Justia Public Benefits Opinion Summaries

The Medicaid statute’s anti-lien provision, 42 U. S. C. 1396p(a)(1), pre-empts state efforts to take any portion of a tort judgment or settlement not “designated as payments for medical care.” A North Carolina statute requires that up to one-third of damages recovered by a beneficiary for a tortious injury be paid to the state to reimburse it for payments made for medical treatment on account of the injury. E. M. A. suffered serious birth injuries that require her to receive 12 to 18 hours of skilled nursing care per day and that will prevent her from working or living independently. North Carolina’s Medicaid program pays part of the cost of her ongoing care. E. M. A. and her parents filed a medical malpractice suit against the physician who delivered her and the hospital where she was born and settled for $2.8 million, due to insurance policy limits. The settlement did not allocate money among medical and nonmedical claims. The state court placed one-third of the recovery into escrow pending a judicial determination of the amount owed by E. M. A. to the state. While that litigation was pending, the North Carolina Supreme Court held in another case that the irrebuttable statutory one-third presumption was a reasonable method for determining the amount due the state for medical expenses. The federal district court, in E.M.A.’s case, agreed. The Fourth Circuit vacated. The Supreme Court affirmed. The federal anti-lien provision pre-empts North Carolina’s irrebuttable statutory presumption that one-third of a tort recovery is attributable to medical expenses. North Carolina’s irrebuttable, one-size-fits-all statutory presumption is incompatible with the Medicaid Act’s clear mandate View "Wos v. E. M. A." on Justia Law

In 1979, Plaintiffs sued under 42 U.S.C. 1983, on behalf of present and future recipients, alleging that Tennessee’s Medicaid program violated federal requirements, 42 U.S.C. 1396, and the Due Process Clause. The decades that followed involved intervenors, consent orders, revisions, and creation of a subclass. In 1994, Tennessee converted to a managed care program, TennCare. In 1995, five class members filed motions alleging that TennCare was being administered inconsistent with a 1992 decree and federal law. In 2009, the district court awarded plaintiffs more than$2.57 million for fees and expenses leading up to a 2005 Revised Consent Decree. Plaintiffs had originally requested a lodestar amount of $3,313,458.00, but the court reduced the award by 20 percent on account of plaintiffs’ “limited” success relative to the breadth of defendants’ requests and the scope of the litigation. The court noted that there was “no dispute that Plaintiffs in this case are the prevailing party, and thus entitled to attorneys’ fees under 42 U.S.C. 1988.” The Sixth Circuit vacated parts of the award, noting that section 1988 “is not for the purpose of aiding lawyers and that the original petition for fees included requests for dry cleaning bills, mini blinds, and health insurance. View "Binta B. v. Gordon" on Justia Law

Tennessee participates in Medicaid through “TennCare,” Tenn. Code 71-5-102. The Medicaid Act requires that TennCare administer an Early and Periodic Screening, Diagnosis, and Treatment program for all enrollees under age 21, 42 U.S.C. 1396a(a)(43), 1396d(r) and must provide outreach to educate its enrollees about these services. In 1998 plaintiffs filed a putative class action under 42 U.S.C. 1983, alleging that TennCare had failed to fulfill these obligations. The district court entered a consent decree that explained in detail the requirements that TennCare had to meet to “achieve and maintain compliance” with the Medicaid Act, based on the assumption that the Act created rights enforceable under section 1983. Eight years later, the Sixth Circuit held that one part of the Medicaid Act was unenforceable under section 1983. Following a remand, the district court vacated paragraphs of the decree that were based on parts of the Act that are not privately enforceable. After a thorough review of TennCare’s efforts, the court then vacated the entire decree, finding that TennCare had fulfilled the terms of the decree’s sunset clause by reaching a screening percentage greater than 80% and by achieving current, substantial compliance with the rest of the decree. The Sixth Circuit affirmed. View "John B. v.Emkes" on Justia Law

Gayheart applied for Social Security disability insurance benefits in 2005 due to manifestations of anxiety, panic disorder, bipolar disorder, and depression. After an initial denial and three separate hearings, an administrative law judge (ALJ) found that the limitations caused by Gayheart’s impairments did not preclude him from performing a significant number of jobs available in the national economy and denied Gayheart’s application. Gayheart’s request for an administrative appeal was denied. The Report and Recommendation issued by the federal court’s assigned magistrate judge concluded that the ALJ’s decision was not supported by substantial evidence and that Gayheart should be awarded benefits. But the district court sustained the Commissioner’s objections and affirmed the ALJ’s decision. The Sixth Circuit reversed and remanded, holding that the ALJ failed to weigh the medical opinions according to 20 C.F.R. 404.1527. View "Gayheart v. Comm'r of Soc. Sec." on Justia Law

While working at a Ford Motor plant, Rudisill was hit in the face by a piece of equipment, was knocked against a wall, fell to the floor, and rolled forward through the floor opening into the hot pit below. He lay there unconscious, being burned, until coworkers pulled him out of the pit. Rudisill had gained consciousness by this time and was screaming in pain. Rudisill sustained a head injury that required several staples to close. He was also burned on his arms and legs, abdomen, and left hand. Rudisill continues to experience pain, dizzy spells, ringing in the ears, and memory problems. He has had numerous surgeries and has undergone physical and occupational therapy. After a safety review immediately following the incident, Ford decided to modify the process so that employees slide metal grates over the pit before removing the guard rails. After receiving workers’ compensation benefits, Rudisill sued Ford, alleging intentional tort; his wife asserted a derivative claim of loss of consortium. The district court granted summary judgment for Ford. The Sixth Circuit affirmed, finding insufficient evidence that Ford acted with deliberate intent to injure Rudisill, as required by Ohio statute. View "Rudisill v. Ford Motor Co." on Justia Law

Plaintiffs, teaching hospitals, received Medicare payments to offset the costs associated with training "full-time equivalent" residents and intern physicians (FTEs). In 1997, Congress capped those payments in such a way that the number of FTEs the hospitals trained in 1996 would dictate the maximum reimbursement in all future years. Although the parties agreed that the 1996 data was not accurate, the Secretary believed that this predicate fact could not be corrected outside the three-year reopening window. The court held that the reopening regulation allowed for modification of predicate facts in closed years provided the change would only impact the total reimbursement determination in open years. Alternatively, the court agreed with the district court that the Secretary had acted arbitrarily in treating similarly situated parties differently. The court rejected the Secretary's claim that the Medicare Act, 42 U.S.C. 1395 et seq., would not allow the intermediary to change the 1996 GME resident count without changing the corresponding reimbursement amount, which all parties conceded would constitute a reopening of an "Intermediary determination." Accordingly, the court affirmed the judgment. View "Kaiser Foundation Hospitals v. Sebelius" on Justia Law

Plaintiffs, thirteenth North Carolina residents who lost access to in-home personal care services (PCS) due to a statutory change, brought suit challenging the new PCS program. The district court granted plaintiffs' motions for a preliminary injunction and class certification. Defendants appealed, raising several points of error. The court agreed with the district court's conclusion that a preliminary injunction was appropriate in this case. The court held, however, that the district court's order failed to comply with Federal Rule of Civil Procedure 65 because it lacked specificity and because the district court neglected to address the issue of security. Accordingly, the court remanded the case. View "Pashby v. Delia" on Justia Law

Full Life Hospice participates in the federal Medicare program. It sought reimbursement for hospice services provided to Medicare recipients from the Department of Health and Human Services (HHS). A fiscal intermediary, acting on behalf of HHS, later contested some of these reimbursements and demanded repayment of funds that it claimed were distributed in excess of a spending cap. Full Life unsuccessfully challenged HHS intermediary’s determination through an administrative appeal, which was denied as untimely. On appeal to the district court, the court found no basis to excuse Full Life's untimely challenge. Upon review, the Tenth Circuit agreed with the district court that it lacked subject matter jurisdiction because of Full Life's failure to file a timely administrative appeal. View "Full Life Hospice v. Sebelius" on Justia Law

The State appealed from the district court's order enjoining it from requiring plaintiff to submit to a suspicionless drug test pursuant to Section 414.0652 of the Florida Statutes, as a condition for receipt of government-provided monetary assistance for which he was otherwise qualified. Plaintiff applied for financial assistance benefits for himself and his son through Florida's Temporary Assistance for Needy Families program (TANF). The court held that the district court did not abuse its discretion in granting the preliminary injunction enjoining the State from enforcing the statute because the court concluded that the State had failed to establish a substantial special need to support its mandatory suspicionless drug testing of TANF recipients. View "Lebron v. Secretary, FL Dept. of Children and Families" on Justia Law

Walker served in the U.S. Army Air Force, 1943 to 1945, as a four-engine airplane pilot and flight instructor. The VA Regional Office denied his 2007 disability claim for bilateral hearing loss. Walker appealed to the Board of Veterans Appeals, including sworn statements from his son and wife that his hearing loss began in service and continued throughout his life. Walker was examined by a VA audiologist. Walker’s service medical records were not available due to a fire. The audiologist concluded that the hearing loss was “less likely as not caused primarily by military service as a pilot,” that age could not be excluded as the primary etiology, and that Walker was exposed to recreational noise by hunting game without use of hearing protection. The Board concluded that Walker failed under the three-element test to establish service connection for his hearing loss. The Federal Circuit affirmed. View "Walker v. Shinseki" on Justia Law