Justia Public Benefits Opinion Summaries

This case involved the interplay between the Medicare Secondary Payer Statute (MSP), 42 U.S.C. 1395y(b), and Texas workers' compensation law. At issue was whether the MSP preempted a state law that required a workers' compensation claimant to obtain preauthorization from the relevant carrier before incurring certain medical expenses. The court held that it did not. The court concluded that Congress intended the MSP to complement, no supplant, state workers' compensation rules. This included the preauthorization requirement that plaintiff failed to meet before he filed suit. The court rejected plaintiff's claim that Medicare's conditional payment for his surgeries - which equated to a determination that his surgeries were medically unnecessary - rendered the state-law preauthorization requirement "moot" because preauthorization likewise depended on a showing of medical necessity. Accordingly, the court affirmed the district court's dismissal of plaintiff's claim for failure to state a claim under Rule 12(b)(6). View "Caldera v. The Ins. Co. of the State of PA" on Justia Law

Plaintiffs, a class of Medicaid beneficiaries who suffered from severe developmental disabilities, sued the NCDHHS, PBH, and the director of PBH, alleging that defendants violated their rights under the Medicaid statute and the Due Process Clause of the Fourteenth Amendment by reducing their health care services without notice and an opportunity for a hearing. On appeal, PBH and the director challenged the district court's entry of a preliminary injunction. However, the NCDHHS did not join the appeal. Given that the NCDHHS had decided not to litigate the appeal, the court concluded that the Medicaid statute, 42 U.S.C. 1396a(a)(5), and accompanying regulations precluded PBH from appealing in the absence of the NCDHHS. Accordingly, the court dismissed the appeal. View "K.C. v. Shipman" on Justia Law

Providers brought suit against the State, asserting that the Adoption Assistance and Child Welfare Act of 1980 (CWA), 42 U.S.C. 670 et seq., gave them a privately enforceable right under 42 U.S.C. 1983 to receive payments from the State sufficient to cover the cost of certain statutorily enumerated components of foster care. At issue was whether Congress, in enacting the CWA, evinced a clear intent to grant foster care providers an individually enforceable right to foster care maintenance payments sufficiently large to cover the costs of each item enumerated in section 675(4)(A). The court held that Congress did not ambiguously confer such a right and, therefore, affirmed the district court's dismissal of the Providers' complaint for failure to state a claim. View "Midwest Foster Care, etc., et al v. Kincade, et al" on Justia Law

This dispute arose from California's implementation of a change to Medicare in 2006. The Centers argued that California mishandled the shift in payment responsibility for dual-eligibles' prescription drug costs from state Medicaid programs to the new, federal Medicare Part D Program. The Centers brought suit for declaratory and injunctive relief. Among other things, the Centers urged the federal courts to declare unlawful California's "seizure" of the Centers' Medicare Part D funds, in excess of what would be owed under the per-visit rate for the Centers' expenses. The court concluded that the Eleventh Amendment barred the Centers' claims for retroactive monetary relief; the court affirmed the district court's dismissal of the Centers' claims to the extent that they sought money damages; however, the court reversed the district court and remanded to allow the district court to assess Ex parte Young's application to the Center's remaining claims. View "North East Medical Services v. CA Dept. of Health" on Justia Law

Plaintiffs, thirteenth North Carolina residents who lost access to in-home personal care services (PCS) due to a statutory change, brought suit challenging the new PCS program. The district court granted plaintiffs' motions for a preliminary injunction and class certification. Defendants appealed, raising several points of error. The court agreed with the district court's conclusion that a preliminary injunction was appropriate in this case. The court held, however, that the district court's order failed to comply with Federal Rule of Civil Procedure 65 because it lacked specificity and because the district court neglected to address the issue of security. Accordingly, the court remanded the case. View "Pashby v. Delia" on Justia Law

The State appealed from the district court's order enjoining it from requiring plaintiff to submit to a suspicionless drug test pursuant to Section 414.0652 of the Florida Statutes, as a condition for receipt of government-provided monetary assistance for which he was otherwise qualified. Plaintiff applied for financial assistance benefits for himself and his son through Florida's Temporary Assistance for Needy Families program (TANF). The court held that the district court did not abuse its discretion in granting the preliminary injunction enjoining the State from enforcing the statute because the court concluded that the State had failed to establish a substantial special need to support its mandatory suspicionless drug testing of TANF recipients. View "Lebron v. Secretary, FL Dept. of Children and Families" on Justia Law

In the four cases giving rise to these eleven consolidated appeals, the Secretary of the Department of Health and Human Services (HHS) and the Director of the California Department of Health Care Services (DHCS), appealed the district court's grant of preliminary injunctions to plaintiffs, various providers and beneficiaries of California's Medicaid program (Medi-Cal). At issue was the implementation of Medi-Cal reimbursement rate reductions. The court held that Orthopaedic Hospital v. Belshe did not control the outcome in these cases because it did not consider the key issue here - the Secretary's interpretation of 42 U.S.C. 1396a(a)(30)(A); the Secretary's approval of California's requested reimbursement rates were entitled to Chevron deference; and the Secretary's approval complied with the Administrative Procedures Act, 5 U.S.C. 500 et seq. The court further held that plaintiffs were unlikely to succeed on the merits on their Supremacy Clause claims against the Director because the Secretary had reasonably determined that the State's reimbursement rates complied with section 30(A). The court finally held that none of the plaintiffs had a viable takings claim because Medicaid, as a voluntary program, did not create property rights. View "Managed Pharmacy Care, et al v. Sebelius, et al" on Justia Law

The dispute before the Tenth Circuit in this case centered on interest earned on block grants made to Indian tribes pursuant to the Native American Housing Assistance and Self-Determination Act. Specifically, Appellant Muscogee (Creek) Nation's Division of Housing challenged both a regulation placing a two-year limit on the investment of grant funds and two notices issued by the U.S. Department of Housing and Urban Development stating that any interest accrued after the expiration of this two-year period must be returned to the Department. The Nation sought declaratory relief invalidating the regulation and notices as well as an injunction to prevent HUD from recouping interest earned on grant funds. The Nation also sought recoupment of the approximately $1.3 million of earned interest it wired to HUD after HUD sent a letter threatening an enforcement action based on the Nation’s investment of grant funds for longer than two years. The district court dismissed the complaint, holding that HUD’s sovereign immunity was not waived by the Administrative Procedures Act and, in the alternative, that the Nation had failed to state a claim on which relief could be granted because HUD’s interpretation of the statute was permissible. Upon review, the Tenth Circuit concluded that HUD was authorized to promulgate a regulation limiting the period for investments, and required to demand remittance of interest earned in violation of the regulation. The Nation was therefore not entitled to recouping the interest it paid to HUD pursuant to HUD's enforcement of its rules. View "Muscogee (Creek) Nation v. HUD, et al" on Justia Law

This appeal concerned the implementation of a federally-assisted Medicaid program by the Commonwealth of Puerto Rico, represented by its Secretary of Health. This was the sixth time the First Circuit Court of Appeals considered issues related to a dispute between the Commonwealth and several federally qualified health centers (FQHCs). The FQHCs here took to federal courts their claims for reimbursement payments owed to them under the Medicaid program. The district court, among other things, set a formula in place by way of a preliminary injunction that calculated payments the Commonwealth owed the FQHCs for providing Medicaid services. The First Circuit (1) concluded the formula that the district court endorsed in its preliminary injunction was not sufficiently supported by the factual record, and therefore, the Court remanded for further reformulation; (2) affirmed the district court's denial of the FQHCs' request for indemnification from debts owed to third party managed care organizations; and (3) affirmed the district court's determination that the Eleventh Amendment precludes a federal court from imposing a judgment for money damages upon the Commonwealth to make payments for periods predating the date of the district court's preliminary injunction. View "Consejo de Salud De La Communidad de Playa de Ponce, Inc. v. Gonzalez-Feliciano" on Justia Law

Defendant Barbara Norris, an organizational payee with the Social Security Administration, pled guilty to social security representative payee fraud. The district court sentenced Defendant to eighteen months in prison, the top of her guideline range. Defendant appealed, arguing that her sentence was substantively unreasonable. The Eighth Circuit Court of Appeals affirmed, holding that the district court did not abuse its discretion in sentencing Defendant to eighteen months in prison, as the court properly applied its wide latitude to weigh the factors in the federal sentencing statute and assigned some factors greater weight than others in determining an appropriate sentence. View "United States v. Norri" on Justia Law