Justia Public Benefits Opinion Summaries

The underlying dispute before the Pennsylvania Supreme Court in this case involved the adequacy of state funding for community participation support ("CPS") services, which were designed to help individuals with autism or intellectual disabilities live independently. The primary issue on appeal related to the exhaustion requirement. The Pennsylvania Department of Human Services ("DHS") issued ODP Announcement 19-024, indicating it intended to change the rate structure for CPS services provided under the Home and Community Based Services (“HCBS”) waivers. Petitioners filed an action for declaratory and injunctive relief, challenging the legality of the new fee schedule and alleged the new reimbursement rates were too low to sustain the provision of CPS services to eligible recipients. Pertinent here, the Commonwealth Court agreed with one of DHS' preliminary objections that Petitioners failed to exhaust their administrative remedies, as required by case precedent, before seeking judicial review. The court acknowledged a narrow exception to the exhaustion requirement whereby a court may consider the merits of a claim for declaratory or injunctive relief if a substantial constitutional question is raised and the administrative remedy is inadequate. It clarified, however, that the exception only applied where the plaintiff raises a facial constitutional challenge to the statute or regulation in question, as opposed to its application in a particular case. Here, the court concluded, the Petitioners were attacking the fee schedule in the Final Notice, which was produced by application of the legal authority cited in that notice, and not advancing a facial constitutional challenge. The court also found Petitioners failed to demonstrate the administrative remedy was inadequate. The Supreme Court affirmed the Commonwealth Court’s order insofar as it sustained the preliminary objection asserting that the Petitioners failed to exhaust their administrative remedies, and dismissed the Petition as to those parties. The order was vacated in all other respects, and the matter was remanded for further proceedings. View "Rehabilitation & Community Providers Association, et al. v. Dept. Human Svcs" on Justia Law

In 1993, Kastman was charged with misdemeanor offenses based on acts of public indecency involving children and disorderly conduct. The state’s attorney initiated a civil commitment proceeding against Kastman under the Sexually Dangerous Persons Act (725 ILCS 205/0.01). Evidence indicated that Kastman suffered from pedophilia, antisocial personality disorder, exhibitionism, and alcohol dependency. Kastman was found to be a sexually dangerous person, and the circuit court granted the petition. In 2016, Kastman was granted conditional release from institutional care.In 2020, he sought financial assistance. Kastman asserted that he was unemployed, disabled, and could not afford his $300 monthly treatment costs and the $1800 monthly rent for housing that complied with the Sex Offender Registration Act. The circuit court of Lake County ordered the Department of Corrections to pay a portion of Kastman’s monthly expenses. The appellate court and Illinois Supreme Court affirmed. The statutes indicate that a sex offender’s ability to pay is a relevant consideration in deciding who should bear the expense of treatment costs; without a clear statutory directive, the legislature is not presumed to have intended that only financially stable individuals are eligible for conditional release. Financial instability and the need for supervision to protect the public are not the same things. View "People v. Kastman" on Justia Law

Under the Social Security Act’s Title IV-E program, states receive reimbursements for foster care maintenance payments (FCMPs), 42 U.S.C. 670–676. Title IV-E’s conditions include having a state plan approved by the Secretary of Health and Human Services (HHS); the removed child’s placement and care must be the responsibility of the state agency administering that plan. Kentucky's approved plan is administered by the Kentucky Cabinet for Health and Family Services. Under Kentucky law, a court may remove a child from her home “to the custody of an adult relative, fictive kin,” or other person or facility or can commit the child to the custody of the Cabinet. The Cabinet does not provide FCMPs to children placed by courts into the care of a relative or fictive kin, although that is a preferred outcome for the child.Caregivers brought a class action, accusing the Cabinet of denying FCMPs to eligible children without notice or a fair hearing, in a way that discriminated against relative caregivers. The district court certified a Children’s Class, a Caregivers’ Class, a Cabinet Custody Class, and a Notice and Hearing Class. The Sixth Circuit affirmed the dismissal of the suit except as to the Cabinet Custody Class. Under Kentucky law, the Cabinet did not have placement and care responsibility over children not in their custody; the Cabinet cannot change a child’s placement without a court order. Only Cabinet Custody Class members were eligible for FCMPs. View "J. B-K. v. Kentucky Cabinet for Health and Family Services" on Justia Law

Access Behavioral Health appeals from the district court’s judgment upholding an order of the Idaho Department of Health and Welfare that demanded recoupment of Medicaid payments made to Access. The Department sought to recoup certain payments made to Access because it failed to meet the Department’s documentation requirements. Following an audit of provider billings, the Department found Access billed Medicaid for two codes for services provided to the same patient on the same day without documentation to support its use of the codes. The Department concluded the documentation deficiencies violated IDAPA Rule 16.03.09.716 and the Handbook. The Idaho Supreme Court determined the Department had legal authority to issue recoupment demands to Access. Access failed to demonstrate an entitlement to payment of those funds sought to be recouped. The False Claims Act's materiality requirement was inapplicable to the Department’s administrative action. Finally, laches did not bar the Department’s administrative actions. Judgment was thus affirmed. View "Access Behavioral Health v. IDHW" on Justia Law

Jarnutowski sought Social Security disability benefits, claiming she could not work due to a foot condition, neck and leg pain, obesity, and mental health issues. Jarnutowski underwent multiple surgeries, X-rays, and CT scans on her foot between 2011-2015. An ALJ awarded Jarnutowski found that she was disabled during September 2013-January 2016, with only the ability to perform light work with some limitations; her foot condition, neck issues, and obesity were severe impairments; and, she was disabled by direct application of the Medical-Vocational Guidelines due to her age. The ALJ concluded that Jarnutowski’s disability ended when she regained the ability to perform medium work after her foot surgery and was again able to perform her past work as a store manager. The ALJ did not explicitly address Jarnutowski’s functional capabilities related to medium work, including Jarnutowski’s ability to lift objects weighing up to 50 pounds and frequently lift or carry objects weighing up to 25 pounds, emphasizing Jarnutowski’s ability to walk.The Seventh Circuit reversed. In Social Security disability determinations, the lifting and carrying weight requirements associated with medium work are more than double those of light work. The ALJ found that Jarnutowski’s “residual functional capacity” was limited to light work with some restrictions before her final foot surgery, but increased to medium work after the surgery without explaining how, after surgery, Jarnutowski could lift or carry objects more than twice the weight that she lifted or carried before surgery. View "Jarnutowski v. Kijakazi" on Justia Law

Class Counsel discovered the Social Security Administration's (SSA’s) systemic failure to perform “Subtraction Recalculations” and recovered over $106 million in past-due disability benefits. After performing the Subtraction Recalculations for all the claimants, the SSA argued that the district court did not have authority under the Social Security Act’s judicial-review provision, 42 U.S.C. 405(g), to order the Subtraction Recalculations and that Class Counsel cannot recover attorney fees under section 406(b) for representation of the claimants.The Sixth Circuit affirmed the award of $15.9 million in attorney fees to Class Counsel. SSA “may not hide behind” the statutory provisions merely because it erred at the end, rather than at the beginning, of the benefits-award process. The district court appropriately exercised judicial review under section 405(g), properly ordered the SSA to perform the Subtraction Recalculations, and properly awarded reasonable attorneys’ fees. The SSA failed to award claimants additional past-due benefits to which they were entitled. Counsel successfully sought judicial assistance to obtain those benefits. Congress did not create a statute that allows attorneys to recover fees when the SSA initially fails to award benefits, only to foreclose fee recovery when the SSA later unlawfully withholds additional benefits. View "Steigerwald v. Commissioner of Social Security" on Justia Law

Clemons worked as a coal miner for 10 years and smoked two packs per day for 30 years. Clemons suffered and died from COPD. His claims for federal black-lung benefits (30 U.S.C. 901) were denied. An ALJ awarded Mrs. Clemons survivor’s benefits after considering three medical opinions. Dr. Sikder diagnosed Clemons with legal pneumoconiosis in the form of COPD that resulted from both cigarette smoking and from coal-mine dust exposure. Doctros Habre and Broudy attributed Clemons’s COPD solely to his cigarette smoking. The ALJ credited Sikder’s opinion as well-documented, well-reasoned, and supported by substantial evidence, irrespective of the length of coal mine employment she considered, so that opinion was accorded “probative weight” while the other opinions did not sufficiently explain why Clemons’s coal-mine dust exposure did not contribute “at least in part” to his COPD. The Benefits Review Board affirmed, concluding that the evidence was sufficient to establish the presence of legal pneumoconiosis.The Sixth Circuit denied a petition for review, finding that the ALJ took the coal mine employment discrepancy into account when he weighed Dr. Sikder’s opinion, and acted within his discretion in explaining that the discrepancy was not so great as to detract from the opinion’s probative value. View "Huscoal, Inc. v. Director, Office of Workers’ Compensation Programs, United States Department of Labor" on Justia Law

The Ninth Circuit reversed in part and vacated in part the district court’s grant of Defendants’ motion to dismiss, and remanded for further proceedings, in an action in which federally-qualified health centers operating in Arizona and their membership organization alleged that the Arizona Health Care Cost Containment System, which administers Arizona’s Medicaid program, and its director violated 42 U.S.C. Section 1396a(bb) and binding Ninth Circuit precedent by failing or refusing to reimburse Plaintiffs for the services of dentists, podiatrists, optometrists, and chiropractors.   First, the panel held that the court’s precedent in California Ass’n of Rural Health Clinics v. Douglas (“Douglas”), 738 F.3d 1007 (9th Cir. 2013), established that FQHC services are a mandatory benefit under Section 1396d(a)(2)(C) for which Plaintiffs have a right to reimbursement under Section 1396a(bb) that is enforceable under 42 U.S.C. Section 1983. The panel rejected Defendants’ interpretation of Section 1396d(a)(2)(C)’s phrase “which are otherwise included in the plan” as applying to both the phrases “FQHC services” and “other ambulatory services offered by a [FQHC.]” The panel, therefore, rejected Defendants’ assertion that Section 1396d(a)(2)(C) only required states to cover FQHC services that are included in the state Medicaid plan.   The panel recognized that Douglas held that the mandatory benefit of “FQHC services” under § 1396d(a)(2)(C) includes “services furnished by . . . dentists, podiatrists, optometrists, and chiropractors” as well as doctors of medicine and osteopathy. The panel held that Arizona’s categorical exclusion of adult chiropractic services violated the unambiguous text of the Medicaid Act as interpreted in Douglas. View "AACHC V. AHCCCS" on Justia Law

The Mississippi Division of Medicaid (DOM) and Yalobusha County Nursing Home (YNH) disputed four costs submitted for reimbursement by YNH in its fiscal year 2013 Medicaid cost report. The DOM appealed a Chancery Court’s judgment ordering the DOM to reverse the four adjustments at issue. Because the DOM correctly interpreted the appropriate statutes and because its decisions were supported by substantial evidence, the Mississippi Supreme Court reversed the chancery court’s order and rendered judgment reinstating the decisions of the DOM. View "Mississippi Division of Medicaid v. Yalobusha County Nursing Home" on Justia Law

When Plaintiff-appellant Linda Smith purchased a prescribed continuous blood glucose monitor (CGM) and its necessary supplies between 2016 and 2018, she sought reimbursement through Medicare Part B. Medicare administrators denied her claims. Relying on a 2017 ruling issued by the Centers for Medicare and Medicaid Services (CMS), Medicare concluded Smith’s CGM was not “primarily and customarily used to serve a medical purpose” and therefore was not covered by Part B. Smith appealed the denial of her reimbursement claims through the multistage Medicare claims review process. At each stage, her claims were denied. Smith then sued the Secretary of the Department of Health and Human Services in federal court, seeking monetary, injunctive, and declaratory relief. Contending that her CGM and supplies satisfied the requirements for Medicare coverage. Instead of asking the court to uphold the denial of Smith’s claims, the Secretary admitted that Smith’s claims should have been covered and that the agency erred by denying her claims. Rather than accept the Secretary’s admission, Smith argued that the Secretary only admitted error to avoid judicial review of the legality of the 2017 ruling. During Smith’s litigation, CMS changed its Medicare coverage policy for CGMs. Prompted by several adverse district court rulings, CMS promulgated a formal rule in December 2021 classifying CGMs as durable medical equipment covered by Part B. But the rule applied only to claims for equipment received after February 28, 2022, so pending claims for equipment received prior to that date were not covered by the new rule. Considering the new rule and the Secretary’s confession of error, the district court in January 2022 remanded the case to the Secretary with instructions to pay Smith’s claims. The district court did not rule on Smith’s pending motions regarding her equitable relief claims; instead, the court denied them as moot. Smith appealed, arguing her equitable claims were justiciable because the 2017 ruling had not been fully rescinded. The Tenth Circuit agreed with the Secretary that Smith’s claims were moot: taken together, the December 2021 final rule and the 2022 CMS ruling that pending and future claims for CGMs would be covered by Medicare deprived the Tenth Circuit jurisdiction for further review. View "Smith v. Becerra" on Justia Law