Justia Public Benefits Opinion Summaries

Florida challenged a federal agency document known as the “Informational Bulletin” that interpreted Medicaid’s hold-harmless rule and threatened to claw back billions in Medicaid funds if certain state practices continued. Florida’s Medicaid funding system relies on a Directed Payment Program, under which local governments assess special fees on private hospitals, pool these fees, and transfer the funds to the state agency, which then uses them to secure additional federal matching funds. The state feared the new federal interpretation could jeopardize its program and moved to preliminarily enjoin the Bulletin’s implementation.The United States District Court for the Southern District of Florida, following a magistrate judge’s recommendation, denied Florida’s motion for a preliminary injunction and dismissed the case for lack of subject matter jurisdiction. The district court held that the Bulletin was not a “final agency action” under the Administrative Procedure Act (APA), and therefore not subject to judicial review.The United States Court of Appeals for the Eleventh Circuit reviewed the case and found that, contrary to the district court’s conclusion, the Bulletin was indeed a final agency action subject to judicial review under the APA. However, the Eleventh Circuit held that Florida was unlikely to succeed on the merits of its challenge, concluding that the Bulletin’s interpretation of the Medicaid hold-harmless rule was consistent with the statutory text, was not arbitrary or capricious, and did not require notice-and-comment rulemaking. The court thus reversed the dismissal of the complaint, affirmed the denial of the preliminary injunction, and remanded the case for further proceedings. View "Florida Agency for Health Care Administration v. Administrator for the Centers for Medicare & Medicaid Services" on Justia Law

The claimant served in the U.S. Navy and, upon his voluntary separation in 1992, received a lump sum Special Separation Benefit (SSB) under 10 U.S.C. § 1174a. Many years later, in 2017, he was awarded VA disability compensation with entitlement to a total disability rating, effective from late 2016. The Department of Veterans Affairs (VA) notified him that it would withhold a portion of his monthly disability benefits to recoup the SSB payment, which the claimant contested, arguing that SSB payments are not subject to recoupment and that the relevant statutory authority did not apply to his situation.The Board of Veterans’ Appeals found that the VA acted properly in withholding his disability compensation to recoup the SSB payment. The claimant then appealed to the United States Court of Appeals for Veterans Claims, which affirmed the Board’s decision. He sought reconsideration, asserting that the court had relied upon the wrong statutory provision. The Veterans Court granted reconsideration, but in its new decision, it again held that the relevant statute required recoupment of his SSB payment from his VA disability compensation, and affirmed the Board’s decision.The United States Court of Appeals for the Federal Circuit reviewed the statutory interpretation de novo. The court held that 10 U.S.C. § 1174(h)(2) applies to SSB payments received under 10 U.S.C. § 1174a, requiring such payments to be deducted from VA disability compensation. The court rejected the claimant’s alternative statutory interpretation, finding it inconsistent with the statutory text and structure. The court also dismissed for lack of jurisdiction arguments that were not addressed by the Veterans Court. The judgment was affirmed in part and dismissed in part. View "COLAGE v. COLLINS " on Justia Law

The case concerns the Montana Department of Public Health and Human Services’ attempt to recover $5,360.89 in Medicaid benefits paid on behalf of a deceased recipient, Florence Pound. The sole heir, Minta Johnson, inherited Pound’s home, the primary estate asset valued at approximately $200,000. After Pound’s death, Johnson, as personal representative, published notice to creditors as required by Montana law. The Department submitted its claim one day after the four-month statutory deadline for creditor claims had expired, and the Probate Court denied the claim as untimely. The estate was then distributed entirely to Johnson.Following the denial of its claim in the Eleventh Judicial District Court (Probate Court), the Department filed a new action in the Fourth Judicial District Court, seeking recovery from Johnson personally under a separate statute, § 53-6-167(2), MCA, which allows the Department to seek reimbursement from anyone who received property from the estate. The District Court granted summary judgment to Johnson, reasoning that the Department’s untimely creditor’s claim barred further action and that issue preclusion applied because the same underlying issue had already been decided in probate.The Supreme Court of the State of Montana reviewed the matter de novo. It held that the Department’s statutory right under § 53-6-167(2), MCA, to recover Medicaid benefits from an heir is independent of the probate creditor claim process, and that a missed probate deadline does not bar a subsequent action against an heir. The Court further found that issue preclusion did not apply because the probate court lacked jurisdiction to consider the Department’s statutory claim against the heir, and the issues in the two proceedings were not identical. The Supreme Court reversed the District Court’s dismissal and remanded for judgment in favor of the Department. View "Department of Public Health and Human Services v. Johnson" on Justia Law

After the death of her husband, who had worked in coal mining for nearly 28 years, a widow applied for survivor benefits under the Black Lung Benefits Act (BLBA). Her husband died in 2014 following a hospitalization, and she filed her claim shortly thereafter. The BLBA provides survivor benefits to eligible dependents if a miner’s death is due to pneumoconiosis (“black lung disease”) arising from coal mine employment. A key question in this case was whether the miner’s terminal arterial blood gas (ABG) studies, taken during his last hospitalization, could be used to establish that he was totally disabled due to a chronic respiratory or pulmonary condition at the time of his death.Initially, the District Director awarded benefits and identified the employer as the responsible operator. The employer requested a hearing before the Office of Administrative Law Judges. The first Administrative Law Judge (ALJ) denied benefits, finding that although the miner worked long enough to invoke a presumption that his death was due to pneumoconiosis, the ABG tests lacked an adequate physician’s report linking the results to a chronic condition, as required by regulation. The widow sought modification, arguing that a mistake of fact had been made. A second ALJ granted modification and awarded benefits, relying on a comprehensive report from one of the physicians that sufficiently connected the ABG results to the miner’s chronic lung disease. The Benefits Review Board (BRB) affirmed, holding that the widow established her entitlement to benefits and that the employer failed to rebut the statutory presumption.The United States Court of Appeals for the Fourth Circuit reviewed the case and denied the employer’s petition. The court held that substantial evidence supported the BRB’s decision affirming the award of benefits. Specifically, the court found the physician’s report was sufficient to link the terminal ABG results to a chronic respiratory condition, thus satisfying regulatory requirements and entitling the widow to the statutory presumption. The court also concluded that the ALJ properly granted modification based on a mistake of fact. View "Clinchfield Coal Company v. Mullins" on Justia Law

A neurologist submitted a Freedom of Information Act (FOIA) request to the United States Social Security Administration (SSA) seeking documents about how the SSA evaluates disability claims for migraines and other headache disorders. The SSA determined that this request was not directly related to the administration of any of its benefit programs. Relying on a provision in the Social Security Act (42 U.S.C. § 1306(c)), the SSA required the requester to pay the full cost of processing the request, which totaled $2,908. The requester paid the fee but later objected because the SSA did not respond within the statutory deadline set by FOIA.The United States District Court for the District of Vermont found in favor of the requester. The district court concluded that FOIA’s provision prohibiting fees when the agency fails to respond on time superseded the Social Security Act’s cost-reimbursement clause. As a result, the court ordered the SSA to refund the fee and awarded the requester attorneys’ fees and costs. The court reasoned that allowing the SSA to charge fees despite late responses would undermine the FOIA amendments designed to ensure agency timeliness.On appeal, the United States Court of Appeals for the Second Circuit considered whether the Social Security Act’s cost-reimbursement provision or FOIA’s fee-preclusion provision controlled. The Second Circuit held that the plain language of § 1306(c), which begins with a “notwithstanding” clause, explicitly exempts the SSA from FOIA’s fee rules for requests not directly related to program administration. The court agreed with the SSA’s determination that the request was not program-related and found the statute unambiguous. Therefore, the court reversed the district court’s judgment and vacated the award of attorneys’ fees and costs. View "Shapiro v. U.S. Soc. Sec. Admin." on Justia Law

The plaintiff, a former security guard, began experiencing panic attacks and anxiety, particularly when using public transportation, which ultimately led to the loss of his job. He was treated with medication, but continued to suffer from symptoms that interfered with his ability to work consistently. He applied for Supplemental Security Income and Social Security Disability Insurance, claiming disability from the time he was terminated due to his condition. The record included testimony from the plaintiff, a vocational expert, and five medical professionals, all of whom opined that he had at least moderate limitations in maintaining concentration, staying on task, and regular work attendance.After an initial denial by the Social Security Administration, the plaintiff requested a hearing before an Administrative Law Judge (ALJ). The ALJ found that the plaintiff had severe impairments but did not meet the criteria for a listed disability. Relying on some aspects of one consultative psychiatrist's opinion, and discounting others, the ALJ concluded that the plaintiff retained the residual functional capacity (RFC) to perform unskilled work in a goal-oriented setting, without finding any specific limitations on his ability to stay on task or maintain regular attendance. The vocational expert testified that an individual who was off task more than 10% of the workday or absent more than one day per month would be unable to maintain employment. The ALJ nonetheless found the plaintiff not disabled. The Appeals Council denied review, making the ALJ's decision final. The United States District Court for the Southern District of New York affirmed the denial.The United States Court of Appeals for the Second Circuit reviewed the administrative record de novo and concluded that the ALJ’s RFC finding was not supported by substantial evidence, particularly given the unanimous medical opinions regarding the plaintiff's limitations and the vocational expert’s testimony. The Second Circuit vacated the district court’s judgment and remanded the case to the Commissioner for further development of the record and reconsideration of the plaintiff’s application. View "Nunez v. Commissioner of Social Security" on Justia Law

Rosa A. Camacho, a retired Class II member of the Northern Mariana Islands Retirement Fund, claimed that she was entitled to cost-of-living allowances (COLAs) as part of her retirement benefits. When Camacho entered the Retirement Fund in 1980, COLAs were not part of the retirement package. In 1989, the Commonwealth legislature amended the Retirement Fund Act to provide a two percent COLA. Over the years, this provision was repeatedly modified, suspended, and ultimately repealed in 2011. The Commonwealth’s financial difficulties led to a class action and a subsequent settlement agreement in 2013, which entitled participants to 75% of their “Full Benefits,” as defined by statute or guaranteed by the Commonwealth Constitution.The United States District Court for the Northern Mariana Islands held that Camacho was not entitled to COLAs under the settlement agreement, reasoning that COLAs were not constitutionally protected benefits at the time she joined the Retirement Fund and were discretionary by statute as of 2013. Camacho appealed, arguing that the statutory introduction of COLAs during her membership created a protected right under Article III, section 20(a) of the Commonwealth Constitution.The United States Court of Appeals for the Ninth Circuit certified to the Supreme Court of the Commonwealth of the Northern Mariana Islands the question of whether section 8334(e) of the Retirement Fund Act conferred a constitutionally protected accrued benefit in the form of COLAs for Class II members employed when the Act took effect. The Commonwealth Supreme Court answered in the negative, finding that COLAs were legislative policy adjustments and not protected contractual benefits. In accordance with this interpretation, the Ninth Circuit held that Camacho did not acquire a constitutionally protected right to COLAs under section 8334(e). The district court’s decision was affirmed. View "Camacho v. Northern Mariana Islands Settlement Fund" on Justia Law

A Chicago police officer was injured in a traffic accident while responding to a call in 2017, resulting in ongoing back and hip problems. Despite returning to unrestricted duty for a period, his condition worsened, leading to medical leave and various treatments, including surgery for a hip injury and ongoing care for back pain. Multiple physicians were involved in his care. His treating orthopedic specialist eventually deemed him permanently disabled from police work, while a Board-appointed independent medical examiner found him capable of full, unrestricted police duty. The officer sought reinstatement with the police department but was not cleared due to medical opinions regarding his disability. He applied to the Retirement Board for duty disability benefits.The Retirement Board of the Policemen’s Annuity and Benefit Fund of the City of Chicago held a hearing and ultimately denied his application for both duty and ordinary disability benefits, finding the Board-appointed physician’s opinion more credible. The Circuit Court of Cook County affirmed the Board’s decision, holding it was not against the manifest weight of the evidence. The officer appealed, and the Appellate Court, First District, reversed and remanded. The appellate court relied on the Illinois Supreme Court’s holding in Kouzoukas v. Retirement Board of the Policemen’s Annuity & Benefit Fund of Chicago, reasoning that the officer was caught in a “catch-22” because he was not offered a suitable position by the police department and therefore should be considered disabled under the statute.The Supreme Court of Illinois reviewed the Retirement Board’s decision, holding that section 5-156 of the Illinois Pension Code does not require proof of disability from a Board-appointed doctor as a prerequisite to granting benefits; the Board remains the ultimate arbiter of disability. The Court found that the Board’s denial of benefits was not against the manifest weight of the evidence, distinguishing the facts from Kouzoukas. The Supreme Court reversed the appellate court’s judgment and affirmed the circuit court and the Board’s denial of benefits. View "Moreland v. Retirement Board of the Policemen Y Annuity and Benefit Fund of the City of Chicago" on Justia Law

Tamica Rainey, a Chicago police officer, was injured in duty-related car accidents in 2013 and 2015. She was awarded duty disability benefits in 2017 based on injuries to her neck and shoulder. As required by statute, Rainey’s disability status was periodically reviewed, and in 2022, after multiple hearings and submissions of medical records, the Retirement Board of the Policemen’s Annuity and Benefit Fund of the City of Chicago discontinued her duty disability benefits, concluding she was no longer disabled from her duty-related injuries. However, when Rainey attempted to return to work, the police department determined she could not perform her duties.Rainey sought administrative review in the Circuit Court of Cook County, which reversed the Board’s decision, relying on precedent that an officer remains disabled if the department cannot provide a position with needed accommodations. The circuit court also awarded Rainey attorney fees and costs under section 5-228(b) of the Illinois Pension Code. The Board appealed, and the Appellate Court of Illinois, First District, affirmed both the restoration of Rainey’s benefits and the award of attorney fees and costs.The Supreme Court of Illinois reviewed the Board’s challenge to the attorney fees and costs award. The court held that section 5-228(b) of the Illinois Pension Code authorizes an award of attorney fees and costs not only to police officers who successfully challenge the initial denial of duty or occupational disease disability benefits, but also to those who successfully challenge the discontinuation of such benefits. The court rejected the Board’s argument that statutory attorney fee awards are limited to initial applications, finding the statute’s plain language and legislative intent favor such awards for both denial and discontinuation challenges. The Supreme Court affirmed the judgments of the appellate and circuit courts and reversed the Board’s decision. View "Rainey v. Retirement Board of the Policemen & Annuity and Benefit Fund of the City of Chicago" on Justia Law

Several employees of the City and County of San Francisco who joined the city’s retirement system at age 40 or older and later retired due to disability challenged the method used to calculate their disability retirement benefits. The city’s retirement system uses two formulas: Formula 1, which provides a higher benefit if certain thresholds are met, and Formula 2, which imputes service years until age 60 but caps the benefit at a percentage of final compensation. Plaintiffs argued that Formula 2 discriminates against employees who enter the system at age 40 or above, in violation of the California Fair Employment and Housing Act (FEHA).Initially, the San Francisco City and County Superior Court sustained the city’s demurrer, finding the plaintiffs had not timely filed an administrative charge. The California Court of Appeal reversed that decision, allowing the case to proceed. After class certification and cross-motions for summary judgment, the trial court found triable issues and held a bench trial. At trial, plaintiffs presented expert testimony based on hypothetical calculations, while the city’s expert criticized the lack of actual data analysis and highlighted factors such as breaks in service and purchased credits.The California Court of Appeal, First Appellate District, Division Four, reviewed the trial court’s post-trial decision. The appellate court affirmed the trial court’s judgment, holding that the plaintiffs failed to prove intentional age discrimination or disparate impact under FEHA. The court found substantial evidence that Formula 2 was motivated by pension status and credited years of service, not age. The plaintiffs’ evidence was insufficient because it relied on hypotheticals rather than actual data showing a disproportionate adverse effect on the protected group. The appellate court also affirmed the denial of leave to amend the complaint, finding no reversible error. The judgment in favor of the city was affirmed. View "Carroll v. City & County of S.F." on Justia Law