Justia Public Benefits Opinion Summaries

At issue in this mandamus proceeding was whether the proportionate-responsbility scheme in Chapter 33 of the Texas Civil Practice and Remedies Code applies to a civil-remedy action under the Texas Medical Fraud Prevention Act (TMFPA).The State sued Xerox Corporation and Xerox State HealthCare, LLC (collectively, Xerox), which administered the Texas Medicaid program, for a civil remedy under the TMFPA. Xerox sought to unite the TMFPA proceedings for purposes of shifting liability to the service providers sued by the State who had directly received disputed Medicaid payments. The trial court granted the State’s motion to strike Xerox’s third-party petition seeking contribution under Chapter 33, holding Chapter 33 inapplicable to the TMFPA action. The court also denied Xerox’s motion to designate responsible third parties under Chapter 33. The Supreme Court denied Xerox’s petition for writ of mandamus, holding that Chapter 33 does not apply to a TMFPA action because (1) the statutory remedy does not constitute “damages” subject to apportionment under Chapter 33; and (2) an irreconcilable conflict exists between the proportionate-responsibility statute and the TMFPA’s mitigation and fault-allocation scheme. View "In re Xerox Corp." on Justia Law

In this interlocutory appeal, the Supreme Court held that sovereign immunity barred the counterclaims filed by Defendants against the State and that it lacked interlocutory jurisdiction to address the trial court’s dismissal of the Defendants’ third-party claims.The State brought this enforcement action under the Texas Medicaid Fraud Prevention Act, alleging that Defendants - several dentists and their professional associations and employees - fraudulently obtained Medicaid payments for providing dental and orthodontic treatments to children. Defendants asserted counterclaims and third-party claims alleging that the State and its contractor mismanaged the payment-approval process and misled Defendants regarding the requirements imposed by the Texas Medical Program. The trial court granted the State’s plea to the jurisdiction against the counterclaims and motion to dismiss the third-party claims. Defendants filed this interlocutory appeal. The court of appeals affirmed the trial court’s order dismissing Defendants’ counterclaims and concluded that it lacked jurisdiction over the order dismissing the third-party claims. The Supreme Court affirmed, holding (1) sovereign immunity barred the counterclaims, and (2) this Court lacked interlocutory jurisdiction to address the order dismissing the third-party claims. View "Nazari v. State" on Justia Law

Plaintiffs were 23 federally qualified health centers (FQHC’s) and rural health clinics (RHC’s) that served medically underserved populations (the Clinics). The dispute before the Court of Appeal centered on coverage for adult dental, chiropractic, and podiatric services the FQHC’s and RHC’s provided to Medi-Cal patients for a period between 2009 and 2013. Prior to July 1, 2009, the Department processed and paid claims for these services. In 2009, in a cost-cutting measure due to budget problems, the Legislature enacted Welfare and Institutions Code section 14131.101 to exclude coverage for these services (and others) “to the extent permitted by federal law.” After the Department stopped paying claims for these services, various FQHC’s and RHC’s challenged the validity of section 14131.10, claiming it conflicted with federal Medicaid law. In California Assn. of Rural Health Clinics v. Douglas, 738 F.3d 1007 (9th Cir. 2013), the Ninth Circuit held section 14131.10 was invalid to the extent it eliminated coverage for these services when provided by FQHC’s and RHC’s because the federal Medicaid Act imposed on participating states the obligation to cover these services by these providers. In response to CARHC, the Department announced it would reimburse FQHC’s and RHC’s for these services for dates of service only on or after September 26, 2013, the date of the Ninth Circuit’s mandate. Seeking reimbursement for services provided prior to September 26, 2103, the Clinics petitioned for a writ of mandate to compel the Department to accept, process, and pay claims for these services for the period July 1, 2009, to September 26, 2013. The trial court granted the petition in part and entered judgment for the Clinics. The Department appeals. Characterizing the Clinics’ writ petition as a suit for damages, it contended: (1) sovereign immunity barred the Clinics’ claims for retroactive payment; (2) the CARHC decision was retroactive because the Medicaid Act is spending clause legislation and its terms were not sufficiently clear as to the requirement to cover adult dental, chiropractic, and podiatric services provided by FQHC’s and RHC’s; and (3) retroactive relief violated the separation of powers doctrine because it forces the Legislature to appropriate money. The Court of Appeal disagreed with the Department’s characterization of the Clinics’ lawsuit. "Rather than a suit for damages, the lawsuit seeks an order to compel performance of a mandatory duty and did not result in a money judgment. Under well-settled California law, such a mandamus proceeding is not barred by sovereign immunity. The Department’s contentions based on spending clause legislation and separation of powers are new arguments raised for the first time on appeal. We exercise our discretion to consider only the spending clause argument. We reject it because the Department has not shown its obligations under Medicaid law, as determined by CARHC, came as a surprise. The separation of powers argument raises factual issues about appropriations that should have been presented in the trial court and we decline to consider this new argument." Accordingly, the Court affirmed the judgment. View "American Indian Health etc. v. Kent" on Justia Law

The Fifth Circuit reversed the denial of social security benefits for plaintiff, a former physician and army veteran, who was diagnosed with post traumatic stress disorder (PTSD), depression, and bipolar disorder. The court held that the ALJ's decision was not supported by substantial evidence where the ALJ erred in finding for step two of the five-step approach that plaintiff's impairments were not severe. Accordingly, the court remanded for further consideration. View "Salmond v. Berryhill" on Justia Law

The IHSS program (Welf. & Inst. Code 12300) provides in-home services to elderly or disabled persons so that they may avoid institutionalization. For purposes of the state unemployment insurance system, IHSS service recipients are considered employers of their service providers if the providers are directly paid by the program or the recipient receives IHSS funds to pay their providers (Unemp. Ins. Code 683.) Generally, an employee of a close family member (child, parent or spouse) is excluded from unemployment insurance coverage. The California Unemployment Insurance Appeals Board ruled that, because a close-family-member IHSS service provider under the Direct Payment Mode is employed by the recipient, the provider is subject to the exclusion of Unemployment Insurance Code 631 (Caldera). Skidgel, an IHSS provider for her daughter, challenged the validity of Caldera, arguing government entities were joint employers with the recipient, thereby qualifying providers for unemployment insurance coverage despite the close-family-member exclusion. The court of appeal rejected the challenge, concluding that the Legislature, in enacting Unemployment Insurance Code section 683, intended to designate the recipient as the IHSS provider’s sole employer for purposes of unemployment insurance coverage. View "Skidgel v. California Unemployment Insurance Appeals Board" on Justia Law

Four veterans appealed the VA's denial of their claims for service-connected disability benefits. Based on delays in their cases, they unsuccessfully sought writs of mandamus from the Veterans Court. The Federal Circuit remanded two cases, citing its 2018 decision, Martin v. O’Rourke, so that the mandamus petitions may be considered under the TRAC standard: “whether the agency’s delay is so egregious as to warrant mandamus.” The TRAC standard involves six factors: the time agencies take to make decisions must be governed by a “rule of reason”; where Congress has provided a timetable or other indication of the speed with which it expects the agency to proceed, that statutory scheme may supply content for this rule of reason; delays that might be reasonable in the sphere of economic regulation are less tolerable when human health and welfare are at stake; the court should consider the effect of expediting delayed action on agency activities of a higher or competing priority; the court should also consider the nature and extent of the interests prejudiced by delay; and the court need not find “any impropriety lurking behind agency lassitude” to hold that agency action is unreasonably delayed. One veteran had died, rendering his appeal moot and another had his claim for benefits granted. View "Rose v. O'Rourke" on Justia Law

The VA denied the veterans’ claims for service-connected disability benefits. Based on delays in their cases, they sought writs of mandamus in the Veterans Court. The Federal Circuit vacated that court’s denial of relief, finding that the court did not apply the proper standard. The court noted the significant delays that occur in most cases and that the government has not explained the cause of the delays; the petitions alleged that a veteran whose disability benefits are denied waits, on average, 1448 days after the denial for a ruling on an appeal.” Whether the agency’s delay is so egregious as to warrant mandamus under the “TRAC” standard requires consideration of six factors: the time agencies take to make decisions must be governed by a “rule of reason”; where Congress has provided an indication of the speed with which it expects the agency to proceed, that statutory scheme may supply content for this rule of reason; delays that might be reasonable in the sphere of economic regulation are less tolerable when human health and welfare are at stake; the court should consider the effect of expediting delayed action on agency activities of a higher or competing priority and the nature and extent of the interests prejudiced by delay; and the court need not find “any impropriety lurking behind agency lassitude” in order to hold that agency action is unreasonably delayed. View "Martin v. O'Rourke" on Justia Law

The First Circuit affirmed the district court’s order upholding an administrative law judge’s (ALJ) denial of Appellant’s application for Social Security Disability Insurance Benefits and Supplemental Security Income. The Court held (1) even if this Court reviews the ALJ’s ruling on the understanding that it must apply a certain Social Security Ruling in reviewing the ALJ’s ruling, the ALJ’s determination that Appellant was not disabled still must be upheld; (2) substantial evidence supported the ALJ’s determination that Appellant’s ability to carry out certain daily activities undermined his contention that he was unable to perform light work; and (3) Appellant’s remaining allegations of error were without merit. View "Coskery v. Berryhill" on Justia Law

The Ninth Circuit reversed the denial of disability insurance benefits and supplemental security income for claimant. The panel held that the ALJ erred in not adequately addressing claimant's 100 percent Veterans Affairs (VA) disability rating in her decision; although the ALJ noted claimant's VA disability rating at the hearing and in her written decision, she did not address how she had considered and weighed the VA's rating or articulated any reasons for rejecting it; and thus remand was appropriate where it was unclear from the record whether the ALJ would be required to find claimant disabled after evaluating the VA disability rating. View "Luther v. Berryhill" on Justia Law

Acree served on active duty in the Navy from 1985-1989 and 2007-2008. He was deployed to Iraq and received Seabee Combat Warfare Medals. Acree was diagnosed with post-traumatic stress disorder (PTSD) while serving in Iraq. After leaving the service, Acree filed several claims for service-connected disability benefits and appealed 11 claims to the Board of Veterans’ Appeals. A representative from the Disabled American Veterans (DAV) organization was present with Acree at the board hearing. Acree said “yes” when asked to withdraw seven issues. The board listed the four issues that would be discussed and would “continue to be in appellate status” and asked the DAV representative whether it had “correctly identified the issues.” The representative responded: “Yes.” The board remanded four and dismissed seven claims. Acree appealed, arguing that a veteran’s withdrawal of a claim “is not effective unless the withdrawal ‘is explicit, unambiguous, and done with a full understanding of the consequences’” and that since he “ha[d] a long history of taking psychotropic medications,” the hearing officer should have inquired as to his capacity to appreciate the consequences of dismissing the claims. The Veterans Court affirmed, citing the hearing transcript. The Federal Circuit vacated. Precedent (DeLisio) explicitly states that a withdrawal is effective only if undertaken with “a full understanding of the consequences of such action on the part of the [veteran].” The Veterans Court was required to make that determination even though a DAV representative was present. View "Acree v. O'Rourke" on Justia Law