Justia Public Benefits Opinion Summaries

Louisiana, represented by its Attorney General, filed this lawsuit in 2014 against defendants, Molina Healthcare, Inc., Molina Information Systems, L.L.C. d/b/a Molina Medicaid Solutions, and Unisys Corporation. As described in the state’s petition, “[o]ver the last thirty (“30”) years, the Defendants have been the fiscal agent responsible for processing Louisiana’s Medical pharmacy provider reimbursement claims.” Pursuant to a contract to which the state itself was allegedly a party, “the Defendants assumed operational liability” of a “customizable” computerized system known as the Louisiana Medicare Management Information System (“LMMIS”). As part of defendants’ duties, they were “responsible for the operation and maintenance of LMMIS, as well as creating and implementing design changes to the LMMIS that comply with State and federal mandates.” The crux of the state’s allegations in this lawsuit is that Unisys caused the Louisiana Department of Health (“LDH”) to overpay Medicaid pharmacy providers through Unisys’ improper operation and management of LMMIS. The Louisiana Supreme Court granted certiorari review in this case to review the correctness of the appellate court’s ruling, sustaining an exception of no right of action for the Attorney General’s lawsuit against the defendants. By statute, the Louisiana Department of Health had the capacity to sue and be sued for programs that it administered, such as Medicaid. However, because the Louisiana Department of Health delegated–and defendants allegedly contractually accepted–some of the administrative functions of the state’s Medicaid program, the Supreme Court found the Attorney General had the capacity, and hence a right of action, to prosecute this lawsuit. View "Louisiana ex rel. Caldwell v. Molina Healthcare, Inc." on Justia Law

The Supreme Court dismissed the appeal brought by the Arkansas Department of Humanitarian Services (DHS) challenging the permanent injunction against its 2015 ARChoices Medicaid waiver rule, holding that this case was moot.During the course of this appeal, DHS promulgated a new rule. The circuit court found that DHS had properly promulgated the rule and dissolved the injunction. DHS argued before the Supreme Court that two exceptions to the mootness doctrine - matters capable of repetition yet evading review and matters of substantial public interest that are likely to be litigated in the future - applied in this case. The Supreme Court disagreed and dismissed this appeal, holding that none of the exceptions to the mootness doctrine applied. View "Arkansas Department of Human Services v. Ledgerwood" on Justia Law

Biestek, a former construction worker, applied for social security disability benefits, claiming he could no longer work due to physical and mental disabilities. To determine whether Biestek could successfully transition to less physically demanding work, the ALJ heard testimony from a vocational expert regarding the types of jobs Biestek could still perform and the number of such jobs that existed in the national economy. The statistics came from her own market surveys. The expert refused Biestek’s attorney's request to turn over the surveys. The ALJ denied Biestek benefits. An ALJ’s factual findings are “conclusive” if supported by “substantial evidence,” 42 U.S.C. 405(g).The Sixth Circuit and the Supreme Court upheld the ALJ’s determination. A vocational expert’s refusal to provide private market-survey data upon the applicant’s request does not categorically preclude the testimony from counting as “substantial evidence.” In some cases, the refusal to disclose data, considered along with other shortcomings, will undercut an expert’s credibility and prevent a court from finding that “a reasonable mind” could accept the expert’s testimony; the refusal will sometimes interfere with effective cross-examination, which a reviewing court may consider in deciding how to credit an expert’s opinion. In other cases, even without supporting data, an applicant will be able to probe the expert’s testimony on cross-examination. The Court declined to establish a categorical rule, applying to every case in which a vocational expert refuses a request for underlying data. The inquiry remains case-by-case, taking into account all features of the expert’s testimony, with the rest of the record, and defers to the presiding ALJ. View "Biestek v. Berryhill" on Justia Law

Blue Valley Hospital, Inc., (“BVH”) appealed a district court’s dismissal of its action for lack of subject matter jurisdiction. The Department of Health and Human Services (“HHS”) and the Centers for Medicare and Medicaid Services (“CMS”) terminated BVH’s Medicare certification. The next day, BVH sought an administrative appeal before the HHS Departmental Appeals Board and brought this action. In this action, BVH sought an injunction to stay the termination of its Medicare certification and provider contracts pending its administrative appeal. The district court dismissed, holding the Medicare Act required BVH exhaust its administrative appeals before subject matter jurisdiction vested in the district court. BVH acknowledged that it did not exhaust administrative appeals with the Secretary of HHS prior to bringing this action, but argued: (1) the district court had federal question jurisdiction arising from BVH’s constitutional due process claim; (2) BVH’s due process claim presents a colorable and collateral constitutional claim for which jurisdictional exhaustion requirements are waived under Mathews v. Eldridge, 424 U.S. 319 (1976); and (3) the exhaustion requirements foreclosed the possibility of any judicial review and thus cannot deny jurisdiction under Bowen v. Michigan Academy of Family Physicians, 476 U.S. 667 (1986). The Tenth Circuit disagreed and affirmed dismissal. View "Blue Valley Hospital v. Azar" on Justia Law

Darrin, age 81, filed a Request for Elder or Dependent Adult Abuse Restraining Orders, alleging that her next-door neighbor Miller and Miller’s boyfriend harassed and intimidated her by taunting her, threatening her, twice removing a wire boundary fence between the properties, and trespassing onto her property where they destroyed a hedge and defaced and damaged a barrier fence. Miller argued that Darrin had no standing to seek an order against her under the Act because Miller had no care or custody arrangement with Darrin and no control over Darrin’s real or personal property. The court of appeal reversed the dismissal of the suit. The plain language of the Elder Abuse Act authorizes a trial court to issue a restraining order against any individual who has engaged in abusive conduct, as defined by statute, toward a person age 65 or older regardless of the relationship between the alleged abuser and victim, Welfare and Institutions Code 15610.07(a)(1). View "Darrin v. Miller" on Justia Law

A 2014 statute and 2013 regulation re-defined which abortions qualified as “medically necessary” for the purposes of Medicaid funding. The statute defined medically necessary abortions as those that “must be performed to avoid a threat of serious risk to the life or physical health of a woman from continuation of the woman’s pregnancy” as a result of a number of listed medical conditions; the regulation was similarly restrictive. Planned Parenthood of the Great Northwest challenged both the statute and regulation as unconstitutional, and the superior court held that both measures violated the equal protection clause of the Alaska Constitution. The court reasoned that these measures imposed a “high-risk, high- hazard” standard on abortion funding unique among Medicaid services, and held that our 2001 decision striking down an earlier abortion funding restriction on equal protection grounds compelled the same result. The State appealed, arguing that the statute and regulation should be interpreted more leniently and therefore do not violate the Alaska Constitution’s equal protection clause. The Alaska Supreme Court affirmed the superior court’s decision: the statute’s and the regulation’s facially different treatment of pregnant women based upon their exercise of reproductive choice required the Court to apply strict scrutiny, and the proposed justifications for the funding restrictions "did not withstand such exacting examination." View "Alaska v. Planned Parenthood of the Great Northwest" on Justia Law

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

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

Michigan’s Medicaid waiver program provides individuals with developmental disabilities community-based services. Washtenaw County changed its budgeting method in 2015. Notices sent to recipients acknowledged that recipients would have to pay service-providers less in order to maintain their approved hours of service. The Association, a nonprofit community organization assisting individuals with developmental disabilities, joined with three individual plaintiffs to filed suit, alleging due process violations and seeking a preliminary injunction. The Association’s CEO testified that 169 individuals, including the three named plaintiffs, had received notices and that the three were Association members. The district court concluded that the Association lacked associational standing because the 169 people for whom it claimed associational standing were not shown to be members; the named members, in their individual capacities, were not entitled to injunctive relief because they had appealed the reductions and received favorable decisions so “there can be no irreparable harm suffered by the named Plaintiffs as a result of the inadequate notice.” The Sixth Circuit affirmed, noting that “standing is not dispensed in gross.” An individual must demonstrate standing for each claim he seeks to press and for each form of relief sought; an association that relies upon an individual member for standing purposes must do the same. The Association has not shown that any named member had standing to seek fresh notices and hearing rights when it filed its complaint.. View "Waskul v. Washtenaw County Community Mental Health" on Justia Law

This matter stemmed from a lawsuit filed by the State of Mississippi against the defendant pharmacies. The State alleged deceptive trade practices and fraudulent reporting of inflated “usual and customary” prices in the defendant’s reimbursement requests to the Mississippi Department of Medicaid. The State argued that Walgreens, CVS, and Fred’s pharmacies purposefully misrepresented these prices to obtain higher prescription drug reimbursements from the State. Finding that the circuit court was better equipped to preside over this action, the DeSoto County Chancery Court transferred the matter to the DeSoto County Circuit Court in response to the defendants’ request. Aggrieved, the State timely filed an interlocutory appeal disputing the chancellor’s decision to transfer the case. After a thorough review of the parties’ positions, the Mississippi Supreme Court found that though the chancery court properly could have retained the action, the chancellor correctly used his discretion to transfer the case, allowing the issues to proceed in front of a circuit-court jury. As a result, the Supreme Court affirmed the chancellor’s decision. View "Mississippi v. Walgreen Co." on Justia Law