Justia Public Benefits Opinion Summaries

The Supreme Court held that “medical assistance” provided to Medicaid recipients includes costs for room and board and other “nonmedical” expenses at nursing facilities, and therefore, those costs can be recovered from the recipient’s estate. In this case, the Nebraska Department of Health and Human Services (DHHS) filed a petition for allowance of a claim for services provided to the decedent while he resided at two different nursing homes. The county court sustained DHHS’ motion for summary judgment, concluding that the services defined as room and board fell within the parameters of services provided under the Medical Assistance Act. The Supreme Court affirmed, holding that DHHS was statutorily authorized to recover the sums it paid for room and board costs and other expenses from the decedent’s estate. View "In re Estate of Vollmann" on Justia Law

In the underlying action, JCHCC sought to permanently enjoin the Parish from evicting it from two Parish-owned facilities in which JCHCC currently provides medical services to medically underserved populations. The district court granted JCHCC's motion for a preliminary injunction, enjoining the Parish from evicting JCHCC but allowing it to terminate the injunction by establishing that the medical needs of the population currently served by the relevant JCHCC facilities would be met if JCHCC were evicted. The court reversed, concluding that JCHCC has not established a substantial likelihood of success on the merits of the only claim that was properly before the court. In this case, JCHCC failed to establish a likelihood of success on the merits of its Medicaid violation claim where JCHCC does not point to any authority suggesting that every local government in every participating state must provide the relevant medical services, nor does it point to authority establishing that the Parish has any obligation under Louisiana state law to provide such services on behalf of the state. View "Jefferson Community Health Care Centers v. Jefferson Parish Government" on Justia Law

Brayden O. was a seventeen-year-old girl who suffered from Coffin-Lowry Syndrome and other disabilities. Brayden had been receiving home and community-based waiver services through the Medicaid division of the Nebraska Department of Health and Human Services (DHHS) for almost a dozen years before the DHHS determined that Brayden no longer met the necessary qualifications for such services. Merie B., Brayden’s mother, appealed DHHS’ determination, which was affirmed after an administrative appeal hearing. The district court affirmed. On appeal, the Supreme Court reversed and remanded with directions that the district court order DHHS to reinstate waiver services to Brayden, effective as of the date services were originally terminated. On remand, Merie requested reimbursement for expenses she incurred due to the wrongful termination of Brayden’s services, along with attorney fees. The district court granted the request and entered judgment against DHHS in the amount of $76,260.48. The Supreme Court reversed, holding that the district court was without authority to expand the mandate in Merie B. I and hold an evidentiary hearing on Merie’s “Motion to Determine Expenses.” View "Merie B. on behalf of Brayden O. v. State" on Justia Law

In 2003, following a physical examination, Contreras, 13 years old, received the Tetanus-Diphtheria and Hepatitis B vaccines. About 24 hours later, he was diagnosed with atypical Guillain-Barre Syndrome (GBS), a peripheral nervous system disease that causes descending paralysis. Three months later, Contreras was discharged from the hospital with a diagnosis of Transverse Myelitis (TM), an inflammatory disease of the spinal cord. His petition for compensation under the Vaccine Act, accompanied by an expert report indicating that he developed both conditions as a result of the vaccines, was denied, on the basis that the time interval between the administration of Contreras’s vaccines and the onset of TM was too short to establish causation. Contreras submitted the expert report of pediatric neurologist concerning his rapid adverse immunological response. In 2012, a Special Master concluded that Contreras failed to establish that the TM arose within a “medically appropriate” timeframe. Following a remand from the Claims Court, the government disclosed that the medical license of its expert (Sladsky) was suspended during the time that he had provided witness services in this case. The Special Master again denied compensation, stating that Sladky’s opinion “retain[ed] some value” and that Contreras did not suffer from GBS—a violation of the court’s instruction to refrain from diagnosing Contreras. The Claims Court again remanded, with instructions to address Sladky’s credibility in light of his misrepresentations and to issue an alternative ruling that disregards Sladky’s testimony. The Special Master denied compensation. The Claims Court denied review based on the time interval. The Federal Circuit vacated. The Special Master improperly diagnosed Contreras and failed to consider evidence relevant to his GBS. View "Contreras v. Secretary of Health & Human Services" on Justia Law

In 2006, Congress amended 42 U.S.C. 1396p(c)(1)(F)(i), which permits individuals and married couples to dispose of their assets (to qualify for Medicaid) by purchasing an annuity, under which the state is named as the remainder beneficiary in the first position for the amount of medical assistance paid. The federal law initially contained a drafting error. It was subsequently amended. A corresponding Kentucky regulation, promulgated four months later, mistakenly included the pre-amendment language, stating that the state had to be the beneficiary for the amount of assistance paid on behalf of the annuitant, rather than the institutionalized spouse. The state agency enforced the corrected federal statute. The Singletons sought Medicaid benefits to support Claude’s full-time nursing home care; in purchasing an annuity, Mary wanted to name the state as a beneficiary for the value of care provided to her, rather than Claude, as the Kentucky regulation seemed to permit. Claude obtained Medicaid eligibility after the purchase of an annuity that complied with the federal regulation. The government paid $98,729.01 in medical expenses before Claude's death. Mary later died, leaving $118,238.41 in the annuity. In compliance with the federal rule, the government’s claim left $19,509.40 for the secondary beneficiaries. The Singleton children sued. The Sixth Circuit rejected their argument that the Medicaid statute gave the state discretion to be more generous concerning annuities and the general spend-down rules. The Kentucky regulation departed from the Medicaid statute’s clear instructions and was preempted. View "Singleton v. Commonwealth of Kentucky" on Justia Law

Relators’ daughter died of a seizure after receiving mental health treatment at Arbour Counseling Services, a facility in Massachusetts owned and operated by Universal Health Services (UHS). When Relators learned that Arbour had employed unlicensed and unsupervised personnel, in violation of state regulations, they brought a qui tam action against UHS under the False Claims Act (FCA), alleging that UHS had fraudulently submitted reimbursement claims to the Commonwealth despite knowing that it was in violation of state regulations (a theory of FCA liability known as the “implied false certification theory”). The district court dismissed the complaint, concluding that the regulatory violations were not conditions of payment as required for a claim to be actionable under the FCA. The First Circuit reversed, holding that the regulatory violations at issue were conditions for payment and that Relators appropriately stated a claim with particularity under the FCA. On certiorari, the Supreme Court held that the implied false certification theory can be a basis for FCA liability but remanded the case for further consideration of whether the complaint sufficiently alleged that the regulatory violations were material to the government’s payment decision. The First Circuit again reversed the district court’s grant of UHS’s motion to dismiss after applying the Supreme Court’s guidance on the question of whether UHS’s misrepresentations were material, holding that Relators’ complaint sufficiently stated a claim under the FCA. View "United States, ex rel. Escobar v. Universal Health Services, Inc." on Justia Law

The consolidated appeals in this case involved a dispute between the Secretary of Health and Human Services and a group of Maine hospitals about certain payments - called disproportionate share payments (DSH payments) - the hospitals had received in reimbursement from the federal government for charity care for fiscal years dating as far back as 1993. Generally speaking, the more low-income patients a hospital services, the higher the hospital’s DSH payment. In this case, the Secretary maintained that the Hospitals were overinclusive in their DSH payment calculations. An intermediary reassessed the DSH payments and recouped from the Hospitals approximately $22 million in alleged overpayments. The Provider Reimbursement Review Board, in turn, ordered the intermediary to restore approximately $17 million to the Hospitals. The Secretary reversed. The Hospitals sought judicial review, but neither side was satisfied with the district court’s ruling. On appeal, the First Circuit reversed in part and affirmed in part, holding (1) the Secretary properly reopened the disputed years and adequately demonstrated that the Hospitals had received substantial overpayments of DSH funds; and (2) the Hospitals’ defenses to repayment were unavailing. View "Maine Medical Center v. Burwell" on Justia Law

Brookdale Senior Living hired Prather to review documentation related to thousands of Brookdale residents who had received home-health services from Brookdale. Medicare claims regarding those patients were on hold and Brookdale faced possible recoupment of payments it had received if it did not review and submit final Medicare claims. Prather noticed that the required certifications stating that the doctor had decided that the patient needed home-health services, established a plan of care, and met with the patient, were signed long after care was provided. Prather repeatedly raised this issue, but was rebuffed. Brookdale, facing financial disaster, began paying doctors to complete the paperwork months after treatment was provided. Prather thought that Brookdale was not just asking treating physicians to complete forgotten paperwork, but had provided the services without physician involvement and then found doctors willing to validate the care after-the-fact. Prather's suit under the False Claims Act, 31 U.S.C. 3729, was dismissed. The Sixth Circuit reversed as to unlawful retention of payments. Completing certifications months after the fact was not “as soon as possible” after the plan was established, as required by regulations. Prather provided a detailed description of the alleged fraudulent scheme and her personal knowledge. Affirming dismissal of her false-records claim, the court concluded that Prather failed to plead with particularity the use of government forms to certify falsely that care had been provided under a doctor’s orders, or that unnecessary care had been provided. View "Prather v. Brookdale Senior Living Communities, Inc." on Justia Law

O.B., two years old, has Down Syndrome, lung disease, and cardiac abnormalities. He is ventilator‐dependent and cannot digest take oral nutrition. O.B. is the named plaintiff in a class action against the Illinois Department of Healthcare and Family Services, alleging violation of the Medicaid Act. The Act defines “medical assistance” as including “early and periodic screening, diagnostic, and treatment services [EPSDT] … for individuals … under the age of 21,” 42 U.S.C. 1396d(a)(4)(B), and requires "reasonable promptness." EPSDT services include “private duty nursing services,” so that the child lives at home. When he was nine months old, the Department approved $19,718 monthly to pay nurses for up to 18 hours a day to care for O.B. at home. It took his parents almost a year to obtain home‐nursing staff so that O.B. could go home. The district judge certified a class of Illinois children who have been approved for home nursing but who have not been able to hire nurses. The judge ordered the Department to “take immediate and affirmative steps to arrange directly or through referral . . . in‐home shift nursing services.” The Seventh Circuit affirmed, noting that Congress has clarified that where the Act refers to the provision of services, a participating state is required to provide (or ensure the provision of) services, not merely pay for them and that O.B.’s in-hospital care cost four times what home nursing would cost. View "O. B. v. Norwood" on Justia Law

In response to secretly recorded videos released by the Center for Medical Progress depicting conversations with Planned Parenthood employees elsewhere, LDHH terminated PPGC Louisiana Medicaid provider agreements. PPGC and the Individual Plaintiffs filed suit against LDHH under 42 U.S.C. 1983, alleging violations of 42 U.S.C. 1396a(a)(23) and the First and Fourteenth Amendments of the U.S. Constitution. The Individual Plaintiffs, three women who are Medicaid beneficiaries and who receive medical care from one of PPGC’s Louisiana facilities, seek to continue receiving care from PPGC’s facilities. The Individual Plaintiffs contend that LDHH’s termination action will deprive them of access to the qualified and willing provider of their choice, PPGC, in violation of Medicaid’s free-choice-of-provider provision. The district court entered a preliminary injunction against LDHH’s termination of PPGC’s Medicaid provider agreements. The court held that the Individual Plaintiffs met their burden to show their entitlement to a preliminary injunction; the district court did not abuse its discretion in preliminarily enjoining LDHH’s termination of PPGC’s provider agreements; and thus the court affirmed the district court's preliminary injunction, remanding for further proceedings. View "Planned Parenthood v. Gee" on Justia Law