Justia Public Benefits Opinion Summaries

An elderly man, Jerome, experienced significant health decline and was moved into a nursing home, prompting his wife, Janet, to petition the Saginaw Probate Court for a protective order under Michigan law. She requested the transfer of all of Jerome’s assets and most of his income to her, citing her increased financial needs and Jerome’s inability to manage his affairs due to physical and mental health issues. Janet’s petition was filed before Jerome’s application for Medicaid was resolved, and the probate court granted the transfer and set a monthly support payment for Janet.The Department of Health and Human Services (DHHS) appealed. The Michigan Court of Appeals affirmed in part but vacated the probate court’s order, relying on its earlier precedent in In re Estate of Schroeder, which prohibited consideration of Medicaid eligibility before a formal determination. The case was remanded for a new assessment of need and current valuation of assets. On remand, the probate court again ordered the transfer and support, applied retroactively, but the Court of Appeals vacated this order as well, citing reliance on outdated asset information and the same legal standard regarding Medicaid eligibility.The Michigan Supreme Court reviewed the case after Jerome’s death, holding that the appeal was not moot because Medicaid benefits can be awarded retroactively, even to a deceased individual’s estate. The Supreme Court ruled that probate courts may consider the likely availability of Medicaid benefits before a final eligibility determination when assessing the needs of an individual and their dependents under MCL 700.5401(3)(b). The Court expressly overruled the contrary rule announced in In re Estate of Schroeder, reinstated the probate court’s 2022 protective order, and remanded the case for further proceedings. View "In Re Estate Of Sizick" on Justia Law

Several individuals who participate in West Virginia’s Medicaid program and have been diagnosed with gender dysphoria sought surgical treatments that are excluded from coverage under West Virginia’s Medicaid plan. The state plan expressly excludes coverage for “sex change” or “transsexual” surgeries, though it covers these procedures for other medical indications, such as cancer or congenital abnormalities. The plaintiffs, representing a class of similarly situated individuals, alleged that this exclusion discriminates against them in violation of the Equal Protection Clause, Section 1557 of the Affordable Care Act, and certain provisions of the Medicaid Act.In proceedings before the United States District Court for the Southern District of West Virginia, the court granted summary judgment to the plaintiffs on all claims. The court found that the exclusion was unlawful under the Equal Protection Clause, the Affordable Care Act’s anti-discrimination provision, and the Medicaid Act’s comparability and availability requirements. The district court issued a declaratory judgment and enjoined enforcement of the exclusion. On appeal, the United States Court of Appeals for the Fourth Circuit sitting en banc affirmed the district court’s judgment. The state defendants then sought review by the Supreme Court, which granted certiorari, vacated the Fourth Circuit’s en banc decision, and remanded for reconsideration in light of two recent Supreme Court cases: United States v. Skrmetti and Medina v. Planned Parenthood South Atlantic.Upon reconsideration, the United States Court of Appeals for the Fourth Circuit reversed the district court. The court held that, under Skrmetti, West Virginia’s exclusion does not violate the Equal Protection Clause or the Affordable Care Act, because the exclusion is based on medical diagnosis rather than sex or transgender status and is supported by rational, non-discriminatory reasons. Applying Medina, the court further held that the Medicaid Act’s comparability and availability requirements do not provide a private right of action, and thus plaintiffs could not sue under those provisions. The Fourth Circuit reversed and remanded the case with instructions to enter summary judgment for the defendants. View "Anderson v. Crouch" on Justia Law

During a contentious divorce and custody dispute, Amanda Hovanec, who had returned to Ohio from South Africa with her children, conspired with Anthony Theodorou, her romantic partner, to kill her husband, T.H. After failed attempts to hire hitmen in South Africa, Theodorou, at Hovanec’s direction, obtained and shipped etorphine, a dangerous animal tranquilizer, to the United States. Hovanec ultimately used the drug to fatally inject T.H. at her mother Anita Green’s home. Green assisted after the murder by helping to select a burial site, driving the others to dig a grave, and later transporting them and the body for burial. The group also undertook efforts to conceal the crime, including disposing of T.H.’s belongings and misleading authorities. All three were arrested after an investigation revealed dashcam footage of the crime.In the United States District Court for the Northern District of Ohio, Hovanec pleaded guilty to multiple controlled-substance offenses resulting in death, and Green pleaded guilty to being an accessory after the fact. Hovanec received a 480-month sentence; Green received 121 months and was ordered to pay restitution for psychological care for T.H.’s and Hovanec’s children. Both defendants appealed their sentences and, in Green’s case, the restitution order.The United States Court of Appeals for the Sixth Circuit affirmed the sentences for both Hovanec and Green. The appellate court upheld the denial of a sentencing reduction for Green based on her lack of candor regarding knowledge of the murder plan. The court also affirmed the sentencing enhancements for Hovanec’s leadership role and obstruction of justice. However, the court reversed the restitution order against Green, holding that under federal law, restitution for psychological care requires evidence of bodily injury, defined as physical harm or physical manifestations of psychological harm, and remanded for further factual findings on this issue. View "United States v. Green" on Justia Law

The Missouri General Assembly enacted two statutes effective August 28, 2023: the SAFE Act, which generally prohibits health care providers from performing gender transition surgeries or prescribing cross-sex hormones and puberty-blocking drugs for minors, and the Medicaid ban, which precludes MO HealthNet payments for such treatments when used for gender transition. The statutes include specific exemptions, such as for treatment of certain medical conditions and for minors already receiving such care prior to enactment. E.N., on behalf of her minor child and joined by medical professionals and organizations, challenged both laws, alleging violations of equal protection, due process, and the gains of industry clause under the Missouri Constitution.The Circuit Court of Cole County conducted a two-week bench trial and entered judgment in favor of the State, upholding the constitutionality of both statutes. The court found the challengers had raised only facial challenges and determined that neither statute violated the constitutional provisions cited. The challengers appealed, raising multiple points of error regarding the constitutional analysis and factual findings at trial.The Supreme Court of Missouri reviewed the circuit court’s determination de novo, applying a presumption of constitutionality. Relying on recent decisions from the United States Supreme Court and the United States Court of Appeals for the Eighth Circuit, the court held that both statutes classify based only on age and medical use, not on sex or transgender status. Thus, rational-basis review applied. The court found that the statutes are rationally related to legitimate state interests, such as safeguarding minors and managing public resources, and do not infringe fundamental rights. The court affirmed the circuit court’s judgment, concluding that the challengers failed to demonstrate any constitutional violation. View "E.N. v. Kehoe" on Justia Law

Nita and Kirtish Patel operated two companies that provided mobile diagnostic medical services. To obtain Medicare reimbursement for neurological testing, they falsely represented that a licensed neurologist would supervise the tests. In reality, Kirtish, who lacked a medical license, wrote the reports, and Nita forged a physician’s signature. Their fraudulent scheme generated over $4 million, including substantial Medicare payments.In 2014, a former employee filed a sealed qui tam action in the United States District Court for the District of New Jersey, alleging healthcare fraud and asserting claims under the False Claims Act. The Patels were subsequently arrested and each pleaded guilty to one count of healthcare fraud. Their plea agreements did not address or preclude future civil or administrative actions. After their guilty pleas, the Government intervened in the qui tam action and obtained summary judgment against the Patels, relying on collateral estoppel from their criminal admissions. The District Court trebled the Medicare loss and imposed civil penalties, resulting in a judgment exceeding $7 million. Nita appealed, and the United States Court of Appeals for the Third Circuit affirmed her liability under the False Claims Act.Both Patels later moved to vacate their criminal sentences under 28 U.S.C. § 2255, arguing ineffective assistance of counsel because their attorneys did not advise them that their guilty pleas could have collateral estoppel effects in the civil qui tam action. The District Court denied their motions, finding that counsel’s performance was not objectively unreasonable and that the Patels were aware their plea agreements did not preclude civil actions.On appeal, the United States Court of Appeals for the Third Circuit held that the Sixth Amendment does not require criminal defense counsel to advise clients of collateral consequences such as civil liability under the False Claims Act. The court affirmed the District Court’s judgment, concluding that Padilla v. Kentucky’s holding is limited to deportation consequences and does not extend to civil liability. View "Patel v. USA" on Justia Law

A personal care assistance provider agency in Minnesota was audited by the Department of Human Services (DHS) for recordkeeping deficiencies related to its provision of services under the state’s Medicaid program. The agency, which served both traditional and PCA Choice recipients, was found to have various documentation errors, including missing or incomplete care plans and timesheets, as well as timesheets lacking required elements. DHS did not allege fraud or that services were not provided, but sought to recover over $420,000 in payments, arguing that these deficiencies constituted “abuse” under state law and justified monetary recovery.After an evidentiary hearing, an administrative law judge (ALJ) recommended limited recovery for some missing documentation but rejected most of DHS’s claims, finding that DHS had not shown the deficiencies resulted in improper payments. The DHS Commissioner disagreed, ordering full repayment. The Minnesota Court of Appeals reversed the Commissioner’s decision, holding that DHS must prove not only that the provider engaged in “abuse” but also that the abuse resulted in the provider being paid more than it was entitled to receive. The court also determined that provider agencies must maintain care plans for both traditional and PCA Choice recipients in their files.The Minnesota Supreme Court affirmed in part, reversed in part, and remanded. It held that, to obtain monetary recovery under Minn. Stat. § 256B.064, subd. 1c(a), DHS must prove either: (1) the provider engaged in conduct described in subdivision 1a and, had DHS known of the conduct before payment, it would have been legally prohibited from paying under a statute or regulation independent of subdivision 1a; or (2) the payment resulted from an error such that the provider received more than authorized by law. The Court also held that provider agencies must keep care plans for all PCA services, including PCA Choice, in their files. View "In the Matter of the SIRS Appeal by Best Care, LLC" on Justia Law

Two children, E.R. and G.S., have severe, complex medical conditions that require constant, skilled care. Their mothers, who are their primary caregivers and sole financial supporters, have been trained by medical professionals to provide the necessary care at home. For years, Indiana’s Medicaid program reimbursed these mothers for providing “attendant care services” under a waiver program designed to keep individuals out of institutions. In July 2024, the Indiana Family and Social Services Administration (FSSA) implemented a policy change that would make parents ineligible to be paid providers of attendant care for their children, threatening to force E.R. and G.S. into institutional care due to the lack of available in-home nurses.The Indiana Protection and Advocacy Services Commission, along with E.R. and G.S., sued to block the policy change and require FSSA to secure in-home nursing. The United States District Court for the Southern District of Indiana initially granted a preliminary injunction requiring FSSA to take steps to obtain in-home nurses and to pay the mothers for a different, lower-paid service. After further proceedings, the court modified its order, ultimately requiring FSSA to pay the mothers for attendant care at the previous rate until in-home nursing could be secured.The United States Court of Appeals for the Seventh Circuit affirmed the district court’s October 1 injunction. The court held that the plaintiffs are likely to succeed on their claims under the Americans with Disabilities Act’s integration mandate, which requires states to provide services in the most integrated setting appropriate. The court found that prohibiting the mothers from providing paid attendant care placed the children at serious risk of institutionalization and that FSSA had not shown that allowing such care would fundamentally alter the Medicaid program or violate federal law. The case was remanded for further proceedings. View "Indiana Protection and Advocacy Services Comm'n v Indiana Family and Social Services Administration" on Justia Law

A skilled nursing facility accepted a new resident who was receiving Medicaid benefits. The resident's husband was designated as her authorized representative. Nearly two years later, the Department of Human Services (DHS) terminated the resident's Medicaid benefits due to excess assets. Both the resident and her husband were incapacitated, and the resident's public guardian submitted a new Medicaid application, which was denied. The nursing facility continued to care for the resident without compensation until her death. The facility later sought an administrative hearing to challenge the eligibility decision, but the request was denied because the facility was not an authorized representative and the appeal was late.The circuit court and the Intermediate Court of Appeals (ICA) affirmed the denial, holding that the nursing home lacked standing to challenge the eligibility determination under Hawai'i Revised Statutes (HRS) § 346-12, which limits appeals to the applicant or recipient. The courts concluded that the nursing home did not have a close relationship with the resident for third-party standing purposes.The Supreme Court of the State of Hawai'i reviewed the case and disagreed with the lower courts regarding standing. The court held that skilled nursing facilities have constitutionally protected property interests in compensation for medical services performed for residents based on DHS eligibility determinations. The court ruled that these facilities have due process rights under the Hawai'i Constitution, including notice and the opportunity to appeal Medicaid eligibility determinations when the beneficiary is incapacitated and no authorized representative is available or willing to appeal. The court vacated the ICA's judgment and the circuit court's order, remanding the case for a new administrative hearing on the merits of the resident's Medicaid eligibility. View "In re FT" on Justia Law

Dionne Marie Nadon applied for disability insurance benefits and supplemental security income in April 2015 and May 2016, respectively, citing conditions such as fibromyalgia, spinal abnormalities, depression, and anxiety. The administrative law judge (ALJ) initially denied her applications in January 2017, finding she could return to her past work as a cashier/checker. On appeal, the case was remanded because the ALJ had not adequately addressed Nadon’s post-traumatic stress disorder (PTSD). On remand, the ALJ again determined that Nadon was not disabled, following the five-step sequential analysis for determining disabilities.The ALJ found that Nadon had engaged in substantial gainful activity as a personal care attendant from July 2021 through 2022 but continued the analysis due to a continuous period of at least twelve months during which Nadon did not engage in substantial gainful activity. The ALJ found that Nadon had severe impairments but did not have an impairment or combination of impairments that met or equaled the severity of a listed impairment. The ALJ determined that Nadon’s residual functional capacity allowed her to perform light work with certain limitations and found that she could perform her past relevant work as a personal care attendant and other work as a housekeeper, marker, or small products assembler.The district court affirmed the ALJ’s decision. The United States Court of Appeals for the Ninth Circuit reviewed the case de novo and affirmed the district court’s decision. The court held that the ALJ did not err by considering Nadon’s work as a personal care attendant, as an ALJ is permitted to consider any work done by a claimant when evaluating a disability claim. The court also found that the ALJ provided several reasons for discounting Nadon’s testimony and the opinions of several healthcare professionals, beyond her work as a personal care attendant. The court rejected Nadon’s argument that the ALJ erred by relying on the vocational expert’s testimony, as it relied on the rejected premise that the ALJ erred in discounting the healthcare professionals’ opinions. View "Nadon v. Bisignano" on Justia Law

Ferida H. Moy suffers from severe PTSD due to her experiences during the Yugoslav Wars. She applied for disability insurance benefits and supplemental security income, citing her PTSD and related mental health issues. An administrative law judge (ALJ) denied her application, finding that she had the residual functional capacity to perform simple, routine tasks with minimal contact with supervisors and co-workers. This decision was upheld by the district court, leading Moy to appeal.The ALJ found that Moy had moderate limitations in concentrating, persisting, or maintaining pace but concluded that she could work at a consistent production pace. The ALJ's decision was based on the testimony of a vocational expert who stated that a person with Moy's limitations could work as a dining room attendant, bus person, scrap sorter, industrial cleaner, or dishwasher. However, the vocational expert also testified that regular absences or being off-task for more than 15% of the workday would result in job loss. The ALJ's decision was affirmed by the district court.The United States Court of Appeals for the Seventh Circuit reviewed the case and found that the ALJ failed to build a logical bridge between Moy's limitations and the conclusion that she could work at a consistent production pace. The court noted that the ALJ's determination did not adequately account for Moy's limitations in concentration, persistence, and pace. The court emphasized that the ALJ's reasoning was internally inconsistent and did not reflect Moy's documented symptoms and treatment needs. Consequently, the Seventh Circuit vacated the judgment and remanded the case to the Commissioner of Social Security for further consideration consistent with its opinion. View "Moy v Bisignano" on Justia Law