Justia Public Benefits Opinion Summaries

Health and Hospital Corporation of Marion County, Indiana is a municipal corporation that operates a major hospital and other facilities, including a health center operated in partnership with Citizens Health to serve the medically under-served population in Indianapolis. The health center was funded in part by a Section 330 Grant, awarded by the federal Health Resources and Services Administration, which is part of the Department of Health and Human Services. Section 330 grants fund qualifying health centers that provide primary health care services to medically under-served populations, 42 U.S.C. 254b. A In 2012, Health and Hospital decided to terminate the partnership with Citizens and relinquish the federal grant, which still had several years of funding remaining. Citizens sued Health and Hospital, HRS, and others in an effort to retain the grant funds. The district court granted defendants summary judgment, concluding that Citizens had no contractual, statutory, or constitutionally cognizable interest in the grant. The Seventh Circuit affirmed, finding that Health and Hospital was the grantee; Citizens had no constitutionally-protected entitlement to the grant; and the terms of the contract between Health and Hospital and Citizens clear; there was no obligation to renew. View "Citizens Health Corp. v. Sebelius" on Justia Law

Massie served on active duty in the Army, 1968-1970 and was awarded VA benefits for varicose veins and related surgery, initially at 10% and increased to 50%, disability effective in 1990. In, 2001, Massie sought an increased disability rating. He submitted a letter from a VA physician who had treated Massie for “multiple medical problems” including “chronic venous insufficiency” that had “persisted in spite of prior surgical treatment with vein stripping” and that left Massie with significant pain when he was on his feet for any period of time. The regional office increased Massie’s rating to 100%, as of the 2001 date of his filing. The Veterans Court determined that the physician’s letter, dated 1999, did not qualify as an informal claim that would entitle Massie to an earlier effective date for the 100% rating. The Federal Circuit affirmed that the letter was not a “report of examination” because it did not describe the results of a “specific, particular examination” and did not suggest that Massie’s condition had worsened. View "Massie v. Shinseki" on Justia Law

In 2011 Wisconsin reduced subsidies for the Wisconsin Care Program, which funds grants for organizations administering programs for disabled persons who live in group homes. The plaintiffs are developmentally disabled and suffered the largest cuts. Persons who had received smaller payments bore smaller cuts. For some (frail elderly) per capita payments increased. Plaintiffs claim that making larger absolute cuts for persons whose care is most expensive violated the Rehabilitation Act and the Americans with Disabilities Act and that reduction in payments increases the risk that they will be moved from group homes to institutions. The district judge noted that states have waived sovereign immunity with respect to the Rehabilitation Act, as a condition to receiving federal funds. The Supreme Court has held that the portions of the ADA that are not designed to implement disabled persons’ constitutional rights cannot be used to override states’ sovereign immunity. The district court concluded that the relevant provisions of the ADA do not concern the Constitution and that other claims were premature because no plaintiff has been moved to an institution. The Seventh Circuit affirmed, noting that without information about care provided to other disabled persons, there is no useful theory of discrimination. View "Amundson v. WI Dep't of Health Servs." on Justia Law

States participating in Medicaid in a managed care environment are required to make, at least every fourth month, supplemental “wraparound” payments to federally-qualified health centers (FQHCs) equal to the difference between a rate set by statute multiplied by the number of Medicaid patient encounters, and the amount paid to FQHCs by managed care organizations (MCOs) for all Medicaid-covered patient encounters, 42 U.S.C.1396. Concerned that gaps in FQHC claim verification led to overpayments, the New Jersey Department of Human Services changed its calculation: instead of basing wraparound payments solely on the number of Medicaid encounters and total MCO receipts as self-reported by FQHCs, the state would rely on data reported by MCOs absent receipt of certain additional data from the FQHCs. Because MCOs report only encounters that they have approved and paid, prior MCO payment would be a prerequisite to wraparound reimbursement under the new system. An association of FQHCs sued, claiming that the change violated their due process rights as well as state and federal law, resulting in budget shortfalls. The district court granted the association summary judgment and a preliminary injunction. The Third Circuit affirmed the holding that the requirement that wraparound payments be contingent on prior MCO payment violated the Medicaid statute’s requirement that FQHCs receive timely full wraparound payment for all Medicaid-eligible claims. View "NJ Primary Care Assoc. v. NJ Dep't of Human Servs." on Justia Law

The Clinics filed suit challenging California Welfare and Institutions Code 14131.10, which eliminated certain Medi-Cal benefits that the state deemed optional, including adult dental, podiatry, optometry, and chiropractic services. The court reversed the district court's holding that the Clinics have a private right of action to challenge the Department's implementation of the state plan amendments (SPA) prior to obtaining approval; affirmed that the Clinics have a private right of action to bring a claim pursuant to 42 U.S.C. 1983 challenging the validity of section 14131.10; and reversed the district court's interpretation of the Medicaid Act, 42 U.S.C. 1396 et seq., holding that section 14131.10 impermissibly eliminated mandatory services from coverage. View "California Ass'n of Rural Health Clinics v. Douglas" on Justia Law

The Black Lung Benefits Act, 30 U.S.C. 901, originally included a “15-year presumption” that total pulmonary or respiratory impairment of a coal worker with 15 years of experience in the mines was due to pneumoconiosis (black lung). Congress removed this presumption in 1981, but in 2010 revived the presumption for claims filed after January 1, 2005, still pending on or after March 23, 2010. Bailey, employed by Consolidation Coal for 26 years, also smoked cigarettes for many years. He was diagnosed with chronic obstructive pulmonary disease and sought benefits. Three claims were considered during the interval when the 15-year presumption was withdrawn. Two were denied, and he withdrew a third. For his current claim, filed in 2007, three doctors agreed that Bailey is totally disabled by COPD. Because of the rejected claims, Bailey was required to show a change in condition. An ALJ, using the 15-year presumption, held that Bailey can now establish pneumoconiosis caused in part by coal dust exposure, two elements deficient in earlier claims, and awarded benefits. The Benefits Review Board affirmed. The Seventh Circuit affirmed. The ALJ correctly applied the 15-year presumption, addressed evidence relating to Bailey’s health and smoking history, and delivered a rational decision, supported by substantial evidence. View "Consolidation Coal Co. v. Dir., Office of Workers Comp. Programs" on Justia Law

Natale,a vascular surgeon, was compensated by Medicare for repairing a patient’s aortic aneurysm. Another doctor reviewed the post-surgical CT scan, which did not match the procedure Natale described in his operative reports. After an investigation, Natale was indicted for health care fraud related to his Medicare billing, mail fraud, and false statements related to health care. A jury acquitted Natale on the fraud counts but convicted him of making false statements, 18 U.S.C. 1035. The trial court used jury instructions that seemingly permitted conviction for false statements completely unrelated to Medicare reimbursement. The Seventh Circuit affirmed, finding the error harmless, but clarified that under the statute, even conviction for false statements made in connection with items or services still must relate to a “matter involving a health care benefit program.” View "United States v. Natale" on Justia Law

Brigance worked as a coal miner for 20 years, until he stopped working in 1994 because of shortness of breath, which prevented him from obtaining other employment. Brigance obtained Kentucky state black lung benefits, which expired after about eight years. Brigance sought federal benefits under the Black Lung Benefits Act. An administrative law judge held that the claim was not barred by the Act’s three-year statute of limitations, 30 U.S.C. 932(f). The Benefits Review Board affirmed an award of benefits. The Sixth Circuit reversed. Brigance admitted that he had a medical determination of total disability (pneumoconiosis) seven years before filing his claim. View "Peabody Coal Co. v. Dir., Office of Workers' Comp." on Justia Law

Madison received a DTaP vaccination at age seven months and the next day suffered a prolonged seizure. Her temperature was recorded as 103.6 degrees. She continued to experience seizures and was admitted to the hospital again, a year later, with recurrent convulsive episodes. When she was about four years old, genetic testing revealed that Madison had a DNA sequence variation that was not inherited and arose spontaneously. Such mutations have been associated with several epilepsy syndromes. Her parents sued under the National Childhood Vaccine Injury Act of 1986, 42 U.S.C. 300aa, which established the National Vaccine Injury Compensation Program through which claimants can obtain compensation for vaccine-related injuries or death. Before the DNA test, a special master concluded that Madison was entitled to compensation, but the DNA test was disclosed during the damages phase. The special master ultimately denied compensation. The Federal Circuit affirmed, finding that the special master properly analyzed whether, after the plaintiffs established a prima facie case, the government carried its burden to prove that a factor unrelated to the vaccine was the sole substantial cause of the injuries. View "Deribeaux v. Sec'y of Health & Human Servs." on Justia Law

Plaintiffs appealed the Secretary's denial of their claims for Medicare coverage for dental services. Plaintiffs contended that this denial was premised on the Secretary's unreasonable interpretation of the Medicare Act, Pub. L. No. 89-97, 79 Stat. 286, which contravened the intent of Congress and violated plaintiffs' right to equal protection under the Fifth Amendment. The court concluded that, although the statutory provision for exclusion of dental services was ambiguous in the sense that plausible divergent constructions could be urged, the Secretary's interpretation of the statute was reasonable. The court also concluded that the Secretary's statutory interpretation warranted Chevron deference and the Secretary's statutory interpretation was reasonable. Accordingly, the court affirmed the judgment. View "Fournier v. Sebelius" on Justia Law