Justia Public Benefits Opinion Summaries

The Supreme Court held that because Plaintiff's state-law claims were based on allegations that his father's health maintenance organization (HMO) plan and healthcare services administrator that managed his father's benefits (collectively, Defendants) breached state-law duties that incorporated and duplicated standards established under Medicare Part C, Part C's preemption provision preempted them.Plaintiff brought this action alleging a state statutory claim under the Elder Abuse Act and common law claims of negligence and wrongful death for the alleged maltreatment of his father, a Medicare Advantage (MA) enrollee who died after being discharged from a skilled nursing facility. Plaintiff alleged that the MA HMO and healthcare services administrator breached a duty to ensure his father received skilled nursing benefits to which he was entitled under his MA plan. Defendants demurred, arguing that the claims were preempted by Part C's preemption provision. The trial court sustained the demurrers, and the court of appeal affirmed. The Supreme Court affirmed, holding that because Plaintiff's state-law claims were based on allegations that Defendants breached state-law duties that incorporate and duplicate standards established under Part C, the claims were expressly preempted. View "Quishenberry v. UnitedHealthcare, Inc." on Justia Law

Plaintiff filed in the U.S. District Court for the Western District of Washington a pro se action to challenge the denial of his claim for disability benefits by the Social Security Administration. A magistrate judge of that court, acting with the full civil authority of that court, reversed and remanded the matter to the agency for rehearing after the government conceded that there was an error in the agency’s adjudication. Plaintiff appealed that decision.   The Ninth Circuit affirmed. The panel considered whether the magistrate judge had authority to exercise the full civil jurisdiction of the district court over Plaintiff’s claim. There is no doubt that the district court had jurisdiction over the case, but Plaintiff challenged whether he had given the consent that was required for a magistrate judge to exercise that jurisdiction. The panel held that it had jurisdiction to review the antecedent question of whether the magistrate judge validly entered judgment on behalf of the district court. The panel rejected Plaintiff’s contention that, as a pro se litigant, he believed he was consenting to the magistrate judge’s issuance of a report and recommendation, not a final judgment. The panel held that Plaintiff was fully informed of the district court’s conclusion that he had knowingly and voluntarily consented to the assignment to the magistrate judge. Further, the court wrote that Plaintiff was unable to show good cause or extraordinary circumstances to withdraw consent. The panel affirmed the district court’s conclusion that Plaintiff consented to magistrate judge jurisdiction. View "VICTOR WASHINGTON V. KILOLO KIJAKAZI" on Justia Law

Relying on the vocational expert (“VE”)’s testimony, the administrative law judge (“ALJ”) found that there were a significant number of jobs in the national economy that Plaintiff could perform, and, therefore, Plaintiff was not disabled. Plaintiff’s attorney sent a letter to the Appeals Council asking it to review the ALJ’s finding that there were a significant number of jobs in the national economy that Plaintiff could perform. The Appeals Council made the attorney’s letter and a six-page attachment part of the record and denied Plaintiff’s request for review of the ALJ’s disability determination because it “found no reason under [the] rules to review the Administrative Law Judge’s decision.” On appeal, Plaintiff challenged only the ALJ’s conclusion that there were a significant number of jobs in the national economy that a person with Plaintiff’s limitations, age, education, and experience could perform.   The Ninth Circuit affirmed the district court’s decision upholding the Commissioner of Social Security’s denial. The panel held that to determine whether the ALJ had a duty to address a conflict in job-number evidence (and failed to discharge that duty), it considers on a case-by-case “meritless or immaterial” or has “significant probative value.” Because Plaintiff did not present his job-number evidence to the ALJ during or after the hearing, the ALJ did not have any occasion to address the purported inconsistency between the VE’s estimates and Plaintiff’s contrary estimates. The panel held that the letter by Plaintiff’s counsel and the six pages of printouts together provided no basis to conclude that these results qualified as significant and probative evidence. View "JAMES WISCHMANN V. KILOLO KIJAKAZI" on Justia Law

Plaintiff filed a claim under 42 U.S.C 405(g), believing the Social Security Administration miscalculated his benefits. He filed his claim more than one year after the SSA verbally denied his request for review, and after he did not receive the requested written documentation of the SSA's denial.The SSA filed a motion to dismiss, arguing that the district court lacked subject matter jurisdiction because Sec. 405(g)’s waiver of sovereign immunity applied only with respect to judicial review of a “final decision of the Commissioner of Social Security” and that Plaintiff had not obtained a final decision, having refused to exhaust the four-step administrative process. The district court granted SSA’s motion.Finding that Sec. 405(g)’s exhaustion requirement is not jurisdictional, the Fourth Circuit nonetheless concluded that exhaustion is a mandatory requirement of the Social Security Act that may be excused only in a narrow set of circumstances, which were not present in this case. Accordingly, the court affirmed the district court’s dismissal. View "L.N.P. v. Kilolo Kijakazi" on Justia Law

More than a decade ago, Medicaid recipients filed this suit alleging that in violation of the Due Process Clause, the District of Columbia is failing to provide them notice and an opportunity to be heard when denying them prescription coverage. The case is now before the DC Circuit for the third time. In the first two appeals, the DC Circuit reversed the district court’s dismissals for lack of standing and for failure to state a claim, respectively. On remand, the district court once more dismissed the case, this time for mootness.   The DC Circuit again reversed and remanded with instructions to proceed expeditiously with discovery and allow Plaintiffs to make their case. The court explained that Plaintiffs challenged the District’s failure to give Medicaid recipients reasons for denying their prescriptions and an explanation of how to appeal, and uncontested evidence demonstrates that, notwithstanding the transmittal memorandum, some number of Plaintiffs are still not receiving the information they claim they are entitled to under the Due Process Clause. Because it is not “impossible for [the district] court to grant any effectual relief,” the case is not moot. View "Elsa Maldonado v. DC" on Justia Law

The Northern Arapaho Tribe and the Indian Health Service (IHS) entered into a contract under the Indian Self-Determination and Education Assistance Act for the Tribe to operate a federal healthcare program. Under the contract, the Tribe provided healthcare services to Indians and other eligible beneficiaries. In exchange, the Tribe was entitled to receive reimbursements from IHS for certain categories of expenditures, including “contract support costs.” The contract anticipates that the Tribe will bill third-party insurers such as Medicare, Medicaid, and private insurers. The Tribe contended that overhead costs associated with setting up and administering this third-party billing infrastructure, as well as the administrative costs associated with recirculating the third-party revenue it received, qualified as reimbursable contract support costs under the Self-Determination Act and the Tribe’s agreement with the IHS. But when the Tribe attempted to collect those reimbursements, IHS disagreed and refused to pay. Contending it had been shortchanged, the Tribe sued the government. The district court, agreeing with the government’s reading of the Self-Determination Act and the contract, granted the government’s motion to dismiss. A divided panel of the Tenth Circuit Court of Appeals voted to reverse (for different reasons). Under either of the jurists' interpretations, the administrative expenditures associated with collecting and expending revenue obtained from third-party insurers qualified as reimbursable contract support costs. View "Northern Arapaho Tribe v. Becerra, et al." on Justia Law

May is a disabled child of a deceased veteran. The VA found that May was disabled from birth, with permanent incapacity for self-support, and granted him entitlement to dependency and indemnity compensation (DIC) benefits in October 2018, with an effective date of May 18, 2016, concluding that May’s entitlement to DIC benefits ended on February 1, 2017, when he married. May sought reinstatement of DIC benefits based on his divorce. May filed a notice of appeal to the Veterans Court in February 2021, listing the date of the Board’s decision as February 19, 2019. The Board had not rendered a decision on February 19, 2019; rather, May had received correspondence that day from a VA regional office certifying an appeal to the Board.The Veterans Court ordered May to show cause why his appeal should not be dismissed. In letters, May asked that his appeal not be dismissed and that his benefits be reinstated. May did not identify a Board decision from which he was appealing, nor did he argue that the Board had unreasonably delayed its decision. The Federal Circuit affirmed the dismissal of the appeal for lack of jurisdiction. The court’s jurisdiction is limited to appeals from Board decisions; absent such a decision, it could not consider May’s appeal, 38 U.S.C. 7252(a), 7266(a)). View "May v. McDonough" on Justia Law

Petitioners PF Sunset Plaza, LLC (“Sunset Plaza”) and PF Holdings, LLC (“Holdings”) were each assessed monetary penalties by the Department of Housing and Urban Development (“HUD”) for violations of their duty to provide “decent, safe, and sanitary housing” to low-income families under Section 8. Petitioners petitioned to reverse ALJ decisions dismissing these HUD enforcement actions against them for lack of subject matter jurisdiction. At issue on appeal is whether the statute operates to bar the appeal of a civil monetary penalty should a respondent miss the fifteen-day deadline to request an administrative hearing?   The DC Circuit answered yes, and denied both petitions. The court explained that Petitioners claim that because the deadline falls under a subheading entitled “Final Orders,” a final order from HUD must occur before operation of the deadline commences. Petitioners argued that HUD’s issuance of a complaint is simply an invitation to engage in litigation, not a triggering of the fifteen-day deadline. Because HUD issued no final order here, they contest that the fifteen-day period never began. The court held that Petitioners misunderstand the statutory subheading. Congress entitled the section “Final Orders” because it enumerates two examples of how HUD’s penalties become final. View "PF Holdings, LLC v. HUD" on Justia Law

Approximately 30 years after Arellano’s honorable discharge from the Navy, a VA regional office granted Arellano service-connected disability benefits for his psychiatric disorders. Applying the default rule in 38 U.S.C. 5110(a)(1), the VA assigned an effective date of June 3, 2011—the day that it received Arellano's claim—to the award. Arellano argued that the effective date should be governed by an exception in section 5110(b)(1), which makes the effective date the day following the date of the veteran’s discharge or release if the application “is received within one year from such date of discharge or release.” Alleging that he had been too ill to know that he could apply for benefits, Arellano maintained that this exception’s one-year grace period should be equitably tolled to make his award effective the day after his 1981 discharge.The Board of Veterans’ Appeals, Veterans Court, Federal Circuit, and Supreme Court disagreed. Section 5110(b)(1) is not subject to equitable tolling. Equitably tolling one of the limited exceptions would depart from the terms that Congress “specifically provided.” The exceptions do not operate simply as time constraints, but also as substantive limitations on the amount of recovery due. Congress has already considered equitable concerns and limited the relief available, aware of the possibility that disability could delay an application for benefits. View "Arellano v. McDonough" on Justia Law

The First Circuit affirmed the judgment of the district court determining that Act 90, passed by the Legislative Assembly of Puerto Rico in 2019, was preempted by federal law, holding that the district court did not err.Act 90 requires that Medicare Advantage plans compensate Puerto Rico healthcare providers in Puerto Rico at the same rate as providers are compensated under traditional Medicare. Plaintiffs, several entities that managed Medicare Advantage plans, filed suit seeking a declaratory judgment and an injunction barring the "mandated price provision," arguing that the Medicare Advantage Act preempted the challenged provision and that provision was unconstitutional. The district court ruled in favor of Plaintiffs. The First Circuit affirmed, holding that Act 90's mandated price provision was preempted by federal law. View "Medicaid & Medicare Advantage Products Ass'n of Puerto Rico, Inc. v. Emanuelli-Hernandez" on Justia Law