Justia Public Benefits Opinion Summaries

The Department of Defense's experiments at Edgewood involved “volunteers,” including Taylor, who was on active duty, 1969-1971. Taylor signed a secrecy oath providing that he would not divulge any information related to the program and that any such action would render him liable to punishment and signed a document stating that the experiment had been explained to him and that he volunteered to participate. Taylor was exposed to a nerve agent, a tear gas agent, and more. Taylor experienced hallucinations, nausea, jumpiness, irritability, sleepiness, dizziness, impaired coordination, and difficulty concentrating. He was subsequently deployed to Vietnam, for two combat tours. The secrecy of the project prevented Taylor from obtaining psychiatric help and from showing extenuating circumstances during his court-martial.In 2006, the Edgewood names were declassified. The VA notified participants that they were permitted to disclose to health care providers information about their involvement at Edgewood that affected their health. In 2007, Taylor sought service-connected benefits for PTSD. A VA medical examiner diagnosed Taylor with PTSD and major depressive disorder, “a cumulative response” to his Edgewood experience and “subsequent re-traumatization in Vietnam.” Taylor had previously sought treatment for his PTSD but was rejected because the provider believed he lied about being an experimental subject.The VA granted Taylor’s claim, with a 2007 effective date, citing the absence of an earlier claim. On remand, the VA failed to obtain the language of Taylor’s secrecy oath and again concluded that the earliest assignable effective date was 2007; “nothing prevented [Taylor] from filing a claim.” The Veterans Court affirmed.The Federal Circuit reversed. The Veterans Court erred in concluding it lacked equitable authority absent an express statutory grant and erred in concluding that 38 U.S.C. 5110(a)(1) is not subject to common law equitable doctrines. The government affirmatively and intentionally prevented veterans from seeking medical care and applying for disability benefits to which they are otherwise entitled under threat of criminal prosecution and loss of the very benefits sought. “If equitable estoppel is ever to lie against the Government, it is here—to preserve the ‘interest of citizens in some minimum standard of decency, honor, and reliability in their dealings with their Government.’” View "Taylor v. McDonough" on Justia Law

The Supreme Court reversed an order of the district court affirming an administrative law judge's proposed order that trust principal consisting of a jointly owned home constituted a countable asset for the purpose of the Medicaid eligibility of Marilyn Scheidecker, holding that there were no circumstances under which payment from the trust's corpus could be made for Marilyn's benefit.The Montana Department of Public Health and Human Services denied Marilyn's application for Medicaid, concluding that Marilyn's one-half interest in the trust's principal was a countable resource placing her over Medicaid's resource limit. The ALJ upheld the denial. The district court affirmed the ALJ's ultimate conclusion that the trust was a countable asset pursuant to 42 U.S.C. 1396p(d)(3), holding that circumstances existed by which payments form the trust's corpus could be made to or for Marilyn's benefit. The Supreme Court reversed, holding that the district court was incorrect in its application of the federal statute. View "Estate of Scheidecker v. Montana Department of Public Health & Human Services" on Justia Law

Rite Aid’s “Rx Savings Program” provides generic prescription drugs at reduced prices. The program is free and widely available but excludes customers whose prescriptions are paid by publicly funded healthcare programs like Medicare or Medicaid. Federal regulations require pharmacies to dispense prescriptions for beneficiaries of those programs at their “usual and customary charge to the general public” (U&C rate). Rahimi alleged that Rite Aid overbilled the government programs because the amounts it charged did not take into account the lower Rx Savings Program prices. Rahimi claimed Rite Aid's submission of bills for those covered by publicly funded health insurance, representing the price to be the U&C rate, violated the False Claims Act, 31 U.S.C. 3729(a).The Sixth Circuit affirmed the dismissal of Rahimi’s claim. The Act’s public disclosure bar precludes qui tam actions that merely feed off prior public disclosures of fraud. From the beginning, communications about the Rx Savings Program have stated that publicly funded health care programs were ineligible for the discounted prices. Before Rahimi’s disclosures, Connecticut investigated membership discount prices; the Department of Health and Human Services announced that it would review Medicaid claims for generic drugs to determine the extent to which large chain pharmacies are billing Medicaid the usual and customary charges for drugs provided under their retail discount generic programs; and a qui tam action was unsealed in California, describing an identical scheme. View "Rahimi v. Rite Aid Corp." on Justia Law

Prosser, a 37-year-old Medicare recipient, suffers from glioblastoma, which causes brain tumors. The five-year survival rate hovers around 5%. Though not curative, Prosser benefits from tumor treating fields therapy (TTF), approved by the FDA in 2011. For most of the day, patients use a device that attaches to the head via adhesive patches that connect to a mobile power supply. The device emits electrical fields to the tumor, which disrupt the division of cancer cells. Early studies show that the device holds promise in prolonging life. TTF therapy is available through a single supplier, Novocure, which rents the device on a monthly basis. The therapy is expensive. Prosser must file a Medicare benefits claim for each period she uses the device. Medicare denied coverage for the treatment period January-April 2018. Though Prosser received the therapy and owed nothing, the denial left Novocure with the bill. Prosser challenged this denial through Medicare’s appeals process before filing suit.The Seventh Circuit affirmed the dismissal of Prosser’s claim for Medicare Part B coverage, holding that she has suffered no injury-in-fact sufficient to satisfy Article III’s standing requirement. Prosser received—and continues to receive—the TTF therapy. She faces no financial liability for the treatment period Medicare denied coverage. Any future financial risk is too attenuated from the denial of the past coverage and far too speculative to establish standing. View "Prosser v. Becerra" on Justia Law

The hospital, located in Philadelphia, received a reclassification into the New York City area, which would sizably increase the hospital’s Medicare reimbursements due to that area’s higher wage index, 42 U.S.C. 1395ww(d). Although a statute makes such reclassifications effective for three fiscal years, the agency updated the geographical boundaries for the New York City area before the close of that period and reassigned the hospital to an area in New Jersey with an appreciably lower wage index. The hospital successfully sued three agency officials in the Eastern District of Pennsylvania.The Third Circuit vacated and remanded for dismissal. The Medicare Act, 42 U.S.C. 1395oo(f)(1), channels reimbursement disputes through administrative adjudication as a near-absolute prerequisite to judicial review. The hospital did not pursue its claim through administrative adjudication before suing in federal court. By not following the statutory channeling requirement, the hospital has no valid basis for subject-matter jurisdiction. View "Temple University Hospital, Inc. v. Secretary United States Department of Health & Human Services" on Justia Law

The “effective date of an award” of disability compensation to a veteran “shall not be earlier than the date” the veteran’s application for such compensation is received by the VA. 38 U.S.C. 5110(a)(1). Section 5110(b)(1) provides an exception that permits an earlier effective date if the VA receives the application within one year of the veteran’s discharge from military service: under such circumstances, the effective date of the award shall date back to “the day following the date of the veteran’s discharge or release.”Arellano filed his application more than 30 years after he was discharged from the Navy, he argued that section 5110(b)(1)’s one-year period should be equitably tolled to afford his award an earlier effective date reaching back to the day after his discharge. The Veterans Court denied Arellano an effective date earlier than the date his disability benefits application was received by the VA. The Federal Circuit previously held that 5110(b)(1) is not a statute of limitations amenable to equitable tolling but merely establishes an effective date for the payment of benefits, thereby categorically foreclosing equitable tolling. The Federal Circuit affirmed as to Arellano, declining to overrule that precedent, stating that the statutory text evinces clear intent to foreclose equitable tolling of section 5110(b)(1)’s one-year period. View "Arellano v. McDonough" on Justia Law

The Supreme Court affirmed the ruling of the district court against Defendant and in favor of Plaintiff finding breach of contract and breach of implied covenant of good faith and fair dealing, holding that the district court erred.Defendant, a managed care organization, entered into a contract with Plaintiff, a dentist, to deliver dental services to Medicaid participants as a member of Defendant's network. Defendant later sent Plaintiff a "notice of non-renewal" of the provider contract. Plaintiff sued, and the district court ruled that the provider contract did not allow Defendant to terminate Plaintiff through non-renewal of the provider contract. At issue was whether Defendant properly ended a provider contract that automatically renewed for successive one-year terms by sending a notice of non-renewal. The Supreme Court affirmed, holding that the district court correctly determined that Defendant possessed no right to terminate by non-renewal. View "Colwell v. MCNA Insurance Co." on Justia Law

Methodist Specialty Care Center (Specialty), a hospital-based nursing facility owned by Methodist Rehabilitation Center (Methodist), included an allocation of Methodist’s Medicaid Assessment in its nursing-facility cost report. The Division of Medicaid (DOM) disallowed the allocation for Specialty’s cost report, finding that Methodist’s assessment was not an allowable cost for Specialty. Specialty appealed the decision to the Chancery Court, which affirmed the decision of the DOM. Because Methodist’s assessment was not an allowable cost for Specialty under the plain language of the State Medical Plan (Plan) and the Medicaid statutory structure, the Mississippi Supreme Court affirmed the decisions of the DOM and the chancery court. View "Mississippi Methodist Hospital & Rehabilitation Center, Inc. v. Mississippi Division of Medicaid et al." on Justia Law

Anania served in the Army, 1972-1975. In 2008, Anania sought an increased evaluation for the degenerative joint disease of his spine and major depressive disorder, and entitlement to a total disability rating based on individual unemployability. The VA issued a rating decision. Anania filed a Notice of Disagreement. In December 2009, the VA denied Anania’s request, describing the process for appeal. Anania had until March 3, 2010—one year after the date of mailing of the notification of the VA’s decision—to file a substantive appeal with the Waco Regional Office. In June 2012, Anania’s counsel, Carpenter, sent a letter to the Board of Veterans’ Appeals requesting confirmation that it had docketed Anania’s substantive appeal of the rating decision.The Board concluded that Anania failed to timely file his substantive appeal, which “was not received into VA custody until June 29, 2012.” Anania urged the Board to find his appeal timely filed under the common law mailbox rule, submitting a signed affidavit from Carpenter, alleging that Carpenter had personally mailed the substantive appeal on January 18, 2010. On remand, the Board again determined that Anania’s appeal was not timely filed, stating that the mailbox rule’s presumption of receipt did not attach because Carpenter’s affidavit was “no more than self-serving testimony.” The Veterans Court affirmed. The Federal Circuit reversed. A party’s affidavit may provide credible evidence to satisfy the mailbox rule, and the government did not challenge the credibility of Carpenter affidavit. View "Anania v. McDonough" on Justia Law

Cameron filed a Notice of Disagreement (NOD) on behalf of an Army veteran in August 2005. The VA denied Cameron attorney’s fees under 38 C.F.R. 14.636(c), which permits an attorney to charge fees for services provided before a final Board decision only where a NOD was filed on or after June 20, 2007. Before the law was amended, attorneys representing veterans in veterans’ benefits cases before the VA were prohibited from charging fees for services provided before a final Board decision.The Veterans Court and the Federal Circuit affirmed the denial, holding that section 14.636(c) is consistent with its authorizing statute, 38 U.S.C. 5904. Congress considered eliminating all fee restrictions under section 5904(c)(1) by repealing subsection (c)(1) entirely but made a legislative choice between the competing purposes of liberalizing the availability of attorney’s fees and avoiding disruption to the veterans’ benefits system, and “adopted a delayed and staggered effective date . . . [to] allow a deliberate and gradual implementation of these policies in order to minimize any disruption to the VA system.” In denying Cameron attorney’s fees, the VA has done no more than give effect to that legislative choice. View "Cameron v. McDonough" on Justia Law