Justia Public Benefits Opinion Summaries

Plaintiff represented psychiatrists who treated patients eligible for both Medicare and Medicaid and defendants were responsible for administering Medicaid in New York and for implementing and enforcing medicaid reimbursement rates. At issue was whether the 2006 amendment to the Social Services law found in a budget bill implementing a coinsurance enhancement for the benefit of psychiatrists who treat patients eligible for both Medicare and Medicaid was intended to be permanent or whether the amendment was intended only to provide a limited one-year enhancement. The court concluded that the Legislature only intended to provide for a one-time coinsurance enhancement, limited to the 2006-2007 fiscal year.View "New York State Psychiatric Assn., Inc. v New York State Dept. of Health" on Justia Law

This case arose from the settlement of a personal injury lawsuit filed by Edward Smalley, who was seriously injured in a motor vehicle accident. Although Smalley qualified for Medicaid as a result of the accident, the Nebraska Department of Health and Human Services (DHHS), Nebraska's Medicaid administrator, refused to pay Smalley's outstanding medical bills prior to the disposition of his third-party liability claims. To facilitate a settlement of those claims, Smalley's attorney agreed that if DHHS paid the medical bills at the discounted Medicaid rate, Smalley would reimburse DHHS dollar-for-dollar out of the settlement proceeds. After DHHS paid the bills as agreed, Smalley objected to full reimbursement as contrary to federal law. The district court determined that under federal law, DHHS was entitled to reimbursement of only a portion of the Medicaid payments it had made. The Supreme Court reversed, holding that DHHS was entitled to full reimbursement.View "Smalley v. Neb. Dep't of Health & Human Servs." on Justia Law

The Nebraska Department of Health and Human Services (DHHS) provided Medicaid benefits for Virginia Lee Cushing during the final years of her life. After her death, DHHS filed a claim against Cushing's estate for recovery of the benefits pursuant to Neb. Rev. Stat. 68-919. The personal representative of the estate appealed from an order of the county court allowing the claim and awarding interest. At issue on appeal was whether DHHS timely presented its claim and, if so, whether it was proved as a matter of law. The Supreme Court concluded the claim was both timely presented and proved as a matter of law but modified the award of interest.View "In re Estate of Cushing" on Justia Law

Plaintiffs, three plaintiff-classes and Sheila Perdue individually, brought a class action complaint seeking declaratory and injunction relief alleging violations of their federal statutory and constitutional rights. Plaintiffs challenged the Indiana Family and Social Services Administration's (FSSA) automated system of processing claims for Medicaid, Food Stamps, and Temporary Assistance to Needy Families benefits. The trial court held (1) the FSSA's denial notices satisfied due process; (2) the FSSA could not deny an application for Food Stamp benefits when the applicant failed to cooperate in the eligibility determination process; and (3) determined that the FSSA had failed to accommodate Perdue's disabilities in violation of the Americans with Disabilities Act and the Rehabilitation Act. The Supreme Court reversed in part and affirmed in part, holding (1) the FSSA's denial notices were insufficiently explanatory in violation of due process; (2) the FSSA may deny an application for Food Stamp benefit when the applicant fails to cooperate in the eligibility determination process; and (3) Perdue was entitled to reasonable accommodations in applying for benefits, but that did not necessarily require providing a caseworker or case management services.View "Perdue v. Gargano" on Justia Law

After an inspection revealed deplorable health conditions for its residents, an intermediate care facility for the developmentally disabled was decertified for Medicaid reimbursement. As a result, until the State appointed a receiver nine months later, the facility operated without receiving federal or state funds. This case was a common-law claim for expenses the facility laid out in the meantime for the individuals still residing there. The trial court denied the facility restitution for the unpaid months under a theory of quantum meruit, afforded relief under related breach of contract claims, but offset that judgment by the amount the State paid for its receiver. The Supreme Court affirmed the trial court's ultimate judgment, which resulted in neither party taking anything from the action, holding (1) the facility exhausted its administrative remedies; (2) the facility's quantum meruit claim failed; and (3) the state was entitled to set off the amount owed to the facility on the breach of contract claim against the amount the State paid in operating the receivership of the facility and which the facility then owed.View "Woodruff ex rel. Legacy Healthcare, Inc. v. Ind. Family & Social Servs. Admin." on Justia Law

Rebecca Kays was convicted of misdemeanor battery and sentenced to 180 days in jail, suspended to twelve months probation. The trial court ordered as a term of probation that Kays pay restitution in the amount of $1,496. Kays appealed, arguing that the trial court improperly ordered restitution as a term of probation because her only source of income was social security disability benefits. The court of appeals reversed, holding that restitution may not be based on social security income, and therefore, the trial court could not take into account Kays' social security income in determining her ability to pay. The Supreme Court granted transfer, thereby vacating the court of appeals, and reversed the trial court. The Court held that social security benefits may be considered by a trial court in determining a defendant's ability to pay restitution, but the trial court erred in failing to determine Kays' ability to pay restitution and to determine her manner of payment.View "Kays v. State" on Justia Law

Appellant Valerie Joy Tronnes appealed a judgment that affirmed the Job Service of North Dakota's decision to deny her claim for unemployment benefits. In 2002, Appellant began working part-time at the Wal-Mart Vision Center. In 2010, Appellant received her paycheck (via a debit-card style card), and purchased a few items at Wal-Mart's customer service center. The amount of the purchase was mistakenly credited to Appellant's account by a different employee rather than deducted, which resulted in a substantial benefit to Appellant. Appellant met with the vision center manager about the extra money on her card, but later testified she believed the amount to be correct. The store gave Appellant the option of resigning as a result of her spending the extra money, but believed the paid time off she was given ( a "D-day"-- so named to give Appellant a day to decide whether to remain employed at Wal-Mart) meant she would be fired soon. Store management negotiated a payment plan for Appellant to repay the amount she was credited and allowed her to return to work. Ultimately the "repayment plan" took the form of the store withholding Appellant's subsequent paychecks to cover the indebtedness. Appellant did not report to work after that payday, and subsequently filed for unemployment benefits. The Job Service determined Appellant was ineligible for benefits because she voluntarily quit her job. Upon review, the Supreme Court concluded the evidence in the record supported the Job Service's denial of benefits to Appellant. View "Tronnes v. Job Service" on Justia Law

Medicaid recipient John Doe and the State appealed a trial court's decision allowing the State to partially recover the amount of its lien against Doe's settlement with a third party. In 1992 when Doe was nine years old, he was catastrophically injured and paralyzed in an automobile accident.  Due to Doe's injuries, his mother applied for Medicaid on his behalf in 1994.  Doe later brought suit in New York Supreme Court against the alleged third-party tortfeasors.  He also sued New York State Transit Authority (NYSTA) in the New York Court of Claims.  The State of Vermont notified Doe in January 2001 that it claimed a lien against any award, judgment, or settlement stemming from the accident.  In 2001, Doe settled the lawsuit against the third parties for $8.75 million. Doe's suit against NYSTA went to trial, and in 2004, the Court of Claims awarded Doe approximately $42 million and allocated approximately $2.9 million to Doe's past medical expenses from the date of injury to the date of trial. Between the 2001 and 2006 settlements, the State paid approximately $771,111 in medical expenses for Doe's care, in addition to the medical expenses paid up to the date of the first settlement.  The State claimed a lien on the 2006 settlement for $506,810, which was the difference between the amount the State paid for Doe's medical care under Medicaid and the State's share of litigation expenses. Doe sued the State of Vermont, seeking a declaratory judgment that he satisfied the State's lien by partial payment.  On summary judgment, the court concluded that it would not undo the 2001 settlement because it was an accord and satisfaction of all claims paid for medical expenses incurred to that point in time. The State argued on appeal to the Supreme Court that the trial court should have reduced the Court of Claims' findings of future economic damages to present value before making its lien allocation. Upon review, the Supreme Court concluded the parties' agreement resolved the issues surrounding the State's lien on Doe's first settlement, while leaving open the possibility that Doe would obtain a judgment against or settlement with the NYSTA.. On these facts, the Court agreed with the trial court that there was an accord and satisfaction, and that the State accepted $594,209.03. The case was reversed and remanded to recalculate the State's lien against $771,111 in medical expenses and reasonable attorney's fees, but affirmed in all other respects.  View "Doe v. Vermont Office of Health Access" on Justia Law

Plaintiffs-Respondents father and daughter Jose and Nayeli Carrillo, father and daughter, sued Boise Tire Co. (Boise Tire), alleging that Boise Tire improperly performed a tire rotation on their vehicle and that as a result, the Carrillos and Marisela Lycan, Jose’s wife and Nayeli's mother, were in a motor vehicle accident. Marisela was killed, Jose was injured, and eighteen-month old Nayeli underwent testing that revealed no physical injury. A jury found that Boise Tire's conduct was reckless. Boise Tire moved for new trial on the grounds that: (1) the Carrillos' pleadings merely alleged negligence and therefore the court committed legal error by permitting the Carrillos to argue that Boise Tire's conduct was reckless; (2) the jury verdict was excessive and the result of passion or prejudice; and (3) the jury verdict was not supported by sufficient evidence. The district court issued a remittitur as to Nayeli's noneconomic damage award but otherwise denied the motion. Boise Tire appealed that denial and the court's holding that I.C. 6-1606 did not require the Carrillos' damage awards to be reduced by the subrogation interest transferred from the Carrillos' insurer to their attorney, nor by social security benefits obtained by the Carrillos. Upon review, the Supreme Court affirmed the district court's denial of Boise Tire's motion for a new trial, vacated the judgment and remanded the case for the district court to reduce Jose's personal injury reward by the value of his social security benefits when judgment was originally entered. View "Carrillo v. Boise Tire Co., Inc." on Justia Law

Main & Associates, Inc., d/b/a Southern Springs Healthcare Facility, filed an action in the Bullock Circuit Court, on behalf of itself and a putative class of Alabama nursing homes, against Blue Cross and Blue Shield of Alabama (BCBS), asserting claims of breach of contract, intentional interference with business relations, negligence and/or wantonness, and unjust enrichment and seeking injunctive relief. BCBS removed the case to the the federal court, arguing among other things, that Southern Springs' claims arose under the Medicare Act and that the Medicare Act, as amended by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (the MMA) completely preempted Southern Springs' state-law claims. Southern Springs moved the federal court to remand the case to the circuit court, arguing that the federal court did not have jurisdiction over its claims. The federal court granted the motion and remanded the case to the Bullock Circuit Court. After remand, BCBS moved the circuit court for a judgment on the pleadings, arguing that Southern Springs had not exhausted its administrative remedies and that the circuit court did not have subject-matter jurisdiction over the case. The circuit court denied BCBS's motion, and BCBS petitioned the Supreme Court for a writ of mandamus to direct the circuit court to dismiss Southern Springs' claims. Upon review, the Court concluded that Southern Springs' claims were inextricably intertwined with claims for coverage and benefits under the Medicare Act and that they were subject to the Act's mandatory administrative procedures and limited judicial review. Southern Springs did not exhaust its administrative remedies, and the circuit court did not have jurisdiction over its claims. Therefore, the Court granted BCBS's petition and issue a writ of mandamus directing the circuit court to dismiss the claims against BCBS. View "Main & Associates, Inc. v. Blue Cross & Blue Shield of Alabama" on Justia Law