Justia Public Benefits Opinion Summaries

Medicare (42 U.S.C. 1395ww) reimbursement includes an adjustment for “disproportionate share hospitals” (DSH), that serve high numbers of low-income patients. The calculation formula takes into account the number of patient days for those patients eligible for Medicaid, and may also include patient days for those patients ineligible for Medicaid, but who received benefits under a Medicaid “demonstration project,” 42 U.S.C. 1315. The Medicare DSH formula was initially regarded by intermediaries, at least in some states, as including days covered under state general assistance (GA) and charity care programs. In 1999 the Centers for Medicare and Medicaid Services clarified that the DSH formula only permitted the inclusion of patient days wherein the patients were eligible for Medicaid, excluding state general assistance and charity plan patient days, but, under the final rule hospitals could count patient days for individuals covered under a Section 1115 waiver project. The Deficit Reduction Act of 2005 essentially ratified the rule. The district court concluded that the regulation was arbitrary and capricious and a violation of the Equal Protection Clause, reasoning there was no rational basis to exclude from reimbursements patients covered by Pennsylvania’s General Assistance plan, while including patients covered under a federal statutory waiver program. The Third Circuit reversed. View "Nazareth Hosp. v. Sec'y, U.S. Dep't of Health & Human Servs." on Justia Law

Petitioners, a group of hospitals that serve a significant number of elderly, very low-income patients, filed suit challenging the Secretary's issuance of a rule concerning the "disproportionate share percentage" calculation of supplemental payments for low-income Medicare patients. When the Secretary published reimbursement calculations for FY 2007, petitioners learned that their payments would decrease by tens of millions of dollars per year. The rule change had an enormous financial consequence on hospitals. The court held that the Secretary did not provide adequate notice and opportunity to comment before promulgating its 2004 rule, and so affirmed the portion of the district court's opinion vacating the rule. The court reversed only the portion of the district court's opinion directing the Secretary to recalculate the hospitals' reimbursements using the alternate methodology. View "Allina Health Services, et al. v. Sebelius" on Justia Law

In enacting comprehensive welfare reform in 1996, Congress rendered various groups of aliens ineligible for federal benefits and also restricted states' ability to use their own funds to provide benefits to certain aliens. As a condition of receiving federal funds, Congress required states to limit eligibility for federal benefits, such as Medicaid, to citizens and certain aliens. Plaintiffs filed suit claiming that Basic Health Hawai'i violated the Equal Protection Clause of the Fourteenth Amendment because it provided less health coverage to nonimmigrant aliens residing in Hawai'i (COFA Residents) than the health coverage that Hawai'i provided to citizens and qualified aliens who are eligible for federal reimbursements through Medicaid. The court concluded that Congress has plenary power to regulate immigration and the conditions on which aliens remain in the United States, and Congress has authorized states to do exactly what Hawai'i had done here - determine the eligibility for, and terms of, state benefits for aliens in a narrow third category, with regard to whom Congress expressly gave states limited discretion. Hawai'i has no constitutional obligation to fill the gap left by Congress's withdrawal of federal funding for COFA Residents. Accordingly, the court vacated the district court's grant of a preliminary injunction preventing Hawai'i from reducing state-paid health benefits for COFA Residents because Hawai'i is not obligated to backfill the loss of federal funds with state funds and its decision not to do so was subject to rational-basis review. View "Korab v. Fink" on Justia Law

Demyanovich, an employee of Cadon for more than 20 years, was terminated after he requested leave under the Family and Medical Leave Act to treat his congestive heart failure. He had previously taken leave and his condition had gotten worse over the course of about 10 years. He claimed that Cadon and his direct supervisor, Ensign, interfered with his exercise of his FMLA rights, retaliated against him for seeking FMLA leave, and discriminated against him on the basis of disability. Ensign denied the FMLA request because he believed that Cadon did not have enough employees to be subject to the Act, but referred to Demyanovich as a “liability” immediately after the request for FMLA leave. The district court entered summary judgment in favor of Cadon. The Sixth Circuit reversed, noting evidence that establishs a genuine factual dispute as to whether Demyanovich was permanently incapable of working at the time that he was terminated. View "Demyanovich v. Cadon Plating & Coating, L.L.C." on Justia Law

M.L. was born in 2003. At his 15-month well-child visit, his pediatrician noted that M.L. was walking and generally developing normally but did not “want to talk.” In 2005, M.L. received several immunizations, including the DTaP vaccination. Hours later, M.L. allegedly began experiencing an abnormally high fever and swelling. He was admitted to the hospital with a diagnosis of “vaccine adverse reaction with secondary fever, angiodema, and anaphylactoid reaction.” The morning after his discharge, M.L.’s mother called an ambulance because M.L. was exhibiting signs of hypothermia and seizure-like episodes. In the months that followed, M.L.’s vocabulary allegedly decreased. An MRI of M.L.’s brain with and without contrast was normal. After observing M.L.’s developmental delays and repetitive behaviors, a pediatric neurologist placed M.L. in the autism spectrum disorder category. A special master rejected claims under the National Childhood Vaccine Injury Act of 1986, 42 U.S.C. 300aa-1 to -34, and the Claims Court affirmed. The Federal Circuit affirmed. While the DTaP vaccination likely caused the initial anaphylactic reaction, there was no reliable medical theory that the M.L.’s anaphylaxis caused a focal brain injury. View "LaLonde v. Sec'y of Health & Human Servs." on Justia Law

Plaintiffs filed suit against the Secretary of Health and Human Services (HHS) and the Commissioner of the Social Security Administration (SSA) raising constitutional challenges to the Patient Protection and Affordable Care Act (ACA), Pub. L. No 111-148, 124 Stat. 119; raising statutory challenges to actions of HHS and the Commissioner relating to the implementation of the ACA and prior Medical legislation; and attacking the failure of defendants to render an "accounting" that would alter the American people to the insolvency towards which Medicare and Social Security programs were heading. On appeal, plaintiffs challenged the district court's dismissal of their claims. The court rejected plaintiffs' claims that 26 U.S.C. 5000A, which was sustained as a valid exercise of the taxing power, violated the Fifth Amendment's prohibition of the taking of private property without just compensation and violated the origination clause. The court concluded that plaintiffs' substantive attack on the Social Security Program Operations Manual System (POMS) provisions was clearly foreclosed by its decision in Hall v. Sebelius, holding that the statutory text establishing Medicare Part A precludes any option not to be entitled to benefits. The court rejected plaintiffs' second statutory claim attacking an interim final rule. Finally, the court concluded that plaintiffs failed to provide a legal argument for their claims against the Commissioner and Secretary, and therefore, the court lacked jurisdiction over plaintiffs' claim to an "accounting." Accordingly, the court affirmed the judgment of the district court. View "Assoc. Amer. Physicians, et al. v. Sebelius, et al." on Justia Law

Relator filed a qui tam action under the False Claims Act (FCA), 31 U.S.C. 3729-3733, against Omnicare, alleging that defendants violated a series of FDA safety regulations requiring that penicillin and non-penicillin drugs be packaged in complete isolation from one another. The court concluded that the public disclosure bar did not divest the district court of jurisdiction over relator's FCA claims. The court concluded that once a new drug has been approved by the FDA and thus qualified for reimbursement under the Medicare and Medicaid statutes, the submission of a reimbursement request for that drug could not constitute a "false" claim under the FCA on the sole basis that the drug had been adulterated as a result of having been processed in violation of FDA safety regulations. The court affirmed the district court's grant of Omnicare's motion to dismiss, holding that relator's complaint failed to allege that defendants made a false statement or that they acted with the necessary scienter. The court also concluded that the district court did not abuse its discretion in denying relator's request to file a third amended complaint. View "United States ex rel. Rostholder v. Omnicare, Inc." on Justia Law

Stallworth served in the U.S. Army, 1974-1975, during which time he experienced a psychotic episode that was attributed to his illicit use of the drug LSD. He recovered with hospitalization, but relapsed following return to active duty and was diagnosed with acute paranoid schizophrenia. A treating physician noted that it was not clear whether Stallworth’s illness was caused by his drug use or by independent psychosis. An Army medical board found him unfit for further military duty. Weeks later, a VA Regional Office awarded Stallworth service connection for schizophrenia at a 50% disability rating. Thereafter, Stallworth was often admitted to inpatient psychiatric facilities where medical professionals repeatedly opined that he had “no mental disorder” and that Stallworth’s service connection diagnosis was in error. The VA severed Stallworth’s service connection on the basis of clear and unmistakable error (CUE) and declined to reopen his claim because of a lack of new evidence. In 1981, the Appeals Board affirmed. The Veterans Court and Federal Circuit affirmed. View "Stallworth v. Shinseki" on Justia Law

Dixon served in the Army, 1979-1992, including as a chemical operations specialist in the Persian Gulf, where he was exposed to pyridostigmine and “encountered smoke from oil fires, diesel, and burning trash,” and had “cutaneous exposure [to] diesel and petrochemical fuel.” In 2003, Dixon was diagnosed with sarcoid lungs and transverse myelitis, which left him temporarily paralyzed from the waist down. He sought service-connected disability benefits. In 2004 a VA regional office denied Dixon’s claim. The Board of Veterans’ Appeals affirmed, Dixon filed a pro se notice of appeal, 60 days after the 120-day filing deadline, 38 U.S.C. 7266(a). The Veterans Court dismissed, concluding that it was “without jurisdiction.” In 2011 the Supreme Court held that the filing deadline is not jurisdictional. The Veterans Court issued an order allowing Dixon and others to move to recall the dismissals. Still acting pro se, Dixon sought equitable tolling, explaining that he suffered from physical and psychiatric disabilities that prevented him from filing in a timely manner, accompanied by a statement from his psychiatrist. The Veterans Court denied Dixon’s motion. Attorneys subsequently agreed to represent Dixon. The Veterans Court allowed until October 4, 2012 to move for reconsideration. The VA refused to provide a copy of the file and the earliest available appointment for reviewing the file was October 1. On that dated, VA staff monitored the review and declined requests for copies of documents. The Federal Circuit reversed the denial of an extension, stating that the disability compensation system is not meant as a trap for the unwary, or a stratagem to deny compensation to a veteran who has a valid claim.View "Dixon v. Shinseki" on Justia Law

Gentry has psoriasis, a chronic autoimmune condition causing patches of raised skin covered with flaky buildup of dead skin cells that crack and bleed and can interfere with sleeping, walking, sitting, standing, and using one’s hands. She also has psoriatic arthritis, an inflammatory disease that causes fatigue, stiffness and swelling in and around the joints, tenderness, pain and swelling in the tendons, swollen fingers and toes, and reduced range of motion. There is no cure for either condition. Gentry suffered severe injuries to her ankle, arm and wrist, and hip in a 1994 car accident and developed avascular necrosis and post-traumatic arthritis. She requires a brace on her leg to walk, has a limp and waddling gait, and has frequent pain in her leg and foot, back, neck, and hands. She also has deformities in her foot, ankylosing spondylitis cervical radiculopathy, cervical stenosis, lumbar spondylosis, possible sacroilitis or facet arthropathy in the low back, degenerative joint disease in the low back, chronic lumbar strain, possible herniated disc carpal tunnel syndrome, and lumbosacral/thoracic radiculopathy, among other things. In 2004, Gentry (age 29) applied for disability benefits under the Social Security Act, 42. U.S.C.401. She had worked 10 years as a pizza maker and delivery driver. She had most recently worked as a receptionist, but was discharged because her psoriasis bled on the paperwork. After Gentry’s application was denied, the case was remanded twice. The district court affirmed the denial of benefits. The Sixth Circuit reversed the denial as not supported by substantial evidence. View "Gentry v. Comm'r of Soc. Sec." on Justia Law