Justia Public Benefits Opinion Summaries

Most people eligible for Medicaid benefits are “categorically needy” because their income falls below a threshold of eligibility. People with higher income but steep medical expenses are “medically needy” once they spend enough of their own assets to qualify, 42 U.S.C. 1396a(a)(10). Plaintiffs contend that medical expenses they incurred before being classified as “medically needy” should be treated as money spent on medical care, whether or not those bills have been paid, which would increase Illinois's payments for their ongoing care.The Seventh Circuit affirmed the dismissal of their suit. Medicaid is a cooperative program through which the federal government reimburses certain expenses of states that abide by the program’s rules. Medicaid does not establish anyone’s entitlement to receive particular payments. The federal-state agreement is not enforceable by potential beneficiaries. Plaintiffs bypassed their administrative remedies and do not have a judicial remedy under 1396a(r)(1)(A). Section 1396a(a)(8) provides that a state’s plan must provide that all individuals wishing to apply for medical assistance under Medicaid shall have the opportunity to do so and that assistance shall be furnished with reasonable promptness to all eligible individuals; some courts have held that this requirement can be enforced in private suits. If such a claim were available, it would fail. Plaintiffs are receiving benefits. The court also rejected claims under the Americans with Disabilities Act, 42 U.S.C. 12131–34, and the Rehabilitation Act, 29 U.S.C. 794. Plaintiffs receive more governmental aid than nondisabled persons. View "Nasello v. Eagleson" on Justia Law

Beeler, a dual citizen of Canada and the U.S., worked in Canada for 19 years and contributed to the Canada Pension Plan. In 1989 Beeler moved to the U.S. Until she retired in 2013, she worked and paid Social Security taxes. Beeler’s Canadian earnings were not subject to Social Security taxes; her U.S. earnings were not subject to Canada Plan taxes. Beeler has received Canada Pension Plan benefits since 2013. In 2013, Beeler was awarded reduced Social Security retirement benefits because she was entitled to Canada Pension Plan benefits based on work not covered by Social Security taxation.Rejecting claims that the reductions did not apply to Beeler and similarly-situated plaintiffs, the Seventh Circuit affirmed summary judgment in favor of the government. The windfall elimination provision, 42 U.S.C. 415(a)(7)(A)(ii), states that an individual who becomes eligible for a monthly payment “which is based in whole or in part upon his or her earnings for service which did not constitute ‘employment’ as defined in [42 U.S.C. 410]” shall have their benefits recomputed. The provision excludes in part “payment by a social security system of a foreign country based on an agreement between the United States and such foreign country" under 42 U.S.C. 433. The plaintiffs’ work in Canada is not considered “employment” under section 410, so section 415 reduces their Social Security benefits. The agency’s interpretations of the provision and its implementing regulation and its application of the provision to reduce their benefits were permissible. View "Lorraine Beeler v. Andrew M. Saul" on Justia Law

Mote served in the Air Force, 1961-1965, participating in missions to Vietnam, where Agent Orange was deployed. Mote later developed coronary artery disease and lung cancer. In 2010, Mote filed a disability claim based. In 2013, Mote filed his Notice of Disagreement with the denial of that claim. He died months later. Mrs. Mote substituted for his claim and filed a dependency-and-indemnity compensation claim. The VA denied Mrs. Mote’s claim in 2015; she filed her Notice of Disagreement and requested a Board of Veterans’ Appeals “Travel Board hearing.”Mote sought mandamus relief, 28 U.S.C. 1651, alleging unreasonable delay. The Veterans Court denied the petition, applying the “Costanza” standard. The government claimed, due to limited resources, it “could not predict how long” Mote might have to wait for a hearing. The Federal Circuit consolidated her appeal with others and held that the Veterans Court should use the Telecommunications Research & Action Center v. FCC (TRAC) standard to evaluate unreasonable-delay mandamus petitions rather than the Costanza standard. On remand, Mote requested a “reasoned decision” from the Board (within 45 days) and periodic progress reports. In March 2019. the Board scheduled her Travel Board hearing for May 2019. The Veterans Court dismissed Mrs. Mote’s mandamus petition without applying the TRAC standard. The Board subsequently remanded for further factual findings.The Federal Circuit again remanded, for a TRAC analysis, noting that Mote sought progress reports, in addition to a decision, and that the Veterans Court was not powerless to fashion other relief, such as a more lenient, specific, deadline. Whether a delay is so egregious as to justify the extraordinary writ depends on issues that are likely to arise frequently among veterans. The Veterans Court is uniquely well-positioned to address these issues first. View "Mote v. Wilkie" on Justia Law

Peeters sought disability benefits, citing degenerative disc disease in the lumbar spine, degenerative joint disease of the right shoulder, depressive disorder, post-traumatic stress disorder, generalized anxiety disorder, and learning disabilities. Peeters has not sustained gainful employment since 2014. After a hearing, an ALJ denied Peeters disability benefits in 2016. On stipulated remand, the Appeals Council instructed the ALJ to reconsider Peeters’ maximum residual functional capacity, obtain evidence and examples of jobs Peeters could perform from a vocational expert, provide a new hearing, and issue a new decision. At the second hearing in 2018, the ALJ issued a 15-page decision denying Peeters disability benefits because he failed to meet the severity requirements of 20 C.F.R. pt. 404 and 20 C.F.R. pt. 416.The district court and Seventh Circuit affirmed the denial as supported by substantial evidence. The court upheld the greater weight given to the opinions of six state agency psychologists who evaluated Peeters; three found Peeters would have moderate limitations completing a normal workday and carrying out detailed instructions, but could handle simple two to three-step instructions, while three found Peeters capable of performing light work. View "Peeters v. Saul" on Justia Law

The plaintiffs sought Social Security disability and/or supplemental security income benefits. In each case, the application was denied, and an ALJ upheld the denial. The Appeals Council denied relief. The plaintiffs sought judicial review. While the appeals were pending, the plaintiffs moved to raise an issue they had not raised during administrative hearings--a challenge to the ALJs’ appointments, citing the Supreme Court’s 2018 "Lucia" decision that SEC ALJs had not been appointed in a constitutionally legitimate manner and that remand for a de novo hearing before a different ALJ was required. The district courts agreed that the Appointments Clause challenges were forfeited and affirmed the denials of benefits.The Sixth Circuit vacated and remanded for new hearings before constitutionally appointed ALJs other than the ALJs who presided over the first hearings. There is no question that Social Security ALJs are inferior officers who were required to be, but were not, appointed consistently with the Appointments Clause. There are no statutory or regulatory exhaustion requirements governing Social Security proceedings and, while a court may still impose an implied exhaustion rule, such a requirement is inappropriate because the regulations provide no notice to claimants that their failure to raise an Appointments Clause challenge at the ALJ level will preclude them from later seeking a judicial decision on the issue. View "Flack v. Commissioner of Social Security" on Justia Law

Brace, now age 40, was injured on the job in 2013 and can no longer perform his past work in health service, food service, and construction. He applied for Social Security disability benefits, claiming persistent back and neck pain and several other conditions. An ALJ found that Brace’s severe impairments from degenerative disc disease, neuropathy in the elbow and forearm, and a history of surgery in his shoulder. did not presumptively establish a disability. The ALJ ruled that Brace could not perform any of his past work. A vocational expert testified that Brace could perform jobs as a callout operator, semiconductor bonder, or registration clerk, or a counter clerk, subject to restrictions and that a significant number of jobs exist across those job categories—an estimated 140,000. Brace’s lawyer asked the vocational expert to explain how he arrived at his job estimates; the answer was inscrutable. The ALJ nonetheless accepted his testimony and rejected Brace’s claim for benefits.The Seventh Circuit reversed. The ALJ’s approach does not satisfy the substantial evidence standard. The court rejected the ALJ’s justifications that Brace’s counsel should have objected to the expert’s qualifications before he testified and that the cited jobs number was so large that “[e]ven if the methodology used create[d] a significant margin of error[,] … a significant number of jobs exist.” View "Brace v. Saul" on Justia Law

Four consolidated appeals presented a question of whether medical providers who provided services under California’s Medi-Cal program were entitled to reimbursement for the costs of providing in-house medical services for their own employees through “nonqualifying” self-insurance programs. Even for nonqualifying self-insurance programs, however, the Provider Reimbursement Manual allowed providers to claim reimbursement for reasonable costs on a “claim-paid” basis. Oak Valley Hospital District (Oak Valley) and Ridgecrest Regional Hospital (Ridgecrest) had self-insurance programs providing health benefits to their employees. Claims for in-house medical services to their employees were included in cost reports submitted to the State Department of Health Care Services (DHS). DHS allowed the costs when Oak Valley and Ridgecrest employees received medical services from outside providers but denied costs when the medical services were provided in-house. DHS determined claims paid to Oak Valley and Ridgecrest out of their self-insurance plan for in-house medical services rendered to their employees were not allowable costs. The trial court granted Oak Valley and Ridgecrest's the writ petitions on grounds that costs of in-house medical services were reimbursable so long as they were “ ‘reasonable’ ” as defined by the Provider Reimbursement Manual. DHS appealed in each case. After review, the Court of Appeal concluded Oak Valley’s and Ridgecrest’s self-insurance programs did not meet the requirements of a qualified plan under CMS guidelines and Provider Reimbursement Manual. The Court of Appeal rejected DHS’s contention that Oak Valley and Ridgecrest costs relating to in-house medical services for their employees were inherently unreasonable. To the extent DHS argued the cost reports were not per se unreasonable, but unreasonable under the circumstances of the actual treatments of Oak Valley and Ridgecrest employees, the Court determined the evidence in the record supports the trial court’s findings that expert testimony established Oak Valley and Ridgecrest incurred actual expenses in providing in-house medical services for their employees that were not otherwise reimbursed. Accordingly, the Court affirmed the trial court’s granting of the petitions for writs of administrative mandate. View "Oak Valley Hospital Dist. v. Cal. Dept. of Health Care Services" on Justia Law

The Department of Health and Human Services disallowed roughly $30 million in Medicaid reimbursements for payments Virginia made to two state hospitals. HHS determined that Virginia had materially altered its payment methodology without notifying HHS or obtaining approval and that the new methodology resulted in payments that overstepped applicable federal limits. Virginia had allocated disproportionate share hospitals (DSH) payments for the two hospitals to fiscal years other than “the actual year in which [related] DSH costs were incurred” by those hospitals for purposes of complying with the annual statewide DSH allotment and hospital-specific limit. The district court and D.C. affirmed. A comparison between Virginia’s previous operation of its plan—as manifested in the state’s prior representations about the plan’s operation—and its later operation of the same plan shows that there was a “[m]aterial change” in “the State’s operation of the Medicaid program,” so that the state was required to amend its plan and present the amendment for approval, 42 C.F.R. 430.12(c)(1)(ii). View "Department of Medical Assistant Services of the Commonwealth of Virginia v. United States Department of Health and Human Services" on Justia Law

The California State Teachers’ Retirement System (CalSTRS) determined that Ernest Moreno’s retirement benefits had been incorrectly calculated and initiated proceedings to adjust Moreno’s retirement benefits and collect the overpayment. The trial court denied Moreno’s petition for writ of administrative mandamus challenging the CalSTRS actions. Moreno appealed, contending: (1) CalSTRS’s adjustment of his retirement benefits and collection of the overpayment were barred by the statute of limitations found in Education Code section 22008 (c) because CalSTRS was on inquiry notice of the problem as early as 2008; and (2) CalSTRS should have been equitably estopped from adjusting his retirement benefits and collecting the overpayments. After review, the Court of Appeal concluded: (1) CalSTRS was not on inquiry notice of the reporting error that led to overpayment until December 2014 when it began an audit of Moreno’s retirement benefits, and, therefore, CalSTRS’s adjustments to Moreno’s retirement benefits and collection of overpayments were not barred by the statute of limitations; and (2) CalSTRS was not equitably estopped because CalSTRS was not apprised of (or on notice about) the overpayments until December 2014. View "Moreno v. Cal. State Teachers' Retirement System" on Justia Law

In this case requiring the Supreme Court to determine the scope of the authority of the Wisconsin Department of Health Services (DHS) to recoup payments made to Medicaid service providers the Supreme Court held that DHS does not have the authority to enforce its recoupment policy.Plaintiffs, Kathleen Papa and Professional Homecare Providers, Inc. (collectively, PHP), challenged DHS's recoupment policy as it had been enforced against PHP nurses to recover payments made for services they provided to Medicaid patients. PHP claimed that DHS recoups payments nurses earned and received for their Medicaid services because the nurses' supporting records contained documentation shortcomings. The Supreme Court held (1) DHS may recoup Medicaid payments from service providers only in cases where DHS cannot verify certain facts; and (2) DHS's recoupment policy exceeds its authority. View "Papa v. Wisconsin Department of Health Services" on Justia Law