Justia Public Benefits Opinion Summaries

The Medicaid statute’s anti-lien provision, 42 U. S. C. 1396p(a)(1), pre-empts state efforts to take any portion of a tort judgment or settlement not “designated as payments for medical care.” A North Carolina statute requires that up to one-third of damages recovered by a beneficiary for a tortious injury be paid to the state to reimburse it for payments made for medical treatment on account of the injury. E. M. A. suffered serious birth injuries that require her to receive 12 to 18 hours of skilled nursing care per day and that will prevent her from working or living independently. North Carolina’s Medicaid program pays part of the cost of her ongoing care. E. M. A. and her parents filed a medical malpractice suit against the physician who delivered her and the hospital where she was born and settled for $2.8 million, due to insurance policy limits. The settlement did not allocate money among medical and nonmedical claims. The state court placed one-third of the recovery into escrow pending a judicial determination of the amount owed by E. M. A. to the state. While that litigation was pending, the North Carolina Supreme Court held in another case that the irrebuttable statutory one-third presumption was a reasonable method for determining the amount due the state for medical expenses. The federal district court, in E.M.A.’s case, agreed. The Fourth Circuit vacated. The Supreme Court affirmed. The federal anti-lien provision pre-empts North Carolina’s irrebuttable statutory presumption that one-third of a tort recovery is attributable to medical expenses. North Carolina’s irrebuttable, one-size-fits-all statutory presumption is incompatible with the Medicaid Act’s clear mandate View "Wos v. E. M. A." on Justia Law

In 1979, Plaintiffs sued under 42 U.S.C. 1983, on behalf of present and future recipients, alleging that Tennessee’s Medicaid program violated federal requirements, 42 U.S.C. 1396, and the Due Process Clause. The decades that followed involved intervenors, consent orders, revisions, and creation of a subclass. In 1994, Tennessee converted to a managed care program, TennCare. In 1995, five class members filed motions alleging that TennCare was being administered inconsistent with a 1992 decree and federal law. In 2009, the district court awarded plaintiffs more than$2.57 million for fees and expenses leading up to a 2005 Revised Consent Decree. Plaintiffs had originally requested a lodestar amount of $3,313,458.00, but the court reduced the award by 20 percent on account of plaintiffs’ “limited” success relative to the breadth of defendants’ requests and the scope of the litigation. The court noted that there was “no dispute that Plaintiffs in this case are the prevailing party, and thus entitled to attorneys’ fees under 42 U.S.C. 1988.” The Sixth Circuit vacated parts of the award, noting that section 1988 “is not for the purpose of aiding lawyers and that the original petition for fees included requests for dry cleaning bills, mini blinds, and health insurance. View "Binta B. v. Gordon" on Justia Law

Tennessee participates in Medicaid through “TennCare,” Tenn. Code 71-5-102. The Medicaid Act requires that TennCare administer an Early and Periodic Screening, Diagnosis, and Treatment program for all enrollees under age 21, 42 U.S.C. 1396a(a)(43), 1396d(r) and must provide outreach to educate its enrollees about these services. In 1998 plaintiffs filed a putative class action under 42 U.S.C. 1983, alleging that TennCare had failed to fulfill these obligations. The district court entered a consent decree that explained in detail the requirements that TennCare had to meet to “achieve and maintain compliance” with the Medicaid Act, based on the assumption that the Act created rights enforceable under section 1983. Eight years later, the Sixth Circuit held that one part of the Medicaid Act was unenforceable under section 1983. Following a remand, the district court vacated paragraphs of the decree that were based on parts of the Act that are not privately enforceable. After a thorough review of TennCare’s efforts, the court then vacated the entire decree, finding that TennCare had fulfilled the terms of the decree’s sunset clause by reaching a screening percentage greater than 80% and by achieving current, substantial compliance with the rest of the decree. The Sixth Circuit affirmed. View "John B. v.Emkes" on Justia Law

Gayheart applied for Social Security disability insurance benefits in 2005 due to manifestations of anxiety, panic disorder, bipolar disorder, and depression. After an initial denial and three separate hearings, an administrative law judge (ALJ) found that the limitations caused by Gayheart’s impairments did not preclude him from performing a significant number of jobs available in the national economy and denied Gayheart’s application. Gayheart’s request for an administrative appeal was denied. The Report and Recommendation issued by the federal court’s assigned magistrate judge concluded that the ALJ’s decision was not supported by substantial evidence and that Gayheart should be awarded benefits. But the district court sustained the Commissioner’s objections and affirmed the ALJ’s decision. The Sixth Circuit reversed and remanded, holding that the ALJ failed to weigh the medical opinions according to 20 C.F.R. 404.1527. View "Gayheart v. Comm'r of Soc. Sec." on Justia Law

Plaintiffs, teaching hospitals, received Medicare payments to offset the costs associated with training "full-time equivalent" residents and intern physicians (FTEs). In 1997, Congress capped those payments in such a way that the number of FTEs the hospitals trained in 1996 would dictate the maximum reimbursement in all future years. Although the parties agreed that the 1996 data was not accurate, the Secretary believed that this predicate fact could not be corrected outside the three-year reopening window. The court held that the reopening regulation allowed for modification of predicate facts in closed years provided the change would only impact the total reimbursement determination in open years. Alternatively, the court agreed with the district court that the Secretary had acted arbitrarily in treating similarly situated parties differently. The court rejected the Secretary's claim that the Medicare Act, 42 U.S.C. 1395 et seq., would not allow the intermediary to change the 1996 GME resident count without changing the corresponding reimbursement amount, which all parties conceded would constitute a reopening of an "Intermediary determination." Accordingly, the court affirmed the judgment. View "Kaiser Foundation Hospitals v. Sebelius" on Justia Law

Plaintiffs, thirteenth North Carolina residents who lost access to in-home personal care services (PCS) due to a statutory change, brought suit challenging the new PCS program. The district court granted plaintiffs' motions for a preliminary injunction and class certification. Defendants appealed, raising several points of error. The court agreed with the district court's conclusion that a preliminary injunction was appropriate in this case. The court held, however, that the district court's order failed to comply with Federal Rule of Civil Procedure 65 because it lacked specificity and because the district court neglected to address the issue of security. Accordingly, the court remanded the case. View "Pashby v. Delia" on Justia Law

Full Life Hospice participates in the federal Medicare program. It sought reimbursement for hospice services provided to Medicare recipients from the Department of Health and Human Services (HHS). A fiscal intermediary, acting on behalf of HHS, later contested some of these reimbursements and demanded repayment of funds that it claimed were distributed in excess of a spending cap. Full Life unsuccessfully challenged HHS intermediary’s determination through an administrative appeal, which was denied as untimely. On appeal to the district court, the court found no basis to excuse Full Life's untimely challenge. Upon review, the Tenth Circuit agreed with the district court that it lacked subject matter jurisdiction because of Full Life's failure to file a timely administrative appeal. View "Full Life Hospice v. Sebelius" on Justia Law

Walker served in the U.S. Army Air Force, 1943 to 1945, as a four-engine airplane pilot and flight instructor. The VA Regional Office denied his 2007 disability claim for bilateral hearing loss. Walker appealed to the Board of Veterans Appeals, including sworn statements from his son and wife that his hearing loss began in service and continued throughout his life. Walker was examined by a VA audiologist. Walker’s service medical records were not available due to a fire. The audiologist concluded that the hearing loss was “less likely as not caused primarily by military service as a pilot,” that age could not be excluded as the primary etiology, and that Walker was exposed to recreational noise by hunting game without use of hearing protection. The Board concluded that Walker failed under the three-element test to establish service connection for his hearing loss. The Federal Circuit affirmed. View "Walker v. Shinseki" on Justia Law

Since enacting a program for black-lung benefits in 1969, known as the Black Lung Benefits Act,83 Stat. 742, Congress has repeatedly amended the claim-filing process, sometimes making it harder for miners and survivors to obtain benefits, sometimes making it easier. The most recent adjustment, part of the 2010 Patient Protection and Affordable Care Act, reinstated a presumption that deceased workers who had worked for at least 15 years in underground coal mines and had developed a totally disabling respiratory or pulmonary impairment were presumed to be totally disabled by pneumoconiosis and to have died from it. The presumption is rebuttable. The Act also reinstated automatic benefits to any survivor of a miner who had been awarded benefits on a claim filed during his lifetime, 124 Stat. at 260. Groves, a miner for 29 years, filed a claim for benefits in 2006 and died four months later. An ALJ denied his widow benefits. The law changed while her appeal was pending. The Benefits Review Board concluded that the new law covered this claim. The Sixth Circuit affirmed. View "Vision Processing, LLC v. Groves" on Justia Law

Reimbursement providers for inpatient services rendered to Medicare beneficiaries is adjusted upward for hospitals that serve disproportionate numbers of patients who are eligible for Supplemental Security Income. The Centers for Medicare & Medicaid Services annually submit the SSI fraction for eligible hospitals to a “fiscal intermediary,” a Health and Human Services contractor, which computes the reimbursement amount and sends the hospitals notice. A provider may appeal to the Provider Reimbursement Review Board within 180 days, 42 U. S. C. 1395oo(a)(3). The PRRB may extend the period, for good cause, up to three years, 42 CFR 405.1841(b). A hospital timely appealed its SSI fraction calculations for 1993 through 1996. The PRRB found that errors in CMS’s methodology resulted in a systematic under-calculation. When the decision was made public, hospitals challenged their adjustments for 1987 through 1994. The PRRB held that it lacked jurisdiction, reasoning that it had no equitable powers save those granted by legislation or regulation. The district court dismissed the claims. The D. C. Circuit reversed. The Supreme Court reversed. While the 180-day limitation is not “jurisdictional” and does not preclude regulatory extension, the regulation is a permissible interpretation of 1395oo(a)(3). Applying deferential review, the Court noted the Secretary’s practical experience in superintending the huge program and the PRRB. Rejecting an argument for equitable tolling, the Court noted that for nearly 40 years the Secretary has prohibited extensions, except as provided by regulation, and Congress not amended the 180-day provision or the rule-making authority. The statutory scheme, which applies to sophisticated institutional providers, is not designed to be “unusually protective” of claimants. Giving intermediaries more time to discover over-payments than providers have to discover underpayments may be justified by the “administrative realities” of the system: a few dozen intermediaries issue tens of thousands of NPRs, while each provider can concentrate on its own NPR. View "Sebelius v. Auburn Reg'l Med. Ctr." on Justia Law