Justia Public Benefits Opinion Summaries

A healthcare provider participated in Kentucky’s Medicaid program, offering in-home services to recipients in rural areas under the Home and Community Based (HCB) Waiver program. The Department for Medicaid Services had, for several years, reimbursed the provider at enhanced rates for “case management” services, even though the relevant administrative regulation did not list “case management” as a reimbursable “revenue code service.” In 2016, the Department determined that these payments were made in error and sought to recoup over $1 million from the provider for services rendered between 2011 and 2013.After the Department initiated recoupment, the provider contested the action through the Cabinet’s administrative process, arguing that the omission of “case management” from the regulation was a drafting error and that the Department should be estopped from recouping the funds due to its prior representations and delay. The administrative hearing officer rejected these arguments, finding the regulation’s text unambiguous and concluding that neither equitable estoppel nor laches applied. The Secretary of the Cabinet adopted this decision. The provider then sought judicial review in the Franklin Circuit Court, which affirmed the agency’s decision. The Kentucky Court of Appeals also affirmed.The Supreme Court of Kentucky reviewed the case and affirmed the Court of Appeals. The Court held that the Department’s regulation unambiguously excluded “case management” from the list of services eligible for enhanced reimbursement, and the Department was within its authority to recoup the overpaid funds. The Court declined to read omitted language into the regulation, found no basis for equitable estoppel or laches against the Department, and rejected the provider’s arguments regarding the sufficiency of the Department’s audit. View "PROFESSIONAL HOME HEALTH CARE V. COMMONWEALTH OF KENTUCKY CABINET FOR HEALTH AND FAMILY SERVICES" on Justia Law

In this interlocutory appeal from the circuit court’s review of an agency ruling, the Supreme Court adopted the United States Supreme Court’s test for standing as set forth in Lujan v. Defenders of Wildlife, 504 U.S. 555, 560-561 (1992) and held that the existence of a plaintiff’s standing is a constitutional requirement to prosecute any action in the courts of the Commonwealth, including seeking judicial review of an administrative agency’s final order.The putative petitioner in this case, a Medicaid beneficiary (the patient), sought judicial review of a final order of the Kentucky Cabinet for Health and Human Services ruling that the patient lacked standing to pursue an appeal of an insurer’s denial of reimbursement to a hospital for the patient’s services. The hospital, acting as the patient’s representative, sought judicial review of the Cabinet’s final order. The circuit court denied the Cabinet and the insurer’s motions to dismiss the petition. The Supreme Court remanded the case with instructions to dismiss the case, holding (1) Kentucky courts have the responsibility to ascertain whether a plaintiff has constitutional standing to pursue the case in court; and (2) under that test, the patient did not have the requisite constitutional standing to pursue her case in the courts of the Commonwealth. View "Commonwealth v. Sexton" on Justia Law

Charles Wimberly filed an application for disability retirement benefits with the Kentucky Retirement Systems (KERS). A hearing officer recommended that Wimberly's application be denied and, before KERS could render a final decision, Wimberly filed a second application pursuant to Kentucky Revised Statute (KRS) 61.600(2). Following the recommendation of another hearing officer, KERS denied that application. Wimberly sought judicial review; the circuit court reversed KERS. KERS appealed to the Court of Appeals, which affirmed the circuit court. The Supreme Court granted discretionary review to address the parties' arguments regarding the application of the doctrine of res judicata and to determine whether the consumption of alcohol was or could be a pre-existing condition. Having reviewed the record and the arguments of the parties, the Supreme Court affirmed. View "Kentucky Retirement Systems v. Wimberly" on Justia Law

Dianne Carson first filed an application for retirement disability benefits in November 2007. Based on the recommendation of a hearing officer, the Kentucky Retirement Systems (KERS) denied Carson's claim. Carson did not seek judicial review of KERS's order, choosing instead to file a second application in October 2009. Based on a recommendation of a different hearing officer, KERS again denied Carson's claim. Carson sought judicial review and the circuit reversed and remanded with instructions for KERS to consider all of the medical evidence Carson submitted. The Court of Appeals affirmed. KERS argued that Carson's second application should have been dismissed under the doctrine of res judicata. "If res judicata applied to this action, Carson would have been barred from filing a second application that was based on the same claim as her first application. However, KRS 61.600(2) requires KERS to accept an employee's timely filed "reapplication based on the same claim of incapacity" and to reconsider the claim 'for disability if accompanied by new objective medical evidence.'" This case was remanded for KERS to undertake the correct review of the evidence. The Supreme Court affirmed the Court of Appeals. View "Kentycky Retirement Systems v. Carson" on Justia Law

The Cabinet for Health and Family Services filed a motion to hold Renee Ivy in contempt after Ivy fell behind in her child support payments. At the hearing on the motion, Ivy presented evidence that her sole source of income was a federal benefit under the Supplemental Security Income program (SSI). The trial court reduced Ivy's support obligation and held her in contempt for having failed to pay the past due amount. The court of appeals reversed, holding that the contempt finding and the order to pay even reduced child support could not stand because evidence showed Ivy did not have the ability to pay. The Supreme Court (1) reversed the court of appeals' decision to the extent that it suggested that a SSI recipient-parent's present inability to pay precludes even the assessment of child support; (2) vacated the existing order and remanded for the family court to determine if the guidelines-based amount would be unjust or inappropriate pursuant to Ky. Rev. Stat. 403.211(2); and (3) affirmed the holding that a contempt finding was inappropriate here where there was essentially uncontroverted evidence that Ivy's failure to provide child support stemmed only from her inability to do so. View "Cabinet for Health & Family Servs. v. Ivy" on Justia Law