Justia Public Benefits Opinion Summaries

Catholic Health filed suit under the Administrative Procedure Act (APA), 5 U.S.C. 500 et seq., challenging the agency's interpretation of the Medicare statute and its application to the 1997 cost-reporting period. The district court held that the Secretary's decision was unlawful because the agency, in calculating reimbursements owed for a 1997 cost-reporting period, had retroactively applied a 2004 rulemaking without congressional authorization. The court concluded that the policy on which the agency relied was first announced in an adjudication in 2000, not in the 2004 rulemaking; the agency's interpretation of the statute was permissible; the denial of reimbursements was not arbitrary and capricious; and Catholic Health had not shown that it relied to its detriment on the position the agency allegedly held before 2000. Accordingly, the court reversed the judgment of the district court. View "Catholic Health Initiatives Iowa Corp. v. Sebelius" on Justia Law

Plaintiffs appealed the Secretary's denial of their claims for Medicare coverage for dental services. Plaintiffs contended that this denial was premised on the Secretary's unreasonable interpretation of the Medicare Act, Pub. L. No. 89-97, 79 Stat. 286, which contravened the intent of Congress and violated plaintiffs' right to equal protection under the Fifth Amendment. The court concluded that, although the statutory provision for exclusion of dental services was ambiguous in the sense that plausible divergent constructions could be urged, the Secretary's interpretation of the statute was reasonable. The court also concluded that the Secretary's statutory interpretation warranted Chevron deference and the Secretary's statutory interpretation was reasonable. Accordingly, the court affirmed the judgment. View "Fournier v. Sebelius" on Justia Law

Plaintiffs, a class of Medicaid beneficiaries who suffered from severe developmental disabilities, sued the NCDHHS, PBH, and the director of PBH, alleging that defendants violated their rights under the Medicaid statute and the Due Process Clause of the Fourteenth Amendment by reducing their health care services without notice and an opportunity for a hearing. On appeal, PBH and the director challenged the district court's entry of a preliminary injunction. However, the NCDHHS did not join the appeal. Given that the NCDHHS had decided not to litigate the appeal, the court concluded that the Medicaid statute, 42 U.S.C. 1396a(a)(5), and accompanying regulations precluded PBH from appealing in the absence of the NCDHHS. Accordingly, the court dismissed the appeal. View "K.C. v. Shipman" on Justia Law

Southwest appealed the district court's dismissal of its claim regarding the Medicare Part D statute, 42 U.S.C. 1395w-101 et seq., for lack of subject matter jurisdiction. Citing Shalala v. Illinois Council on Long Term Care, Southwest argued that its claim provided a narrow exception to 42 U.S.C. 405(h)'s requirement that required a plaintiff to exhaust administrative remedies before filing a claim in federal court. The court concluded that caselaw interpreting the application of section 405(h) to Medicare claims emphasized that the Illinois Council exception was extremely narrow and appropriately applied only in cases where judicial review would be entirely unavailable through the prescribed administrative procedures. Because Southwest has not carried its heavy burden of showing that the Illinois Council exception applied, the court affirmed the district court's order dismissing the suit. View "Southwest Pharmacy Solutions, Inc. v. Centers for Medicare & Medicaid, et al" on Justia Law

Under the Medicaid program, the federal government offsets some state expenses for medical services to low-income persons; a state’s plan must cover medical assistance for specific populations, but a state may expand its Medicaid program by obtaining a waiver for an “experimental, pilot, or demonstration project.” In 1993, Tennessee obtained a waiver for TennCare, to cover uninsured and uninsurable individuals. Following approval, hospitals received reimbursement under the umbrella of TennCare. Because hospitals serving large numbers of low-income patients generally incur higher costs than Medicaid flat payment rates reflect, hospitals that treated a disproportionate share of low-income patients could apply for the “DSH” adjustment. A fiscal intermediary processed requests for reimbursement, including DSH adjustment payments. Due to discrepancies between the practices of fiscal intermediaries in different states, the Secretary issued a 2000 rule, providing that eligibility waiver patients were to be included as individuals “eligible for medical assistance” under Medicaid for purposes of DSH adjustment calculations. The 2005 Deficit Reduction Act ratified the rule. Adventist, a not-for-profit hospital network, provided more than 1,200 patient care days to TennCare expansion waiver patients 1995-2000. The fiscal intermediary did not include those days in calculating the adjustment. The Secretary’s Provider Reimbursement Review Board upheld the exclusion. The district court dismissed, concluding that section 1315 provided the Secretary discretion to exclude expansion waiver patient days from the DSH calculation. The Sixth Circuit affirmed. View "Adventist Health Sys./Sunbelt, Inc. v. Sebelius" on Justia Law

Providers brought suit against the State, asserting that the Adoption Assistance and Child Welfare Act of 1980 (CWA), 42 U.S.C. 670 et seq., gave them a privately enforceable right under 42 U.S.C. 1983 to receive payments from the State sufficient to cover the cost of certain statutorily enumerated components of foster care. At issue was whether Congress, in enacting the CWA, evinced a clear intent to grant foster care providers an individually enforceable right to foster care maintenance payments sufficiently large to cover the costs of each item enumerated in section 675(4)(A). The court held that Congress did not ambiguously confer such a right and, therefore, affirmed the district court's dismissal of the Providers' complaint for failure to state a claim. View "Midwest Foster Care, etc., et al v. Kincade, et al" on Justia Law

The County appealed from a judgment of the district court finding that the County was in violation of its duty to promote source-of-income legislation under a Stipulation and Order of Settlement and Dismissal (consent decree) entered into by the County with the United States to resolve a qui tam action initially brought by relator, ADC, under the False Claims Act, 31 U.S.C. 3729-33, alleging the submission of false claims by the County to HUD in order to obtain federal grant monies for fair housing. As a preliminary matter, the court held that the district court had jurisdiction to review the decision of the reviewing magistrate judge under the consent decree. On the merits, the court held that the County violated the terms of the consent decree. Accordingly, the court affirmed the judgment. View "United States v. Westchester County, New York" on Justia Law

MedQuest is a diagnostic testing company that operates more than 90 testing facilities in 13 states. In 2006 a former MedQuest employee, brought a qui tam suit against MedQuest alleging violations of the False Claims Act. The United States intervened and obtained summary judgment ($11,110,662.71) that MedQuest used supervising physicians who had not been approved by the Medicare program and the local Medicare carrier to supervise the range of tests offered at the Nashville-area sites, and after acquiring one facility, MedQuest failed to properly re-register the facility to reflect the change in ownership and enroll the facility in the Medicare program, instead using the former owner’s payee ID number. The Sixth Circuit reversed, stating that the Medicare regulatory scheme (42 U.S.C. 1395x) does not support FCA liability for failure to comply with the supervising-physician regulations. MedQuest’s failure to satisfy enrollment regulations and its use of a billing number belonging to a physician’s practice it controlled do not trigger the hefty fines and penalties created by the FCA. View "United States v. MedQuest Assocs, Inc." on Justia Law

Rohrer Towers is a housing facility for low-income elderly residents in Haddon Township, Camden County, New Jersey. Haddon leased Rohrer Towers to Housing Authority of the Township of Haddon, which entered into a housing assistance payments contract (HAP) with the U.S. Department of Housing and Urban Development (HUD) under the Housing Act of 1937, 88 Stat. 633, 662–66. Haddon sued in 2007 alleging that HUD breached the HAP Contract from 2001-2006 by requiring rent “comparability studies” to be submitted along with requests for annual rent adjustments and adopting a one-percent reduction of the annual adjustment factors for units occupied by the same tenants from the previous year. The Claims Court agreed and ordered rent adjustments for all years other than 2002. The government claimed that the complaint should have been dismissed on statute of limitations grounds and appealed the decision that regulatory imposition of a mandatory one-percent rent reduction for non-turnover units was arbitrary, and beyond HUD’s authority. The Federal Circuit reversed the holding that the prevention doctrine applied to the circumstances surrounding Haddon’s 2001 and 2003 rent adjustment, but affirmed the holdings with respect to the contract years 2002 and 2004-2006. View "Haddon Housing Assocs. v. United States" on Justia Law

Tennessee participates in Medicaid through “TennCare,” Tenn. Code 71-5-102. The Medicaid Act requires that TennCare administer an Early and Periodic Screening, Diagnosis, and Treatment program for all enrollees under age 21, 42 U.S.C. 1396a(a)(43), 1396d(r) and must provide outreach to educate its enrollees about these services. In 1998 plaintiffs filed a putative class action under 42 U.S.C. 1983, alleging that TennCare had failed to fulfill these obligations. The district court entered a consent decree that explained in detail the requirements that TennCare had to meet to “achieve and maintain compliance” with the Medicaid Act, based on the assumption that the Act created rights enforceable under section 1983. Eight years later, the Sixth Circuit held that one part of the Medicaid Act was unenforceable under section 1983. Following a remand, the district court vacated paragraphs of the decree that were based on parts of the Act that are not privately enforceable. After a thorough review of TennCare’s efforts, the court then vacated the entire decree, finding that TennCare had fulfilled the terms of the decree’s sunset clause by reaching a screening percentage greater than 80% and by achieving current, substantial compliance with the rest of the decree. The Sixth Circuit affirmed. View "John B. v.Emkes" on Justia Law