Justia Public Benefits Opinion Summaries

Tennessee family medicine physicians, mostly in rural areas, received increased Medicaid payments in 2013-2014. In 2015 Tennessee’s Medicaid agency, TennCare, brought an administrative action to “recoup” an average of more than $100,000 per physician, alleging that the physicians had not met the 60-percent requirement of the Final Medicaid Payment Rule. Under 42 U.S.C. 13961(a)(13(C), a state plan for medical assistance must provide payment for primary care services furnished in 2013 and 2014 by a physician with a primary specialty designation of family medicine, general internal medicine, or pediatric medicine at a specified rate; “primary specialty designation” was interpreted to mandate that the physician either show board certification in that specialty or that 60 percent of her recent Medicaid billings were for certain primary care services. The Sixth Circuit affirmed summary judgment in favor of the physicians, declaring the Rule invalid. The Centers for Medicare and Medicaid Services interpreted “a physician with a primary specialty designation” to have different meanings in parallel provisions of the Affordable Care Act although the context was the same. There is no 60-percent-of-billings requirement in 42 U.S.C. 1396a(a). The phrase “a physician with a primary specialty designation” means in section 1396a(a) the same thing that the agency said it means in section 1395l(x): a physician who has himself designated, as his primary specialty, one of the specialties recited in those provisions. View "Averett v. United States Department of Health & Human Services" on Justia Law

For four years, nurse practitioner Jordan treated Clanton’s severe hypertension. Jordan, an employee of the U.S. Public Health Service, failed to properly educate Clanton about his disease or to monitor its advancement. Clanton’s hypertension developed into Stage V kidney disease requiring dialysis and a transplant. Clanton successfully sued the government under the Federal Tort Claims Act. The court determined that Clanton had not contributed at all to his own injuries, noting that Clanton did not understand why it was important to take his medication and to attend appointments. The court awarded $30 million in damages. The Seventh Circuit vacated, finding that the court erred in its analysis of comparative negligence. Clanton’s subjective understanding does not end the inquiry. Illinois law requires the court to take the additional step of comparing Clanton’s understanding of his condition to that of a reasonable person in his situation. Clanton was in the position of a person whose caregiver failed to provide information about the severity of his condition but he had external clues that he was seriously unwell: two employment-related physicals showed that he had dangerously high blood pressure. The court upheld the court’s method of calculating damages and agreed that Clanton’s Medicare benefits are collateral to his damages award under Illinois law, so the government is not entitled to a partial offset. View "Clanton v. United States" on Justia Law

Brooke Rojas received food stamp benefits to which she was not legally entitled. Colorado charged her with two counts of theft under the general theft statute, section 18-4-401(1)(a), C.R.S. (2019). Rojas moved to dismiss these charges, arguing that she could only be prosecuted under section 26-2-305(1)(a), C.R.S. (2019), because it created the specific crime of theft of food stamps. The trial court denied the motion, and a jury convicted Rojas of the two general theft counts. Rojas contended on appeal to the Colorado Supreme Court that the trial court erred by denying the motion to dismiss because section 26-2-305(1)(a) abrogated the general theft statute in food stamp benefit cases. A split division of the court of appeals agreed with her. The Supreme Court, however, disagreed with Rojas and the division majority. Based on the statute’s plain language, the Court held that the legislature didn’t create a crime separate from general theft by enacting section 26-2-305(1)(a). View "Colorado v. Rojas" on Justia Law

The Fourth Circuit affirmed the denial of social security disability benefits to plaintiff, holding that there was no conflict between the language describing her residual functioning capacity (RFC) and the DOT's definition of Level 2 reasoning. In this case, the ALJ found that plaintiff could perform jobs limited to simple, routine repetitive tasks of unskilled work. Furthermore, there was no comparable inconsistency between plaintiff's RFC and Level 2's notions of detailed but uninvolved instructions and tasks with a few variables. View "Lawrence v. Saul" on Justia Law

Defendant Leola Allen plead guilty to committing felony welfare fraud in 1993, 1997, and 2000 (and to committing felony perjury in 2000). At sentencing in each case, the trial court ordered Allen to pay direct victim restitution and various fines and fees. In 2018, Allen petitioned pursuant to Penal Code sections 1203.4 and 1203.42 seeking discretionary "expungement" of her convictions on the basis she had been rehabilitated. She also sought to stay, dismiss, or delete her court-ordered fines and fees because she asserted she was unable to pay them. The prosecution opposed the expungement requests because Allen still owed about $9,000 in direct victim restitution; the prosecution did not oppose the request for relief from the fines and fees. The trial court denied Allen's petitions based on her outstanding victim restitution obligations, but did not directly address her request for relief from the fines and fees. On appeal, Allen argued that under the recent decision in California v. Duenas, 30 Cal.App.5th 1157 (2019), the trial court's denial of her expungement petitions violated her due process or equal protection rights because she was financially unable to pay the victim restitution. Alternatively, Allen contended the trial court erred in its conclusion her outstanding restitution obligations deprived the court of the authority to grant discretionary expungement. The Court of Appeal found Duenas was materially distinguishable: it involved revenue-generating assessments and a punitive restitution fine, whereas this case involves voter-mandated direct victim restitution intended to make the victim whole. Furthermore, the Court agreed with the analysis of numerous courts that rejected Duenas's due process framework. On remand, however, the Court directed the trial court to conduct further proceedings: (1) because the trial court did not directly address Allen's request for relief from the court-ordered fines and fees (other than victim restitution); and (2) because the record was unclear regarding whether Allen paid all the victim restitution owed in connection with her convictions in 2000. In all other respects, judgment was affirmed. View "California v. Allen" on Justia Law

In this personal injury action, the Supreme Court affirmed the judgment of the court of appeals reversing the judgment of the district court deducting from a damages award to Respondent the amount of discounts negotiated by Respondent's managed-care organizations, holding that the discounts were payments made pursuant to the United States Social Security Act under Minn. Stat. 548.251, subd. 1(2).After her car struck a school bus that failed to yield at an intersection, Respondent brought this action against the driver and the owner of the bus (collectively, Appellants). The medical expenses of Respondent, a medical-assistance enrollee, were covered by two managed-care organizations that contracted with Minnesota's Prepaid Medical Assistance Plan under the state's Medicaid program. The jury awarded damages, but the district court deducted from the award the discounts negotiated by the managed-care organizations. The court of appeals reversed. The Supreme Court affirmed, holding that the negotiated discounts were "payments made pursuant to the United States Social Security Act" under section 548.251, subd. 1(2), and therefore, Appellants could not offset the damages award for those payments. View "Getz v. Peace" on Justia Law

Brooke Rojas received food stamp benefits to which she was not legally entitled. The prosecution charged her with two counts of theft under the general theft statute, section 18-4-401(1)(a), C.R.S. (2019). Rojas moved to dismiss these charges, arguing that she could only be prosecuted under section 26-2-305(1)(a), C.R.S. (2019), because it created the specific crime of theft of food stamps. The trial court denied the motion, and a jury convicted Rojas of the two general theft counts. Rojas contended on appeal that the trial court erred by denying the motion to dismiss because section 26-2-305(1)(a) abrogated the general theft statute in food stamp benefit cases. A split division of the court of appeals agreed with her. The Colorado Supreme Court, however, disagreed with Rojas and the division majority. Based on the statute’s plain language, the Supreme Court held the legislature didn’t create a crime separate from general theft by enacting section 26-2-305(1)(a). View "Colorado v. Rojas" on Justia Law

Plaintiff argued that the Housing Authority abused its discretion in terminating her participation in the Section 8 Housing Program in the absence of any fraud, and that the Housing Authority did not have the discretion to terminate plaintiff's participation in the Program based on a misreport.The Court of Appeal held that the Housing Authority may not terminate a participant from the Program for an immaterial misreport, but that a false answer to a question about marital status did not fall within that category. The court affirmed the trial court's finding that plaintiff's false statements support her termination from the Program even in the absence of fraudulent intent, and affirmed the trial court's judgment finding that adequate grounds existed to terminate plaintiff from the Program. The court directed the trial court to remand the case to the Housing Authority to consider whether to exercise its discretion to take into account other circumstances in determining the appropriate remedy for plaintiff's violations. View "Crooks v. Housing Authority of the City of Los Angeles" on Justia Law

Skelton sustained an ankle injury in 2012, and a shoulder injury in 2014, while working for the DMV. In the latter incident, she also claimed to have sustained an injury to her neck. Skelton filed separate workers’ compensation benefits applications. Skelton sought to be reimbursed for her wage loss for time missed at work for medical treatment and for medical evaluations (temporary disability indemnity (TDI)). Skelton’s work hours were not flexible, and she could not visit her doctors on weekends. She initially used her sick and vacation leave but eventually, her paycheck was reduced for missed time. She was then “forced to miss doctors’ appointments.” Skelton’s shoulder injury was found permanent and stationary in November 2017. Her ankle injury was not yet permanent and stationary at the time of the hearing. DMV contended that Skelton was not entitled to TDI because she had returned to work, citing Labor Code section 4600(e)(1). The Appeals Board affirmed that Skelton was not entitled to TDI for wage loss to attend medical treatment appointments following her return to work but was entitled to TDI for wage loss to attend medical-legal evaluations. The court of appeal affirmed. DMV’s obligation to pay temporary disability benefits is tied to Skelton’s actual incapacity to perform the tasks usually encountered in her employment and the resulting wage loss. View "Skelton v. Workers Compensation Appeals Board" on Justia Law

Chang filed a qui tam action against the Center, asserting claims on behalf of the United States and the state under the False Claims Act (FCA). and the Delaware False Claims Act. Chang alleged that the Center had sought and received funding from the state and federal governments by misrepresenting material information. Both governments declined to intervene as plaintiffs. Chang filed an amended complaint and the Center answered. Nearly three years after Chang filed his original complaint, the U.S. and Delaware moved to dismiss the case, asserting that they had investigated Chang’s allegations and discovered them to be “factually incorrect and legally insufficient.” The court granted the motions without conducting an in-person hearing or issuing a supporting opinion. The Third Circuit affirmed. If the government chooses not to intervene, the relator may still “conduct the action” but the government may still “dismiss the action notwithstanding the objections of the person initiating the action if the person has been notified by the Government of the filing of the motion and the court has provided the person with an opportunity for a hearing on the motion,” 31 U.S.C. 3730(c)(2)(A). Chang never requested a hearing; the FCA does not guarantee an automatic in-person hearing to relators before their cases may be dismissed. View "Chang v. Children's Advocacy Center of Delaware" on Justia Law