Justia Public Benefits Opinion Summaries

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The underlying dispute before the Pennsylvania Supreme Court in this case involved the adequacy of state funding for community participation support ("CPS") services, which were designed to help individuals with autism or intellectual disabilities live independently. The primary issue on appeal related to the exhaustion requirement. The Pennsylvania Department of Human Services ("DHS") issued ODP Announcement 19-024, indicating it intended to change the rate structure for CPS services provided under the Home and Community Based Services (“HCBS”) waivers. Petitioners filed an action for declaratory and injunctive relief, challenging the legality of the new fee schedule and alleged the new reimbursement rates were too low to sustain the provision of CPS services to eligible recipients. Pertinent here, the Commonwealth Court agreed with one of DHS' preliminary objections that Petitioners failed to exhaust their administrative remedies, as required by case precedent, before seeking judicial review. The court acknowledged a narrow exception to the exhaustion requirement whereby a court may consider the merits of a claim for declaratory or injunctive relief if a substantial constitutional question is raised and the administrative remedy is inadequate. It clarified, however, that the exception only applied where the plaintiff raises a facial constitutional challenge to the statute or regulation in question, as opposed to its application in a particular case. Here, the court concluded, the Petitioners were attacking the fee schedule in the Final Notice, which was produced by application of the legal authority cited in that notice, and not advancing a facial constitutional challenge. The court also found Petitioners failed to demonstrate the administrative remedy was inadequate. The Supreme Court affirmed the Commonwealth Court’s order insofar as it sustained the preliminary objection asserting that the Petitioners failed to exhaust their administrative remedies, and dismissed the Petition as to those parties. The order was vacated in all other respects, and the matter was remanded for further proceedings. View "Rehabilitation & Community Providers Association, et al. v. Dept. Human Svcs" on Justia Law

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Child foster care systems in this country are administered by state governments. The federal government reimburses states for “foster care maintenance payments” that the state makes to certified foster caregivers who meet federal-eligibility requirements. In Ohio, there are also foster caregivers (typically relatives) whom the state does not certify as meeting those federal requirements. Ohio withholds payments for those caregivers and provides these non-certified caregivers with less generous payments through a separate state program. The plaintiffs, foster caregivers whom Ohio has considered ineligible to receive the higher foster care maintenance payments, sued. The district court dismissed, finding that the caregivers did not have to meet the same licensing standards as licensed caregivers in Ohio and thus were not “foster family homes” as required by federal law.The Sixth Circuit affirmed. Title IV-E of the Social Security Act, 42 U.S.C. 671 (a), requires that all foster family homes eligible for payments under federal law meet the same licensing standards; the plaintiffs are subject to different standards than “licensed” caregivers are not “foster family home,” and are not eligible for the higher payments. View "T.M. v. DeWine" on Justia Law

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In 1993, Kastman was charged with misdemeanor offenses based on acts of public indecency involving children and disorderly conduct. The state’s attorney initiated a civil commitment proceeding against Kastman under the Sexually Dangerous Persons Act (725 ILCS 205/0.01). Evidence indicated that Kastman suffered from pedophilia, antisocial personality disorder, exhibitionism, and alcohol dependency. Kastman was found to be a sexually dangerous person, and the circuit court granted the petition. In 2016, Kastman was granted conditional release from institutional care.In 2020, he sought financial assistance. Kastman asserted that he was unemployed, disabled, and could not afford his $300 monthly treatment costs and the $1800 monthly rent for housing that complied with the Sex Offender Registration Act. The circuit court of Lake County ordered the Department of Corrections to pay a portion of Kastman’s monthly expenses. The appellate court and Illinois Supreme Court affirmed. The statutes indicate that a sex offender’s ability to pay is a relevant consideration in deciding who should bear the expense of treatment costs; without a clear statutory directive, the legislature is not presumed to have intended that only financially stable individuals are eligible for conditional release. Financial instability and the need for supervision to protect the public are not the same things. View "People v. Kastman" on Justia Law

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The Department of Veterans Affairs rating schedule standardizes the evaluation of how severely diseases and injuries resulting from military service impair veterans’ earning capacity, 38 C.F.R. 4.1. The rating schedule is divided into diagnostic codes that provide disability ratings for various symptoms or conditions. The Federal Circuit, pursuant to 38 U.S.C. 502, reviewed the VA’s interpretation of two diagnostic codes: DCs 5055 and 5257: the “Knee Replacement Manual Provision” and the “Knee Joint Stability Manual Provision.” The court concluded that DC 5055 is ambiguous as to whether it includes partial knee replacements and, that under controlling Supreme Court precedent, the Secretary’s interpretation is not entitled to deference. A “Guidance” promulgated to clarify that the Provision applied only to total joint replacement did not go through the notice-and-comment procedure followed when the original Diagnostic Code was enacted. The court, therefore, applied the “pro-veteran” canon of construction. The court dismissed the challenge to the Knee Joint Stability Manual Provision as moot because the Secretary rescinded the Manual provision. View "Nova v. Secretary of Veterans Affairs" on Justia Law

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Under the Social Security Act’s Title IV-E program, states receive reimbursements for foster care maintenance payments (FCMPs), 42 U.S.C. 670–676. Title IV-E’s conditions include having a state plan approved by the Secretary of Health and Human Services (HHS); the removed child’s placement and care must be the responsibility of the state agency administering that plan. Kentucky's approved plan is administered by the Kentucky Cabinet for Health and Family Services. Under Kentucky law, a court may remove a child from her home “to the custody of an adult relative, fictive kin,” or other person or facility or can commit the child to the custody of the Cabinet. The Cabinet does not provide FCMPs to children placed by courts into the care of a relative or fictive kin, although that is a preferred outcome for the child.Caregivers brought a class action, accusing the Cabinet of denying FCMPs to eligible children without notice or a fair hearing, in a way that discriminated against relative caregivers. The district court certified a Children’s Class, a Caregivers’ Class, a Cabinet Custody Class, and a Notice and Hearing Class. The Sixth Circuit affirmed the dismissal of the suit except as to the Cabinet Custody Class. Under Kentucky law, the Cabinet did not have placement and care responsibility over children not in their custody; the Cabinet cannot change a child’s placement without a court order. Only Cabinet Custody Class members were eligible for FCMPs. View "J. B-K. v. Kentucky Cabinet for Health and Family Services" on Justia Law

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Access Behavioral Health appeals from the district court’s judgment upholding an order of the Idaho Department of Health and Welfare that demanded recoupment of Medicaid payments made to Access. The Department sought to recoup certain payments made to Access because it failed to meet the Department’s documentation requirements. Following an audit of provider billings, the Department found Access billed Medicaid for two codes for services provided to the same patient on the same day without documentation to support its use of the codes. The Department concluded the documentation deficiencies violated IDAPA Rule 16.03.09.716 and the Handbook. The Idaho Supreme Court determined the Department had legal authority to issue recoupment demands to Access. Access failed to demonstrate an entitlement to payment of those funds sought to be recouped. The False Claims Act's materiality requirement was inapplicable to the Department’s administrative action. Finally, laches did not bar the Department’s administrative actions. Judgment was thus affirmed. View "Access Behavioral Health v. IDHW" on Justia Law

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With the agreement of her supervisor, Johar, a salesperson, left work for about a week to care for a terminally ill relative. While she was away her employer (SWS) decided she had quit. Upon her return, SWS stated business was slow and gave her no new sales appointments. Johar sought unemployment benefits, citing a “temporary layoff.” SWS denied laying Johar off. While conceding that she left with her supervisor’s approval, SWS claimed that Johar’s failure to provide a return date or otherwise communicate with her supervisor while she was away amounted to a voluntary quit. The Employment Development Department agreed, found Johar ineligible for unemployment benefits, ordered reimbursement of benefits improperly paid, and imposed a penalty for willful misrepresentation. The California Unemployment Insurance Appeals Board (CUIAB) affirmed.After Johar sought judicial review, CUIAB confessed error for failing to consider new evidence discovered by Johar while the administrative appeal was pending. The court dismissed the case without reaching the merits. The court of appeal reversed. Johar was entitled to relief on the existing record. She left her job in emergency circumstances with the employer’s approval, thus for good cause; an employee who leaves work for good cause is presumed to have not voluntarily quit. SWS’ evidence did not establish that Johar positively repudiated her obligation to return in clear terms. View "Johar v. California Unemployment Insurance Appeals Board" on Justia Law

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Jarnutowski sought Social Security disability benefits, claiming she could not work due to a foot condition, neck and leg pain, obesity, and mental health issues. Jarnutowski underwent multiple surgeries, X-rays, and CT scans on her foot between 2011-2015. An ALJ awarded Jarnutowski found that she was disabled during September 2013-January 2016, with only the ability to perform light work with some limitations; her foot condition, neck issues, and obesity were severe impairments; and, she was disabled by direct application of the Medical-Vocational Guidelines due to her age. The ALJ concluded that Jarnutowski’s disability ended when she regained the ability to perform medium work after her foot surgery and was again able to perform her past work as a store manager. The ALJ did not explicitly address Jarnutowski’s functional capabilities related to medium work, including Jarnutowski’s ability to lift objects weighing up to 50 pounds and frequently lift or carry objects weighing up to 25 pounds, emphasizing Jarnutowski’s ability to walk.The Seventh Circuit reversed. In Social Security disability determinations, the lifting and carrying weight requirements associated with medium work are more than double those of light work. The ALJ found that Jarnutowski’s “residual functional capacity” was limited to light work with some restrictions before her final foot surgery, but increased to medium work after the surgery without explaining how, after surgery, Jarnutowski could lift or carry objects more than twice the weight that she lifted or carried before surgery. View "Jarnutowski v. Kijakazi" on Justia Law

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Class Counsel discovered the Social Security Administration's (SSA’s) systemic failure to perform “Subtraction Recalculations” and recovered over $106 million in past-due disability benefits. After performing the Subtraction Recalculations for all the claimants, the SSA argued that the district court did not have authority under the Social Security Act’s judicial-review provision, 42 U.S.C. 405(g), to order the Subtraction Recalculations and that Class Counsel cannot recover attorney fees under section 406(b) for representation of the claimants.The Sixth Circuit affirmed the award of $15.9 million in attorney fees to Class Counsel. SSA “may not hide behind” the statutory provisions merely because it erred at the end, rather than at the beginning, of the benefits-award process. The district court appropriately exercised judicial review under section 405(g), properly ordered the SSA to perform the Subtraction Recalculations, and properly awarded reasonable attorneys’ fees. The SSA failed to award claimants additional past-due benefits to which they were entitled. Counsel successfully sought judicial assistance to obtain those benefits. Congress did not create a statute that allows attorneys to recover fees when the SSA initially fails to award benefits, only to foreclose fee recovery when the SSA later unlawfully withholds additional benefits. View "Steigerwald v. Commissioner of Social Security" on Justia Law

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A Social Security Administration ALJ, appointed by agency staff rather than by the Commissioner as required, reviewed and denied claimant’s initial claims. Without challenging the ALJ’s appointment, the claimant appealed to the district court and prevailed in part. The district court vacated the 2017 ALJ decision and ordered a new hearing because the ALJ failed to properly consider certain evidence. The case returned to the same ALJ, who by then had been properly ratified by the Acting Commissioner. The ALJ again denied benefits, and claimant appealed to the district court, raising the issue of an Appointments Clause violation. The district court affirmed the ALJ decision and denied the Appointments Clause claim because the 2017 decision had been vacated and the ALJ was properly appointed when she issued the 2019 decision.   Because the ALJ’s decision was tainted by a prior Appointments Clause violation, the Ninth Circuit vacated the district court’s decision affirming the Commissioner of Social Security’s denial of claimant’s application for benefits under the Social Security Act and remanded with instructions to the Commissioner to assign the case to a different, validly appointed ALJ to rehear and adjudicate claimant’s case de novo. The panel held that under Lucia, the claimant was entitled to a new hearing before a different ALJ. The panel concluded that claimants are entitled to an independent decision issued by a different ALJ if a timely challenged ALJ decision is tainted by a pre-ratification ALJ decision. View "BRIAN CODY V. KILOLO KIJAKAZI" on Justia Law