Justia Public Benefits Opinion Summaries

The First Circuit affirmed the district court’s ruling that the “set-off rule” announced by the United States Secretary of Health and Human Services (Secretary) in the form of answers to Frequently Asked Questions (FAQs) posted on medicaid.gov represented a substantive policy decision that could not be adopted without notice and comment.In 1981, Congress authorized the payment of sums in addition to Medicaid payments hospitals that treat indigent patients receive in order to cover the full costs of care. Congress later passed a law seeking to cap those payments at each hospital’s “costs incurred.” At issue was to what extent “costs incurred” equals the total costs of service rather than the costs net of payments from sources such as Medicare and private insurance. With two exceptions, Congress stated that “costs incurred” are “as determined by the Secretary.” In 2010, the Secretary made its FAQs announcement that the payments to be offset against total costs in calculating “costs incurred” also included reimbursements received from Medicare and private insurance. The First Circuit held that the Secretary’s rule was procedurally improper for having failed to observe the notice-and-comment procedures prescribed by the Administrative Procedure Act. View "New Hampshire Hospital Ass’n v. Hargan" on Justia Law

The First Circuit affirmed the district court’s decision affirming an administrative law judge’s (ALJ) finding that Appellant was not disabled within the meaning of the Social Security Act and thus not entitled to Supplemental Security Income benefits, holding that the ALJ’s determination was supported by substantial evidence. Specifically, the Court held (1) the ALJ did not err in according only slight weight to the testimony of an orthopedic physician who treated Appellant for a non-displaced fracture of her left femur; and (2) the ALJ was entitled to rely on testimony of an impartial vocational expert presented by the Commissioner of the Social Security Administration about available jobs that Appellant was entitled to perform. View "Purdy v. Berryhill" on Justia Law

The Supreme Court affirmed in part and reversed in part a district court order granting in part and denying in part judicial review of the Montana Department of Public Health and Human Services (DPHHS) fair hearing proposed decision that DPHHS overpaid IMS under the Medicaid program and was entitled to reimbursement in the amount of $670,152 from Independence Medical Supply, Inc. (IMS). IMS appealed, and DPHHS cross appealed the district court’s order. The Supreme Court held (1) the district court did not abuse its discretion by affirming the hearing officer’s determination that physician affidavits introduced by IMS did not cure technical violations of the supply orders submitted to DPHHS; and (2) the district court erred in holding that a letter sent by DPHHS on January 8, 2014 commenced an action for recovery of the overpayment because DPHHS did not commence an action within the meaning of Mont. Code Ann. 27-2-102(1)(b) and Mont. R. Civ. P. 3. View "Independence Medical Supply, Inc. v. Montana Department of Public Health & Human Services" on Justia Law

Six judges who were elected to the superior court in mid-term elections in 2012, but who did not take office until January 7, 2013, claimed entitlement to benefits under the Judges’ Retirement System II (JRS II) as in effect at the time they were elected, rather than at the time they assumed office. On January 1, 2013, JRS II became subject to the California Public Employees’ Pension Reform Act of 2013 (PEPRA), Government Code section 75500, which amended virtually all state employee retirement systems to address the state’s enormous unfunded pension liability and return these systems to actuarially sound footing. PEPRA increases employee contributions, provides for fluctuating contribution rates based on market performance and actuarial projections, and bases the amount of monthly pension payments on an employee’s final three years of compensation, rather than on only the final year. The court of appeal held that the judges did not obtain a vested right in JRS II benefits as judges-elect, but rather obtained a vested right to retirement benefits only upon taking office after PEPRA went into effect. PEPRA’s provisions pertaining to fluctuating pension contributions do not violate the non-diminution clause of the California Constitution nor do they impermissibly delegate legislative authority over judicial compensation. View "McGlynn v. State of California" on Justia Law

Johnson worked successively as a firefighter for South San Francisco (CSSF) and Pacifica. He developed nasopharyngeal cancer. Labor Code section 3212.11 establishes a presumption that cancer manifesting during and for a specified period following employment in certain public safety positions, including firefighters, arose out of and in the course of that employment. Section 5500.5(a) limits employer liability for a cumulative injury to the employer who employed the applicant during the one year preceding the earliest of the date of injury or the last date of injurious exposure to the hazards that caused the injury, so either CSSF or Pacifica would be potentially responsible for compensation for the entire injury. CSSF settled Johnson's workers’ compensation claim and sought contribution from Pacifica. An arbitrator denied the petition, ruling that evidence of the latency period for Johnson's cancer showed the injurious exposure occurred during Johnson’s earlier employment with CSSF. The Workers’ Compensation Appeals Board adopted the order. CSSF argued the Board erroneously utilized a more lenient preponderance evidentiary standard in applying section 5500.5(a), rather than the more stringent cancer presumption rebuttal standard of section 3212.1. The court of appeal affirmed; the evidence supports the award. Worker protection policies embodied in section 3212.1 are not implicated in the allocation of liability between employers. View "City of South San Francisco v. Workers' Compensation Appeals Board" on Justia Law

Johnson worked successively as a firefighter for South San Francisco (CSSF) and Pacifica. He developed nasopharyngeal cancer. Labor Code section 3212.11 establishes a presumption that cancer manifesting during and for a specified period following employment in certain public safety positions, including firefighters, arose out of and in the course of that employment. Section 5500.5(a) limits employer liability for a cumulative injury to the employer who employed the applicant during the one year preceding the earliest of the date of injury or the last date of injurious exposure to the hazards that caused the injury, so either CSSF or Pacifica would be potentially responsible for compensation for the entire injury. CSSF settled Johnson's workers’ compensation claim and sought contribution from Pacifica. An arbitrator denied the petition, ruling that evidence of the latency period for Johnson's cancer showed the injurious exposure occurred during Johnson’s earlier employment with CSSF. The Workers’ Compensation Appeals Board adopted the order. CSSF argued the Board erroneously utilized a more lenient preponderance evidentiary standard in applying section 5500.5(a), rather than the more stringent cancer presumption rebuttal standard of section 3212.1. The court of appeal affirmed; the evidence supports the award. Worker protection policies embodied in section 3212.1 are not implicated in the allocation of liability between employers. View "City of South San Francisco v. Workers' Compensation Appeals Board" on Justia Law

Aponte moved into his mother's one-bedroom New York City Housing Authority (NYCHA)-owned apartment and cared for her until she died in 2012. Two requests for Aponte to be granted permanent permission to live with his mother were denied. After she died, Aponte requested to be allowed to lease her apartment as a "remaining family member." NYCHA denied his request, finding that Aponte lacked permanent permission to reside in the apartment; management properly denied such permission because Aponte's presence would have violated occupancy rules for overcrowding. A person lacking permanent permission to reside in an apartment is not eligible for RFM status. The Court of Appeals upheld the denial. Under its rules, NYCHA could not have granted Aponte permanent permission to reside in his mother's apartment, and thus could not have granted his request for RFM status. NYCHA's rules contemplate that a tenant may require a live-in home-care attendant, either for a transient illness or the last stages of life, and expressly allow for such an attendant as a temporary resident, even if that permission will result in "overcrowding," regardless of whether the attendant is related to the tenant. NYCHA's policy is not arbitrary and capricious for not allowing Aponte to bypass the 250,000-household waiting line as a reward for enduring an "overcrowded" living situation while caring for his mother. View "Aponte v Olatoye" on Justia Law

At issue was the relationship between Conn. Gen. Stat. 45a-655(b) and (d) in determining whether a spousal support order previously rendered by the probate court was binding on the Commission of Social Services when calculating the allowance that may be diverted to the support of the community spouse of a Medicaid eligible institutionalized person pursuant to 42 U.S.C. 1396r-5. The Commissioner decided to set a community spouse allowance for Paul Valliere in the amount of $0 with respect to the Medicaid benefit that paid for the long-term residential care of his wife, Majorie Valliere. The trial court sustained the administrative appeal brought by Plaintiffs, Paul and Ellen Shea, conservatrix and executrix of Majorie’s estate. The Supreme Court affirmed, holding that the probate court did not exceed its authority under section 45a-655 by ordering community spouse support in an amount that exceeded that which the Department of Social Services could order pursuant to 42 U.S.C. 1396r-5. View "Valliere v. Commissioner of Social Services" on Justia Law

At issue was the relationship between Conn. Gen. Stat. 45a-655(b) and (d) in determining whether a spousal support order previously rendered by the probate court was binding on the Commission of Social Services when calculating the allowance that may be diverted to the support of the community spouse of a Medicaid eligible institutionalized person pursuant to 42 U.S.C. 1396r-5. The Commissioner decided to set a community spouse allowance for Paul Valliere in the amount of $0 with respect to the Medicaid benefit that paid for the long-term residential care of his wife, Majorie Valliere. The trial court sustained the administrative appeal brought by Plaintiffs, Paul and Ellen Shea, conservatrix and executrix of Majorie’s estate. The Supreme Court affirmed, holding that the probate court did not exceed its authority under section 45a-655 by ordering community spouse support in an amount that exceeded that which the Department of Social Services could order pursuant to 42 U.S.C. 1396r-5. View "Valliere v. Commissioner of Social Services" on Justia Law

The North Dakota Department of Human Services appealed a district court judgment reversing the Department's order deciding Sanford HealthCare Accessories received overpayments for medical equipment supplied to Medicaid recipients and ordering recoupment. The North Dakota Supreme Court reversed and remanded, concluding the district court erred in deciding the Department's failure to comply with the statutory time requirement for issuing its final order precluded the Department from acting. View "Sanford Healthcare Accessories, LLC v. N.D. Dep't of Human Services" on Justia Law