Justia Public Benefits Opinion Summaries

Plaintiffs sued the Government, seeking to disclaim their legal entitlement to Medicare Part A benefits for hospitalization costs. Plaintiffs wanted to disclaim their legal entitlement to such benefits because their private insurers limited coverage for patients who were entitled to Medicare Part A benefits. Plaintiffs preferred to receive coverage from their private insurers rather than from the Government. The district court granted summary judgment for the Government because there was no statutory authority for those who were over 65 or older and receiving Social Security benefits to disclaim their legal entitlement to Medicare Part A benefits. The court understood plaintiffs' frustration with their insurance coverage. But based on the law, the court affirmed the judgment of the district court. View "Hall, et al. v. Sebelius, et al." on Justia Law

Mrs. T. was the mother of C.T., a fifteen-year-old boy with severe disabilities. At issue in this case was C.T.'s eligibility for the Department of Health and Human Services' home and community-based waiver program. C.T. was approved for the waiver program but was not receiving services under the waiver when the Department instituted a new regulation that closed the program to children but grandfathered children who were already receiving services. Mrs. T. subsequently filed a grievance with the Department seeking to have C.T. declared waiver-eligible. The Commissioner of the Department accepted the recommendation of an administrative hearing officer that denied the grievance. The superior court affirmed. Mrs. T. appealed, contending that the Department was equitably estopped from denying services because she reasonably relied to her detriment on misinformation she received that C.T. was eligible. The Supreme Court affirmed, holding that because Mrs. T. did not meet her burden to prove that her reliance on the misinformation given to her by the Department caused any detriment to C.T., the hearing officer did not err in finding that the Department was not equitably estopped from declaring C.T. ineligible for a waiver. View "Mrs. T. v. Dep't of Health & Human Servs." on Justia Law

Alohacare, a health maintenance organization (HMO), submitted a proposal to the Department of Human Services to bid for a Quest Expanded Access contract to provide healthcare services for participants in the state's Medicaid program. The Department of Human Services awarded Quest contracts to United HealthCare Insurance (United) and WellCare Health Insurance (Ohana) but not to Alohacare. Alohacare petitioned the Insurance Commissioner of the Department of Commerce and Consumer Affairs for declaratory relief that the Quest contracts required the accident and health insurers to carry an HMO license. The Commissioner concluded that the license was not required to offer the Quest managed care product because the services required under the contracts were not services that could be provided only by an HMO. The circuit court affirmed. The Supreme Court affirmed, holding (1) AlohaCare had standing to appeal the Commissioner's decision; (2) both accident and health insurers and HMOs were authorized to offer the model of care required by the Quest contracts; and (3) this holding did not nullify the Health Maintenance Organization Act. View "Alohacare v. Ito" on Justia Law

Defendant was convicted by a jury of defrauding Medicaid and Medicare of $1.4 million. On appeal, defendant argued that the evidence was insufficient; prejudicial evidence was admitted; the jury instructions were flawed; her sentencing level was erroneously increased for obstruction of justice; and the district court erred by denying her request for post-trial contact with a juror. The court affirmed the judgment because there was sufficient evidence to support the conviction and there was no reversible error. View "United States v. Delgado" on Justia Law

Organizations challenged a rule issued by the Secretary of Veterans Affairs (amending 38 C.F.R 3.304(f)) with respect to claims for service-connected disability benefits for post-traumatic stress disorder. The new rule: allows a veteran to establish PTSD without supporting evidence; applies the lower evidentiary standard only if a VA psychologist or psychiatrist, or one contracted with the VA, confirms the claimed-stressor supports the diagnosis; and defines the veteran’s "fear of hostile military or terrorist activity" as involving a response characterized by "a psychological or psycho-physiological state of fear, helplessness, or horror." The Federal Circuit upheld the rule as not violating the statutory requirement that the Secretary consider all medical evidence and give the benefit of the doubt to the claimant when there is an approximate balance of evidence. There is a rational basis for the distinction between private practitioners and VA associated practitioners. View "Nat'l Org. of Veterans' Advocates, Inc. v. Sec'y Veterans Affairs." on Justia Law

In 2003, the New Hampshire Department of Health and Human Services and a certified class of Medicaid-eligible children reached a settlement agreement and proposed a consent decree that outlined the Department's obligations to provide dental services to Medicaid-enrolled children in accordance with federal law. The district court approved the Decree in 2004. Between 2007 and 2010, the district court denied four motions alleging that the Department was not in compliance. The First Circuit affirmed, upholding the district court's requirement that the Class to file a motion for contempt to enforce the Decree; denial of a 2010 motion for contempt; denial of a request for an evidentiary hearing in 2010; and holding the Class to a clear and convincing burden of proof on its 2010 motion to modify or extend the Decree. View "Hawkins v. Dep't of Health & Human Servs. for the State of NH" on Justia Law

This case involved Commonwealth Care, a state-initiated program that provided structured premium assistance for low-income Massachusetts residents. In 2009, the Legislature made certain changes to the eligibility requirements of Commonwealth Care, enacted in a two-part supplemental appropriation for fiscal year 2010. Section 31(a) of the appropriation excluded all aliens who were federally ineligible under the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), 8 U.S.C. 1601-1646, from participation in Commonwealth Care. Plaintiffs were individuals who either have been terminated from Commonwealth Care or have been denied eligibility solely as a result of their alienage. The court held that section 31(a) could not pass strict scrutiny and that the discrimination against legal immigrants that its limiting language embodied violated their rights to equal protection under the Massachusetts Constitution. View "Finch & others v. Commonwealth Health Ins. Connector Auth. & others" on Justia Law

Plaintiffs, Washington Medicaid beneficiaries with severe mental and physical disabilities, appealed the district court's denial of their motion for a preliminary injunction. Plaintiffs sought to enjoin the operation of a regulation promulgated by Washington's DSHS that reduced the amount of in-home "personal care services" available under the state's Medicaid plan. The court concluded that plaintiffs have demonstrated a likelihood of irreparable injury because they have shown that reduced access to personal care services would place them at serious risk of institutionalization. The court further concluded that plaintiffs have raised serious questions going to the merits of their Americans with Disabilities Act, 42 U.S.C. 12132, and Rehabilitation Act, 29 U.S.C. 794(a), claims, that the balance of hardships tipped sharply in their favor, and that a preliminary injunction would serve the public interest. Accordingly, the court remanded for entry of a preliminary injunction. View "M. R., et al. v. Dreyfus, et al." on Justia Law

Medicare Part A reimburses hospitals according to a Prospective Payment System (42 U.S.C. 1395ww(d), which uses a predetermined formula to calculate reimbursement for each patient discharge without regard to the actual cost incurred. The formula includes the average hourly wage of the employees in the geographic region, including paid lunch hours. Hospitals objected to the practice because some hospitals give paid lunch breaks, which depresses the average area hourly wage and, in turn, their Medicare reimbursements. The district court granted summary judgment for the government. The Seventh Circuit affirmed, reasoning that counting all paid hours, for the sake of administrative simplicity, is not arbitrary. View "Adventist GlenOaks Hosp. v. Sebelius" on Justia Law

From 2007 to 2008, Dorothy Rogers received Medicare benefits through Pacificare's federally-approved Medicare Advantage Plan, Secure Horizons. Rogers and Pacificare entered into separate contracts each year providing the terms and conditions of coverage. After receiving treatment from the Endoscopy Center of Southern Nevada (ECSN), a facility approved by Pacificare for use by its Secure Horizons plan members, Rogers tested positive for hepatitis C. Rogers sued Pacificare, alleging that Pacificare should be held responsible for her injuries because it failed to adopt and implement an appropriate quality assurance program. Pacificare moved to dismiss her claims and compel arbitration based on a provision in the parties' 2007 contract. The district court determined that the 2007 contract governed, but held that the arbitration provision was unconscionable and, thus, unenforceable. The Supreme Court reversed, holding (1) because the parties in this case did not expressly rescind the arbitration provision at issue, the provision survived the 2007 contract's expiration and was properly invoked; and (2) as the Medicare Act expressly preempts any state laws or regulations with respect to the Medicare plan at issue in this case, Nevada's unconscionability doctrine was preempted to the extent that it would regulate federally-approved Medicare plans. View "Pacificare of Nevada v. Rogers" on Justia Law