Justia Public Benefits Opinion Summaries

Jerilyn Braaten, the personal representative of the Frederick Ardell Krueger Estate, appealed an order holding the Department of Human Services could recover 100 percent of the net proceeds from the sale of Krueger's home to pay for medical assistance benefits previously received by his deceased spouse. The North Dakota Supreme Court concluded the district court erred in ruling the Department is entitled to 100 percent of the net sale proceeds. For purposes of Medicaid recovery from a surviving spouse's estate, the Department's recovery from a deceased recipient's joint tenancy property is limited to the deceased recipient's fractional interest in the property. The matter was reversed and remanded fo the trial court to permit the Department to recover 50 percent of the net sale proceeds. View "Estate of Krueger" on Justia Law

A 2014 statute and 2013 regulation re-defined which abortions qualified as “medically necessary” for the purposes of Medicaid funding. The statute defined medically necessary abortions as those that “must be performed to avoid a threat of serious risk to the life or physical health of a woman from continuation of the woman’s pregnancy” as a result of a number of listed medical conditions; the regulation was similarly restrictive. Planned Parenthood of the Great Northwest challenged both the statute and regulation as unconstitutional, and the superior court held that both measures violated the equal protection clause of the Alaska Constitution. The court reasoned that these measures imposed a “high-risk, high- hazard” standard on abortion funding unique among Medicaid services, and held that our 2001 decision striking down an earlier abortion funding restriction on equal protection grounds compelled the same result. The State appealed, arguing that the statute and regulation should be interpreted more leniently and therefore do not violate the Alaska Constitution’s equal protection clause. The Alaska Supreme Court affirmed the superior court’s decision: the statute’s and the regulation’s facially different treatment of pregnant women based upon their exercise of reproductive choice required the Court to apply strict scrutiny, and the proposed justifications for the funding restrictions "did not withstand such exacting examination." View "Alaska v. Planned Parenthood of the Great Northwest" on Justia Law

Tramble worked for various Kentucky coal companies from at least May 1963 until June 1985. Tramble’s 1987 claim for benefits under the Black Lung Benefits Act (BLBA), 30 U.S.C. 901–944, indicated that he had stopped working due to a job-related back injury. That claim was denied although the parties stipulated to 17 years of qualifying coal mine employment. The ALJ found that medical evidence established that Tramble suffered from coal workers’ pneumoconiosis but was not totally disabled. After his 2008 death, Tramble’s widow sought survivor’s benefits. Reversing an award by an ALJ, the Department of Labor Benefits Review Board found that the ALJ failed to explain adequately how he calculated the 15.25-years of underground coal mine employment that justified application of the 15-year statutory presumption of entitlement to benefits. On remand, the ALJ again awarded benefits. The Board again reversed. The Sixth Circuit remanded. Further fact-finding is required to ensure that all relevant evidence has been considered. The court rejected Incoal’s argument that, in order to be credited with one year of coal mine employment, a miner must be on the payroll of a mining company for 365 consecutive days and have worked 125 of those days in or around a coal mine . View "Shepherd v. Incoal, Inc." on Justia Law

On November 20, 2018, the Acting Governor of Idaho issued a proclamation that Proposition 2 had passed, and subsequently the Idaho Code was amended to add section 56-267, a statute to expand Medicaid eligibility in Idaho. Petitioner Brent Regan argued 56-267 violated Idaho’s Constitution by delegating future lawmaking authority regarding Medicaid expansion to the federal government. Regan requested the Idaho Supreme Court declare section 56-267 unconstitutional and issue a writ of mandamus to direct the Secretary of State Lawerence Denney to remove section 56-267 from the Idaho Code. Finding the statute constitutional, the Supreme Court dismissed Regan’s petition and denied his request for a writ of mandamus. View "Regan v. Denney" on Justia Law

For representation in administrative proceedings, the Social Security Act provides that if a fee agreement exists, fees are capped at the lesser of 25% of past-due benefits or a set dollar amount—currently $6,000, 42 U.S.C. 406(a)(2)(A); absent an agreement, the agency may set any “reasonable” fee, section 406(a)(1). In either case, the agency is required to withhold up to 25% of past-due benefits for direct payment of fees. For representation in court proceedings, section 406(b) caps fees at 25% of past-due benefits; the agency may withhold benefits to pay these fees. Culbertson represented Wood in Social Security disability benefit proceedings before the agency and in court. The agency ultimately awarded Wood past-due benefits, withheld 25%, and awarded Culbertson fees under section 406(a) for representation before the agency. Culbertson sought a separate award under 406(b) for the court proceedings, requesting 25% of past-due benefits. The Eleventh Circuit held that 406(b)’s 25% limit applies to the total fees awarded under both sections.The Supreme Court reversed. Section 406(b)(1)(A)’s 25% cap applies only to fees for court representation, not to the aggregate fees awarded under 406(a) and (b). The subsections address different stages of the representation and use different methods for calculating fees. Applying 406(b)’s 25% cap on court-stage fees to 406(a) agency-stage fees, or the aggregate fees, would make little sense and would subject 406(a)(1)’s reasonableness limitation to 406(b)’s 25% cap—a limitation not included in the statute. The fact that the agency presently withholds a single pool of past-due benefits for payment of fees does not support an aggregate reading. The amount of past-due benefits that the agency can withhold for payment does not delimit the amount of fees that can be approved for representation before the agency or the court. View "Culbertson v. Berryhill" on Justia Law

Ashlee Oldham and Robert Prunckun (collectively, “Recipients”) were the only two Delaware Medicaid recipients housed at Judge Rotenberg Center (“JRC”), a facility in Massachusetts and the only facility in the United States known to use electric shock therapy as part of their comprehensive behavioral treatment plans. These services were covered by Medicaid with the knowledge and approval of Delaware’s Department of Health and Social Services (“DHSS”). in 2012, the Center for Medicare and Medicaid Services (“CMS”) advised the Massachusetts state agency responsible for Medicaid administration that continued use of electric shock therapy would place that state’s waiver program in jeopardy of losing federal funding. Following CMS’s letter to Massachusetts, Delaware took measures to avoid placing its own Home and Community Based Services (“HCBS”) waiver program at risk. DHSS finally terminated JRC as a qualified provider after JRC refused to cease using electric shock therapy. Although the procedural history was complex, the gist of Appellants’ challenge on appeal to the Delaware Supreme Court was that they were denied due process because Delaware’s administrative hearing officer bifurcated proceedings to address what she concluded was a threshold issue, namely, whether electric shock therapy was a covered Medicaid service under the Medicaid HCBS Waiver program. Instead, Recipients contended they should have been allowed to introduce evidence that electric shock therapy was medically necessary, and that by removing shock services, DHSS threatened Recipients’ ability to remain in a community-based setting (a conclusion they desired to prove through evidence and expert testimony). The Supreme Court determined the hearing officer's determination that electric shock therapy was not a covered service under federal and state law was supported by substantial evidence and free from legal error, and affirmed the district court. View "Prunckun v. Delaware Dept. of Health & Social Services" on Justia Law

McHenry, a 49-year-old former hair stylist who suffers from several physical and mental disabilities, challenged the denial of her application for Social Security disability benefits. The ALJ had concluded that, although McHenry suffers from degenerative disc disease and fibromyalgia, she lacked sufficient medical evidence that the conditions were disabling, and that she was not credible about her limitations. The district court affirmed. The Seventh Circuit vacated. The ALJ erred by failing to have a medical expert review a consequential MRI report. The court rejected arguments that the ALJ improperly determined McHenry’s residual functional capacity by not accounting for McHenry’s anxiety-related limits on social functioning and limits in her ability to sustain concentration because of her medications’ side effects and by discounting McHenry’s credibility. View "McHenry v. Berryhill" on Justia Law

After the Settlement Agreement Appeal Panel affirmed the Claim Administrator's classification of the Arcadia Facility as a "Failed Business," Graphic Packaging sought and was denied discretionary review from the district court. The Fifth Circuit affirmed the district court's denial of discretionary review, holding that the Appeals Panel did not misapply the Settlement Agreement. Even if it did, Graphic Packaging merely disputed the correctness of a discretionary administrative decision in the facts of a single claimant's case. The court rejected Graphic Packaging's remaining claim that the decision merits review because it contradicts a previous Appeals Panel decision. View "Claimant ID 100262194 v. BP Exploration & Production, Inc." on Justia Law

Petitioner Kyle Guillemette challenged a determination by the Administrative Appeals Unit (AAU) of the New Hampshire Department of Health and Human Services (DHHS) that the notice requirements set forth in RSA 171-A:8, III (2014) and New Hampshire Administrative Rules, He-M 310.07 did not apply when Monadnock Worksource notified Monadnock Developmental Services of its intent to discontinue providing services to petitioner because that act did not constitute a “termination” of services within the meaning of the applicable rules. Petitioner received developmental disability services funded by the developmental disability Medicaid waiver program. MDS was the “area agency,” which coordinated and developed petitioner’s individual service plan. Worksource provides services to disabled individuals pursuant to a “Master Agreement” with MDS. Worksource began providing day services to the petitioner in August 2012. On March 31, 2017, Worksource notified MDS, in writing, that Worksource was terminating services to petitioner “as of midnight on April 30.” The letter to MDS stated that “[t]he Board of Directors and administration of . . . Worksource feel this action is in the best interest of [the petitioner] and of [Worksource].” Petitioner’s mother, who served as his guardian, was informed by MDS of Worksource’s decision on April 3. The mother asked for reconsideration, but the Board declined, writing that because the mother “repeatedly and recently expressed such deep dissatisfaction with our services to your son, the Board and I feel that you and [petitioner] would be better served by another agency . . . .” Thereafter, petitioner filed a complaint with the Office of Client and Legal Services alleging that his services had been terminated improperly and requesting that they remain in place pending the outcome of the investigation of his complaint. Because the New Hampshire Supreme Court concluded that the AAU’s ruling was not erroneous, it affirmed. View "Petition of Kyle Guillemette" on Justia Law

At issue in this appeal was whether the district court lacked subject matter jurisdiction to consider Azar Webb’s 42 U.S.C. 1983 claim in the same lawsuit in which the court considered an appeal from a contested case under the Administrative Procedure Act (APA) and whether, as a result, the court lacked the authority to award Webb attorney fees.After the Nebraska Department of Health and Human Services (DHHS) ended Webb’s Medicaid benefits and denied his petition for reinstatement, Webb filed a claim in the district court under the APA for unlawful termination of Medicaid eligibility, adding a claim of violation of his federal rights under section 1983. The district court reversed DHHS’ decision and ordered reinstatement of Webb’s coverage and reimbursement of medical expenses that should have been covered. The court further found in favor of Webb as to his 1983 claim and enjoined DHHS officials from denying Webb Medicaid eligibility. The Supreme Court affirmed, holding that once the district court resolved Webb’s APA claim, the court had the authority to grant Webb relief under section 1983 and his request for attorney fees pursuant to 42 U.S.C. 1988. View "Webb v. Nebraska Department of Health & Human Services" on Justia Law