Justia Public Benefits Opinion SummariesArticles Posted in Health Care Law
Dube v. New Hampshire Dept. of Health & Human Svcs.
This case involved a petition for injunctive and declaratory relief brought by plaintiffs Harbor Homes, Inc. and Gary Dube, Thomas Taylor, Cynthia Washington, and Arthur Furber against defendants the New Hampshire Department of Health and Human Services (DHHS), the Commissioner of DHHS, the Associate Commissioner of DHHS, and the Administrator of the Bureau of Behavioral Health seeking, in part, to enjoin DHHS from denying the individual plaintiffs the right to obtain Medicaid-funded services from their chosen provider, Harbor Homes. The individual plaintiffs received Medicaid-funded rehabilitative services from Harbor Homes. Since 1991, Harbor Homes participated in New Hampshire's Medicaid program pursuant to a Medicaid Provider Enrollment Agreement. On June 23, 2008, Harbor Homes entered into an interagency agreement (IAA) with a community mental health program, Community Council of Nashua, NH, now known as Greater Nashua Mental Health Center (GNMHC), which authorized Harbor Homes to provide certain Medicaid-funded rehabilitative services to GNMHC patients. In February 2011, Harbor Homes learned that GNMHC did not intend to renew its IAA and that the Medicaid reimbursable services provided by Harbor Homes would be transitioned to GNMHC. This was done pursuant to Administrative Rule He-M 426.04(a)(2), which meant that Harbor Homes would no longer have an IAA with a community mental health provider, and it would no longer be permitted to provide Medicaid funded mental health services to approximately one hundred and forty of its clients, including the individual plaintiffs in this case. Plaintiffs filed a petition for injunctive and declaratory relief, seeking a court order enjoining DHHS from "terminating or limiting Harbor Homes' status as a qualified Medicaid provider" and to direct the State to allow the individual plaintiffs to obtain community mental health services from Harbor Homes, the provider of their choice. Following two hearings, the court denied the plaintiffs' request for a preliminary injunction. Thereafter, all parties moved for partial summary judgment on the plaintiffs' claim that DHHS's reliance upon the IAA requirement as a reason to terminate Harbor Homes' status as a qualified Medicaid provider was improper because the requirement was invalid both on its face and as applied in this case. Plaintiffs appealed rulings of the Superior Court that denied their summary judgment motions and granting the defendants' cross-motions for summary judgment on two counts in the plaintiffs' petition. Upon review of the matter, the Supreme Court reversed the Superior Court's ruling that New Hampshire Administrative Rules, He-M 426.04(a)(2) did not violate the federal Medicaid Act. The case was remanded for further proceedings. View "Dube v. New Hampshire Dept. of Health & Human Svcs." on Justia Law
Martin H. Handler, M.D., P.C. v. DiNapoli
Petitioners were two medical providers whose patients included individuals insured by the State’s primary health benefit plan. The State Comptroller reviewed Petitioners’ billing records as part of an audit of billing practices in the health care industry for claims paid by the State. While Petitioners conceded that the State paid eighty percent of the costs of their services, Petitioners challenged the Comptroller’s authority to audit their books. Supreme Court concluded that the Comptroller lacked constitutional authority to audit Petitioners because Petitioners were “not a political subdivision of the State.” The Appellate Division modified Supreme Court’s orders to reinstate the audits. The Court of Appeals affirmed, holding that the State Constitution does not limit the Comptroller’s authority to audit, as part of its audit of State expenditures, the billing records of private companies that provide health care to beneficiaries of a State insurance program.View "Martin H. Handler, M.D., P.C. v. DiNapoli" on Justia Law
Appalachian Reg’l Healthcare v. W. Va. Dep’t of Health & Human Res.
Beckley Appalachian Regional Hospital (Beckley ARH) was a voluntary provider of medical services through the Medicaid program pursuant to an agreement executed between it and the West Virginia Bureau for Medical Services (BMS). Beckley ARH filed a lawsuit against the West Virginia Department of Health and Human Resources and its secretary and the BMS and its commissioner (collectively, Respondents), seeking a remedy for inadequate Medicaid reimbursement rates. The circuit court dismissed the complaint for failure to state a claim upon which relief could be granted. The Supreme Court affirmed, holding that W. Va. Code 9-15-16 and 16-29B-20 do not provide for an express or implied private cause of action by a Medicaid provider for judicial review of reimbursement rates for medical services.View "Appalachian Reg'l Healthcare v. W. Va. Dep't of Health & Human Res." on Justia Law
Koch v. Sheehan
The Office of the Medicaid Inspector General (OMIG) terminated a physician's participation in the Medicaid program on the basis of a Bureau of Professional Medical Conduct (BPMC) consent order, in which the physician pleaded no contest to charges of professional misconduct and agreed to probation. Supreme Court annulled the OMIG's determination. The Appellate Division affirmed, concluding (1) the agency acted arbitrarily and capriciously in barring the physician from treating Medicaid patients when the BPMC permitted him to continue to practice; and (2) the OMIG was required to conduct an independent investigation before excluding a physician from Medicaid on the basis of a BPMC consent order. The Court of Appeals affirmed but for another reason, holding (1) the OMIG is authorized to remove a physician from Medicaid in reliance solely on a consent order between the physician and the BMPC, regardless of whether BPMC chooses to suspend the physician's license or OMIG conducts an independent investigation; but (2) because OMIG did not explain why the BPMC consent order caused it to exclude the physician from the Medicaid program, the agency's determination was arbitrary and capricious.View "Koch v. Sheehan" on Justia Law
PremierTox 2.0 v. Circuit Court
Appellants, PremierTox, Inc. and PremierTox 2.0 (collectively, PremierTox) filed an action against Kentucky Spirit Health Plan, Inc. and others (collectively, Appellees), alleging that it was owed $1.8 million by Kentucky Spirit for services it had provided to Medicaid patients and for which Kentucky Spirit had allegedly been paid by the Commonwealth. The circuit court ordered Appellees to deposit $1.8 million into an escrow account controlled by the circuit court pending adjudication of the claim. The court of appeals issued a writ to prohibit enforcement of the circuit court's order, concluding that the circuit court lacked the authority to require Appellees to pay the demanded judgment into court in advance of an adjudication that Appellees owed the money. The Supreme Court affirmed the decision of the court of appeals to issue the writ of prohibition, holding (1) the circuit court acted erroneously in ordering Appellees to escrow the disputed funds under Ky. R. Civ. P. 67.02; (2) the circuit court's order was essentially a pre-judgment attachment for which Appellees lacked an adequate remedy on appeal or otherwise; and (3) Appellees satisfied the "irreparable injury" prong of the proper writ analysis. View "PremierTox 2.0 v. Circuit Court" on Justia Law
Sunrise Ret. Cmty. v. Iowa Dep’t of Human Servs.
Plaintiffs, several nursing homes approved by the Iowa Department of Human Services (DHS) as Medicaid providers, submitted annual reports disclosing their income and expenses to DHS. DHS used the reports to calculate the Medicaid per diem reimbursement rates for the nursing homes. Some of the facilities' expenses were disallowed by DHS, and DHS reduced reimbursement rates accordingly. The facilities appealed the adjustments. The director of human services upheld the action. The district court affirmed. The court of appeals reversed, concluding that the DHS rules did not support its decision that the disputed costs were not allowable. The Supreme Court affirmed, holding that DHS's exclusion of the facilities' lab, x-ray, and prescription drug costs from the nursing homes' reports was based on an incorrect interpretation of its rules.View "Sunrise Ret. Cmty. v. Iowa Dep't of Human Servs." on Justia Law
El Paso County Hosp. Dist. v. Tex. Health & Human Servs.
In an earlier suit, fourteen Texas hospitals filed a declaratory relief action against the Texas Health and Human Services Commission and its Executive Commissioner (collectively HHSC), challenging a cutoff date used by HHSC to cap the collection of data used to calculate Medicaid reimbursement rates for inpatient services. The Supreme Court declared the cutoff-date rule invalid and enjoined its enforcement. The Court further remanded the cause to the district court, where the hospitals argued that the Court's judgment should apply retroactively to provide them a basis to reopen their earlier administrative appeals and to seek reimbursement for the underpayment of past Medicaid claims calculated under the invalid cutoff-date rule. The district court found in favor of the hospitals. The court of appeals reversed, determining that the injunction should only operate prospectively. The Supreme Court affirmed, holding that the court of appeals correctly concluded that the Court's earlier opinion and judgment did not purport to reopen past rate determinations or closed administrative proceedings.View "El Paso County Hosp. Dist. v. Tex. Health & Human Servs." on Justia Law
Christus Health Gulf Coast v. Aetna, Inc.
Several hospitals (Hospitals) sued Aetna, Inc. and Aetna Health, Inc. (collectively Aetna) for allegedly violating the Prompt Pay Statute. Aetna provided a Medicare plan (Plan) through an HMO called NYLCare. It delegated the administration of its Plan to North American Medical Management of Texas (NAMM), a third-party administrator. IPA Management Services (Management Services) provided medical services to Plan enrollees. Management Services entered into contracts with the Hospitals to secure hospital services for the Plan employees. Aetna was not a party to these contracts. The Hospitals submitted hospital bills to NAMM for payment. After NAMM and Management Services became insolvent, Aetna de-delegated NAMM and assumed responsibility for processing and paying claims. However, Aetna instructed the Hospitals to continue submitting their bills to NAMM. The Hospitals argued that Aetna was liable for NAMM's failure to timely pay claims and was responsible for $13 million in outstanding bills. The trial court granted summary judgment for Aetna. The court of appeals affirmed, concluding that because the Hospitals entered into contracts with Management Services and not with Aetna directly, the Hospitals had no viable prompt-pay claim. The Supreme Court affirmed, holding that the lack of privity between the Hospitals and Aetna precluded the Hospitals' suit.View "Christus Health Gulf Coast v. Aetna, Inc." on Justia Law
Nelson v. Dep’t of Social Servs.
Appellant, a forty-eight-year-old who lived independently for two decades, had "borderline intellectual functioning," an expressive language disorder, and a learning disorder. Appellant applied for Home and Community Based Services (HCBS), a federal-state Medicaid Waiver program that provides assistance to individuals with developmental disabilities. The South Dakota Department of Human Services (the Department) denied Appellant's application, determining that Appellant was not eligible for HCBS. After a hearing, an ALJ affirmed the Department's denial. The circuit court affirmed. The Supreme Court also affirmed, holding that the ALJ did not clearly err in finding that Appellant did not qualify for benefits, as the evidence indicated that Appellant was a generally independent client who was able to function with little supervision or in the absence of a continuous active treatment program.View "Nelson v. Dep't of Social Servs." on Justia Law
In re E.B.
Infant was born with severe brain damage. Respondent, Infant's mother, on behalf of Infant, applied for and received Medicaid benefits from the West Virginia Department of Health and Human Resources (DHHR). Respondent later filed a medical malpractice lawsuit on behalf of Infant. Subsequently, Respondent petitioned the circuit court for approval of the settlement, requesting that Medicaid not be reimbursed. DHHR intervened. The court granted the motion of Respondent for allocation of the $3,600,000 settlement, holding that, pursuant to Arkansas Department of Health and Human Services v. Ahlborn, a proportional reduction of DHHR's recovery was required based on the ratio of the settlement to the "full value" of the case among the various damages categories. Using this allocation method, the court reduced DHHR's statutory reimbursement from the requested amount of $289,075 to $79,040 and directed that the net settlement proceeds be placed in a special needs trust for the benefit of Infant. The Supreme Court reversed in part and affirmed in part, holding (1) a $500,000 cap on noneconomic damages was applicable in this case; and (2) under the formula applied in Ahlborn, the DHHR was entitled to approximately $98,080, less its pro rata share of attorney's fees and costs. Remanded.View "In re E.B." on Justia Law