Justia Public Benefits Opinion Summaries

Articles Posted in Public Benefits
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Once a person turns 65 or has received federal disability benefits for 24 months, he becomes “entitled” to Medicare Part A, 42 U.S.C. 426(a)–(b) benefits. Not all patients who qualify for Medicare Part A have their hospital treatment paid for by the program; a patient’s stay may exceed Medicare’s 90-day cap or a patient may be covered by private insurance.Medicare pays hospitals a fixed rate for in-patient treatment based on the patient’s diagnosis, regardless of the hospital’s actual cost, subject to the “disproportionate share hospital” (DSH) adjustment, which provides higher-than-usual rates to hospitals that serve a higher-than-usual percentage of low-income patients. The DSH adjustment is calculated by adding the Medicare fraction (proportion of a hospital’s Medicare patients who have low incomes) and the Medicaid fraction (proportion of a hospital’s total patients who are not entitled to Medicare and have low incomes). A 2004 HHS regulation provides: If the patient meets the basic statutory criteria for Medicare, that patient counts in the denominator and, if poor, in the numerator of the Medicare fraction. The Ninth Circuit declared the regulation invalid.The Supreme Court reversed. In calculating the Medicare fraction, individuals “entitled to" Medicare Part A benefits are all those qualifying for the program, regardless of whether they receive Medicare payments for a hospital stay. Counting everyone who qualifies for Medicare benefits in the Medicare fraction—and no one who qualifies for those benefits in the Medicaid fraction—accords with the statute’s attempt to capture, through separate measurements, two different segments of a hospital’s low-income patient population. Throughout the Medicare statute, “entitled to benefits” is essentially a term of art meaning “qualifying for benefits” and coexists with limitations on payment. View "Becerra v. Empire Health Foundation, For Valley Hospital Medical Center" on Justia Law

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The employer-sponsored group health plan offers all of its participants the same limited coverage for outpatient dialysis. A dialysis provider sued the plan, citing the Medicare Secondary Payer statute, which makes Medicare a “secondary” payer to an individual’s existing insurance plan for certain medical services, including dialysis, when that plan already covers the same services, 42 U.S.C. 1395y(b)(1)(C), (2), (4). To prevent plans from circumventing their primary-payer obligation for end-stage renal disease treatment, a plan may not differentiate in the benefits it provides between individuals having end-stage renal disease and other individuals based on the existence of end-stage renal disease, the need for renal dialysis, “or in any other manner” and may not take into account that an individual is entitled to or eligible for Medicare due to end-stage renal disease. The Sixth Circuit ruled that the limited payments for dialysis treatment had a disparate impact on individuals with end-stage renal disease.The Supreme Court reversed. The plan's coverage terms for outpatient dialysis do not violate section 1395y(b)(1)(C) because those terms apply uniformly to all covered individuals. The statute prohibits a plan from differentiating in benefits between individuals with and without end-stage renal disease; it cannot be read to encompass a disparate-impact theory. The statute simply coordinates payments between group health plans and Medicare without dictating any particular level of dialysis coverage. The plan does not “take into account” whether its participants are entitled to or eligible for Medicare. View "Marietta Memorial Hospital Employee Health Benefit Plan v. DaVita Inc." on Justia Law

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Plaintiff’s doctors prescribed him Optune, a medical technology that had recently received FDA approval for treating recurrent GBM. The device delivers tumor treating field therapy (TTFT) to inhibit cancer-cell replication. A company called Novocure is the sole supplier of the Optune device, which is rented by patients on a monthly basis.   Because Plaintiff is a Medicare Part B beneficiary, he and Novocure asked Medicare to cover his TTFT. Novocure was held liable for the claims. Plaintiff and Novocure submitted 13 claims to Medicare, corresponding to 13 months of TTFT. The district court held that Plaintiff lacked standing because he hadn’t suffered an injury in fact.   The Eleventh Circuit was tasked with deciding whether Plaintiff has standing to challenge a denial of Medicare coverage where the costs of his treatment were imposed not on him, but rather on a third-party supplier. The court affirmed the district court’s determination that Plaintiff hadn’t suffered an injury in fact.   Here, Plaintiff’s alleged harm will only come to pass due to the challenged action if, at some indefinite point in the future: (1) his condition worsens, (2) he has paid his premiums and stayed on Medicare Part B, (3) he elects to resume TTFT, (4) his doctor prescribes the therapy (5) Plaintiff receives the treatment, (6) he files a claim, (7) which is denied at every level of the Medicare appeals process, (8) the adjudicators determine that Plaintiff’s hypothetical future case presents a “comparable situation,” and (9) they further find that the instant coverage denial and no other source put Plaintiff on notice that he could be held liable. View "Edwin R. Banks v. Secretary, Department of Health and Human Services" on Justia Law

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The U.S. military sprayed over 17 million gallons of herbicides over Vietnam during “Operation Ranch Hand,” primarily Agent Orange. Concerns about the health effects of veterans’ exposure to Agent Orange led to the Agent Orange Act of 1991, 105 Stat. 11. For veterans who served in the Republic of Vietnam during a specified period, the Act presumes exposure to an herbicide agent containing 2,4-D or dioxin, 38 U.S.C. 1116(f), and presumes a service connection for certain diseases associated with herbicide-agent exposure, such as non-Hodgkin’s lymphoma and soft-tissue sarcoma. The VA subsequently issued regulations extending similar presumptions to other groups of veterans. In 2017, the House of Representatives Armed Services Committee expressed concern that additional exposures to Agent Orange may have occurred in Guam.In 2018, MVA petitioned the VA to issue rules presuming herbicide-agent exposure for veterans who served on Guam or Johnston Island during specified periods. The VA denied MVA’s petition. The Federal Circuit rejected MVA’s petitions under 38 U.S.C. 502 to set aside the VA’s denial. MVA has not shown that the VA’s determination that the evidence did not warrant presuming exposure for every single veteran who served in named areas during the relevant period was contrary to law nor that the denial “lacked a rational basis.” View "Military-Veterans Advocacy Inc. v. Secretary of Veterans Affairs" on Justia Law

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The government alleges that Medicare overpaid Plaintiff and his medical practice approximately $5.31 million. While the third level of administrative review, a hearing before an Administrative Law Judge (“ALJ”), was pending, Medicare began to recover the overpaid funds by withholding new reimbursements. Plaintiff argued that recovery prior to an ALJ hearing and decision violates procedural due process. He moved for a preliminary injunction to prevent Medicare from recovering payments prior to the ALJ decision. The district court denied the preliminary injunction and Plaintiff appealed.   The Eighth Circuit affirmed the denial of the preliminary injunction finding that Plaintiff has not satisfied the requirements for a preliminary injunction. Further, he has not shown that he is likely to prevail on the merits of his procedural due process claim nor that he is likely to suffer irreparable harm. The court explained that if an audit shows that a provider has been overpaid, Medicare may seek to recover the overpaid funds. Moreover, if a Medicare contractor determines a provider has been overpaid, the provider may challenge that decision through administrative and judicial review.   Here, Plaintiff’s interest in avoiding erroneous recoupment outweighs the government’s interest in prompt repayment. However, there is no evidence in the record that any delay in recovery against Plaintiff will cause long-term harm to Medicare or prevent Medicare from providing services to other beneficiaries. Further, Plaintiff’s claims of irreparable harm are undercut by his apparent failure to try to ease the burdens of recoupment. View "Gurpreet Padda v. Xavier Becerra" on Justia Law

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George joined the Marine Corps in 1975 without disclosing his history of schizophrenic episodes. His medical examination noted no mental disorders. George suffered an episode during training. The Marines medically discharged him. George applied for veterans’ disability benefits based on his schizophrenia, 38 U.S.C. 1110. The Board of Veterans’ Appeals denied his appeal from a regional office denial in 1977. In 2014, George asked the Board to revise its final decision. When the VA denies a benefits claim, that decision generally becomes “final and conclusive” after the veteran exhausts the opportunity for direct appeal. George sought collateral review under an exception allowing revision of a final benefits decision at any time on grounds of “clear and unmistakable error,” 38 U.S.C. 5109A, 7111. He claimed that the Board applied a later-invalidated regulation to deny his claim without requiring the VA to rebut the statutory presumption that he was in sound condition when he entered service.The Veterans Court, Federal Circuit, and Supreme Court affirmed the denial of relief. The invalidation of a VA regulation after a veteran’s benefits decision becomes final cannot support a claim for collateral relief based on clear and unmistakable error. Congress adopted the “clear and unmistakable error doctrine” developed under decades of prior agency practice. The invalidation of a prior regulation constitutes a “change in interpretation of law” under historical agency practice, not “clear and unmistakable error.” That approach is consistent with the general rule that the new interpretation of a statute can only retroactively affect decisions still open on direct review. The fact that Congress did not expressly enact the specific regulatory principle barring collateral relief for subsequent changes in interpretation does not mean that the principle did not carry over. View "George v. McDonough" on Justia Law

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The formula that the Department of Health and Human Services must employ annually to set reimbursement rates for certain outpatient prescription drugs provided by hospitals to Medicare patients, 42 U.S.C. 1395l(t)(14)(A)(iii), provides two options. If HHS has conducted a survey of hospitals’ acquisition costs for each covered outpatient drug, it may set reimbursement rates based on the hospitals’ “average acquisition cost” for each drug, and may “vary” the reimbursement rates “by hospital group.” Absent a survey, HHS must set reimbursement rates based on “the average price” charged by manufacturers for the drug as calculated and adjusted by the Secretary. For 2018 and 2019, HHS did not conduct a survey but issued a final rule establishing separate reimbursement rates for hospitals that serve low-income or rural populations through the “340B program” and all other hospitals. The district court concluded that HHS had acted outside its statutory authority. The D.C. Circuit reversed. A unanimous Supreme Court reversed. The statute does not preclude judicial review of HHS’s reimbursement rates. Absent a survey of hospitals’ acquisition costs, HHS may not vary the reimbursement rates only for 340B hospitals; HHS’s 2018 and 2019 reimbursement rates for 340B hospitals were therefore unlawful. HHS’s power to increase or decrease the price is distinct from its power to set different rates for different groups of hospitals and HHS’s interpretation would make little sense given the statute’s overall structure. Congress, when enacting the statute, was aware that 340B hospitals paid less for covered prescription drugs and may have intended to offset the considerable costs of providing healthcare to the uninsured and underinsured in low-income and rural communities. View "American Hospital Association v. Becerra" on Justia Law

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Appellants, Medicaid providers and former members of public-sector unions, challenge the district courts’ dismissals of two cases, consolidated on appeal. When Appellants joined the unions, they authorized the California State Controller to deduct union dues from their Medicaid reimbursements. Appellants now contend that, when the Controller made these deductions, she violated the “anti-reassignment” provision of the Medicaid Act, which prohibits state Medicaid programs from paying anyone other than the providers or recipients of covered services.   The Ninth Circuit affirmed the district court’s dismissal. The court explained that California uses some of its Medicaid funding to provide assistance with daily activities to elderly and disabled beneficiaries under a program called In-Home Support Services (IHSS). The recipients of these services are responsible for employing and overseeing the work of their IHSS providers, who are often family members. The Controller makes a variety of standard payroll deductions, including for federal and state income tax, unemployment compensation, and retirement savings. California law also authorizes the Controller to deduct union dues from the paychecks of IHSS providers.   Thus, the court held that the Medicaid Act’s anti-reassignment provision, 42 U.S.C. Section 1396a(a)(32), does not confer a right on Medicaid providers enforceable under Section 1983. The text and legislative history of the anti-reassignment provision make clear that Congress was focused on preventing fraud and abuse in state Medicaid programs rather than on serving the needs of Medicaid providers. Because Congress did not intend to benefit Medicaid providers, the anti-reassignment provision did not confer a right as enforceable under Section 1983. View "DELORES POLK V. BETTY YEE" on Justia Law

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Gallardo suffered catastrophic injuries resulting in permanent disability when a truck struck her as she stepped off her Florida school bus. Florida’s Medicaid agency paid $862,688.77 to cover Gallardo’s initial medical expenses and continues to pay her medical expenses. Gallardo’s suit against the truck’s owner and the School Board resulted in an $800,000 settlement, with $35,367.52 designated as compensation for past medical expenses. The settlement did not specifically allocate any amount for future medical expenses.The Medicaid Act requires participating states to pay for certain individuals’ medical costs and to make reasonable efforts to recoup those costs from liable third parties, 42 U.S.C. 1396k(a)(1)(A). Under Florida’s Medicaid Third-Party Liability Act, a beneficiary who accepts medical assistance from Medicaid automatically assigns to the state any right to third-party payments for medical care; Florida was entitled to $300,000--presumptively representing the portion of the recovery that is for past and future medical expenses.The Supreme Court affirmed the Eleventh Circuit. The Medicaid Act permits a state to seek reimbursement from settlement payments allocated for future medical care. The Act’s anti-lien provision, prohibiting states from recovering medical payments from a beneficiary’s “property,” does not foreclose recovery from settlement amounts other than those allocated for past medical care paid for by Medicaid. Florida’s statute is expressly authorized by section 1396k(a) and is within the recognized exception to the anti-lien provision. The relevant distinction is between medical and nonmedical expenses, not between past and future medical expenses. Section 1396k(a)(1)(A) does not authorize a “lifetime assignment” covering any rights acquired in the future but covers only rights the individual possesses while on Medicaid. View "Gallardo v. Marstiller" on Justia Law

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The Supreme Court affirmed the judgment of the court of appeals affirming the district court's denial of Appellant's postconviction petition in which she argued that her restitution order should be reduced, holding that there was no error or abuse of discretion.Appellant was convicted of medical assistance fraud for submitting fraudulent Medicaid claims to the Minnesota Department of Human Services through a company she owned and operated. The district court convicted Appellant of racketeering and ordered her to pay a $2.64 million restitution award. In her postconviction motion Appellant argued that her restitution award should be reduced because DHS's economic loss had to account for the economic benefit it received from her offense. The district court denied relief. The Supreme Court affirmed, holding (1) Minn. Stat. 611A.045, subd. 1(a)(1) requires a district court to consider the value of any economic benefits a defendant conferred on a victim when calculating a restitution award; and (2) the district court did not abuse its discretion when it calculated DHS's economic loss. View "State v. Currin" on Justia Law