Justia Public Benefits Opinion Summaries

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Kentucky and Arkansas residents sued the Secretary of Health and Human Services based on the approval under 42 U.S.C. 1315(a) of an “experimental, pilot, or demonstration projects which, in the judgment of the Secretary, is likely to assist in promoting the objectives” of Medicaid. The district court held that the Secretary failed to analyze whether the projects would promote the primary objective of Medicaid—to furnish medical assistance. Kentucky terminated its project and obtained voluntary dismissal. The D.C. Circuit affirmed with respect to the Arkansas Works program, which required beneficiaries aged 19-49 to “work or engage in specified educational, job training, or job search activities for at least 80 hours per month,” except beneficiaries who show they are medically frail or pregnant, caring for a dependent child under age six, participating in a substance treatment program, or are full-time students. Works proposed to eliminate retroactive coverage, to lower the income eligibility threshold from 133% to 100% of the federal poverty line, and eliminated using Medicaid funds to assist beneficiaries in paying the premiums for employer-provided health care coverage. Instead of analyzing whether the demonstration would promote the objective of providing coverage, the Secretary identified three alternative objectives. Congress has not conditioned the receipt of Medicaid benefits on fulfilling work requirements or taking steps to end receipt of governmental benefits View "Gresham v. Azar" on Justia Law

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Of two people injured in a car wreck in April 2012, one was a Medicare beneficiary who received her benefits from an MAO-Florida Healthcare Plus, which later assigned its claims to appellant MSPA Claims 1, LLC. The other party involved in the accident was insured by appellee Kingsway Amigo Insurance. The Medicare beneficiary obtained medical treatment for her accident-related injuries between April 29, 2012 and July 26, 2012, and Florida Healthcare made $21,965 in payments on her behalf. On March 28, 2013, the beneficiary settled a personal-injury claim with Kingsway and received a $6,667 settlement payment. The issue this case presented for the Eleventh Circuit’s review centered on the timeliness requirement with which the government had to comply as a prerequisite to filing suit to seek reimbursements that it made on behalf of the Medicare beneficiary, and whether filing suit beyond a statutory three-year period beginning on the date on which medical services were rendered was fatal to the government’s claim. The district court held that MSPA’s claim was stale because it didn’t comply with what the court (somewhat confusingly) called “the three-year limitation requirement.” The Eleventh Circuit disagreed and reversed. “The Medicare Secondary Payer Act’s private cause of action, and our cases interpreting it lead us to conclude that the Act’s claims-filing provision, doesn’t erect a separate bar that private plaintiffs must overcome in order to sue. A closer look at the claims-filing provision’s text and the Act’s structure confirms that conclusion. Accordingly, the district court erred in granting Kingsway’s motion for judgment on the pleadings.” View "MSPA Claims 1, LLC v. Kingsway Amigo Insurance Company" on Justia Law

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Central Mississippi Medical Center (CMMC) appealed a Chancery Court decision denying its appeal of a Division of Medicaid (DOM) hearing. The DOM had determined that CMMC owed it $1.226 million due to overpayment. The Mississippi Supreme Court recently decided a reimbursement dispute involving the DOM, Crossgates River Oaks Hosp. v. Miss. Div. of Medicaid, 240 So. 3d 385 (Miss. 2018). In Crossgates, the hospitals prevailed because the DOM had failed to adhere to the Medicare State Plan Agreement. Applying the same legal principles to this case, the Supreme Court ruled the DOM prevailed because the DOM adhered to the Plan. The chancellor found sufficient evidence to support the DOM’s decision, decreed that it was neither arbitrary nor capricious, and decreed that it did not exceed the DOM’s authority or violate any of CMMC’s statutory or constitutional rights. View "Central Mississippi Medical Center v. Mississippi Division of Medicaid" on Justia Law

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The Court of Appeals confirmed the determination of a local services agency, confirmed by a state agency, that child support payments a parent receives, made for the benefit of her five children living at home, are included as "household" income in deciding whether the household is eligible for benefits under the Supplemental Nutrition Assistance Program (SNAP), holding that, for the purposes of SNAP, child support directly received by a parent is household income, even if it is used for the benefit of an ineligible college student living at home. The Suffolk County Department of Social Services (DSS) discontinued the household's benefits because its income exceeded the upper limit for the household. Because the two college children were ineligible for SNAP, DSS did not count them as household members but did include the full amount of child support in its calculation of household income. The mother appealed, arguing that the college children's pro rata share of the child support payment should be excluded from household income, rendering the household SNAP-eligible. The Office of Temporary and Disability Assistance (OTDA) upheld the determination. The Appellate Division confirmed the OTDA's determination. The Court of Appeals also confirmed, holding that the OTDA's interpretation of the relevant federal statutes was not irrational and was entitled to deference. View "Leggio v. Devine" on Justia Law

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The Supreme Court affirmed the decision of the court of appeals affirming the determination of Scott County that Consumer Directed Community Support (CDCS) money that Cindy Ali, whose son was disabled, had allocated to herself as wages to care for her child was not excluded from the annual income calculation for the purpose of Section 8 eligibility, holding that amounts allocated to a parent to care for her disabled child are not excluded as income under 24 C.F.R. 5.609(c)(16). This dispute arose from the interplay between two public welfare programs, the state CDCS option for families with disabled members, and Section 8, an income-based federal housing program. Ali participated in the Section 8 housing program until Scott County, the local housing administrator, determined that the amounts Ali paid herself under the CDCS option were not excluded from her income when calculating her eligibility for Section 8 housing. As a result, Ali lost her Section 8 eligibility. The court of appeals affirmed. The Supreme Court affirmed, holding that the CDCS amounts Ali received as compensation for her services in caring for her child were correctly included as annual income when calculating Ali's Section 8 eligibility. View "In re Cindi Ali" on Justia Law

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Under the Medicaid program, 42 U.S.C. 1396, states must ensure that certain medical assistance is available to all eligible beneficiaries. Illinois administers its Medicaid program through HFS. For managed care programs, HFS contracts with Medicaid managed care organizations (MCOs), which a flat monthly fee per patient. The MCOs pay providers for services rendered to Medicaid beneficiaries. Plaintiffs, consultants who offer business services to Illinois nursing homes and supportive living facilities, sued on behalf of a class of nursing home residents entitled to Medicaid benefits, alleging violations of Title XIX of the Social Security Act, the Americans with Disabilities Act, the Rehabilitation Act, and the Due Process and Equal Protection Clauses. They alleged that the MCOs failed to process timely payments for claims submitted by nursing homes—the plaintiff‐consultants’ clients—to the MCOs, putting the resident‐beneficiaries at risk of being discharged from the facilities. The Seventh Circuit affirmed the dismissal of the case for lack of subject matter jurisdiction. The regulation cited by plaintiffs does not permit authorized representatives to bring civil lawsuits on behalf of Medicaid beneficiaries so the plaintiffs lacked standing. The residents would be unlikely to benefit if the plaintiffs won; they apparently filed suit in an effort to push the state to pay outstanding bills owed to the consultants’ clients. View "Bria Health Services, LLC v. Eagleson" on Justia Law

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Stacey Janssen alleged Lawrence Memorial Hospital ("LMH") engaged in two healthcare schemes to fraudulently receive money from the United States. Janssen first contended LMH falsified patients’ arrival times in order to increase its Medicare reimbursement under certain pay-for-reporting and pay-for-performance programs the Government used to study and improve hospitals’ quality of care. Second, Janssen contended LMH falsely certified compliance with the Deficit Reduction Act in order to receive Medicare reimbursements to which it was otherwise not entitled. LMH moved for summary judgment below, arguing Janssen failed to show her allegations satisfied the Act’s materiality requirement - that the alleged falsehoods influenced the Government’s payment decision as required under the FCA. The district court granted LMH summary judgment on all of Janssen’s claims on this basis, and finding no reversible error, the Tenth Circuit affirmed. View "United States ex rel. Janssen v. Lawrence Memorial Hospital" on Justia Law

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Martin, a 67-year-old woman, sought Social Security Disability benefits. Her persistent back pain stems from two car accidents; she also suffers from depression, anxiety, bipolar disorder, panic disorder, and PTSD. These conditions caused Martin to stop working in 2009. Before then she had worked as a home health aide, data entry clerk, and administrative assistant. An ALJ determined that Martin’s severe impairments left her capable of performing only a limited range of sedentary jobs. The district court remanded for a more thorough consideration of Martin’s mental health problems. A new ALJ then found that Martin had no physical limitations whatsoever and declined to award benefits. The Seventh Circuit reversed, finding the second ALJ’s decision not supported by substantial evidence, and took “the rare step of ordering the award of benefits.” The court rejected Martin’s argument that the ALJ’s residual functional capacity determination failed to translate her mental health symptoms into limitations related to concentration, persistence, and pace but the record is clear that Martin’s physical limitations leave her unable to perform any work above the light level. Given her restricted range of motion and symptoms of pain, light exertion would likely be a challenge for Martin because it requires “a good deal of walking or standing.” View "Martin v. Saul" on Justia Law

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O’Brien is a Vietnam veteran whose service-connected disabilities make him eligible to receive compensation for himself and for certain “dependents,” 38 U.S.C. 1115. Section 1115 does not define “dependents,” but lists specific allotments for veterans with “a spouse but no child,” “a spouse and one or more children,” “no spouse but one or more children,” and “a parent dependent upon such veteran for support.” Under title 38, a “child” is an unmarried person who meets certain age restrictions “and who is a legitimate child, a legally adopted child, a stepchild who is a member of a veteran’s household or was a member at the time of the veteran’s death, or an illegitimate child [in certain circumstances].” O’Brien took legal guardianship of D.B., his stepdaughter’s minor son, then requested dependency compensation. He and his late wife were D.B.’s caretakers since D.B.’s mother was in a nursing home and his father was absent. The VA denied compensation for D.B., indicating that O’Brien could reopen his claim with proof of D.B.’s adoption. The Board of Veterans’ Appeals, Veterans Court, and Federal Circuit upheld the denial as a matter of first impression. Despite not expressly defining “dependents,” Congress unambiguously limited that term to “spouses, children, and dependent parents” by specifying the amount payable for each. View "O'Brien v. Wilkie" on Justia Law

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In 2009-2011, Hernandez sustained on-the-job injuries and received medical treatment. In 2016, she filed a voluntary Chapter 7 bankruptcy petition and reported unsecured claims held by three health care providers to whom she owed $28,709.60, $58,901.20, and $50,161.26 respectively. She reported minimal assets: $1300 in bank accounts and her pending workers’ compensation claim, valued at $31,000. Two days after filing her petition, Hernandez settled her workers’ compensation claim for $30,566.33 without consulting the bankruptcy trustee. She believed the settlement was exempt under section 21 of the Workers’ Compensation Act (820 ILCS 305/21). That statute provides: “No payment, claim, award or decision under this Act shall be assignable or subject to any lien, attachment or garnishment, or be held liable in any way for any lien, debt, penalty or damages….” The health care providers objected; the district court ruled in their favor. The Illinois Supreme Court answered a question of Illinois law certified by the Seventh Circuit: After the 2005 amendments to section 8 of the Workers’ Compensation Act and the enactment of section 8.2 of the Act, section 21 of the Act does exempt the proceeds of a workers’ compensation settlement from the claims of medical-care providers who treated the illness associated with that settlement or injury. View "In re Hernandez" on Justia Law