Justia Public Benefits Opinion Summaries

McCord injured his back while serving in the Army and was discharged with a 20% disability rating. Because his rating was below 30% and he served for less than 20 years, McCord received severance pay instead of ongoing military retirement pay and received monthly VA benefits. The Army Board for Correction of Military Records later corrected his record to reflect a 30% disability rating and entitlement to medical retirement pay, rather than severance pay. McCord later challenged the government’s calculation of his entitlement to military retirement back pay and its claimed right to recover the severance pay and requested damages for medical expenses that he incurred because he was not afforded TRICARE coverage before the correction. The Claims Court rejected McCord’s approach to back pay calculation as “double-dipping,” denied relief regarding the recoupment of severance pay “as not ripe,” and held that McCord failed to exhaust administrative procedures for securing TRICARE benefits. The Federal Circuit affirmed except as to the out-of-pocket medical expenses. The court cited 10 U.S.C. 1201, 1203, 1212(d)(a), and 2774, as defining entitlement to retirement pay or severance pay, VA benefits, and the circumstances for recoupment of severance pay. A veteran receiving VA benefits may face a disadvantage if he also secures an award of military retirement pay because he would not be entitled to severance pay but military retirement pay includes TRICARE coverage. View "McCord v. United States" on Justia Law

Tennessee family medicine physicians, mostly in rural areas, received increased Medicaid payments in 2013-2014. In 2015 Tennessee’s Medicaid agency, TennCare, brought an administrative action to “recoup” an average of more than $100,000 per physician, alleging that the physicians had not met the 60-percent requirement of the Final Medicaid Payment Rule. Under 42 U.S.C. 13961(a)(13(C), a state plan for medical assistance must provide payment for primary care services furnished in 2013 and 2014 by a physician with a primary specialty designation of family medicine, general internal medicine, or pediatric medicine at a specified rate; “primary specialty designation” was interpreted to mandate that the physician either show board certification in that specialty or that 60 percent of her recent Medicaid billings were for certain primary care services. The Sixth Circuit affirmed summary judgment in favor of the physicians, declaring the Rule invalid. The Centers for Medicare and Medicaid Services interpreted “a physician with a primary specialty designation” to have different meanings in parallel provisions of the Affordable Care Act although the context was the same. There is no 60-percent-of-billings requirement in 42 U.S.C. 1396a(a). The phrase “a physician with a primary specialty designation” means in section 1396a(a) the same thing that the agency said it means in section 1395l(x): a physician who has himself designated, as his primary specialty, one of the specialties recited in those provisions. View "Averett v. United States Department of Health & Human Services" on Justia Law

For four years, nurse practitioner Jordan treated Clanton’s severe hypertension. Jordan, an employee of the U.S. Public Health Service, failed to properly educate Clanton about his disease or to monitor its advancement. Clanton’s hypertension developed into Stage V kidney disease requiring dialysis and a transplant. Clanton successfully sued the government under the Federal Tort Claims Act. The court determined that Clanton had not contributed at all to his own injuries, noting that Clanton did not understand why it was important to take his medication and to attend appointments. The court awarded $30 million in damages. The Seventh Circuit vacated, finding that the court erred in its analysis of comparative negligence. Clanton’s subjective understanding does not end the inquiry. Illinois law requires the court to take the additional step of comparing Clanton’s understanding of his condition to that of a reasonable person in his situation. Clanton was in the position of a person whose caregiver failed to provide information about the severity of his condition but he had external clues that he was seriously unwell: two employment-related physicals showed that he had dangerously high blood pressure. The court upheld the court’s method of calculating damages and agreed that Clanton’s Medicare benefits are collateral to his damages award under Illinois law, so the government is not entitled to a partial offset. View "Clanton v. United States" on Justia Law

Brooke Rojas received food stamp benefits to which she was not legally entitled. The prosecution charged her with two counts of theft under the general theft statute, section 18-4-401(1)(a), C.R.S. (2019). Rojas moved to dismiss these charges, arguing that she could only be prosecuted under section 26-2-305(1)(a), C.R.S. (2019), because it created the specific crime of theft of food stamps. The trial court denied the motion, and a jury convicted Rojas of the two general theft counts. Rojas contended on appeal that the trial court erred by denying the motion to dismiss because section 26-2-305(1)(a) abrogated the general theft statute in food stamp benefit cases. A split division of the court of appeals agreed with her. The Colorado Supreme Court, however, disagreed with Rojas and the division majority. Based on the statute’s plain language, the Supreme Court held the legislature didn’t create a crime separate from general theft by enacting section 26-2-305(1)(a). View "Colorado v. Rojas" on Justia Law

Chang filed a qui tam action against the Center, asserting claims on behalf of the United States and the state under the False Claims Act (FCA). and the Delaware False Claims Act. Chang alleged that the Center had sought and received funding from the state and federal governments by misrepresenting material information. Both governments declined to intervene as plaintiffs. Chang filed an amended complaint and the Center answered. Nearly three years after Chang filed his original complaint, the U.S. and Delaware moved to dismiss the case, asserting that they had investigated Chang’s allegations and discovered them to be “factually incorrect and legally insufficient.” The court granted the motions without conducting an in-person hearing or issuing a supporting opinion. The Third Circuit affirmed. If the government chooses not to intervene, the relator may still “conduct the action” but the government may still “dismiss the action notwithstanding the objections of the person initiating the action if the person has been notified by the Government of the filing of the motion and the court has provided the person with an opportunity for a hearing on the motion,” 31 U.S.C. 3730(c)(2)(A). Chang never requested a hearing; the FCA does not guarantee an automatic in-person hearing to relators before their cases may be dismissed. View "Chang v. Children's Advocacy Center of Delaware" on Justia Law

Plaintiff-relator Matthew Omlansky, by virtue of knowledge gleaned as a state employee involved with the Medi-Cal program, brought this qui tam action in the name of the State of California alleging that defendant Save Mart Supermarkets (Save Mart) had violated the False Claims Act in its billings to Medi-Cal for prescription and nonprescription medications, charging a higher price than cash customers paid in violation of 2009 statutory provisions capping Medi-Cal charges at a provider’s usual and customary price (“statutory cap”). Per the trial court, the gist of the alleged fraud upon Medi-Cal, Save Mart generally offered a lower price for medications to cash customers, and would also match a lower price that a competitor was offering (although it appears from an exhibit to the complaint that the latter applied only to prescriptions), but did not apply these discounts from its list prices in the billings it submitted to Medi-Cal. The State declined to intervene. The trial court sustained a demurrer to the original complaint because all of the alleged violations occurred during a period when the 2009 statutory cap was subject to a federal injunction. Plaintiff then filed an essentially identical amended complaint. The only significant change was an allegation in paragraph 45 that Save Mart’s billing practices favoring cash customers continued from December 2016 to March 2017 after the expiration of the injunction, specifying six examples of “illegal pricing.” The court sustained Save Mart’s demurrer to this pleading as to two of the six grounds raised, and denied leave to amend. It entered a judgment of dismissal. Plaintiff timely appealed, but the Court of Appeal concurred with the grounds for the trial court’s ruling, thereby affirming dismissal of Plaintiff’s complaint. View "Omlansky v. Save Mart Supermarkets" on Justia Law

Plaintiff appealed the denial of his application for Social Security disability benefits, claiming that he had various physical impairments and that he suffered from bipolar disorder. The Eleventh Circuit held that, although plaintiff's claim of bias was forfeited, the ALJ's conclusion contained errors that must be addressed. In this case, the ALJ failed to articulate good cause for discounting two treating physicians' opinions; substantial evidence does not support the finding that plaintiff's bipolar disorder was non-severe; and the ALJ failed to consider plaintiff's mental impairments when assessing his residual functional capacity. Accordingly, the court affirmed in part, reversed in part, and remanded with instructions. View "Schink v. Commissioner of Social Security" on Justia Law

Rodriguez, a Gulf War veteran, served as a Santa Cruz police officer. 1995-2007. He applied for industrial disability retirement in 2011 with the California Public Employee’s Retirement System based on his PTSD diagnosis that was caused in part by his work for the city. After litigation, the city granted Rodriguez disability retirement but denied his claim of industrial causation. He began receiving benefits in December 2016. Rodriguez requested a finding that his disability was industrial from the Workers’ Compensation Appeals Board in April 2017. The Board concluded that Rodriguez’s disability was industrial, but that he was barred from receiving industrial disability retirement benefits because his claim for a finding of industrial causation was untimely under the five-year time limitation in Government Code section 21171. The court of appeal reversed. Section 21171 applies only to rescind, alter or amend an earlier industrial determination. Section 21174 applies to initial determinations and states that a retiree claiming an industrial disability that is disputed will not receive the additional benefits “unless the application for that determination is filed with the Workers’ Compensation Appeals Board... within two years after the effective date of the member’s retirement.” If a claimant applies for a determination of industrial causation within two years of retirement but more than five years after the injury, the Board cannot modify its determination that an injury is industrial or not; nothing precludes the Board from making the initial determination of industrial causation. View "Rodriguez v. Workers' Compensation Appeals Board" on Justia Law

A1 learned that government auditors thought that the company had overcharged a federal agency by several million dollars for services provided to Medicare beneficiaries. A1 challenged the auditors’ decisions at two levels of the Medicare appeals process but changed the auditors’ minds only in a few minor ways. The government tried to start collecting the money, as the regulatory regime allows, 42 U.S.C. 1395ff(a)(5), (c)(3)(E). Fearing bankruptcy from the government’s recoupment efforts, A1 obtained a preliminary injunction, barring the government from recouping the money until A1 received a hearing before an administrative law judge. The Sixth Circuit vacated the injunction, first holding that although A1 did not proceed to the third and fourth levels of the administrative appeal, the district court had jurisdiction over A1’s constitutional claims. On the merits, the court identified unanswered questions regarding the statistics concerning the relief likely to be obtained at the third level of administrative review; details about A1’s choice not to take advantage of an option to escalate its claim to the fourth and final level of administrative review; and the parties’ awareness of a recoupment option that might have allowed A1 to obtain an ALJ hearing before making most or even all of its recoupment payments. View "A1 Diabetes & Medical Supply v. Alex Azar II" on Justia Law

In February 2015, Johnson’s landlord under the Housing and Community Development Act Section 8 housing assistance program (42 U.S.C. 1437f(o)) served a “lease violation notice” informing Johnson that she had violated her lease by following another tenant to his apartment and using profanity. In June 2015, Landlord issued a “notice to cease” stating that management had received a complaint from a resident alleging that she had used pepper spray against him. On February 29, 2016, Landlord served a “ninety-day notice of termination of tenancy.” In June, when Johnson failed to vacate, Landlord filed an unlawful detainer action. In August, the action was settled by a stipulation; Landlord agreed to reinstate Johnson’s tenancy on the condition that she conform her conduct to the lease. Landlord retained the right to apply for entry of judgment based on specified evidence of breach. In October, Landlord applied for entry of judgment, claiming that Johnson violated the stipulation. Johnson was evicted in January 2017. In February, the Oakland Housing Authority, which administers the Section 8 program, terminated Johnson's benefits. The court of appeal found no violation of Johnson’s procedural due process rights in terminating her from the program. Johnson was given sufficient notice of the grounds for termination: she failed to supply the Authority with required eviction documentation; she committed and was evicted for serious repeated lease violations. The hearing officer did not abuse its discretion in refusing to excuse the violation. View "Johnson v. Housing Authority of City of Oakland" on Justia Law