Justia Public Benefits Opinion SummariesArticles Posted in Government & Administrative Law
Marietta Memorial Hospital Employee Health Benefit Plan v. DaVita Inc.
The employer-sponsored group health plan offers all of its participants the same limited coverage for outpatient dialysis. A dialysis provider sued the plan, citing the Medicare Secondary Payer statute, which makes Medicare a “secondary” payer to an individual’s existing insurance plan for certain medical services, including dialysis, when that plan already covers the same services, 42 U.S.C. 1395y(b)(1)(C), (2), (4). To prevent plans from circumventing their primary-payer obligation for end-stage renal disease treatment, a plan may not differentiate in the benefits it provides between individuals having end-stage renal disease and other individuals based on the existence of end-stage renal disease, the need for renal dialysis, “or in any other manner” and may not take into account that an individual is entitled to or eligible for Medicare due to end-stage renal disease. The Sixth Circuit ruled that the limited payments for dialysis treatment had a disparate impact on individuals with end-stage renal disease.The Supreme Court reversed. The plan's coverage terms for outpatient dialysis do not violate section 1395y(b)(1)(C) because those terms apply uniformly to all covered individuals. The statute prohibits a plan from differentiating in benefits between individuals with and without end-stage renal disease; it cannot be read to encompass a disparate-impact theory. The statute simply coordinates payments between group health plans and Medicare without dictating any particular level of dialysis coverage. The plan does not “take into account” whether its participants are entitled to or eligible for Medicare. View "Marietta Memorial Hospital Employee Health Benefit Plan v. DaVita Inc." on Justia Law
Military-Veterans Advocacy Inc. v. Secretary of Veterans Affairs
The U.S. military sprayed over 17 million gallons of herbicides over Vietnam during “Operation Ranch Hand,” primarily Agent Orange. Concerns about the health effects of veterans’ exposure to Agent Orange led to the Agent Orange Act of 1991, 105 Stat. 11. For veterans who served in the Republic of Vietnam during a specified period, the Act presumes exposure to an herbicide agent containing 2,4-D or dioxin, 38 U.S.C. 1116(f), and presumes a service connection for certain diseases associated with herbicide-agent exposure, such as non-Hodgkin’s lymphoma and soft-tissue sarcoma. The VA subsequently issued regulations extending similar presumptions to other groups of veterans. In 2017, the House of Representatives Armed Services Committee expressed concern that additional exposures to Agent Orange may have occurred in Guam.In 2018, MVA petitioned the VA to issue rules presuming herbicide-agent exposure for veterans who served on Guam or Johnston Island during specified periods. The VA denied MVA’s petition. The Federal Circuit rejected MVA’s petitions under 38 U.S.C. 502 to set aside the VA’s denial. MVA has not shown that the VA’s determination that the evidence did not warrant presuming exposure for every single veteran who served in named areas during the relevant period was contrary to law nor that the denial “lacked a rational basis.” View "Military-Veterans Advocacy Inc. v. Secretary of Veterans Affairs" on Justia Law
George v. McDonough
George joined the Marine Corps in 1975 without disclosing his history of schizophrenic episodes. His medical examination noted no mental disorders. George suffered an episode during training. The Marines medically discharged him. George applied for veterans’ disability benefits based on his schizophrenia, 38 U.S.C. 1110. The Board of Veterans’ Appeals denied his appeal from a regional office denial in 1977. In 2014, George asked the Board to revise its final decision. When the VA denies a benefits claim, that decision generally becomes “final and conclusive” after the veteran exhausts the opportunity for direct appeal. George sought collateral review under an exception allowing revision of a final benefits decision at any time on grounds of “clear and unmistakable error,” 38 U.S.C. 5109A, 7111. He claimed that the Board applied a later-invalidated regulation to deny his claim without requiring the VA to rebut the statutory presumption that he was in sound condition when he entered service.The Veterans Court, Federal Circuit, and Supreme Court affirmed the denial of relief. The invalidation of a VA regulation after a veteran’s benefits decision becomes final cannot support a claim for collateral relief based on clear and unmistakable error. Congress adopted the “clear and unmistakable error doctrine” developed under decades of prior agency practice. The invalidation of a prior regulation constitutes a “change in interpretation of law” under historical agency practice, not “clear and unmistakable error.” That approach is consistent with the general rule that the new interpretation of a statute can only retroactively affect decisions still open on direct review. The fact that Congress did not expressly enact the specific regulatory principle barring collateral relief for subsequent changes in interpretation does not mean that the principle did not carry over. View "George v. McDonough" on Justia Law
American Hospital Association v. Becerra
The formula that the Department of Health and Human Services must employ annually to set reimbursement rates for certain outpatient prescription drugs provided by hospitals to Medicare patients, 42 U.S.C. 1395l(t)(14)(A)(iii), provides two options. If HHS has conducted a survey of hospitals’ acquisition costs for each covered outpatient drug, it may set reimbursement rates based on the hospitals’ “average acquisition cost” for each drug, and may “vary” the reimbursement rates “by hospital group.” Absent a survey, HHS must set reimbursement rates based on “the average price” charged by manufacturers for the drug as calculated and adjusted by the Secretary. For 2018 and 2019, HHS did not conduct a survey but issued a final rule establishing separate reimbursement rates for hospitals that serve low-income or rural populations through the “340B program” and all other hospitals. The district court concluded that HHS had acted outside its statutory authority. The D.C. Circuit reversed. A unanimous Supreme Court reversed. The statute does not preclude judicial review of HHS’s reimbursement rates. Absent a survey of hospitals’ acquisition costs, HHS may not vary the reimbursement rates only for 340B hospitals; HHS’s 2018 and 2019 reimbursement rates for 340B hospitals were therefore unlawful. HHS’s power to increase or decrease the price is distinct from its power to set different rates for different groups of hospitals and HHS’s interpretation would make little sense given the statute’s overall structure. Congress, when enacting the statute, was aware that 340B hospitals paid less for covered prescription drugs and may have intended to offset the considerable costs of providing healthcare to the uninsured and underinsured in low-income and rural communities. View "American Hospital Association v. Becerra" on Justia Law
Arapahoe County v. Velarde & Moore
The Department of Human Services for Arapahoe County (“the Department”) sued Monica Velarde and Michael Moore to enforce a final order it had issued against them to recover Medicaid overpayments. But the Department did so only after undertaking extensive efforts on its own to recoup the fraudulently obtained benefits. The district court dismissed the Department’s suit, finding that section 24-4-106(4), C.R.S. (2021), which was part of the State Administrative Procedure Act (“APA”), required an agency seeking judicial enforcement of one of its final orders to do so within thirty-five days of the order’s effective date. The Colorado Supreme Court determined district court and the court of appeals incorrectly relied on an inapplicable statutory deadline in ruling that the complaint was untimely filed. Each court was called upon to determine whether a thirty-five-day deadline governing proceedings initiated by an adversely affected or aggrieved person seeking judicial review of an agency’s action also applied to proceedings initiated by an agency seeking judicial enforcement of one of its final orders. Both courts answered yes. The Supreme Court, however, answered no. Judgment was reversed and the case remanded for further proceedings. View "Arapahoe County v. Velarde & Moore" on Justia Law
ResCare Health Services Inc. v. Indiana Family & Social Services Administration
The Supreme Court reversed the judgment of the trial court denying ResCare Health Service's request for a declaratory judgment, holding that ResCare sufficiently pleaded its declaratory judgment request.ResCare, which operates intermediate care facilities in Indiana for individuals with intellectual disabilities, petitioned for administrative reconsideration after an auditor with the Indiana Family & Social Services Administration’s Office of Medicaid Policy and Planning (FSSA) adjusted cost reports to prevent ResCare from recovering costs for over-the-counter medicines under Medicaid. An ALJ granted summary judgment for ResCare. The trial court affirmed the agency's final decision. The Supreme Court reversed, holding (1) ResCare did not need to file a separate complaint for a declaratory judgment; (2) ResCare sufficiently pleaded its declaratory judgment claim; and (3) ResCare's patients did not have to be joined to the litigation before the declaratory judgment request could be considered. View "ResCare Health Services Inc. v. Indiana Family & Social Services Administration" on Justia Law
Hawkins, et al. v. Ivey, et al.
In response to economic conditions related to the spread of COVID-19, Congress established several programs that made additional federal funds available to the states for providing enhanced unemployment-compensation benefits to eligible individuals. Alabama elected to participate in the programs, and Shentel Hawkins, Ashlee Lindsey, Jimmie George, and Christina Fox, were among the Alabamians who received the enhanced benefits. As the spread of COVID-19 waned, Governor Kay Ivey announced that Alabama would be ending its participation in the programs. When Alabama did so, the claimants received reduced unemployment-compensation benefits or, depending on their particular circumstances, no benefits at all. Two months later, the claimants sued Governor Ivey and Secretary of the Alabama Department of Labor Fitzgerald Washington in their official capacities, alleging that Alabama law did not permit them to opt Alabama out of the programs. After a circuit court dismissed the claimants' lawsuit based on the doctrine of State immunity, the claimants appealed. Finding no reversible error, the Alabama Supreme Court affirmed the circuit court. View "Hawkins, et al. v. Ivey, et al." on Justia Law
St. Francis Hospital, et al. v. Becerra
Three teaching hospitals challenged the denial of Medicare reimbursements. At that time, a teaching hospital could obtain reimbursement only by incurring “substantially all” of a resident’s training costs. Because the teaching hospitals had shared the training costs for each resident, the government denied reimbursement. The denials led the teaching hospitals to file administrative appeals. While they were pending, Congress enacted the Affordable Care Act (ACA), which created a new standard for reimbursement. The parties disagreed on whether the ACA’s new standard applied to proceedings reopened when Congress changed the law. The agency answered no, and the district court granted summary judgment to the agency. Finding no reversible error in that decision, the Tenth Circuit affirmed. View "St. Francis Hospital, et al. v. Becerra" on Justia Law
Grotts v. Kijakazi
In 2009, Grotts applied for Social Security disability benefits, citing depression and low functional capacity. She had previously worked as a caretaker for a child with disabilities and he cared for her own child. Her case was remanded four times. Five times, an ALJ concluded that Grotts was not disabled. The final ALJ found that she could still perform light work with some restrictions and because a significant number of jobs fitting that description existed in the national economy.The district court agreed. The Seventh Circuit affirmed, rejecting arguments that the ALJ erred in its evaluation of Grotts’s subjective complaints about her symptoms, in its evaluation of the medical opinion evidence, and in its residual functional capacity determination. Substantial evidence supported the ALJ’s weighing of the medical opinion evidence and its RFC determination. The ALJ did not patently err in its evaluation of Grotts’s subjective complaints. View "Grotts v. Kijakazi" on Justia Law
Samons v. National Mines Corp.
After working underground in coal mines for three decades, Casey developed pneumoconiosis (black-lung disease). His widow, Mabel, sought benefits under the Black Lung Benefits Act, 30 U.S.C. 901–44. It took the Department of Labor 17 years to deny her claims. During this time, the claims bounced back and forth between an ALJ and the Benefits Review Board. In the last appeal, the Board also rejected one of Mabel’s main arguments, citing “law-of-the-case,” without reaching the merits. The Department of Labor then delayed things further by filing an incomplete and disorganized administrative record in the Sixth Circuit.The Sixth Circuit affirmed. While the government’s actions “perhaps could be described as poor customer service, they do not show any reversible legal error.” The Board could lawfully invoke the discretionary law-of-the-case doctrine to avoid reexamining an issue on which it had affirmed the ALJ years before. The credibility findings concerning the conflicting medical opinions concerning whether Casey was totally disabled or had only “moderate impairment” pass muster under the deferential “substantial evidence” test. View "Samons v. National Mines Corp." on Justia Law