Justia Public Benefits Opinion Summaries

A state agency responsible for Medicaid administration alleged that a pharmacy and its owner, operating as a Medicaid provider, received excess Medicaid payments between 2011 and 2016 by submitting claims for more medications than records supported. After an audit, an administrative law judge upheld the agency’s determination of overpayment. The agency issued a final order demanding repayment, which survived several unsuccessful challenges by the pharmacy. In 2022, the agency, represented by the Attorney General, filed a civil action in Ingham County seeking to enforce its order and alleging common-law and statutory conversion, breach of contract, and unjust enrichment related to the overpayments.The defendants moved to change venue, arguing that the action should be heard in Wayne County, where the pharmacy owner resided and where the acts giving rise to the claims allegedly occurred, based on Michigan’s tort venue statutes. The Ingham Circuit Court transferred the case to Oakland County, identifying it as the site of the original injury. The Michigan Court of Appeals affirmed, holding that the tort venue statutes took precedence over the Attorney General venue provisions and that venue was proper in Oakland County, where the pharmacy’s registered office was located and where the funds were allegedly wrongfully withheld.The Supreme Court of Michigan reviewed the case and agreed with the Court of Appeals that the tort venue statutes, specifically MCL 600.1629 as mandated by MCL 600.1641(2), governed the venue determination because the complaint contained multiple claims, including a tort. However, the Supreme Court held that the “original injury” occurred in Ingham County, where the state agency was deprived of the funds and conducts its business. Therefore, venue was proper in Ingham County, not Oakland County. The Court affirmed in part, reversed in part, and remanded for transfer of the case to the Ingham Circuit Court. View "Department Of Health And Human Services v. Nrk Rx Inc." on Justia Law

Four individuals who were Medicaid beneficiaries in Illinois were admitted to long-term care facilities between 2018 and 2023. The facilities submitted required electronic admission packets to the Illinois Department of Healthcare and Family Services so that the cost of care could be reimbursed by Medicaid. In each case, the Department either rejected or mishandled these admission packets, resulting in the facilities not being reimbursed for all or part of the care provided. Despite regulations prohibiting providers from billing Medicaid beneficiaries for unreimbursed care, the facilities sent bills to the plaintiffs. The plaintiffs, however, did not pay these bills, nor did they suffer any loss of benefits or interruption in care.The plaintiffs filed a proposed class action in the United States District Court for the Northern District of Illinois against state officials responsible for Medicaid administration. They alleged violations of due process and the Medicaid Act, and requested only injunctive relief to require systemic changes in the admission packet review process. The defendants moved to dismiss, arguing both lack of standing and failure to state a claim. The district court found that the plaintiffs had standing because they received bills, but it dismissed the case for failure to state a claim, reasoning that the plaintiffs were not denied benefits or services and no statutory or constitutional rights were violated.On appeal, the United States Court of Appeals for the Seventh Circuit reviewed only standing. The appellate court held that the plaintiffs lacked standing for injunctive relief because they did not allege a real and immediate threat of repeated injury. The prior receipt of bills did not amount to legal harm, as the plaintiffs had no obligation to pay. The court modified the district court’s judgment to reflect a jurisdictional dismissal for lack of standing and affirmed the judgment as modified. View "Arcidiacono v Whitehorn" on Justia Law

A part-time airport guide was terminated at the onset of the COVID-19 pandemic by her employer, a tour operations company serving Japanese-speaking tourists. The employer cited three incidents as reasons for termination: the employee’s failure to sign an acknowledgment of a revised handbook (containing an at-will employment clause), an incident involving attempted unauthorized use of a TSA priority lane at the airport, and a complaint from an airline about the employee’s conduct with staff. The employee, who was not proficient in English, did not sign the acknowledgment form due to lack of understanding and requested an explanation, as directed by the handbook.Following her termination, the employee applied for unemployment benefits. The Department of Labor and Industrial Relations’ Employment Security Appeals Referees’ Office initially granted benefits, but after a hearing (which the employee missed), an appeals officer reversed that decision, finding misconduct based on the three incidents. After a second hearing with interpretation services, the appeals officer reaffirmed the misconduct finding. The Circuit Court of the First Circuit affirmed the agency’s decision, finding no abuse of discretion or error, and adequate support in the record. The Intermediate Court of Appeals also affirmed, concluding the appeals officer did not clearly err and the employee had a fair opportunity to present her case.The Supreme Court of the State of Hawai‘i reviewed the case on certiorari. It held that none of the three incidents constituted misconduct under Hawai‘i unemployment law, which requires a wilful or wanton disregard of the employer’s interests. The Court reasoned that the failure to sign the acknowledgment did not meet this standard, especially since the employer’s own deadline was flexible and progressive discipline was not properly followed. The customer service incidents did not display the necessary degree of disregard. The Supreme Court vacated the decisions of the DLIR, circuit court, and ICA, and remanded for proceedings to determine the employee’s unemployment benefit amount. View "Choi v. Tachibana Enterprises, LLC" on Justia Law

A patrol officer with the Anoka Police Department completed a 12-hour shift during which he responded to multiple calls, including emergency situations such as a domestic dispute involving a report of a child with a knife. The following day, the officer died from a vascular rupture. His widow applied for state line-of-duty death benefits, submitting medical evidence that the stressful nature of police work contributed to his fatal condition. While her application for federal death benefits was approved, the Commissioner of Public Safety denied her application for Minnesota death benefits, concluding the officer’s death did not meet the statutory criteria for being “killed in the line of duty.”After the Commissioner’s denial, the widow appealed to the Office of Administrative Hearings, where the Administrative Law Judge (ALJ) granted summary disposition in favor of the Commissioner. The ALJ found that the officer’s final shift did not involve “nonroutine stressful or strenuous physical law enforcement activity” as required by statute. The Minnesota Court of Appeals reversed, holding that there was a genuine issue of material fact regarding whether the officer engaged in such nonroutine activity during his last shift. The court also concluded that the definition of “killed in the line of duty” from prior Minnesota Supreme Court cases did not apply to deaths specifically addressed by the legislature in the statute.The Supreme Court of Minnesota reviewed the case and clarified the statutory presumption for certain heart-related deaths. The Court held that an emergency response is presumptively “nonroutine” under the statute, regardless of how frequently it occurs or how it is characterized by the agency. It also determined that the phrase “nonroutine stressful or strenuous physical” modifies all activities listed in the statute. Additionally, the Court held that if the statutory presumption does not apply or is rebutted, the officer’s estate may still prove line-of-duty death under the legal standard set forth in Kramer v. State, Peace Officers Benefit Fund, and Johnson v. City of Plainview. The decision of the Court of Appeals was affirmed in part and reversed in part. View "In re Public Safety Officer Death Benefit for Groebner" on Justia Law

The appellant, a military veteran, developed significant neck and back issues following his service, which worsened in May 2012. Medical imaging revealed cervical spondylosis with a herniated disk, leading to spinal fusion surgery in October 2012. He continued to suffer pain and functional limitations, including weakness in his left arm, and received limited disability benefits from the Department of Veterans Affairs. In 2021, he applied for Social Security disability benefits, claiming a disability onset date in 2012 and eligibility through the end of 2016.His application was denied by an Administrative Law Judge (ALJ) after a hearing, where both the appellant and a vocational expert testified. The ALJ found that, despite severe impairments, the appellant retained the residual functional capacity to perform light work, including his past relevant work as generally performed and other jobs available in the national economy. The ALJ discounted the only medical opinion addressing his functional ability—a 2016 evaluation by a physician’s associate—because it was inconsistent with other medical records. The Social Security Appeals Council denied review. The United States District Court for the Western District of Missouri affirmed the ALJ’s decision, holding that the ALJ’s findings were supported by substantial evidence.On appeal, the United States Court of Appeals for the Eighth Circuit reviewed whether the ALJ’s decision was supported by substantial evidence and free from legal error. The court held that the ALJ properly based the residual functional capacity determination on all relevant medical evidence, not just specific functional medical opinions. The court found that the ALJ thoroughly considered the record, including conflicting medical findings, and was not required to obtain additional functional evidence. The judgment of the district court, affirming the denial of disability benefits, was affirmed. View "Bonham v. Bisignano" on Justia Law

A legal advocacy organization petitioned for a writ of mandamus to compel the Department of Veterans Affairs (VA) to update its mailing addresses, alleging that the VA continued to send correspondence to incorrect addresses despite repeated notifications of changes. The petitioner requested court intervention to ensure the VA updated its address records, ceased sending correspondence to wrong addresses, and imposed financial penalties for future errors.The United States Court of Appeals for Veterans Claims dismissed the petition as moot after the VA voluntarily corrected the addresses and created a policy to guide attorneys on updating their addresses. The VA also provided affidavits and a fact sheet to confirm these corrections. The petitioner subsequently sought attorney fees under the Equal Access to Justice Act (EAJA), asserting that the Veterans Court’s order requiring affidavits constituted the necessary “judicial imprimatur” for prevailing-party status. The Veterans Court denied the application, relying on Cavaciuti v. McDonough, and found there was no court-mandated decision on the merits and no material alteration to the parties’ legal relationship.On appeal, the United States Court of Appeals for the Federal Circuit reviewed whether the Veterans Court erred in denying attorney fees under EAJA. The Federal Circuit held that a court order requiring a party only to confirm voluntary corrective actions for the purpose of assessing mootness does not constitute sufficient judicial imprimatur to confer prevailing-party status under EAJA. The court found that the Veterans Court’s order did not address the merits of the petition or alter the legal relationship between the parties. The Federal Circuit therefore affirmed the Veterans Court’s denial of the EAJA application. View "VETERANS LEGAL ADVOCACY GROUP v. COLLINS " on Justia Law

The petitioner began working as an Operational Support Technician with the Federal Bureau of Investigation in Miramar, Florida, in 1987. Her duties required her physical presence at the office, and she commuted daily from her home. In December 2016, she was found to have engaged in workplace misconduct—specifically, being under the influence while on duty—and was removed from her position in July 2018. In April 2019, she applied for Federal Employees’ Retirement System (FERS) disability retirement benefits, claiming that recurring seizures prevented her from commuting to work and performing the essential duties of her position.The Office of Personnel Management denied her application and subsequent request for reconsideration, determining that she had not established that her medical condition rendered her unable to provide “useful and efficient service” in her position. The petitioner appealed to the Merit Systems Protection Board. An administrative judge affirmed OPM’s determination, finding insufficient evidence that she was unable to perform the essential functions of her job. The judge also rejected her argument that her inability to commute, due to seizures and lack of transportation options, should be considered in assessing her disability status. The full Board adopted the administrative judge’s findings.The United States Court of Appeals for the Federal Circuit reviewed the Board’s final decision. The court held that, under 5 U.S.C. § 8451(a)(1)(B), the statutory definition of disability for FERS benefits does not include an employee’s ability to commute; only the refusal of reassignment to a position within the commuting area is governed by such considerations under § 8451(a)(2)(A). The court also ruled that it is statutorily barred from reviewing factual determinations underlying OPM’s disability findings. Accordingly, the Federal Circuit affirmed the Board’s decision. View "CHAFIN v. OPM " on Justia Law

Several individuals applied for federal Supplemental Security Income (SSI) but experienced delays in receiving a determination of eligibility. While they waited, New York State provided them with interim public assistance through the Safety Net Assistance (SNA) program, which required participation in work experience programs (WEPs). The value of the assistance was tied to the minimum wage for the hours worked. Once petitioners were deemed eligible for SSI, the Social Security Administration issued retroactive SSI payments covering the period of delay, and New York was reimbursed from these payments for the interim assistance it had provided. Petitioners received the remainder of the retroactive SSI after reimbursement.Following an unsuccessful administrative challenge, petitioners commenced a combined CPLR article 78 proceeding and putative class action, contending that New York’s practice of recouping the full value of SNA from their retroactive SSI awards violated the Fair Labor Standards Act (FLSA) by effectively creating an unlawful “kick-back” of minimum wage earned through WEP participation. Supreme Court ruled in petitioners’ favor, holding that the reimbursement process was subject to the FLSA and must reflect the value of WEP labor. The Appellate Division, Third Department, unanimously reversed, determining that petitioners were not deprived of minimum wage compensation because they had already received the value of their work in interim assistance and that reimbursement merely prevented duplicate payments for the same period.The New York Court of Appeals affirmed the Appellate Division’s order. It held that reimbursement to New York from petitioners’ retroactive SSI awards for interim assistance, conditioned on WEP participation, does not violate the FLSA. The Court concluded that petitioners received all compensation to which they were entitled under federal law, including the minimum wage, and that federal law expressly authorizes such reimbursement to prevent windfalls. The holding applies regardless of whether interim assistance is conditioned on work activities. View "Andersen v Hein" on Justia Law

A Medicaid recipient in her late 80s, suffering from serious health conditions, applied in 2019 for 24-hour at-home personal care services through New York’s Medicaid program. The state, which provides varying levels of in-home care to eligible Medicaid recipients, partners with private managed long-term care plans (MLTCPs) to assess needs and offer care plans. The plaintiff was initially offered only eight hours of daily care by all MLTCPs she applied to, though she believed she required around-the-clock assistance. Under New York’s regulations, individuals cannot immediately appeal the initial level of care offered; they must first enroll in the plan, request an increase, and only appeal if that request is denied. The plaintiff followed this process and ultimately received 24-hour care after subsequent assessments, but with a delay and a gap in retroactive reimbursement for services.The United States District Court for the Southern District of New York granted summary judgment to the defendants—the State's Health Commissioner and the MLTCP—holding that the plaintiff did not have a cognizable property interest in a particular level of care, and therefore no due process rights were implicated. The court also denied class certification. The plaintiff appealed these decisions.The United States Court of Appeals for the Second Circuit reviewed the case de novo. The Second Circuit disagreed with the District Court’s conclusion regarding the existence of a property interest. It held that New York’s laws, regulations, and practices substantially restrict discretion in determining eligibility for 24-hour personal care services, thereby creating a property interest for qualifying Medicaid recipients and triggering due process protections. However, the court determined that New York’s current appeals procedures, though delayed, are constitutionally adequate because the delay is modest, expedited procedures exist for urgent cases, and the overall private interests at stake are sufficiently protected. On this alternative ground, the Second Circuit affirmed the District Court’s grant of summary judgment to the defendants. View "Bellin v. McDonald" on Justia Law

A former court reporter who worked for nearly four decades for a California county discovered, as she approached retirement, that the county had failed to enroll her in the state retirement system (CalPERS) for several years early in her employment. Upon learning this, she attempted to secure a complete employment record from the county, which CalPERS required to adjust her retirement benefits. The county failed to provide complete records, reportedly due to records being lost or destroyed, and provided only incomplete information to CalPERS. This left her unable to purchase prior service credit or receive full retirement benefits, causing her financial harm and forcing her to delay retirement.After filing a claim with the county and receiving no response, the plaintiff brought multiple causes of action in the Humboldt County Superior Court, including alleged violations of statutory duties and negligence against the county and individual employees. The trial court sustained the defendants’ demurrers, dismissing all statutory claims without leave to amend and granting leave to amend only the negligence claim. When the plaintiff submitted an amended complaint limited to negligence, the trial court again sustained the demurrer without leave to amend, finding no statutory duty supported the claim.The California Court of Appeal, First Appellate District, Division One, reviewed the case. It held that the plaintiff had stated valid causes of action against the county for violation of mandatory statutory duties to maintain personnel records and to enroll eligible employees in CalPERS under Government Code section 815.6. The court also held, in an unpublished portion, that the plaintiff stated a viable negligence claim against the individual defendants, with the county potentially vicariously liable. The appellate court reversed the trial court’s dismissal of these claims and remanded for further proceedings. View "Gibbs v. County of Humboldt" on Justia Law