Justia Public Benefits Opinion Summaries

After two administrative hearings, Brown was awarded disability insurance benefits and supplemental security income benefits by an ALJ, who concluded that, as of April 25, 2018, Brown was “disabled” within the meaning of the Social Security Act, 42 U.S.C. 416(i), 423(d), 1382c(a)(3)(A), but rejected Brown’s claim that he was disabled prior to that date. The district court upheld the ALJ’s decision.The Ninth Circuit remanded with instructions to set aside the ALJ’s determination and to conduct a new disability hearing before a different, and properly appointed ALJ. The ALJ who conducted Brown’s hearings was not appointed in conformity with the Appointments Clause of the Constitution. Because this proceeding did not arise from a direct appeal from a decision of one or more invalidly appointed officers, nor was it a direct petition for review that might similarly have brought the entirety of the administrative decision before the court, the Commissioner may not challenge the portions of that decision that are favorable to Brown. The court held that it had no authority under 42 U.S.C. 405(g). to set aside, or to disturb, the grant of benefits for the time period on or after April 25, 2018, View "Brown v. Kijakazi" on Justia Law

Decker employed Pehringer at its Montana open-pit surface mine, 1977-1999. There were periods when Pehringer did not work, including a roughly three-year-long strike. For most of his mining career, Pehringer was regularly exposed to coal dust while working primarily as a heavy equipment operator. After being laid off in 1999, Pehringer was awarded Social Security total disability benefits. He never worked again. In 2014 a month before his sixty-fifth birthday, Pehringer sought black lung benefits, citing his severe COPD, 30 U.S.C. 923(b). A physician determined that “Pehringer is 100% impaired from his COPD” and that coal “dust exposure and smoking are significant contributors to his COPD impairment.”The Benefits Review Board affirmed a Department of Labor (DOL) ALJ’s award of benefits. The Ninth Circuit affirmed, first rejecting a constitutional challenge to 5 U.S.C. 7521(a), which permits removal of an ALJ only for good cause determined by the Merits Systems Protection Board. DOL ALJ decisions are subject to vacatur by people without tenure protection; properly appointed, they can adjudicate cases without infringing the President’s executive power. The ALJ did not err in adjudicating Pehringer’s claim nor in rejecting untimely evidentiary submissions. Decker did not rebut the presumption of entitlement to benefits after a claimant established legal pneumoconiosis and causation, having worked for at least 15 years in substantially similar conditions to underground coal mines. View "Decker Coal Co. v. Pehringer" on Justia Law

UnitedHealthcare Medicare Advantage insurers challenged the Overpayment Rule, promulgated by the Centers for Medicare and Medicaid Services (CMS) under 42 U.S.C. 1301-1320d-8, 1395-1395hhh, in an effort to trim costs. The Rule requires that, if an insurer learns that a diagnosis submitted to CMS for payment lacks support in the beneficiary’s medical record, the insurer must refund that payment within 60 days. UnitedHealth claims that the Overpayment Rule is subject to a principle of “actuarial equivalence,” and fails to comply. Two health plans that pay the same percentage of medical expenses are said to have benefits that are actuarially equivalent.The D.C. Circuit rejected the challenge. Actuarial equivalence does not apply to the Overpayment Rule or the statutory overpayment-refund obligation under which it was promulgated. Reference to actuarial equivalence appears in a different statutory subchapter from the requirement to refund overpayments; neither provision cross-references the other. The actuarial-equivalence requirement and the overpayment-refund obligation serve different ends. The actuarial-equivalence provision requires CMS to model a demographically and medically analogous beneficiary population in traditional Medicare to determine the prospective lump-sum payments to Medicare Advantage insurers. The Overpayment Rule, in contrast, applies after the fact to require Medicare Advantage insurers to refund any payment increment they obtained based on a diagnosis they know lacks support in their beneficiaries’ medical records. View "UnitedHealthcare Insurance Co v. Becerra" on Justia Law

The Montgomery County Council established the Emergency Assistance Relief Payment Program (EARP) in March 2020 to provide emergency cash assistance to County residents with incomes equal to or less than 50% of the federal poverty benchmark who were not eligible for federal or state pandemic relief. Although eligibility for EARP aid is not dependent on a person’s status as an undocumented immigrant, such individuals are eligible to receive EARP payments. To fund EARP, the County appropriated $10,000,000 from reserve funds to the County’s Department of Health and Human Services. Taxpayers filed suit in Maryland state court, asserting that EARP violated 8 U.S.C. 1621(a), which, with few exceptions, generally prohibits undocumented persons from receiving state and local benefits. Recognizing that Section 1621 does not authorize private enforcement, the plaintiffs cited the Maryland common law doctrine of taxpayer standing, which “permits taxpayers to seek the aid of courts, exercising equity powers, to enjoin illegal and ultra vires acts of [Maryland] public officials where those acts are reasonably likely to result in pecuniary loss to the taxpayer.” The case was removed to federal court based on federal question jurisdiction, 28 U.S.C. 1331. The court granted the County summary judgment. The Fourth Circuit affirmed. Congress has declined to authorize private parties to enforce Section 1621, a legislative decision that cannot be circumvented by invocation of a state’s law of taxpayer standing. View "Bauer v. Elrich" on Justia Law

This appeal arose from a district court order affirming the North Dakota Department of Human Services’ determination that Harold Ring was ineligible for Medicaid. In Ring v. North Dakota Department of Human Services, 2020 ND 217, 950 N.W.2d 142 (“Ring I”), the North Dakota Supreme Court remanded the case for the district court to determine whether a party should be substituted due to Ring’s death, which occurred before the court entered its order. On remand, the district court found substitution of a party was unwarranted and entered an order dismissing the case. The North Dakota Supreme Court affirmed the dismissal order. View "Ring v. NDDHS" on Justia Law

North Dakota Workforce Safety and Insurance (“WSI”) appealed a district court judgment reversing an administrative order sustaining a WSI order denying Bruce Bahmiller’s claim for workers’ compensation benefits. After review, the North Dakota Supreme Court affirmed the district court judgment, concluding the administrative law judge’s (“ALJ”) finding that Bahmiller failed to file a timely claim for benefits within one year of his work injury was not supported by the weight of the evidence. View "Bahmiller v. WSI, et. al." on Justia Law

Plaintiff Family Health Centers of San Diego operated a federally qualified health center (FQHC) that provided various medical services to its patients, some of whom are Medi-Cal beneficiaries. Section 330 of the Public Health Service Act authorized grants to be made to FQHC’s. In addition, FQHC’s could seek reimbursement under Medi-Cal for certain expenses, including reasonable costs directly or indirectly related to patient care. Plaintiff appealed a trial court’s order denying its petition for writ of mandate seeking to compel the State Department of Health Care Services (DHCS) to reimburse plaintiff for money it expended for outreach services. The Court of Appeal rejected plaintiff’s contention that the trial court and the DHCS improperly construed and applied applicable guidelines in the Centers for Medicare & Medicaid Services Publication 15-1, The Provider Reimbursement Manual (PRM). The Court concluded that the monies spent by plaintiff were not an allowable cost because they were akin to advertising to increase patient utilization of plaintiff’s services. View "Family Health Centers of S.D. v. State Dept. of Health Care Services" on Justia Law

The 2017 Veterans Appeals Improvement and Modernization Act (AMA) reforms the VA's administrative appeals system, 131 Stat. 1105, replacing the existing system, which had shepherded all denials of veteran disability claims through a one-size-fits-all appeals process. Under the AMA, claimants may choose between three procedural options: filing a supplemental claim based on additional evidence, requesting higher-level review within the VA based on the same evidentiary record, and filing a notice of disagreement to directly appeal to the Board of Veterans Appeals. The VA promulgated regulations to implement the AMA. Veterans’ service organizations, a law firm, and an individual (Petitioners) filed separate petitions raising 13 rulemaking challenges to these regulations under 38 U.S.C. 502.1The Federal Circuit concluded that two veterans’ service organizations had associational standing based on claimed injuries to their members to collectively bring three of their challenges. No Petitioner demonstrated standing to raise any of the remaining challenges. The regulations the organizations have standing to challenge are invalid for contravening the unambiguous meaning of their governing statutory provisions: 38 C.F.R. 14.636(c)(1)(i), limiting when a veteran’s representative may charge fees for work on supplemental claims; 38 C.F.R. 3.2500(b) barring the filing of a supplemental claim when adjudication of that claim is pending before a federal court; and 38 C.F.R. 3.155 excluding supplemental claims from the intent-to-file framework. View "Military-Veterans Advocacy v. Secretary of Veterans Affairs" on Justia Law

The Supreme Judicial Court affirmed the judgment of the superior court reversing the determination of the Massachusetts Office of Medicaid's board of hearings that Plaintiff's home was a countable asset, making her ineligible for Medicaid long-term care benefits, holding that the superior court did not err.While they were both still living, Plaintiff and her husband created an irrevocable trust, the corpus of which included their home. The terms of the trust granted Plaintiff, during her lifetime, a limited power of appointment to appoint all or any portion of the trust principal to a nonprofit or charitable organization over which she had no controlling interest. MassHealth denied Plaintiff's application for long-term care benefits, determining that the home was a countable asset because Plaintiff purportedly could use her limited power of appointment to appoint portions of the home's equity, which was included as part of the trust principal, to the nursing home where Plaintiff lived as payment for her care. The superior court reversed. The Supreme Judicial Court reversed, holding that the plain terms of the trust neither intended for nor permitted Plaintiff to exercise her limited power of appointment for her benefit, as contemplated by MassHealth. View "Fournier v. Secretary of Executive Office of Health & Human Services" on Justia Law

Disabled children are entitled to benefits from the Social Security Administration, 42 U.S.C. 1382c(a)(3)(C). While benefits for an adult depend on a work history plus current inability to perform a job, administrative officials ask whether the child’s limitations meet one of the many listed categories of disability or are functionally equivalent to one of them. When determining whether a child’s impairment is functionally equivalent to a listing, the issue is whether it produces a marked limitation in at least two—or an extreme limitation in one—of six “domains of functioning.”McCavic argued that his son, N., is disabled by attention deficit hyperactivity disorder, intellectual limitations (an IQ near 70), oppositional defiant disorder, and nocturnal enuresis. He claimed that these conditions meet, or are functionally equivalent to certain listings. An ALJ found that N. did not meet any of the listings and has a marked limitation in only one functional category, “acquiring and using information.” A district judge affirmed. The ALJ was entitled to credit the views of a special-education teacher, who knew N well and had a good grasp of gradations among children with intellectual shortcomings. While N. may have met the standards of the old version of the regulations, but not the new one, the change applies “to claims that are pending on or after the effective date.” View "McCavitt v. Kijakazi" on Justia Law