Justia Public Benefits Opinion Summaries

Caring Hearts Personal Home Services, Inc. provided physical therapy and skilled nursing services to “homebound” Medicare patients. It sought reimbursement from Medicare for services provided. The definition of who qualified as "homebound" or what services qualified as "reasonable and necessary" was unclear, even to the Centers for Medicare & Medicaid Services (CMS). CMS has developed its own rules on both subjects that had been repeatedly revised and expanded over time. In an audit, CMS purported to find that Caring Hearts provided services to at least a handful of patients who didn’t qualify as “homebound” or for whom the services rendered weren’t “reasonable and necessary.” As a result, CMS ordered Caring Hearts to repay the government over $800,000. It was later found that in reaching its conclusions CMS applied the wrong law: the agency did not apply the regulations in force in 2008 when Caring Hearts provided the services in dispute. Instead, it applied considerably more onerous regulations the agency adopted years later, "[r]egulations that Caring Hearts couldn’t have known about at the time it provided its services." The Tenth Circuit found that Caring Hearts "[made] out a pretty good case that its services were entirely consistent with the law as it was at the time they were rendered" when CMS denied Caring Hearts' request for reconsideration. The Tenth Circuit reversed the district court's judgment affirming CMS' denial to Caring Hearts for reimbursement, and remanded for further proceedings. View "Caring Hearts v. Burwell" on Justia Law

A class of Tennessee residents who applied for Medicaid sought declaratory and injunctive relief, alleging that the delays they have experienced in receiving eligibility determinations on their applications violate 42 U.S.C. 1396a(a)(8) of the Medicaid statute, and that the state’s failure to provide a fair hearing on their delayed applications violates that statute and the Due Process Clause. Regulations implementing the statute provide that “the determination of eligibility for any applicant may not exceed” 90 days for those “who apply for Medicaid on the basis of disability” and 45 days for all other applicants. The district court certified a class and granted a preliminary injunction, which requires the state to grant a fair hearing on delayed applications to class members who request one. The Sixth Circuit affirmed the preliminary injunction, holding that the matter is not moot and that the federal government is not a required party. The court noted that the federal government submitted an amicus brief, supporting plaintiffs’ position. Despite the passage of the Affordable Care Act, states remain ultimately responsible for ensuring their Medicaid programs comply with federal law. View "Wilson v.Gordon" on Justia Law

VRC filed suit against HHS and the Secretary, seeking the recoupment of payments VRC returned to Medicare after it was issued notice of an overpayment. At issue is the reimbursement rate of the intravitreal injection of Lucentis. VRC did not follow the Lucentis label’s instructions limiting dosage to one per vial. Instead, VRC treated up to three patients from a single vial. Because VRC was extracting up to three doses from a single vial, it was reimbursed for three times the average cost of the vial and three times the amount it would have received had it administered the drug according to the label. The court affirmed the denial of recoupment, concluding that VRC's charge to Medicare did not reflect its expense and was not medically reasonable; the Secretary's decision was supported by substantial evidence; and VRC is liable for the overpayment. View "Vitreo Retinal Consultants v. U.S. Dep't of Health & Human Servs." on Justia Law

Mission purchased the assets of South Coast and attempted by an assets-only purchase to avoid South Coast's potential liabilities under South Coast's Medicare provider agreement. These liabilities encompassed potential mandated reimbursement to Medicare for any previous overpayments made to South Coast. The Secretary determined that Mission was not entitled to bill Medicare for patient services at its new facility until that facility had a provider agreement of its own. Mission appealed the Secretary's decision. The court rejected Mission's assertion that former 42 C.F.R. 489.13(d)(1)(i) permitted it to avoid South Coast’s Medicare liabilities. The court cited to the Fifth Circuit's opinion in United States v. Vernon Home Health, Inc.: “federal law governs cases involving the rights of the United States arising under a nationwide federal program such as the Social Security Act. The authority of the United States in relation to funds disbursed and the rights acquired by it in relation to those funds are not dependent upon state law.” It is equally true that private parties have no power to alter their legal obligations with Medicare under their provider agreements. The court also rejected Mission's argument that it is entitled to the benefit of the retroactivity provision in 42 C.F.R. 489.13(d)(2). The court concluded that the Secretary's interpretations and decisions rendered by the DAB in this case were reasonable. Accordingly, the court affirmed the judgment. View "Mission Hosp. Reg'l Med. Ctr. v. Burwell" on Justia Law

Eilise was born in 1996 and had problems with gross motor skills and language development. After therapy, Eilise showed dramatic improvement. In 2001, Eilise received three vaccinations, including her second dose of the measles, mumps, and rubella vaccine. Five days later, Eilise’s brother witnessed her arching her back, thrusting her head back, rolling her eyes, and jerking. He did not know what was happening. Her parents, who did not witness the seizure, noted that Eilise was feverish and lethargic. Eilise had a grand mal seizure at school. She was taken to a hospital. She had another seizure there. Eilise’s MRI results were generally normal, but her EEG results were “consistent with a clinical diagnosis of epilepsy.” She continued to suffer seizures until she started a ketogenic diet. Her parents filed suit under the National Childhood Vaccine Injury Compensation Program, 42 U.S.C. 300aa, alleging that Eilise suffered from autism as a result of her vaccinations; they later amended to allege, instead, that Eilise suffered from a “seizure disorder and encephalopathy.” The Claims Court affirmed denial of her petition. The Federal Circuit vacated: in certain cases, a petitioner can prove a logical sequence of cause and effect between a vaccination and the injury with a physician’s opinion where the petitioner has proved that the vaccination can cause the injury and that the vaccination and injury have a close temporal proximity. View "Moriarty v. Sec'y of Health & Human Servs." on Justia Law

In 2012, Illinois enacted legislation requiring prior approval for reimbursement for more than four prescriptions for one Medicaid patient within a 30‐day period. 305 ILCS 5/5‐5.12(j). Ciarpaglini is an Illinois Medicaid recipient and suffers from chronic conditions, including bipolar disorder, attention deficit hyperactivity disorder, panic disorder, and generalized anxiety disorder. Doctors have prescribed at least seven medications to manage these conditions. Ciarpaglini alleges that after the prior‐approval requirement took effect, he could not, at least at times, obtain medications he needed and that he has contemplated committing suicide, committing petty crimes so that he would be jailed, or checking himself into hospitals just to get medications. He challenged the requirement under federal Medicaid law, the Americans with Disabilities Act, the Rehabilitation Act, and the Constitution. Illinois subsequently moved Ciarpaglini from the general fee‐for‐service Medicaid program to a new managed care program, under which the requirement does not apply. The district court dismissed the matter as moot. The Seventh Circuit remanded, finding insufficient evidence to determine whether the claims were moot, given Ciarpaglini’s stated desire to move to another county and the lack of information about whether the change in his program was individual or part of a change in policy. View "Ciarpaglini v. Norwood" on Justia Law

Plaintiff filed a class action against the Commissioner, challenging New York’s coverage restrictions on certain medical services provided under its Medicaid plan. Plaintiffs argued that New York’s 2011 plan amendments, which restrict coverage of orthopedic footwear and compression stockings to patients with certain enumerated medical conditions, violate the Medicaid Act’s, 42 U.S.C. 1396 et seq., reasonable standards, home health services, due process, and comparability provisions, as well as the anti‐discrimination provision and integration mandate of Title II of the Americans with Disabilities Act (ADA), 42 U.S.C. 12131 et seq., and section 504 of the Rehabilitation Act, 29 U.S.C. 794. Because neither the Medicaid Act nor the Supremacy Clause confers a private cause of action to enforce the reasonable standards provision, the court vacated the district court’s grant of summary judgment to plaintiffs on that claim; the court declined to reach plaintiffs’ unequal treatment claim under the ADA and Rehabilitation Act as largely duplicative of their integration mandate claim; and the court affirmed the summary judgment rulings with respect to the remaining claims. Defendant is entitled to summary judgment on plaintiffs' home health services plan because orthopedic footwear and compression stockings constitute optional “prosthetics” rather than mandatory “home health services” under the Medicaid Act; defendant is entitled to summary judgment on the hearing element and plaintiffs are entitled to summary judgment on the notice element of plaintiffs’ due process claim, because the due process provision required New York to provide plaintiffs with written notice – though not evidentiary hearings – prior to terminating their benefits; plaintiffs are entitled to summary judgment on their comparability provision claim because New York’s coverage restrictions deny some categorically needy individuals access to the same scope of medically necessary services made available to others; and plaintiffs are entitled to summary judgment on their anti‐discrimination claims because New York’s restrictions violate the integration mandate of the ADA and Rehabilitation Act. Finally, the court vacated the injunction and remanded for further consideration on the appropriate relief because the injunction is broader than is warranted by the court's liability conclusions. View "Davis v. Shah" on Justia Law

SEARK, operator of two hospice-care facilities, voluntarily entered into a provider agreement with the Secretary of Health and Human Services to receive Medicare reimbursement pursuant to the Medicare Act, 42 U.S.C. 1395c, 1395f(a)(7), 1395cc. The Act annually caps Medicare reimbursement. SEARK filed suit after the Secretary sent it seven demands for repayment, arguing that the cap violates the Takings Clause of the Fifth Amendment. The district court concluded that SEARK’s voluntary participation in the Medicare program precludes a takings claim. The court concluded that SEARK has not met its burden to prove the demands for repayment based on the statutory cap are a taking where the reimbursement cap allocates the government's capacity to subsidize healthcare; SEARK presented no evidence to suggest the cap makes it impossible to profitably engage in their business; and SEARK voluntarily chose to participate in the Medicare hospice program. Accordingly, the court affirmed the judgment. View "Southeast Arkansas Hospice v. Burwell" on Justia Law

The Hospital system filed suit seeking to obtain a writ of mandamus compelling HHS to adjudicate immediately its administrative appeals on claims for Medicare reimbursement. The parties agree that, as of February 2014, the Secretary had 480,000 appeals awaiting assignment to an ALJ, and the Secretary conceded in her brief that the number had by then climbed to more than 800,000 appeals, creating a ten-year backlog. The court concluded that the Medicare Act, 42 U.S.C. 1395 et seq., does not guarantee a healthcare provider a hearing before an ALJ within 90 days, as the Hospital System claims. Rather, it provides a comprehensive administrative process that a healthcare provider must exhaust before ultimately obtaining review in a United States district court. The court further concluded that the issuance of a judicial order now, however, directing the Secretary to hear the Hospital System’s claims in the middle of the administrative process, would unduly interfere with the process and, at a larger scale, the work of the political branches. Moreover, such intervention would invite other healthcare providers suffering similar delays to likewise seek a mandamus order, thereby effectively causing the judicial process to replace and distort the agency process. Accordingly, the court affirmed the district court's dismissal of the complaint. View "Cumberland Cnty. Hosp. v. Burwell" on Justia Law

Stark worked at GM for over 10 years as a yard driver. Her back pain started in 2000, when she underwent her first of three surgeries. She has been diagnosed with degenerative disc disease, nerve root irritation, moderate-to-severe spinal stenosis, and possible radiculopathy. Stark underwent numerous nonsurgical treatments for pain, including epidural spinal injections and a nerve root block, with a regimen of Neurontin, Darvocet, Celebrex, Oxycocone, Avinza, physical exercises, and physical therapy. Stark’s pain control was “fair-to-poor.” She stopped working in 2009. A doctor assessed that Stark could do light physical demand activities based on her full range of motion and ability to squat, kneel, and walk. A medical consultant estimated that Stark occasionally could lift or carry 20 pounds and sit for about 6 hours in an 8-hour day. At a 2012 hearing, Stark testified to a “tremendous amount of pain every day.” She could no longer take narcotic pain relievers because of a hepatitis C diagnosis. An ALJ denied benefits, finding that “the objective evidence does not substantiate the extreme symptoms and limitations to which she testified” and that her testimony regarding daily activities “demonstrates a level of daily function not inconsistent with light work activity.” The Seventh Circuit reversed, finding the credibility analysis flawed. View "Stark v. Colvin" on Justia Law