Justia Public Benefits Opinion Summaries

NOVA challenged a 2017 Veterans Administration (VA) amendment to 38 C.F.R. 3.321(b)(1), confining the preexisting regulation (as interpreted by a 2014 Federal Circuit ruling) and authorizing the VA “[t]o accord justice to the exceptional case where the schedular evaluation is inadequate to rate a single service-connected disability,” by adopting “an extra-schedular evaluation commensurate with the average impairment of earning capacity due exclusively to the disability.” The regulation does not permit the VA to award extra-schedular disability compensation by considering the synergistic impact of multiple disabilities together. The Federal Circuit upheld the regulation. The VA’s explanation for the change was adequate; the regulation is not on its face arbitrary and capricious. It does not limit “extraschedular rating to a single service-connected disability” but provides for combining multiple disabilities, but not in the manner opponents prefer. The VA explained that the amendment is consistent with the agency’s historical interpretation of the regulation and its predecessors. The VA reasonably concluded that determination of an extra-schedular rating with respect to a single disability is likely to result in a more logical and consistent system of extra-schedular rating than one in which the decision-maker must determine on an ad hoc basis whether extra-schedular rating is appropriate for the synergistic effect of combined disabilities. View "National Organization of Veterans' Advocates, Inc. v. Secretary of Veterans Affairs" on Justia Law

The First Circuit affirmed the judgment of the district court concluding that transfers of assets by individuals age sixty-five or older into "pooled special needs trusts" are among those transfers that the Medicaid statute counts against eligibility for long-term care benefits, holding that when a beneficiary who is age sixty-five years or older gives up her assets for less than fair market value to a pooled special needs trust, there has been a transfer that triggers a temporary period of ineligibility.Following Yvonne Richardson's deposit of funds into her Maine Pooled Disability Trust (MPDT) account, the Maine Department of Health and Human Services (MDHHS) issued a notice threatening to suspend Medicaid coverage. Richardson and MPDT filed this lawsuit seeking a declaration that her transfer of assets into a pooled special needs trust was not a transfer that affected Medicaid eligibility. The district court dismissed the complaint, concluding that MDHHS correctly applied the governing statute in reaching its conclusion. The First Circuit affirmed, holding that the district court's judgment granting MDHHS's motion to dismiss rested on a reasonable interpretation of the statute. View "Maine Pooled Disability Trust v. Hamilton" on Justia Law

Shea began serving in the Air Force in October 2006. Her pre-enlistment examination indicated a normal psychiatric condition. A January 2007 medical examination resulted in a diagnosis of an adjustment disorder with anxiety and depressed mood. Days later, Shea was struck by a truck while on base and sustained multiple physical injuries. Her subsequent medical records report anxiety, depression, and impaired memory. A medical evaluation board recommended that Shea be discharged. Shea was transferred to Dover Air Force Base, where her then-husband was stationed, to continue her treatment. A physical evaluation board determined in May 2007 that Shea’s pelvic fractures and transverse process fracture were unfitting conditions that were compensable and ratable but that her adjustment disorder with depression and anxiety was not separately unfitting nor compensable or ratable. In July 2007, Shea was discharged because of her physical disabilities. She sought benefits in October 2007. The VA granted benefits for her physical and psychiatric conditions, but rejected a request for a 2007 effective date for the psychiatric-disability benefits. The Veterans Court affirmed. The Federal Circuit vacated and remanded to allow the Veterans Court to articulate the correct legal standard in considering Shea’s October 2007 informal application for benefits. While a pro se claimant "must identify the benefit sought,” the identification need not be explicit and should be read in conjunction with other submissions and service treatment records. View "Shea v. Wilkie" on Justia Law

The Eighth Circuit affirmed the denial of social security disability benefits to claimant, holding that the denial of benefits was supported by substantial evidence. The court held that the ALJ did not err in determining claimant's Residual Functional Capacity and did not err in determining that the medical records did not support the limitations stated by her treating physician. The court also held that the ALJ did not err by discrediting the physician's testimony to the extent that it exceeded the supported limitations. View "Despain v. Berryhill" on Justia Law

The Eighth Circuit affirmed the denial of disability insurance benefits to claimant. The court held that the agency was justified in reopening claimant's case based on new and material information; there was no due process violation and claimant had adequate notice that the reopened proceedings could result in a determination that she was not disabled; res judicata did not bar the Commissioner from revising a determination; substantial evidence supported the ALJ's determination that claimant was not disabled from 2012 onward; claims of witness and evidentiary errors rejected; the ALJ did not err in determining that claimant could perform her past relevant work; and there was no error in the ALJ's statement regarding claimant's residual functional capacity (RFC) to the vocational expert where substantial evidence supported the omission of certain limitations from her RFC. View "Schwandt v. Berryhill" on Justia Law

The Second Circuit held that the district court properly deferred to the decision of the New York State Review Officer (SRO), which concluded that student W.E. was not denied a free and appropriate public education (FAPE) for the eighth grade school year and that Northwood School was not an appropriate unilateral private school placement for the ninth grade school year. Accordingly, the court affirmed the district court's November 2016 judgment and order in part.To the extent that the district court failed to accord appropriate deference to the SRO's conclusion that Northwood did not provide W.E. specially designed instruction so as to constitute an appropriate private school placement for the tenth grade school year, the court reversed in part the district court's opinion and vacated the award of tuition reimbursement to plaintiffs for that school year. The court also affirmed a July 2017 opinion and order granting the district court's grant of summary judgment and vacating the award of compensatory education for the eighth grade year. View "W.A.v. Hendrick Hudson Central School District" on Justia Law

The Medicare program offers additional payments to institutions that serve a “disproportionate number” of low-income patients, 42 U.S.C. 1395ww(d)(5)(F)(i)(I), calculated using the hospital’s “Medicare fraction.” The fraction’s denominator is the time the hospital spent caring for patients entitled to Medicare Part A benefits; the numerator is the time the hospital spent caring for Part-A-entitled patients who were also entitled to income support payments under the Social Security Act. Medicare Part C (Medicare Advantage) was created in 1997. Part C, beneficiaries may choose to have the government pay their private insurance premiums rather than pay for their hospital care directly. Part C enrollees tend to be wealthier than Part A enrollees, so counting them makes the fraction smaller and reduces hospitals’ payments. In 2014, the Medicare website indicated that fractions for fiscal year 2012 included Part C patients. Hospitals sued, claiming violation the Medicare Act’s requirement to provide public notice and a 60-day comment period for any “rule, requirement, or other statement of policy . . . that establishes or changes a substantive legal standard governing . . . the payment for services.”The Supreme Court affirmed the D.C. Circuit in agreeing with the hospitals. The government has not identified a lawful excuse for neglecting its statutory notice-and-comment obligations. The 2014 announcement established or changed a “substantive legal standard” not an interpretive legal standard. The Medicare Act and the Administrative Procedures Act do not use the word “substantive” in the same way. The Medicare Act contemplates that “statements of policy” can establish or change a “substantive legal standard." Had Congress wanted to follow the APA in the Medicare Act and exempt interpretive rules and policy statements from notice and comment, it could have cross-referenced the APA exemption, 5 U.S.C. 553(b)(A). View "Azar v. Allina Health Services" on Justia Law

Medicare pays for doctors’ home visits if a patient is homebound. Mobile Doctors offered physician services to homebound Medicare beneficiaries, hiring doctors who assigned their Medicare billing rights to the company. Upon receipt of payment, Mobile would pay the physician-employee a percentage of what Mobile received from billing Medicare. Many of Mobile’s patients did not actually qualify as homebound. Some doctors signed certifications for additional unneeded treatment from companies that provided at-home nursing or physical therapy services—companies that had referred the patients to Mobile. Mobile submitted Medicare codes for more serious and more expensive diagnoses or procedures than the provider actually diagnosed or performed. Mobile instructed physicians to list at least three diagnoses in the patient file; if the doctors did not list enough, a staff member added more. Mobile only paid the physicians if they checked at least one of the top two billing codes. Doctors who billed for the higher of the top two codes were paid more. Mobile also paid for “standing orders” for testing, although Medicare prohibits testing done under standing orders. Daneshvar joined Mobile as a physician in 2012. After following Mobile’s policies Daneshvar was convicted of conspiracy to commit healthcare fraud but found not guilty of healthcare fraud; he was sentenced to 24 months' imprisonment. The Sixth Circuit affirmed. Daneshvar’s trial was fair; none of the district court’s rulings during that proceeding should be reversed. There was no reversible error with his sentencing. View "United States v. Daneshvar" on Justia Law

The Second Circuit vacated the district court's decision affirming the Commissioner's denial of social security disability benefits. The court held that the ALJ failed to comply with the procedural mandates of the treating physician rule where it explicitly failed to consider the first Burgess factor before assigning "little weight" to the opinion of plaintiff's treating psychiatrist. Furthermore, there was a lack of other "good reasons" to support that decision. Accordingly, the court remanded for the ALJ to reconsider plaintiff's claim for disability benefits consistent with the procedural mandates of the Social Security Act and this court. View "Estrella v. Berryhill" on Justia Law

The Social Security Act permits judicial review of “any final decision . . . after a hearing” by the Social Security Administration (SSA), 42 U.S.C. 405(g). Claimants for Title XVI supplemental security income disability benefits must generally proceed through a four-step process before federal-court review: seek an initial determination of eligibility; seek reconsideration; request a hearing before an administrative law judge (ALJ); and seek review of the ALJ’s decision by the Appeals Council within 60 days of receiving the ALJ’s ruling. If the claimant misses that deadline and cannot show good cause for doing so, the Appeals Council dismisses the request. Smith’s claim for disability benefits was denied on initial determination, upon reconsideration, and on the merits by an ALJ. The Appeals Council dismissed Smith’s request for review as untimely. Smith sought judicial review of the dismissal. The Sixth Circuit affirmed dismissal for lack of jurisdiction, holding that the Appeals Council’s dismissal of an untimely petition is not a “final decision.”A unanimous Supreme Court reversed. An Appeals Council dismissal on timeliness grounds after a claimant has had an ALJ hearing on the merits qualifies as a “final decision . . . made after a hearing” under section 405(g). The Appeals Council’s dismissal is the final stage of review, 20 CFR 416.1472; Smith obtained the kind of hearing that section 405(g) most naturally suggests. The dismissal is not merely collateral but an end to a proceeding in which a substantial factual record has been developed. The Court noted that “Congress designed [the statute as a whole] to be ‘unusually protective’ of claimants” and “the strong presumption that Congress intends judicial review of administrative action.” View "Smith v. Berryhill" on Justia Law