Justia Public Benefits Opinion Summaries

Plaintiff appealed the district court’s order affirming the Social Security Administration’s (“SSA”) denial of her application for Social Security Disability Insurance (“SSDI”). In her application, she alleged major depressive disorder (“MDD”), anxiety disorder, and attention deficit disorder (“ADHD”). Following a formal hearing, the Administrative Law Judge (“ALJ”) determined that Plaintiff suffered from severe depression with suicidal ideations, anxiety features and ADHD, but he nonetheless denied her claim based on his finding that she could perform other simple, routine jobs and was, therefore, not disabled. Plaintiff contends that the ALJ erred by (1) according to only little weight to the opinion of her long-time treating psychiatrist (“Dr. B”) and (2) disregarding her subjective complaints based on their alleged inconsistency with the objective medical evidence in the record.   The Fourth Circuit reversed and remanded with instructions to grant disability benefits. The court agreed with Plaintiff that the ALJ failed to sufficiently consider the requisite factors and record evidence by extending little weight to Dr. B’s opinion. The ALJ also erred by improperly disregarding Plaintiff’s subjective statements. Finally, the court found that the ALJ’s analysis did not account for the unique nature of the relevant mental health impairments, specifically chronic depression. The court explained that because substantial evidence in the record clearly establishes Plaintiff’s disability, remanding for a rehearing would only “delay justice.” View "Shelley C. v. Commissioner of Social Security Administration" on Justia Law

Plaintiff appealed from the 2021 opinion of the district court affirming the final decision of Defendant Kijakazi, as the Acting Commissioner of Social Security, which denied Plaintiff’s claim for disability benefits.   The Fourth Circuit, without resolving the merits, vacated the judgment of the district court and directed a remand to the Commissioner for a new and plenary hearing on Plaintiff’s disability benefits claim, to be conducted before a different and properly appointed administrative law judge (ALJ). The court agreed with Plaintiff’s appellate contention that, pursuant to the Supreme Court’s 2018 decision in Lucia v. SEC, 138 S. Ct. 2044 (2018), the (“ALJ Bright”) who rendered the Commissioner’s final decision did so in contravention of the Constitution’s Appointments Clause.   The court explained that the Supreme Court made clear that if an ALJ makes a ruling absent a proper constitutional appointment, and if the claimant interposes a timely Appointments Clause challenge, the appropriate remedy is for the claim to be reheard before a new decisionmaker. Plaintiff did not receive that remedy. The Appointments Clause violation as to Plaintiff was thus not cured, and the 2019 ALJ Decision was likewise rendered in contravention of that Clause. View "Camille Brooks v. Kilolo Kijakazi" on Justia Law

The Supreme Judicial Court remanded these consolidated cases seeking a judgment declaring the parties' respective rights to each of the remainder proceeds of two annuity contracts, holding that the cases were governed in all material respects by the Court's decision today in Dermody v. Executive office of Health & Human Servs., 491 Mass. __ (2023).In each of these cases, the Executive Office of Health and Human Services (Commonwealth) claimed entitlement to remainder proceeds of the two annuity contracts up to the amount of medical assistance paid on behalf of an institutionalized spouse, whose eligibility for Medicaid long-term care benefits was obtained through the purchase of an annuity during the relevant "look-back" period, as defined under 42 U.S.C. 1396p(c). The Supreme Judicial Court held that the Commonwealth was entitled to remainder proceeds from the annuities to the extent of benefits it paid on behalf of the institutionalized spouses in this case. View "Executive Office of Health & Human Services v. Mondor" on Justia Law

Van Dermark served in the Navy from 1963 until his 1976 honorable discharge. The VA found Van Dermark to be totally and permanently disabled due to service-connected injuries. Van Dermark received treatment in Thailand (where he lived) at non-VA facilities, from physicians and others not affiliated with VA, in 2016 and in 2018, both times for cardiac conditions not related to his service-connected disability. For each of the two instances of treatment abroad, Van Dermark filed a claim with VA under 38 U.S.C 1728 and 1725 seeking VA payment—to him or his medical creditors—for the surgical or other heart-related treatment he received abroad.VA Community Care denied both claims. The Board of Veterans’ Appeals maintained the denials. The Veterans Court and Federal Circuit affirmed. Section 1724(a) prohibits the VA from “furnish[ing] hospital . . . care or medical services” abroad, where the care or services are unrelated to the service-connected disability. The “furnishing” phrase encompasses the payment for a veteran’s hospital care or medical expenses abroad at issue here; sections 1728 and 1725 do not override that prohibition. View "Van Dermark v. McDonough" on Justia Law

The First Circuit affirmed the judgment of the district court determining that Act 90, passed by the Legislative Assembly of Puerto Rico in 2019, was preempted by federal law, holding that the district court did not err.Act 90 requires that Medicare Advantage plans compensate Puerto Rico healthcare providers in Puerto Rico at the same rate as providers are compensated under traditional Medicare. Plaintiffs, several entities that managed Medicare Advantage plans, filed suit seeking a declaratory judgment and an injunction barring the "mandated price provision," arguing that the Medicare Advantage Act preempted the challenged provision and that provision was unconstitutional. The district court ruled in favor of Plaintiffs. The First Circuit affirmed, holding that Act 90's mandated price provision was preempted by federal law. View "Medicaid & Medicare Advantage Products Ass'n of Puerto Rico, Inc. v. Emanuelli-Hernandez" on Justia Law

Kristin Anton appealed a district court judgment affirming an order by Job Service North Dakota denying Anton pandemic unemployment assistance benefits. Anton stopped working on March 12, 2020 when the public schools closed due to the COVID-19 pandemic. Anton stopped working because she relied on the school system to provide childcare for at least one of her children. Her employer, Heart River Cleaning, did not close and did not hold Anton’s position for her while she stayed home to watch her children. Anton challenged the finding that she had failed to prove she was entitled to pandemic unemployment benefits under the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). Finding no reversible error, the North Dakota Supreme Court affirmed the district court. View "Anton v. Klipfel, et. al." on Justia Law

In this case arising out of the Department of Human Services' attempt to recover payments made to Dr. Frederick Nitta from its Medicaid Primary Care Physician Program the Supreme Court vacated the judgment of the intermediate court of appeals (ICA) to the extent it remanded the case and otherwise affirmed, holding that DHS's claims largely lacked merit.The Program at issue was established by 42 U.S.C. 1396a(a)(13)(C) of the Affordable Care Act (ACA) and enabled certain physicians to temporarily receive increased payments for primary care services provided in 2013 and 2014 to Medicaid patients. In this case, DHS demanded repayment of more than $200,000 in enhanced payments received by Nitta through the program after it determined that Nitta was ineligible for participation in the Program because he did not meet specialty requirements as set forth in a federal administrative rule. While Nitta's appeal was pending, the Court of Appeals for the Sixth Circuit invalidated the rule and remanded the case. The ICA adopted the Sixth's Circuit's analysis. The Supreme Court largely affirmed, (1) the rule is invalid because it contravenes the statute; and (2) Nitta was entitled to enhanced payments under the statute. View "Nitta v. Department of Human Services" on Justia Law

The Mississippi Division of Medicaid (DOM) and Yalobusha County Nursing Home (YNH) dispute four costs submitted for reimbursement by YNH in its fiscal year 2013 Medicaid cost report. The DOM appeals the Hinds County Chancery Court’s judgment ordering the DOM to reverse the four adjustments at issue. Because the DOM correctly interpreted the appropriate statutes and because its decisions were supported by substantial evidence, the Mississippi Supreme Court reversed the chancery court’s order and rendered judgment reinstating the decisions of the DOM. View "Mississippi Division of Medicaid v. Yalobusha County Nursing Home" on Justia Law

The underlying dispute before the Pennsylvania Supreme Court in this case involved the adequacy of state funding for community participation support ("CPS") services, which were designed to help individuals with autism or intellectual disabilities live independently. The primary issue on appeal related to the exhaustion requirement. The Pennsylvania Department of Human Services ("DHS") issued ODP Announcement 19-024, indicating it intended to change the rate structure for CPS services provided under the Home and Community Based Services (“HCBS”) waivers. Petitioners filed an action for declaratory and injunctive relief, challenging the legality of the new fee schedule and alleged the new reimbursement rates were too low to sustain the provision of CPS services to eligible recipients. Pertinent here, the Commonwealth Court agreed with one of DHS' preliminary objections that Petitioners failed to exhaust their administrative remedies, as required by case precedent, before seeking judicial review. The court acknowledged a narrow exception to the exhaustion requirement whereby a court may consider the merits of a claim for declaratory or injunctive relief if a substantial constitutional question is raised and the administrative remedy is inadequate. It clarified, however, that the exception only applied where the plaintiff raises a facial constitutional challenge to the statute or regulation in question, as opposed to its application in a particular case. Here, the court concluded, the Petitioners were attacking the fee schedule in the Final Notice, which was produced by application of the legal authority cited in that notice, and not advancing a facial constitutional challenge. The court also found Petitioners failed to demonstrate the administrative remedy was inadequate. The Supreme Court affirmed the Commonwealth Court’s order insofar as it sustained the preliminary objection asserting that the Petitioners failed to exhaust their administrative remedies, and dismissed the Petition as to those parties. The order was vacated in all other respects, and the matter was remanded for further proceedings. View "Rehabilitation & Community Providers Association, et al. v. Dept. Human Svcs" on Justia Law

Access Behavioral Health appeals from the district court’s judgment upholding an order of the Idaho Department of Health and Welfare that demanded recoupment of Medicaid payments made to Access. The Department sought to recoup certain payments made to Access because it failed to meet the Department’s documentation requirements. Following an audit of provider billings, the Department found Access billed Medicaid for two codes for services provided to the same patient on the same day without documentation to support its use of the codes. The Department concluded the documentation deficiencies violated IDAPA Rule 16.03.09.716 and the Handbook. The Idaho Supreme Court determined the Department had legal authority to issue recoupment demands to Access. Access failed to demonstrate an entitlement to payment of those funds sought to be recouped. The False Claims Act's materiality requirement was inapplicable to the Department’s administrative action. Finally, laches did not bar the Department’s administrative actions. Judgment was thus affirmed. View "Access Behavioral Health v. IDHW" on Justia Law