Justia Public Benefits Opinion Summaries

Plaintiffs claimed that PacifiCare was not entitled to any reimbursement payments out of the wrongful death benefits paid by an insurance policy to them. PacifiCare counterclaimed, arguing that it was entitled to reimbursement under both the terms of its contract with the deceased (Count I) and directly under the Medicare Act (Count 11), 42 U.S.C. 1395. At issue was whether a private Medicare Advantage Organization (MAO) plan could sue a plan participant's survivors, seeking reimbursement for advanced medical expenses out of the proceeds of an automobile insurance policy. Because interpretation of the federal Medicare Act presented a federal question, the district court had subject matter jurisdiction to determine whether that act created a cause of action in favor of PacifiCare against plaintiffs. The district court properly dismissed the causes of action arising under the Medicare Act for failure to state a claim where section 1395y(b)(2) did not create a federal cause of action in favor of a MAO and where, under section 1395y(b)(3)(A), the Private Cause of Action applied in the case of a primary plan which failed to provide for primary payment, which was not applicable in this instance. The court affirmed the district court's dismissal of Count II for failure to state a claim as well as its decision to decline to exercise supplemental jurisdiction over Count 1. View "Parra v. Pacificare of Arizona" on Justia Law

Providers brought suit against the State, asserting that the Adoption Assistance and Child Welfare Act of 1980 (CWA), 42 U.S.C. 670 et seq., gave them a privately enforceable right under 42 U.S.C. 1983 to receive payments from the State sufficient to cover the cost of certain statutorily enumerated components of foster care. At issue was whether Congress, in enacting the CWA, evinced a clear intent to grant foster care providers an individually enforceable right to foster care maintenance payments sufficiently large to cover the costs of each item enumerated in section 675(4)(A). The court held that Congress did not ambiguously confer such a right and, therefore, affirmed the district court's dismissal of the Providers' complaint for failure to state a claim. View "Midwest Foster Care, etc., et al v. Kincade, et al" on Justia Law

Vazquez-Claudio is a Vietnam veteran. Following his service, Vazquez-Claudio filed a claim with the VA seeking disability compensation for post-traumatic stress disorder. In 2005, after finding that his PTSD was service- connected, the VA granted his request for benefits with an effective date in June, 1994. The VA rated Mr. Vazquez-Claudio’s PTSD as 50 percent disabling, Vazquez-Claudio appealed, arguing entitlement to a 70 percent rating. He had been unable to work since 1994, when he left his job as a police officer as the result of an emotional breakdown following a prisoner’s suicide. The Board of Veterans’ Appeals found that other than occasional suicidal ideation, social isolation, and some difficulty adapting to stressful situations, none of his symptoms corresponded to impairment greater than 50 percent. The Veterans Court agreed, stating that “[t]he issue before the Board was not how many ‘areas’ Mr. Vazquez-Claudio has demonstrated deficiencies in but, rather, ‘the frequency, severity, and duration of the psychiatric symptoms, the length of remissions, and Mr. Vazquez-Claudio’s capacity for adjustment during periods of remission.’” The Federal Circuit affirmed. View "Vazquez-Claudio v. Shinseki" on Justia Law

The County appealed from a judgment of the district court finding that the County was in violation of its duty to promote source-of-income legislation under a Stipulation and Order of Settlement and Dismissal (consent decree) entered into by the County with the United States to resolve a qui tam action initially brought by relator, ADC, under the False Claims Act, 31 U.S.C. 3729-33, alleging the submission of false claims by the County to HUD in order to obtain federal grant monies for fair housing. As a preliminary matter, the court held that the district court had jurisdiction to review the decision of the reviewing magistrate judge under the consent decree. On the merits, the court held that the County violated the terms of the consent decree. Accordingly, the court affirmed the judgment. View "United States v. Westchester County, New York" on Justia Law

This dispute arose from California's implementation of a change to Medicare in 2006. The Centers argued that California mishandled the shift in payment responsibility for dual-eligibles' prescription drug costs from state Medicaid programs to the new, federal Medicare Part D Program. The Centers brought suit for declaratory and injunctive relief. Among other things, the Centers urged the federal courts to declare unlawful California's "seizure" of the Centers' Medicare Part D funds, in excess of what would be owed under the per-visit rate for the Centers' expenses. The court concluded that the Eleventh Amendment barred the Centers' claims for retroactive monetary relief; the court affirmed the district court's dismissal of the Centers' claims to the extent that they sought money damages; however, the court reversed the district court and remanded to allow the district court to assess Ex parte Young's application to the Center's remaining claims. View "North East Medical Services v. CA Dept. of Health" on Justia Law

In 2008, Pepper, then 54 years old, applied for Supplemental Security Disability Insurance Benefits, alleging that she became unable to work in November 1998 as a result of numerous physical and mental impairments. The alleged onset date was later amended to October 2002, when Pepper last worked. Extensive medical records show that Pepper sought treatment for numerous health concerns over the years. At various times, Pepper has been assessed as having ongoing neck pain and limited range of motion in her neck, degenerative disc disease in her spine, left knee problems, migraine headaches, problems with her vision, diabetes, asthma, mitral valve prolapse, sciatica, dyslipidemia, hyperglycemia, hypertension, allergic rhinitis, obesity, plantar fasciitis in her left heel, caregiver stress, and depression. An ALJ denied the claim and the district court affirmed. The Seventh Circuit affirmed, rejecting arguments that the ALJ erred when addressing Pepper’s residual function capacity and that the ALJ’s credibility determination was inadequately supported and patently wrong. Substantial evidence supported denial of benefits. View "Pepper v. Astrue" on Justia Law

Theresa was married to Myron when he retired from the federal government in 1989. Myron elected to receive a reduced annuity and named Theresa to receive a survivor annuity. In 1998, they divorced. Myron married Roksoliana. Myron received annual notices from the Office of Personnel Management explaining that if he wanted to provide survivor benefits to a spouse that he married after retirement, he had to send a signed request within two years after the date of marriage. In 2002 Myron sent a letter requesting survivor annuity benefits for Roksoliana. OPM denied Myron’s request as not submitted within two years of his marriage and instructed Myron to send his divorce decree to change or eliminate the survivor election previously made. In 2006 Myron sent the divorce decree and the certificate documenting his marriage to Roksoliana. OPM sent notification that his election to transfer full survivor benefits to his new spouse was effective immediately. Myron died in 2009. OPM granted Roksoliana benefits and denied Theresa’s application. An ALJ reversed; the Merit Systems Protection Board affirmed. The Federal Circuit reversed, finding OPM’s annual notice insufficient to inform Myron of his rights and obligations and that the Board’s award to Theresa was not supported by substantial evidence. View "Dachniwskyj v.Office of Pers. Mgmt." on Justia Law

MedQuest is a diagnostic testing company that operates more than 90 testing facilities in 13 states. In 2006 a former MedQuest employee, brought a qui tam suit against MedQuest alleging violations of the False Claims Act. The United States intervened and obtained summary judgment ($11,110,662.71) that MedQuest used supervising physicians who had not been approved by the Medicare program and the local Medicare carrier to supervise the range of tests offered at the Nashville-area sites, and after acquiring one facility, MedQuest failed to properly re-register the facility to reflect the change in ownership and enroll the facility in the Medicare program, instead using the former owner’s payee ID number. The Sixth Circuit reversed, stating that the Medicare regulatory scheme (42 U.S.C. 1395x) does not support FCA liability for failure to comply with the supervising-physician regulations. MedQuest’s failure to satisfy enrollment regulations and its use of a billing number belonging to a physician’s practice it controlled do not trigger the hefty fines and penalties created by the FCA. View "United States v. MedQuest Assocs, Inc." on Justia Law

In 2004 the U.S. Department of Health and Human Services promulgated 42 C.F.R. § 412.106(b), concerning the amount that certain hospitals are entitled to receive as enhancements to their regular reimbursement payments from the Medicare program. In connection with the Medicare program, Congress created a statutory formula to identify hospitals that serve a disproportionate number of low-income patients and to calculate the increased payments due such hospitals. Metropolitan Hospital challenged the way that the Secretary of HHS interprets this statutory formula to exclude certain patients who are simultaneously eligible for benefits under both Medicare and Medicaid, claiming that exclusion of dual-eligible patients cost it more than $2.1 million in 2005. The district court ruled that the challenged HHS regulation was invalid as violating the statute that it purported to implement. The Sixth Circuit reversed, upholding HHS’s interpretation of 42 U.S.C. 1395. View "Metro. Hosp. v. U.S. Dept of Health & Human Servs." on Justia Law

Rohrer Towers is a housing facility for low-income elderly residents in Haddon Township, Camden County, New Jersey. Haddon leased Rohrer Towers to Housing Authority of the Township of Haddon, which entered into a housing assistance payments contract (HAP) with the U.S. Department of Housing and Urban Development (HUD) under the Housing Act of 1937, 88 Stat. 633, 662–66. Haddon sued in 2007 alleging that HUD breached the HAP Contract from 2001-2006 by requiring rent “comparability studies” to be submitted along with requests for annual rent adjustments and adopting a one-percent reduction of the annual adjustment factors for units occupied by the same tenants from the previous year. The Claims Court agreed and ordered rent adjustments for all years other than 2002. The government claimed that the complaint should have been dismissed on statute of limitations grounds and appealed the decision that regulatory imposition of a mandatory one-percent rent reduction for non-turnover units was arbitrary, and beyond HUD’s authority. The Federal Circuit reversed the holding that the prevention doctrine applied to the circumstances surrounding Haddon’s 2001 and 2003 rent adjustment, but affirmed the holdings with respect to the contract years 2002 and 2004-2006. View "Haddon Housing Assocs. v. United States" on Justia Law