by
The Tennessee Hospital Association and three hospitals sued, challenging efforts by the Centers for Medicare and Medicaid Services (CMS) to direct states to recoup certain reimbursements made under the Medicaid program. The hospitals serve a disproportionate share of Medicaid-eligible patients and are thereby entitled to supplemental payments under the Medicaid Act, (DSH payments), 42 U.S.C. 1396a(a)(13)(A)(iv); 1396r-4(b). The Act limits the amount of DSH payments each hospital can receive in a given year. CMS contends that the hospitals miscalculated their DSH payment-adjustments for fiscal year 2012 and received extra payments. Plaintiffs argued, and the district court agreed, that CMS’s approach to calculating DSH payment adjustments is inconsistent with the Act and the regulations that CMS implemented in 2008. The Sixth Circuit affirmed, agreeing that CMS’s policy is inconsistent with its 2008 rule and cannot be enforced unless it is promulgated pursuant to notice-and-comment rulemaking. The court disagreed with the district court’s conclusion that CMS’s policy exceeds the agency’s authority under the Medicaid Act. CMS’s payment-deduction policy is a reasonable interpretation of an ambiguous section of the Act but is not a valid interpretative rule. CMS attempted to exercise its delegated discretion to “determine[]” the “costs incurred” in serving Medicaid-eligible patients—precisely the sort of agency action that requires notice-and-comment rulemaking. View "Tennessee Hospital Association v. Azar" on Justia Law

by
Cook served on active duty in the Navy, 1972-1973. Cook’s service records indicate that he experienced back pain. In 2000, Cook sought service connection for back problems and later filed a claim for total disability based on individual unemployability (TDIU), also back-related. The regional office (RO) denied both claims. Cook appealed and testified at a Board hearing in 2012. The Board remanded; the RO again denied both claims. Cook again appealed and requested an additional hearing to present further evidence. The Board denied Cook that additional hearing and denied both of his claims. The Veterans Court, upon joint motion, vacated and remanded because the Board did not adequately explain its decision. On remand, Cook again requested another Board hearing. The Board denied a hearing and denied Cook’s claims for service connection and TDIU. The Veterans Court vacated and ordered a hearing. The Federal Circuit affirmed. The Veterans’ Judicial Review Act codified a veteran’s longstanding right to a Board of Veterans’ Appeals hearing, 38 U.S.C. 7107(b). The courts concluded that the statute entitles an appellant to an opportunity for a hearing whenever the Board decides an appeal, including on remand. View "Cook v. Wilkie" on Justia Law

by
Hardy, a 55-year old man who worked previously as a maintenance mechanic, had a discectomy in 2005 and a lumbar spinal fusion in 2006. His previous application for Disability Insurance Benefits was denied in 2012. Hardy filed another application for DIB benefits, claiming an onset date of April 2012. The agency denied Hardy’s claim; state-agency doctors reviewed Hardy’s file and determined that he had postural limitations, could frequently lift up to 10 pounds and could stand or walk for six hours during a workday so that Hardy could perform light work. His treating doctors reported that Hardy was unable to work and that his “legs give out and he tends to fall.” In concluding that Hardy was not disabled, an ALJ determined that Hardy had not engaged in substantial gainful employment since his alleged onset date; that his conditions were severe impairments; that these conditions did not equal a listed impairment; that he had the residual functional capacity to perform light work, with limitations; and that he could work as a wire assembler, assembly press operator, circuit board screener, or finish assembler. The Seventh Circuit vacated the denial of benefits. A treating doctor’s opinion generally is entitled to controlling weight if it is consistent with the record, and it cannot be rejected without a “sound explanation.” The ALJ impermissibly discounted the opinions of Hardy’s treating neurosurgeon. View "Hardy v. Berryhill" on Justia Law

by
After the Department of Education issued a proposed determination that Texas was ineligible for $33.3 million of future grants because of the shortfall in both aggregate and per capita state funding, the state argued that it had complied with the "maintenance of state financial support" (MFS) requirement because funding under a weighted-student model had remained constant. The Fifth Circuit denied Texas' petition for review and held that the weighted-student model contravenes the plain meaning of the MFS clause. The court explained that, under the weighted-student model, Texas may reduce the amount of funding for special education if it determines that the needs of children with disabilities have changed. In this case, Texas violated the plain requirements of the MFS clause by doing so and was therefore ineligible for the corresponding amount of future Individuals and Disabilities Education Act Part B grants. Finally, the MFS clause did not exceed Congress's spending power by failing to provide sufficiently clear notice of its requirements. View "Texas Education Agency v. United States Department of Education" on Justia Law

by
Ashby’s son was a member of his elementary school choir. In 2014 and 2015, the choir performed a Christmas concert at a local museum in a historic building. The building was not then accessible to persons with disabilities. Ashby, who uses a wheelchair, was unable to attend the concerts. She sued the School Corporation, alleging discrimination under the Americans with Disabilities Act, 42 U.S.C. 12132, and the Rehabilitation Act. The district court concluded that the Christmas concert was not a “service, program, or activity of” the Warrick Schools, nor was the concert an activity “provided or made available” by the School Corporation and granted summary judgment. The Seventh Circuit affirmed, accepting the Department of Justice’s suggestion that when a public entity offers a program in conjunction with a private entity, the question of whether a service, program, or activity is one “of” a public entity is fact-based and that there is a “spectrum” of possible relationships ranging from a “true joint endeavor” to participation in a wholly private event. The Department’s interpretation of its regulations is a reasonable one that offers a loose but practical framework that aids in decision-making. Upon close examination of the record, it is clear that the event in question was not a service, program, or activity provided or made available by the School Corporation. View "Ashby v. Warrick County School Corp" on Justia Law

by
Garcia served in the Army from 1952-1954. The military’s records of his medical treatment during service were among those destroyed in a fire in 1973 at the National Personnel Records Center in St. Louis. The record of his medical examination upon leaving the service was not destroyed and reveals a normal psychiatric state and no severe illnesses or injuries. Garcia saw Dr. Smoker, in 1965 for a burn from a welding accident. In 1969, Dr. Smoker diagnosed Garcia with, and prescribed medication for, paranoid schizophrenia. In 2002, Garcia sought disability benefit, alleging service connection of disability-causing paranoid schizophrenia. The regional office denied the claim. The Board of Veterans’ Appeals remanded for a VA psychiatric examination. Although García claimed to have been seen twice for his condition while in service, a VA examiner found it “impossible to say, without resorting to mere speculation, as to whether this veteran’s schizophrenia, paranoid type actually started in Service, without more documentation and records.” The previous denial was “confirmed.” Garcia collaterally challenged the 2006 Board decision, alleging clear and unmistakable error (CUE). The Board and Veterans Court rejected Garcia’s CUE arguments. The Federal Circuit affirmed, upholding the Veterans Court’s application of 38 C.F.R. 20.1409(c) to bar a due process allegation of CUE. View "García v. WIlkie" on Justia Law

by
The Eighth Circuit affirmed the denial of plaintiff's application for disability insurance benefits and supplemental security income. The court held that good reasons and substantial evidence supported the ALJ's determination that plaintiff's claimed limitations were not entirely credible. In this case, the ALJ considered plaintiff's alleged limitations, and substantial evidence supported the ALJ's residual functional assessment. Finally, the district court properly denied plaintiff's request for another hearing. View "Nash v. Commissioner, Social Security Administration" on Justia Law

by
Burchett and Jude suffered from serious mental illnesses. Each hired attorney Conn to represent them in applying for Social Security disability benefits, 42 U.S.C. 405(a), which were granted in 2009 and 2010. Conn was perpetrating a fraudulent scheme. Conn paid doctors to submit fraudulent letters concerning his clients' ailments and bribed an ALJ to assign Conn’s cases to his own docket and to decide nearly all of those cases in favor of Conn. Plaintiffs allege that the SSA had reason to suspect Conn's fraud in 2007 due to the reports of internal whistle-blowers. In 2011, the Wall Street Journal published a story about Conn’s exploits. Conn was indicted and pleaded guilty. The Huntington, West Virginia SSA office's former Chief ALJ, pleaded guilty to retaliation against a whistle-blower. The SSA’s Appeals Council informed Jude and Burchett that it was legally required to redetermine their eligibility for benefits (42 U.S.C. 1320a-8(l). Their benefits were suspended pending redeterminations. Each requested additional time to gather evidence. About two weeks after the SSA notices, before the SSA granted those requests, Jude and Burchett each committed suicide. Their estates filed Federal Tort Claims Act (FTCA) claims for wrongful death with the SSA, 28 U.S.C. 1346(b) and 2671, and a Bivens claim alleging procedural due process violations. The Federal Circuit affirmed dismissal of the claims, concluding that the FTCA’s discretionary function exception applied to preclude that claim and that the Bivens claim was improperly formulated. View "Jude v. Commissioner of Social Security" on Justia Law

by
In this interlocutory appeal from the circuit court’s review of an agency ruling, the Supreme Court adopted the United States Supreme Court’s test for standing as set forth in Lujan v. Defenders of Wildlife, 504 U.S. 555, 560-561 (1992) and held that the existence of a plaintiff’s standing is a constitutional requirement to prosecute any action in the courts of the Commonwealth, including seeking judicial review of an administrative agency’s final order. The putative petitioner in this case, a Medicaid beneficiary (the patient), sought judicial review of a final order of the Kentucky Cabinet for Health and Human Services ruling that the patient lacked standing to pursue an appeal of an insurer’s denial of reimbursement to a hospital for the patient’s services. The hospital, acting as the patient’s representative, sought judicial review of the Cabinet’s final order. The circuit court denied the Cabinet and the insurer’s motions to dismiss the petition. The Supreme Court remanded the case with instructions to dismiss the case, holding (1) Kentucky courts have the responsibility to ascertain whether a plaintiff has constitutional standing to pursue the case in court; and (2) under that test, the patient did not have the requisite constitutional standing to pursue her case in the courts of the Commonwealth. View "Commonwealth v. Sexton" on Justia Law

by
Pursuant to the terms of Social Security Ruling 00-4p, and in light of the overall regulatory scheme that governs disability claims, the ALJs within the SSA have an affirmative duty to identify apparent conflicts between the testimony of a Vocational Expert (VE) and the DOT and resolve them. The Eleventh Circuit held that this duty requires more of the ALJ than simply asking the VE whether his testimony is consistent with the DOT. The court explained that, once the conflict has been identified, the Ruling requires the ALJ to offer a reasonable explanation for the discrepancy, and detail in his decision how he has resolved the conflict. Furthermore, the failure to discharge this duty means that the ALJ's decision, when based on the contradicted VE testimony, is not supported by substantial evidence. In this case, the ALJ failed to meet his obligations to identify, explain, and resolve an apparent conflict between the testimony of the VE and the DOT on a matter of considerable importance. Accordingly, the court reversed and remanded with instructions. View "Washington v. Commissioner of Social Security" on Justia Law