims through a one-size-fits-all appeals process. Under the AMA, claimants may choose between three procedural options: filing a supplemental claim based on additional evidence, requesting higher-level review within the VA based on the same evidentiary record, and filing a notice of disagreement to directly appeal to the Board of Veterans Appeals. The VA promulgated regulations to implement the AMA. Veterans’ service organizations, a law firm, and an individual (Petitioners) filed separate petitions raising 13 rulemaking challenges to these regulations under 38 U.S.C. 502.1The Federal Circuit concluded that two veterans’ service organizations had associational standing based on claimed injuries to their members to collectively bring three of their challenges. No Petitioner demonstrated standing to raise any of the remaining challenges. The regulations the organizations have standing to challenge are invalid for contravening the unambiguous meaning of their governing statutory provisions: 38 C.F.R. 14.636(c)(1)(i), limiting when a veteran’s representative may charge fees for work on supplemental claims; 38 C.F.R. 3.2500(b) barring the filing of a supplemental claim when adjudication of that claim is pending before a federal court; and 38 C.F.R. 3.155 excluding supplemental claims from the intent-to-file framework. View "Military-Veterans Advocacy v. Secretary of Veterans Affairs" on Justia Law

by
Ortiz served during the Vietnam era, a “period of war,” under 38 U.S.C. 1110, which provides for compensation for service-connected disabilities. The VA denied Ortiz’s 1997 claim for disability benefits based on PTSD, finding Ortiz did not provide corroborating evidence, as required by the PTSD regulation. The VA reopened and granted the claim in 2012, pursuant to the 2010 addition of 38 C.F.R. 3.304(f)(3), an exception to the corroborating evidence requirement. The VA rated Ortiz 100 percent disabled and made the benefits effective as of May 2012, when it received the request to reopen. Ortiz contended that the effective date should have been one year earlier; 38 C.F.R. 3.114(a), provides that when compensation “is awarded or increased pursuant to a liberalizing law, or a liberalizing VA issue approved by the Secretary” and the “claim [for compensation] is reviewed at the request of the claimant more than 1 year after the effective date of the law or VA issue,” the effective date is “1 year prior to the date of receipt of such request.”The Board of Veterans’ Appeals and the Veterans Court rejected his request for an earlier effective date. The Federal Circuit reversed. The regulatory change that enabled Ortiz to obtain the benefits was a “liberalizing” one, entitling Ortiz to the earlier effective date, and a larger award. View "Ortiz v. McDonough" on Justia Law

by
The Supreme Judicial Court affirmed the judgment of the superior court reversing the determination of the Massachusetts Office of Medicaid's board of hearings that Plaintiff's home was a countable asset, making her ineligible for Medicaid long-term care benefits, holding that the superior court did not err.While they were both still living, Plaintiff and her husband created an irrevocable trust, the corpus of which included their home. The terms of the trust granted Plaintiff, during her lifetime, a limited power of appointment to appoint all or any portion of the trust principal to a nonprofit or charitable organization over which she had no controlling interest. MassHealth denied Plaintiff's application for long-term care benefits, determining that the home was a countable asset because Plaintiff purportedly could use her limited power of appointment to appoint portions of the home's equity, which was included as part of the trust principal, to the nursing home where Plaintiff lived as payment for her care. The superior court reversed. The Supreme Judicial Court reversed, holding that the plain terms of the trust neither intended for nor permitted Plaintiff to exercise her limited power of appointment for her benefit, as contemplated by MassHealth. View "Fournier v. Secretary of Executive Office of Health & Human Services" on Justia Law

by
Saunders worked as a bus attendant for the Washington, D.C., school system, helping students with special needs and those in wheelchairs on and off the bus. On January 7, 2014, she slipped and fell on ice at work, suffering a hip contusion and back pain. Saunders never returned to work but filed a disability claim with the Social Security Administration six months after her fall. She obtained multiple opinions from Dr. Williams, her generalist, and Dr. Liberman, her neurologist. Saunders received disability benefits from the Washington, D.C., workers’ compensation board.After Saunders’s federal disability claims were denied an ALJ held a hearing and concluded that she was not disabled. The ALJ gave “some” weight to certain medical opinions but “no weight” to others, including Dr. Lieberman’s opinion that Saunders was permanently disabled. The ALJ placed considerable weight on the vocational expert’s testimony and found that someone with Saunders’s functional capacity could perform her past work as generally performed in the national economy. The district court affirmed. The D.C. Circuit remanded. The ALJ erroneously failed to consider certain medical opinions, particularly those of Saunders’s treating physician. View "Saunders v. Kijakazi" on Justia Law

by
The Supreme Court affirmed in part and vacated in part the judgment of the circuit court rejecting Plaintiffs' claims challenging the refusal by the Department of Social Services (DSS) to provide MO HealthNet coverage, holding that the circuit court erred in declaring Mo. Const. art. IV, 36(c) constitutionally invalid.Plaintiffs, three Missourians eligible for MO HealthNet coverage under article IV, section 36(c), brought this action challenging the DSS's refusal to provide coverage on the grounds that the General Assembly failed to appropriate adequate funding. The circuit court rejected the claims, finding that the ballot initiative that enacted article IV, section 36(c) violated Mo. Const. art. III, 51, which prohibits initiatives from appropriating money without creating revenue to fund the initiative. The Supreme Court affirmed in part and vacated in part the circuit court's judgment, holding (1) article IV, section 36(c) does not appropriate money and does not remove the General Assembly's discretion in appropriating money to MO HealthNet; and (2) therefore, the circuit court erred in concluding that article IV, section 36(c) violates article III, section 51. View "Doyle v. Tidball" on Justia Law

by
Disabled children are entitled to benefits from the Social Security Administration, 42 U.S.C. 1382c(a)(3)(C). While benefits for an adult depend on a work history plus current inability to perform a job, administrative officials ask whether the child’s limitations meet one of the many listed categories of disability or are functionally equivalent to one of them. When determining whether a child’s impairment is functionally equivalent to a listing, the issue is whether it produces a marked limitation in at least two—or an extreme limitation in one—of six “domains of functioning.”McCavic argued that his son, N., is disabled by attention deficit hyperactivity disorder, intellectual limitations (an IQ near 70), oppositional defiant disorder, and nocturnal enuresis. He claimed that these conditions meet, or are functionally equivalent to certain listings. An ALJ found that N. did not meet any of the listings and has a marked limitation in only one functional category, “acquiring and using information.” A district judge affirmed. The ALJ was entitled to credit the views of a special-education teacher, who knew N well and had a good grasp of gradations among children with intellectual shortcomings. While N. may have met the standards of the old version of the regulations, but not the new one, the change applies “to claims that are pending on or after the effective date.” View "McCavitt v. Kijakazi" on Justia Law

by
The Ninth Circuit reversed the district court's grant of summary judgment in favor of Agendia in an action alleging that the HHS wrongfully denied its claims for reimbursement for diagnostic tests under the Medicare health insurance program. Agendia contends that the denial was improper because the local coverage determination was issued without notice and opportunity for comment in violation of a provision of the Medicare Act—specifically, 42 U.S.C. 1395hh.The panel held that section 1395hh's notice-and-comment requirement does not apply to local coverage determinations, and that the district court erred in interpreting the statute otherwise. The panel rejected Agendia's alternative argument that the Medicare Act and its implementing regulations have unconstitutionally delegated regulatory authority to Medicare contractors by permitting them to issue local coverage determinations. The panel held that, because those contractors act subordinately to the HHS officials implementing Medicare, there is no unconstitutional delegation. View "Agendia, Inc. v. Becerra" on Justia Law

by
Tadlock served in the Army, 1982-2003, including service in the Persian Gulf. In 2010, he suffered a pulmonary embolism (PE) that resulted in a heart attack. Tadlock sought presumptive service connection under 38 U.S.C. 1117, which refers to a “qualifying chronic disability” for veterans who served in the Persian Gulf War. The regulations limit the definition of “qualifying chronic disability” to one that, “[b]y history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis.” Tadlock underwent a final medical examination by a VA physician, who explained that Tadlock’s PE “is not an undiagnosed illness.” The Board of Veterans Appeals based its denial of service connection on that opinion.Neither the Board nor the examiner made any finding that Tadlock’s condition was not a “medically unexplained chronic multisymptom illness” (MUCMI). Tadlock contended that the statute expressly includes both “an undiagnosed illness” and a MUCMI. The Veterans Court found that Tadlock's PE was "not characterized by overlapping signs and symptoms and unique features ... and disproportional disability when compared with physical findings.” It held that "any error in the Board decision regarding whether his diagnosed illness could count as a MUCMI is harmless.”The Federal Circuit vacated. The Veterans Court exceeded its authority in making a fact-finding in the first instance that Tadlock’s illness did not qualify as a MUCMI because of a lack of overlapping symptoms. The Veterans Court’s jurisdiction to consider prejudicial error does not give it the right to make de novo findings of fact or otherwise resolve matters that are open to debate. View "Tadlock v. McDonough" on Justia Law

by
The Ninth Circuit affirmed the district court's preliminary injunction ordering E.E.'s current educational placement as his "stay put" placement during the pendency of judicial proceedings in a suit brought under the Individuals with Disabilities Education Act (IDEA).The panel concluded that the ALJ acted without legal authority in determining that E.E.'s potential future placement in the 2020 individualized education plan (IEP) constituted his current placement for purposes of E.E.'s stay put placement. Therefore, because the ALJ acted ultra vires, her stay put determination was void. Consequently, the parents' stay put motion did not seek to modify an existing stay put order, so the district court correctly entered an automatic preliminary injunction pursuant to Joshua A. v. Rocklin Unified Sch. Dist., 559 F.3d 1036, 1037 (9th Cir. 2009). Furthermore, the school district's proposed exception to the stay put provision is not supported by either the text of the IDEA or any other legal authority, and the panel declined to adopt it. View "E.E. v. Norris School District" on Justia Law