Justia Public Benefits Opinion Summaries

Kathy Inwards was injured while employed as an assembler by Bobcat. WSI accepted liability for her claim and awarded Inwards vocational rehabilitation benefits to assist her in returning to work. In early June 2011, WSI issued a notice of intention to discontinue benefits ("NOID") stating her disability benefits would end then convert to retraining benefits. She had 30 days to request reconsideration of the decision. WSI issued a formal order requiring Inwards to "enter into training at Hutchinson Community College, Hutchinson, Kansas, in the Business Management & Entrepreneurship AAS program." Inwards requested reconsideration of the vocational rehabilitation plan, but attended two college courses during the summer of 2011 in accordance with the plan. Inwards complained to her physician that she was having increased pain as a result of her course work. Although Inwards registered for fall courses at the college, she withdrew from them. In October 2011, WSI issued a NOID to Inwards stating "[t]here is no medical evidence that supports your professed inability to attend the classes as outlined in the administrative order dated June 27, 2011. You are now considered to be in non-compliance with vocational rehab." Inwards timely requested reconsideration of this NOID, and on January 13, 2012, WSI issued a formal order suspending Inwards' rehabilitation benefits based on her noncompliance with the rehabilitation plan. Inwards timely requested a hearing to challenge WSI's finding of noncompliance and suspension of benefits. The ALJ reversed WSI's January 13, 2012 order suspending benefits for noncompliance with the vocational rehabilitation plan. WSI appealed to district court and Inwards moved to dismiss the appeal, claiming the court lacked subject matter jurisdiction because WSI failed to serve the notice of appeal and specification of errors on Inwards and her employer. The court denied the motion to dismiss, concluding Inwards had no standing to object to defective service on her employer and there was good cause to excuse WSI's mistake about recently mandated court electronic filing requirements. The court reversed the ALJ's decision, concluding the finding of good cause was "not supported by law," and reinstated WSI's January 13, 2012 order of noncompliance. The Supreme Court concluded the ALJ erred as a matter of law in ruling Inwards had good cause for failing to comply with a retraining program because WSI's previous order requiring Inwards to participate in the retraining program had been appealed and had not been finally resolved at the time she withdrew from the retraining program. The Court affirmed the district court judgment reversing the ALJ's decision and reinstating WSI's order of noncompliance. View "Inwards v. WSI" on Justia Law

Plaintiff, a former laborer, applied for social security disability benefits, claiming he was unable to work a full 40-hour week because of acute lower back pain that radiates into his right leg. He has had various treatments and takes several medications such as oxycodone and percocet. His application was denied; the Appeals Council and district court affirmed. The Seventh Circuit reversed and remanded, reasoning that the administrative law judge was likely mistaken in believing that one physician’s report refuted the findings of the other physician. What was relevant was not the cause of the pain and numbness but the severity of these symptoms and whether they disabled plaintiff from working full time. Both physicians diagnosed radiculopathy. If the administrative law judge remains skeptical of the claim, he can order a further examination of the plaintiff by a qualified physician instructed to offer a medical opinion (if possible) on the plaintiff’s physical ability to engage in full-time work. The court stated references to the credibility of the applicant are “a recurrent feature of the government’s defense of denials of social security disability benefits” that constitutes “professional misconduct and if it continues we’ll have to impose sanctions.” View "Hanson v. Colvin" on Justia Law

Reimbursement providers for inpatient services rendered to Medicare beneficiaries is adjusted upward for hospitals that serve disproportionate numbers of patients who are eligible for Supplemental Security Income. The Centers for Medicare & Medicaid Services annually submit the SSI fraction for eligible hospitals to a “fiscal intermediary,” a Health and Human Services contractor, which computes the reimbursement amount and sends the hospitals notice. A provider may appeal to the Provider Reimbursement Review Board within 180 days, 42 U. S. C. 1395oo(a)(3). The PRRB may extend the period, for good cause, up to three years, 42 CFR 405.1841(b). A hospital timely appealed its SSI fraction calculations for 1993 through 1996. The PRRB found that errors in CMS’s methodology resulted in a systematic under-calculation. When the decision was made public, hospitals challenged their adjustments for 1987 through 1994. The PRRB held that it lacked jurisdiction, reasoning that it had no equitable powers save those granted by legislation or regulation. The district court dismissed the claims. The D. C. Circuit reversed. The Supreme Court reversed. While the 180-day limitation is not “jurisdictional” and does not preclude regulatory extension, the regulation is a permissible interpretation of 1395oo(a)(3). Applying deferential review, the Court noted the Secretary’s practical experience in superintending the huge program and the PRRB. Rejecting an argument for equitable tolling, the Court noted that for nearly 40 years the Secretary has prohibited extensions, except as provided by regulation, and Congress not amended the 180-day provision or the rule-making authority. The statutory scheme, which applies to sophisticated institutional providers, is not designed to be “unusually protective” of claimants. Giving intermediaries more time to discover over-payments than providers have to discover underpayments may be justified by the “administrative realities” of the system: a few dozen intermediaries issue tens of thousands of NPRs, while each provider can concentrate on its own NPR. View "Sebelius v. Auburn Reg'l Med. Ctr." on Justia Law

Respondent gave birth to twins conceived through in vitro fertilization using her deceased husband's frozen sperm. Respondent applied for Social Security survivors benefits for the twins, relying on 42 U.S.C. 416(e) of the Social Security Act, which defined child to mean, inter alia, "the child or legally adopted child of an [insured] individual." The Social Security Administration (SSA), however, identified subsequent provisions of the Act, sections 416(h)(2) and (h)(3)(C), as critical, and read them to entitle biological children to benefits only if they qualified for inheritance from the decedent under state intestacy law, or satisfied one of the statutory alternatives to that requirement. The Court concluded that the SSA's reading was better attuned to the statute's text and its design to benefit primarily those supported by the deceased wage earner in his or her lifetime. And even if the SSA's longstanding interpretation was not the only reasonable one, it was at least a permissible construction that garnered the Court's respect under Chevron U.S.A. Inc. v. Natural Resources Defense Council, Inc.View "Astrue v. Capato" on Justia Law

The Court granted certiorari in these cases to decide whether Medicaid providers and recipients could maintain a cause of action under the Supremacy Clause to enforce a federal Medicaid law. Since the Court granted certiorari, however, the relevant circumstances have changed. The federal agency in charge of administering Medicaid, CMS, approved the state statutes as consistent with the federal law. In light of the changed circumstances, the Court believed that the question before it was whether, once the agency approved the state statutes, groups of Medicaid providers and beneficiaries could still maintain a Supremacy Clause action asserting that the state statutes were inconsistent with the federal Medicaid law. Given the present posture of the cases, the Court did not address whether the Ninth Circuit properly recognized a Supremacy Clause action to enforce the federal law before the agency took final action. To decide whether these cases could proceed under the Supremacy Clause now that the agency has acted, it would be necessary on remand to consider at least the matters addressed by the Court. Accordingly, the Court vacated the judgment and remanded for further proceedings.View "Douglas v. Independent Living Center of Southern Cal., Inc." on Justia Law

Petitioners, a group of hospitals that serve a significant number of elderly, very low-income patients, filed suit challenging the Secretary's issuance of a rule concerning the "disproportionate share percentage" calculation of supplemental payments for low-income Medicare patients. When the Secretary published reimbursement calculations for FY 2007, petitioners learned that their payments would decrease by tens of millions of dollars per year. The rule change had an enormous financial consequence on hospitals. The court held that the Secretary did not provide adequate notice and opportunity to comment before promulgating its 2004 rule, and so affirmed the portion of the district court's opinion vacating the rule. The court reversed only the portion of the district court's opinion directing the Secretary to recalculate the hospitals' reimbursements using the alternate methodology. View "Allina Health Services, et al. v. Sebelius" on Justia Law

In enacting comprehensive welfare reform in 1996, Congress rendered various groups of aliens ineligible for federal benefits and also restricted states' ability to use their own funds to provide benefits to certain aliens. As a condition of receiving federal funds, Congress required states to limit eligibility for federal benefits, such as Medicaid, to citizens and certain aliens. Plaintiffs filed suit claiming that Basic Health Hawai'i violated the Equal Protection Clause of the Fourteenth Amendment because it provided less health coverage to nonimmigrant aliens residing in Hawai'i (COFA Residents) than the health coverage that Hawai'i provided to citizens and qualified aliens who are eligible for federal reimbursements through Medicaid. The court concluded that Congress has plenary power to regulate immigration and the conditions on which aliens remain in the United States, and Congress has authorized states to do exactly what Hawai'i had done here - determine the eligibility for, and terms of, state benefits for aliens in a narrow third category, with regard to whom Congress expressly gave states limited discretion. Hawai'i has no constitutional obligation to fill the gap left by Congress's withdrawal of federal funding for COFA Residents. Accordingly, the court vacated the district court's grant of a preliminary injunction preventing Hawai'i from reducing state-paid health benefits for COFA Residents because Hawai'i is not obligated to backfill the loss of federal funds with state funds and its decision not to do so was subject to rational-basis review. View "Korab v. Fink" on Justia Law

The Federal Grant and Cooperative Agreement Act, 31 U.S.C. 6301, states that an executive agency must use: “a procurement contract . . . when . . . the principal purpose … is to acquire … property or services for the direct benefit or use” of the government and must adhere to the Competition in Contracting Act and the Federal Acquisition Regulation However, an “agency shall use a cooperative agreement . . . when . . . the principal purpose … is to transfer a thing of value … to carry out a public purpose of support or stimulation … instead of acquiring . . . property or service” and can avoid procurement laws. Under Section 8 of the Housing Act, HUD provides rental assistance, including entering Housing Assistance Program (HAP) contracts and paying subsidies directly to private landlords. A 1974 amendment gave HUD the option of entering an Annual Contributions Contract (ACC) with a Public Housing Agency (PHA), which would enter into HAP contracts with owners and pay subsidies with HUD funds. In 1983, HUD’s authority was amended. HUD could administer existing HAP contracts, and enter into new HAP contracts for existing Section 8 dwellings by engaging a PHA if possible, 42 U.S.C. 1437f(b)(1). Later, HUD began outsourcing services and initiated a competition to award a performance-based ACC to a PHA in each state, with the PHA to assume “all contractual rights and responsibilities of HUD.” After making an award, HUD chose to re-compete, seeking greater savings, expressly referring to “cooperative agreements,” outside the scope of procurement law. The Government Accountability Office agreed with protestors that the awards were procurement contracts. HUD disregarded that recommendation. The Claims Court denied a request to set aside the award. The Federal Circuit reversed, finding that the awards are procurement contracts, not cooperative agreements.View "CMS Contract Mgmt. Servs. v. United States" on Justia Law

Plaintiffs filed suit against the Secretary of Health and Human Services (HHS) and the Commissioner of the Social Security Administration (SSA) raising constitutional challenges to the Patient Protection and Affordable Care Act (ACA), Pub. L. No 111-148, 124 Stat. 119; raising statutory challenges to actions of HHS and the Commissioner relating to the implementation of the ACA and prior Medical legislation; and attacking the failure of defendants to render an "accounting" that would alter the American people to the insolvency towards which Medicare and Social Security programs were heading. On appeal, plaintiffs challenged the district court's dismissal of their claims. The court rejected plaintiffs' claims that 26 U.S.C. 5000A, which was sustained as a valid exercise of the taxing power, violated the Fifth Amendment's prohibition of the taking of private property without just compensation and violated the origination clause. The court concluded that plaintiffs' substantive attack on the Social Security Program Operations Manual System (POMS) provisions was clearly foreclosed by its decision in Hall v. Sebelius, holding that the statutory text establishing Medicare Part A precludes any option not to be entitled to benefits. The court rejected plaintiffs' second statutory claim attacking an interim final rule. Finally, the court concluded that plaintiffs failed to provide a legal argument for their claims against the Commissioner and Secretary, and therefore, the court lacked jurisdiction over plaintiffs' claim to an "accounting." Accordingly, the court affirmed the judgment of the district court. View "Assoc. Amer. Physicians, et al. v. Sebelius, et al." on Justia Law

Relator filed a qui tam action under the False Claims Act (FCA), 31 U.S.C. 3729-3733, against Omnicare, alleging that defendants violated a series of FDA safety regulations requiring that penicillin and non-penicillin drugs be packaged in complete isolation from one another. The court concluded that the public disclosure bar did not divest the district court of jurisdiction over relator's FCA claims. The court concluded that once a new drug has been approved by the FDA and thus qualified for reimbursement under the Medicare and Medicaid statutes, the submission of a reimbursement request for that drug could not constitute a "false" claim under the FCA on the sole basis that the drug had been adulterated as a result of having been processed in violation of FDA safety regulations. The court affirmed the district court's grant of Omnicare's motion to dismiss, holding that relator's complaint failed to allege that defendants made a false statement or that they acted with the necessary scienter. The court also concluded that the district court did not abuse its discretion in denying relator's request to file a third amended complaint. View "United States ex rel. Rostholder v. Omnicare, Inc." on Justia Law