Justia Public Benefits Opinion Summaries

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

In 2006-2008, plaintiffs each applied, unsuccessfully, for Social Security disability benefits, 42 U.S.C. 423(d)(2)(A), 1382c(a)(3)(B). Each plaintiff retained Kentucky attorney Conn to assist with a subsequent hearing. Each plaintiff’s application included medical records from one of four examining doctors. In each case, ALJ Daugherty relied exclusively on the doctor's opinion to conclude, without a hearing, that plaintiffs were disabled and entitled to benefits. Daugherty took bribes from Conn to assign Conn’s cases to himself and issue favorable rulings. Nearly 10 years after the agency learned of the scheme, it initiated “redeterminations” of plaintiffs’ eligibility for benefits and held new hearings, disregarding all medical evidence submitted by the four doctors participating in Conn’s scheme. Plaintiffs had no opportunity to rebut the assertion of fraud as to this evidence. Each plaintiff was deemed ineligible for benefits as of the date of their original applications; their benefits were terminated. Plaintiffs sued, alleging violations of the Due Process Clause and the Social Security Act. The Sixth Circuit held that the plaintiffs are entitled to summary judgment on their due-process claim and the agency is entitled to summary judgment on the Social Security Act claims. The agency must proffer some factual basis for believing that the plaintiffs’ evidence is fraudulent. Plaintiffs must have an opportunity to “rebut the Government’s factual assertions before a neutral decisionmaker.” Congress has already told the agency what to do when redetermination proceedings threaten criminal adjudications; the answer is not to deprive claimants of basic procedural safeguards. View "Griffith v. Commissioner of Social Security" on Justia Law

The Tennessee Hospital Association and three hospitals sued, challenging efforts by the Centers for Medicare and Medicaid Services (CMS) to direct states to recoup certain reimbursements made under the Medicaid program. The hospitals serve a disproportionate share of Medicaid-eligible patients and are thereby entitled to supplemental payments under the Medicaid Act, (DSH payments), 42 U.S.C. 1396a(a)(13)(A)(iv); 1396r-4(b). The Act limits the amount of DSH payments each hospital can receive in a given year. CMS contends that the hospitals miscalculated their DSH payment-adjustments for fiscal year 2012 and received extra payments. Plaintiffs argued, and the district court agreed, that CMS’s approach to calculating DSH payment adjustments is inconsistent with the Act and the regulations that CMS implemented in 2008. The Sixth Circuit affirmed, agreeing that CMS’s policy is inconsistent with its 2008 rule and cannot be enforced unless it is promulgated pursuant to notice-and-comment rulemaking. The court disagreed with the district court’s conclusion that CMS’s policy exceeds the agency’s authority under the Medicaid Act. CMS’s payment-deduction policy is a reasonable interpretation of an ambiguous section of the Act but is not a valid interpretative rule. CMS attempted to exercise its delegated discretion to “determine[]” the “costs incurred” in serving Medicaid-eligible patients—precisely the sort of agency action that requires notice-and-comment rulemaking. View "Tennessee Hospital Association v. Azar" on Justia Law

Cook served on active duty in the Navy, 1972-1973. Cook’s service records indicate that he experienced back pain. In 2000, Cook sought service connection for back problems and later filed a claim for total disability based on individual unemployability (TDIU), also back-related. The regional office (RO) denied both claims. Cook appealed and testified at a Board hearing in 2012. The Board remanded; the RO again denied both claims. Cook again appealed and requested an additional hearing to present further evidence. The Board denied Cook that additional hearing and denied both of his claims. The Veterans Court, upon joint motion, vacated and remanded because the Board did not adequately explain its decision. On remand, Cook again requested another Board hearing. The Board denied a hearing and denied Cook’s claims for service connection and TDIU. The Veterans Court vacated and ordered a hearing. The Federal Circuit affirmed. The Veterans’ Judicial Review Act codified a veteran’s longstanding right to a Board of Veterans’ Appeals hearing, 38 U.S.C. 7107(b). The courts concluded that the statute entitles an appellant to an opportunity for a hearing whenever the Board decides an appeal, including on remand. View "Cook v. Wilkie" on Justia Law

Hardy, a 55-year old man who worked previously as a maintenance mechanic, had a discectomy in 2005 and a lumbar spinal fusion in 2006. His previous application for Disability Insurance Benefits was denied in 2012. Hardy filed another application for DIB benefits, claiming an onset date of April 2012. The agency denied Hardy’s claim; state-agency doctors reviewed Hardy’s file and determined that he had postural limitations, could frequently lift up to 10 pounds and could stand or walk for six hours during a workday so that Hardy could perform light work. His treating doctors reported that Hardy was unable to work and that his “legs give out and he tends to fall.” In concluding that Hardy was not disabled, an ALJ determined that Hardy had not engaged in substantial gainful employment since his alleged onset date; that his conditions were severe impairments; that these conditions did not equal a listed impairment; that he had the residual functional capacity to perform light work, with limitations; and that he could work as a wire assembler, assembly press operator, circuit board screener, or finish assembler. The Seventh Circuit vacated the denial of benefits. A treating doctor’s opinion generally is entitled to controlling weight if it is consistent with the record, and it cannot be rejected without a “sound explanation.” The ALJ impermissibly discounted the opinions of Hardy’s treating neurosurgeon. View "Hardy v. Berryhill" on Justia Law