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Neighbors is a skilled nursing facility participating in Medicare and Medicaid. The Centers for Medicare and Medicaid Services (CMS) determined that Neighbors inadequately addressed sexual interactions between three cognitively impaired residents and that Neighbors’ failure to act put the residents in “immediate jeopardy,” and issued Neighbors a citation and an $83,800 penalty under 42 U.S.C. 1395i‐3(h)(2)(B)(ii)(I). An ALJ and the Department of Health and Human Services Departmental Appeals Board upheld the decision. The Seventh Circuit affirmed, concluding that substantial evidence supports the Agency’s determinations and rejecting claims that the sexual interactions were consensual. The court noted findings that staff, aware of the sexual interactions, did not talk to the residents about their feelings about these “relationships”; did not document the residents’ capacity for consent (or lack thereof) or communicate with residents’ physicians for medical assessment of how their cognitive deficits impacted that capacity; did not discuss the developments with the residents’ responsible parties; and did not record any monitoring of the behaviors or make any care plans to account for them. Neighbors’ non‐intervention policy prevented any real inquiry into consent, except in the extreme situation where a resident was yelling or physically acting out. View "Neighbors Rehabilitation Center, LLC v. United States Department of Health and Human Services" on Justia Law

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Petitioner Kyle Guillemette challenged a determination by the Administrative Appeals Unit (AAU) of the New Hampshire Department of Health and Human Services (DHHS) that the notice requirements set forth in RSA 171-A:8, III (2014) and New Hampshire Administrative Rules, He-M 310.07 did not apply when Monadnock Worksource notified Monadnock Developmental Services of its intent to discontinue providing services to petitioner because that act did not constitute a “termination” of services within the meaning of the applicable rules. Petitioner received developmental disability services funded by the developmental disability Medicaid waiver program. MDS was the “area agency,” which coordinated and developed petitioner’s individual service plan. Worksource provides services to disabled individuals pursuant to a “Master Agreement” with MDS. Worksource began providing day services to the petitioner in August 2012. On March 31, 2017, Worksource notified MDS, in writing, that Worksource was terminating services to petitioner “as of midnight on April 30.” The letter to MDS stated that “[t]he Board of Directors and administration of . . . Worksource feel this action is in the best interest of [the petitioner] and of [Worksource].” Petitioner’s mother, who served as his guardian, was informed by MDS of Worksource’s decision on April 3. The mother asked for reconsideration, but the Board declined, writing that because the mother “repeatedly and recently expressed such deep dissatisfaction with our services to your son, the Board and I feel that you and [petitioner] would be better served by another agency . . . .” Thereafter, petitioner filed a complaint with the Office of Client and Legal Services alleging that his services had been terminated improperly and requesting that they remain in place pending the outcome of the investigation of his complaint. Because the New Hampshire Supreme Court concluded that the AAU’s ruling was not erroneous, it affirmed. View "Petition of Kyle Guillemette" on Justia Law

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At issue in this appeal was whether the district court lacked subject matter jurisdiction to consider Azar Webb’s 42 U.S.C. 1983 claim in the same lawsuit in which the court considered an appeal from a contested case under the Administrative Procedure Act (APA) and whether, as a result, the court lacked the authority to award Webb attorney fees. After the Nebraska Department of Health and Human Services (DHHS) ended Webb’s Medicaid benefits and denied his petition for reinstatement, Webb filed a claim in the district court under the APA for unlawful termination of Medicaid eligibility, adding a claim of violation of his federal rights under section 1983. The district court reversed DHHS’ decision and ordered reinstatement of Webb’s coverage and reimbursement of medical expenses that should have been covered. The court further found in favor of Webb as to his 1983 claim and enjoined DHHS officials from denying Webb Medicaid eligibility. The Supreme Court affirmed, holding that once the district court resolved Webb’s APA claim, the court had the authority to grant Webb relief under section 1983 and his request for attorney fees pursuant to 42 U.S.C. 1988. View "Webb v. Nebraska Department of Health & Human Services" on Justia Law

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Nursing Homes, on behalf of eleven residents, filed suit against the Secretaries, alleging that the Secretaries wrongfully denied the residents Medicaid benefits in violation of the Fourteenth Amendment and several federal statutes. The Fourth Circuit affirmed the district court's dismissal of the complaint for lack of subject matter jurisdiction and failure to state a claim. The court held that the Eleventh Amendment barred the Nursing Homes' constitutional and Medicaid Act claims for damages or other relief based on past actions; the Nursing Homes' claims for declaratory and injunctive relief were moot and required dismissal because the court lacked subject matter jurisdiction; and, because the Nursing Homes failed to state a viable Americans with Disabilities Act claim, they failed to state a cognizable Rehabilitation Act claim. View "Wicomico Nursing Home v. Padilla" on Justia Law

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Wilkerson mined coal for over 25 years. In 1994, he retired from the Island Creek’s Crescent mine, where he had worked most recently as an electrician. In 2012, Wilkers sought benefits under the Black Lung Benefits Act, which provides compensation to miners disabled by pneumoconiosis, 30 U.S.C. 902(b), 922(a)(1). The Sixth Circuit denied a petition for review, upholding the Benefits Review Board’s award of benefits. The defendant forfeited an argument that the ALJ lacked authority to hear the case under the Appointments Clause by failing to raise it in its opening brief. Appointments Clause challenges arise under the U.S. Constitution, but are “not jurisdictional and thus are subject to ordinary principles of waiver and forfeiture.” Substantial evidence supports the award. An ALJ may presume an applicant suffers from the disease if he worked for 15 years at a qualifying coaling mine and suffers “a totally disabling respiratory or pulmonary impairment.” Wilkerson worked for more than 15 years at a qualifying mine, and substantial evidence showed that he suffered total disability due to a respiratory or pulmonary impairment. Faced with the conflicting medical evidence, the ALJ turned to the four doctors who testified, credited testimony from one doctor, discounted the three others for legitimate reasons, and concluded that Wilkerson suffered from a disability. The doctor’s conclusion about Wilkerson’s disability tracked the newest available data. View "Island Creek Coal Co. v. Wilkerson" on Justia Law

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The Supreme Court affirmed the judgment of the district court affirming the position of the Iowa Department of Human Services (DHS) determining that transfers made by Petitioners, nursing home residents, to a pooled special needs trust were for less than fair market value and required a delay in Petitioners’ eligibility for Medicaid benefits, holding that the district court and DHS correctly construed and applied federal law requiring the delay in Medicaid benefits for long-term institutional care. Federal eligibility requirements provide that state ensure that Medicaid benefits are reserved for persons who lack financial means and have not transferred personal asserts that could pay for their care. Petitioners, at age sixty-five, transferred more than one-half million dollars to a pooled special needs trust. The Supreme Court held that the district court and DHS properly interpreted federal law effectively requiring Petitioner’s to tap their pooled trust assets first to pay for their nursing home care. View "Cox v. Iowa Department of Human Services" on Justia Law

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In 2006-2008, plaintiffs each applied, unsuccessfully, for Social Security disability benefits, 42 U.S.C. 423(d)(2)(A), 1382c(a)(3)(B). Each plaintiff retained Kentucky attorney Conn to assist with a subsequent hearing. Each plaintiff’s application included medical records from one of four examining doctors. In each case, ALJ Daugherty relied exclusively on the doctor's opinion to conclude, without a hearing, that plaintiffs were disabled and entitled to benefits. Daugherty took bribes from Conn to assign Conn’s cases to himself and issue favorable rulings. Nearly 10 years after the agency learned of the scheme, it initiated “redeterminations” of plaintiffs’ eligibility for benefits and held new hearings, disregarding all medical evidence submitted by the four doctors participating in Conn’s scheme. Plaintiffs had no opportunity to rebut the assertion of fraud as to this evidence. Each plaintiff was deemed ineligible for benefits as of the date of their original applications; their benefits were terminated. Plaintiffs sued, alleging violations of the Due Process Clause and the Social Security Act. The Sixth Circuit held that the plaintiffs are entitled to summary judgment on their due-process claim and the agency is entitled to summary judgment on the Social Security Act claims. The agency must proffer some factual basis for believing that the plaintiffs’ evidence is fraudulent. Plaintiffs must have an opportunity to “rebut the Government’s factual assertions before a neutral decisionmaker.” Congress has already told the agency what to do when redetermination proceedings threaten criminal adjudications; the answer is not to deprive claimants of basic procedural safeguards. View "Griffith v. Commissioner of Social Security" on Justia Law

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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

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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

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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