Justia Public Benefits Opinion Summaries

Hargett, born in 1965, has a high-school education and previously worked as a semi-truck driver, municipal worker, maintenance mechanic, and industrial cleaner. He last worked in March 2015. Hargett applied for disability insurance benefits; he had high blood pressure, type-two diabetes, curvature of the spine, and COPD. Hargett’s primary care physician, Lucardie, referred Hargett to a physical therapist for a functional capacity evaluation (FCE), which indicated that Hargett had a maximum lifting capacity of 35 pounds and maximum carrying capacity of 20 pounds--the “medium strength” category-- but that Hargett could continuously stand for no more than five minutes; could continuously walk for no more than 0.1 miles; could never balance while standing, crouching, or walking; and could never crouch, stoop, or crawl. Lucardie reviewed and signed the FCE.An ALJ denied Hargett’s claim, finding that Hargett retained the residual functional capacity to perform light work. The ALJ gave only “partial weight” to the FCE, discounting its indication that Hargett’s ability to stand or walk did not meet any standard for work activity. The Sixth Circuit vacated. The ALJ should have considered the FCE as a treating-source opinion, which, in 2015, had to be given controlling weight if “well-supported by medically acceptable clinical and laboratory diagnostic techniques” and “not inconsistent with the other substantial evidence.” The error was not harmless. View "Hargett v. Commissioner of Social Security" on Justia Law

The Supreme Court reversed the decision of the court of appeals affirming the order of the district court that non-homestead life estates should not be included in Marvin Schmalz's assets, holding that the term "individual" in Minn. Stat. 256B.056, subd. 4a applies only to the applicant for medical assistance.Esther Schmalz was living at a long-term-care facility when she submitted an application for medical assistance for long-term-care benefits. As part of the assessment of her husband Marvin's assets, Renville County Human Services (RCHS) included Marvin's portion of several non-homestead life estate interests that he and Esther owned. Esther appealed, arguing that the life estates should not be included in the total amount of assets that Marvin may retain. The human services judge concluded that RCHS properly denied Esther's application for medical assistance based on the inclusion of the life estate assets owned by Marvin. The Commissioner of Minnesota Department of Human Services adopted the human services judge's recommendation. The district court concluded that the non-homestead life estates should not be included in Marvin's assets, ruling that the term "individual" in section 256B.056, subd. 4a included Marvin. The Supreme Court reversed, holding that an "individual" in the statute refers to the medical assistance applicant and not a community spouse. View "In re Schmalz" on Justia Law

In this class action, the Supreme Court reversed the judgment of the court of appeals affirming the common pleas court's decision to certify the class, holding that the common pleas court lacked subject matter jurisdiction over the class action for the named and prospective class plaintiffs whose claims for recovery fell within the express language of Ohio Rev. Code 5160.37.The class action sought a declaratory judgment that former Ohio Rev. Code 5101.58 relating to Medicaid reimbursements is unconstitutional. The action further sought to recover all sums paid to the Ohio Department of Medicaid (Department) under section 5101.58. Plaintiff moved to certify as a class all persons who paid any amount to the Department pursuant to the statute from April 6, 2007 to the present. The trial court certified the class. The court of appeals affirmed. The Supreme Court reversed, holding (1) section 5160.37 now provides the sole remedy for Medicaid program participants to recover excessive reimbursement payments made to the Department on or after September 29, 2007; and (2) therefore, the common pleas court lacked jurisdiction over the claims asserted by Plaintiffs. View "Pivonka v. Corcoran" on Justia Law

Daugherty, an ALJ hearing disability-benefits applications for the Social Security Administration, took bribes. Conn, who represented many claimants, paid Daugherty $400 per favorable decision; Conn received $5,000 or more per case out of the benefits that Daugherty awarded. Four physicians, including Huffnagle, submitted evaluations to support Daugherty’s decisions, even if the applicant failed to appear for examination. Conn and Daugherty pleaded guilty to federal felonies. One of the physicians was convicted. Huffnagle died. The total cost of benefits granted by Daugherty exceeds $500 million. Following an investigation, a notice under 42 U.S.C. 1320a–8(l), set in motion a process for redetermination of the benefits awarded in connection with the scheme. In a suit under 42 U.S.C. 405(g), 1383(c)(3), Jaxson claimed that the ALJ who presided over his redetermination should have considered Huffnagle’s report but declined to do so only because an internal claims-processing manual and ruling say that an ALJ cannot accept evidence that the Inspector General found is likely a product of fraud. The Seventh Circuit affirmed a ruling in favor of Jaxson. Jaxson may have a hard time persuading an ALJ that there is not even “reason to believe” that Huffnagle’s report is fraudulent but he is entitled to try; 42 U.S.C. 405(b)(1), requires a “reasonable notice and opportunity for a hearing”, and “hearing” means a procedure at which both sides can present views on potentially dispositive matters. View "Jaxson v. Saul" on Justia Law

General’s clinicians perform services in long-term care facilities. General bills Medicare under 42 U.S.C. 1395. A Centers for Medicare and Medicaid Services (CMS) contractor, AdvanceMed, initiated audits in 2002 after the CMS fraud unit received complaints about General’s billing practices. In 2004 AdvanceMed initiated an audit of General’s physicians without providing any notice to General. AdvanceMed sent records requests to physicians at 12 General facilities, covering 382 claims involving 278 patients in 2002-2004. General was not notified of these requests. AdvanceMed did not request any records from General. AdvanceMed determined that 35 of the 382 claims were allowed as billed; 33 claims were allowed at different levels than billed. The remaining 314 claims were denied: 3 did not meet policy guidelines, 73 had no documentation to support the services, and 238 were medically unnecessary.General learned of this audit when it received a letter in 2007, indicating that General had been overpaid by $16,778.80; the overpayment was extrapolated to a universe of 41,818 claims. The total amount of overpayment demanded was $1,836,646.56. The Appeals Council determined and the Sixth Circuit affirmed that no remedy should be granted because the lack of notice was inconsequential and did not prevent General from ably and thoroughly arguing the principal issues resulting from the audit, the validity of the sampling methodology, and the coverage of the reviewed claims. The addition of more medical records would not have materially impacted its findings. View "General Medicine, P.C. v. Azar" on Justia Law

At issue in this case was the correct interpretation of Ariz. Rev. Stat. 23-750(E)(5), which provides that income earned by any individual who performed certain services while employed by an entity that provides such services to or on behalf of an "educational institution" cannot be used to qualify for unemployment during breaks between academic terms if that person is guaranteed reemployment.Plaintiffs were employees of Chicanos For La Cause (CPLC), a nonprofit corporation that administered federally funded Early Head Start and Migrant Seasonal Head Start programs and provided services to help school districts comply with their obligations under the Individuals with Disabilities Education Act (IDEA), 20 U.S.C. 1400 et seq. When the summer break began, Plaintiffs applied for unemployment insurance benefits from Arizona Department of Economic Security (ADES), which granted benefits. The ADES Appeals Board reversed. The Supreme Court remanded the case to ADES to award unemployment benefits to two plaintiffs and for further proceedings to resolve the claims of the remaining plaintiffs, holding that section 23-750(E)(5) applies to plaintiffs only if they performed services for CPLC that CPLC supplied to the school districts. View "Rosas v. Arizona Department of Economic Security" on Justia Law

In separate claims, appellees Willie Carr and Kim Minor sought disability benefits from the Social Security Administration (“SSA”). In each case, the administrative law judge (“ALJ”) denied the claim, and the agency’s Appeals Council declined to review. While his case was pending in district court, the U.S. Supreme Court held that Securities and Exchange Commission (“SEC”) ALJs were “inferior officers” under the Appointments Clause, and therefore must be appointed by the President, a court, or head of the agency. Shortly thereafter, Minor also sued in district court to challenge the denial of benefits in her case. In response to the Supreme Court case, Lucia v. S.E.C., 138 S. Ct. 2044 (2018), the SSA Commissioner appointed the SSA's ALJs to address any Appointments Clause questions Lucia posed. After the Commissioner’s action, Carr and Minor each filed a supplemental brief, asserting for the first time that the ALJs who had rejected their claims had not been properly appointed under the Appointments Clause. The district court upheld the ALJs’ denials of the claims, but it agreed with the Appointments Clause challenges. The court vacated the SSA decisions and remanded for new hearings before constitutionally appointed ALJs. It held that appellees did not waive their Appointments Clause challenges by failing to raise them in their SSA proceedings. On appeal, the Commissioner argued Appellees waived their Appointments Clause challenges by failing to exhaust them before the SSA. The Tenth Circuit agreed with the Commissioner and reversed. View "Carr v. Commissioner, SSA" on Justia Law

The Orange County Department of Child Support Services (Department) has withdrawn money from Daniel Lak’s (Father) Social Security Disability Insurance benefits (SSDI) to pay for child/spousal support arrears since 2015. Father disputed the Department's authority to withdraw money, and at a hearing, sought reimbursement for overpayments and maintained the Department violated Family Code section 5246 (d)(3) by collecting more than five percent from his SSDI. The court denied Father’s requests and determined the Department could continue withdrawing money from SSDI for support arrears. On appeal, Father maintaned the court misinterpreted the law and failed to properly consider his motion for sanctions. Finding his contentions lack merit, the Court of Appeal affirmed the court’s order the Department did not overdraw money for arrears, Father failed to demonstrate he qualified for section 5246(d)(3)’s five percent rule, and sanctions were not warranted. View "Lak v. Lak" on Justia Law

The Eighth Circuit reversed the district court's order affirming the ALJ's denial of plaintiff's application for disability benefits. The court held that the ALJ's error in failing to provide good reason for giving plaintiff's treating psychiatrist's opinion limited weight was not harmless error. In this case, the failure to comply with SSA regulations is more than a drafting issue, it is legal error. Furthermore, the court cannot determine whether the ALJ would have reached the same decision denying benefits, even if the ALJ had followed the proper procedure for considering and explaining the value of the psychiatrist's opinion. Accordingly, the court remanded for further administrative proceedings and for reconsideration of plaintiff's claims. View "Lucus v. Saul" on Justia Law

Methodist Specialty Care Center was the only nursing facility for the severely disabled (NFSD) in Mississippi. NFSDs generally incur higher costs than other nursing facilities, and because of this, Methodist received a percentage adjustment to its new-bed-value (NBV) calculation when the Mississippi Division of Medicaid (DOM) determined how much it should reimburse Methodist for its property costs through the DOM’s fair-rental system. A NBV was intended to reflect what it would cost to put a new bed into service in a nursing facility today. Methodist had received a NBV adjustment of 328.178 percent added to the standard NBV every year since it opened in 2004 until State Plan Amendment (SPA) 15-004 was enacted. During the 2014 Regular Session, the Mississippi Legislature passed House Bill 1275, which authorized the DOM to update and revise several provisions within the State Plan; one such amendment changed Methodist's adjustment rate, and made the facility experience a substantial decrease in its NBV, while all other nursing facilities in the state received increases. Methodist appealed the DOM’s changes to its NBV that were enacted in SPA 15-004. After a hearing, an Administrative Hearing Officer (AHO) upheld the decreased percentage adjustment to Methodist’s NBV, but also determined the DOM had miscalculated Methodist’s NBV adjustment. The DOM had planned to calculate Methodist’s adjustment as 175 percent of the base NBV, but the AHO found that Methodist’s adjusted NBV should be calculated in the same manner as it was calculated preamendment - by taking 175 percent of the standard NBV and adding that value to the standard NBV. Methodist still felt aggrieved because its NBV adjustment rate had not been restored to the preamendment rate. Methodist appealed the DOM’s final decision to the Chancery Court. When the chancellor affirmed the DOM’s final decision, Methodist appealed to the Mississippi Supreme Court. After review, the Supreme Court found the DOM’s final decision was supported by substantial evidence, was not arbitrary or capricious, did not violate Methodist’s constitutional or statutory rights and that the DOM was acting within its power in reaching and adopting its final decision. View "Methodist Specialty Care Center v. Mississippi Division of Medicaid" on Justia Law