Justia Public Benefits Opinion Summaries

Jessica Stuart was convicted of health care fraud and using false identification after she falsely claimed to be a Board-Certified Behavioral Analyst, rendering services to children with autism and causing significant financial losses to her employer and Medicaid. Her criminal history included multiple instances of fraud and larceny, such as issuing bad checks, stealing from individuals with whom she resided, and manipulating payments for personal gain. After serving her sentence, Stuart’s supervised release was marked by additional violations, including failing to make restitution payments, moving without approval, committing new frauds involving food stamps and unemployment benefits, and failing to report police contact.The United States District Court for the District of Connecticut initially sentenced Stuart to incarceration and supervised release. When she violated conditions of her supervised release, the court, now presided over by Judge Nagala, imposed a new special condition authorizing the Probation Office to notify third parties—including employers, potential employers, and others to whom Stuart might pose a risk—of her criminal history and past conduct. Stuart objected, arguing the condition improperly delegated judicial authority to the Probation Office by granting it sole discretion to determine who qualifies as a third party at risk.The United States Court of Appeals for the Second Circuit reviewed the challenge. Applying an abuse of discretion standard and reviewing legal questions de novo, the court held that the district court had sufficiently limited the Probation Office’s discretion. The condition was found permissible because it was rooted in Stuart’s varied and opportunistic risk profile, and the court had provided enough guidance to constrain arbitrary use of delegated authority. The Probation Office’s role was determined to be execution, not imposition, of the condition. Accordingly, the Second Circuit affirmed the judgment of the district court. View "United States v. Stuart" on Justia Law

A hospice provider participated in the Medicare program and sought reimbursement for hospice services provided to several patients. Medicare, through its contractor, conducted a review and determined that a substantial number of the provider's claims did not meet the required coverage criteria, resulting in a demand for repayment of nearly $1 million. The contractor’s decision was partially reversed at the next level of administrative review for some claims, but a significant number were still denied. The provider pursued further administrative appeals, including a hearing before an administrative law judge (ALJ), where testimony and medical records were considered. The ALJ ultimately found that some additional claims were covered but upheld the denial of coverage for others, concluding that the provider was financially responsible for those denied claims and could not benefit from the statutory safe harbor.After the Medicare Appeals Council failed to resolve the provider’s appeal within the prescribed time, the provider sought judicial review in the United States District Court for the Northern District of Ohio. The district court affirmed the ALJ’s decision, agreeing with the denial of coverage for the disputed claims and with the determination that the provider was not entitled to the safe harbor protection.On appeal, the United States Court of Appeals for the Sixth Circuit reviewed two issues: whether substantial evidence supported the ALJ’s denial of Medicare coverage for the claims, and whether the ALJ properly applied the Medicare statute’s safe harbor provision. The appellate court held that substantial evidence did support the denial of coverage. However, it determined that the ALJ had applied the wrong legal standard to the safe harbor inquiry. The Sixth Circuit clarified that the correct standard requires assessment of whether the provider reasonably interpreted the relevant Medicare guidance as covering the disputed claims. The court vacated the district court’s judgment as to the safe harbor issue and remanded with instructions to return the case to the ALJ for application of the correct safe harbor standard to each disputed claim. View "In Home Health, LLC v. Kennedy" on Justia Law

Four individuals who were Medicaid beneficiaries in Illinois were admitted to long-term care facilities between 2018 and 2023. The facilities submitted required electronic admission packets to the Illinois Department of Healthcare and Family Services so that the cost of care could be reimbursed by Medicaid. In each case, the Department either rejected or mishandled these admission packets, resulting in the facilities not being reimbursed for all or part of the care provided. Despite regulations prohibiting providers from billing Medicaid beneficiaries for unreimbursed care, the facilities sent bills to the plaintiffs. The plaintiffs, however, did not pay these bills, nor did they suffer any loss of benefits or interruption in care.The plaintiffs filed a proposed class action in the United States District Court for the Northern District of Illinois against state officials responsible for Medicaid administration. They alleged violations of due process and the Medicaid Act, and requested only injunctive relief to require systemic changes in the admission packet review process. The defendants moved to dismiss, arguing both lack of standing and failure to state a claim. The district court found that the plaintiffs had standing because they received bills, but it dismissed the case for failure to state a claim, reasoning that the plaintiffs were not denied benefits or services and no statutory or constitutional rights were violated.On appeal, the United States Court of Appeals for the Seventh Circuit reviewed only standing. The appellate court held that the plaintiffs lacked standing for injunctive relief because they did not allege a real and immediate threat of repeated injury. The prior receipt of bills did not amount to legal harm, as the plaintiffs had no obligation to pay. The court modified the district court’s judgment to reflect a jurisdictional dismissal for lack of standing and affirmed the judgment as modified. View "Arcidiacono v Whitehorn" on Justia Law

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