Justia Public Benefits Opinion Summaries

Clark sought attorney fees under the Equal Access to Justice Act (EAJA), 28 U.S.C. 2412(d)(2)(A): $6,790.52 in fees for 34.75 attorney hours at an hourly rate of $176.13, plus 6.70 paralegal hours at an hourly rate of $100. The rate exceeded the $125 rate set by the EAJA. Clark argued that her counsel should receive a cost of living adjustment, based on the U.S. Bureau of Labor Statistics Consumer Price Index (CPI) for “Midwest Urban Consumers.” The agency requested that the court award fees at no more than $140, "the current reasonable and customary rate for experienced Social Security practitioners in the Western District of Kentucky." In her reply, Clark attached a declaration from her attorney, stating that he had practiced disability law from his Syracuse, New York, office for several years and provided his firm’s non-contingent hourly rate. Clark cited 2014 Sixth Circuit precedent, concluding that the requested rate of $176.13 was modest and appeared to be reasonable; she argued that other courts have held that the CPI alone was sufficient to justify a rate above the statutory cap. The district court awarded fees at an hourly rate of $140. The Sixth Circuit affirmed; there must be some understanding of the rates charged locally before a court can adjust for cost of living or other factors. View "Clark v. Commissioner of Social Security" on Justia Law

The Centers for Medicare & Medicaid Services (CMS) pays Medicare Advantage organizations fixed monthly amounts for each enrollee. Medicare Advantage organizations have a financial incentive to exaggerate an enrollee’s health risks by reporting diagnosis codes unsupported by the enrollee’s medical records, and therefore, Medicare regulations require a Medicare Advantage organization to certify that the risk adjustment data is submits are accurate and truthful. Qui Tam Relator James Swoben filed a third amended complaint alleging that Medicare Advantage organizations performed biased retrospective medical record reviews, which rendered Defendants’ periodic certifications false, in violation of the False Claims Act. Defendants moved to dismiss Swoben’s claims. In response, Swoben sought to amend his complaint. The district court dismissed the third amended complaint with prejudice, concluding that Swoben failed to allege a claim with particularity as required by Fed. R. Civ. P. 9(b). The court also denied leave to amend, citing both futility of amendment and undue delay. The Ninth Circuit vacated the district court’s judgment, holding that the dismissing Swoben’s third amended complaint without leave to amend based on futility of amendment and undue delay and that leave to amend was proper in this case. View "United States v. United Healthcare Insurance Co." on Justia Law

The Sixth Circuit declined to stay a preliminary injunction requiring the delivery of bottled water households served by the Flint water system that lack properly installed water filters. For many homes without a proper filter, safe drinking water is inaccessible due to the limited hours of the points of distribution and transportation issues. The cost of verifying and maintaining water filters and delivering bottled water to residents that are not part of the allegedly 96% of homes that have a functioning filter is "nowhere near $10.5 million" claimed by the defendants. There is still $100 million left of the $212 million that Michigan allocated to respond to the Flint water crisis. The court rejected an argument that delivering bottled water will slow down the recovery of Flint’s water system by decreasing the amount of water moving through the delivery lines. The defendants did not demonstrate a strong likelihood of success on their arguments, nor have they shown that portions of the preliminary injunction, including the provisions requiring the delivery of bottled water to non-exempt households, are overbroad. A stay would not support the public interest. Flint residents continue to suffer irreparable harm from the lack of reliable access to safe drinking water. View "Concerned Pastors for Social Action v. Khouri" on Justia Law

Under the Department of Housing and Urban Development’s (HUD) Housing Choice Voucher Program, 42 U.S.C. 1437f, housing agencies use HUD funds to issue housing subsidy vouchers based on family size. The Montgomery County, Maryland Housing determined, based on a medical form, that Angelene has a disability and requires a live-in aide. HUD regulations mandate that any approved live-in aide must be counted in determining family size. The Commission issued Angelene a two-bedroom voucher. Angelene’s sister was Angelene’s live-in aide. Angelene decided to move to the District of Columbia. Program vouchers are portable. Angelene obtained a two-bedroom voucher from the D.C. Housing Authority. The sisters moved into a two-bedroom District apartment. Within weeks, they received a letter revoking Angelene’s right to a live-in aide and her legal entitlement to a two-bedroom voucher. They sued, citing the Americans with Disabilities Act, 42 U.S.C. 12132, Rehabilitation Act, 29 U.S.C. 794, and Fair Housing Act, 42 U.S.C. 3604(f)(1). The court denied motions for a temporary restraining order and to seal their complaint, medical records, and “nondispositive materials.” While the case was pending, the Authority sent another letter reaffirming that Angelene’s request for a live-in aide was denied, but stating that the decision did not reverse the two-bedroom voucher. The court dismissed, finding no allegation of injury-in-fact. The D.C. Circuit reversed with respect to the motion to seal and the dismissal. At the pleadings stage, plaintiff’s allegation that the government denied or revoked a benefit suffices to show injury-in-fact. Angelene’s loss of a statutory entitlement traces directly to the Authority’s letter and would be redressed by a court order to approve her aide request. View "Hardaway v. District of Columbia Housing Authority" on Justia Law

Coursey’s application for Social Security benefits was denied. He sought judicial review. The district court granted a joint motion to reverse the decision. Coursey sought attorney fees. Although the Equal Access to Justice Act (EAJA), 28 U.S.C. 2412, sets the presumptive maximum hourly rate an attorney may recover at $125. Coursey sought $185.18 per hour. Coursey submitted the Bureau of Labor Statistics’ Consumer Price Index (CPI), which documents that the statutory amount would, when adjusted for the cost of living in the Midwest in 2015, be the equivalent of $185.18. The court concluded that the CPI and the attorney's affidavit were insufficient to justify the requested rate and approved an award of $140 per hour, consistent with recent cases in the district awarding that amount for EAJA attorney-fee requests in Social Security cases. The Sixth Circuit affirmed. A plaintiff seeking an attorney’s fee of greater than $125 per hour must show by competent evidence that the cost of living justifies a higher rate and that the fee is “in line with those prevailing in the community for similar services by lawyers of reasonably comparable skill, experience, and reputation.” The court properly relied on evidence, judicial findings in previous cases, that the prevailing market rate for similar services within its venue was $140 per hour. View "Coursey v. Commissioner of Social Security" on Justia Law

In 2006, Congress amended 42 U.S.C. 1396p(c)(1)(F)(i), which permits individuals and married couples to dispose of their assets (to qualify for Medicaid) by purchasing an annuity, under which the state is named as the remainder beneficiary in the first position for the amount of medical assistance paid. The federal law initially contained a drafting error. It was subsequently amended. A corresponding Kentucky regulation, promulgated four months later, mistakenly included the pre-amendment language, stating that the state had to be the beneficiary for the amount of assistance paid on behalf of the annuitant, rather than the institutionalized spouse. The state agency enforced the corrected federal statute. The Singletons sought Medicaid benefits to support Claude’s full-time nursing home care; in purchasing an annuity, Mary wanted to name the state as a beneficiary for the value of care provided to her, rather than Claude, as the Kentucky regulation seemed to permit. Claude obtained Medicaid eligibility after the purchase of an annuity that complied with the federal regulation. The government paid $98,729.01 in medical expenses before Claude's death. Mary later died, leaving $118,238.41 in the annuity. In compliance with the federal rule, the government’s claim left $19,509.40 for the secondary beneficiaries. The Singleton children sued. The Sixth Circuit rejected their argument that the Medicaid statute gave the state discretion to be more generous concerning annuities and the general spend-down rules. The Kentucky regulation departed from the Medicaid statute’s clear instructions and was preempted. View "Singleton v. Commonwealth of Kentucky" on Justia Law

Fleming had a sporadic work history in the coal industry. Between 1970 and 1991, Fleming worked for 25 different employers. In 2010, Fleming sought Black Lung Benefits Act payments. The DOL Office of Workers’ Compensation calculated that Fleming was employed as a miner for nine and one-quarter years and that he had contracted pneumoconiosis as a result of that employment. Aberry was designated as the employer responsible for payment of benefits. On appeal, an ALJ determined that Fleming could show he had worked 273.50 weeks in the industry (about 5.25 years), but that Fleming was credible and established that he had either been paid under the table or without proper records having been kept. Based on that determination, the ALJ found that Fleming engaged in coal-mine employment “for at least 15 years,” which entitled Fleming to the presumption of total disability under 30 U.S.C. 921(c)(4). The Benefits Review Board remanded, stating that the ALJ had neither explained how he resolved the conflict between Fleming’s “not [being] a good historian” and the ALJ’s crediting of Fleming’s testimony, nor resolved the conflicting evidence. The ALJ's second Decision again awarded benefits. finding that Fleming worked more than 15 years in coal-mine employment. The Sixth Circuit vacated. The evidence was insufficient to establish that Fleming had 15 years of employment. View "Aberry Coal, Inc. v. Fleming" on Justia Law

The Centers for Medicare & Medicaid Services (CMS) terminated its Provider Agreement with Parkview Adventist Medical Center after finding that Parkview was no longer a “hospital” under the Medicare statute. Parkview, which had filed for bankruptcy, attempted to use the Bankruptcy Code to challenge the actions of CMS in terminating the agreement. Parkview filed a motion to compel post-petition performance of executory contracts, arguing that the Provider Agreement was an “executory contract” under 11 U.S.C. 365 and accordingly within the bankruptcy court’s jurisdiction and, as such, CMS’s termination of the agreement was a post-petition termination without court authority in violation of the Bankruptcy Code. Further, Parkview argued that CMS’s termination of the Provider Agreement violated the automatic stay in 11 U.S.C. 362(a)(3) and the non-discrimination provision in 11 U.S.C. 525(a). The bankruptcy court concluded that it lacked jurisdiction over the motion and that CMS had not violated either the automatic stay or the non-discrimination provision. The district court affirmed. The First Circuit affirmed, holding (1) the automatic stay did not bar CMS’s termination of the Provider Agreement; and (2) CMS’s termination of the Provider Agreement was not impermissible discrimination. View "Parkview Adventist Medical Center v. United States" on Justia Law

Relators’ daughter died of a seizure after receiving mental health treatment at Arbour Counseling Services, a facility in Massachusetts owned and operated by Universal Health Services (UHS). When Relators learned that Arbour had employed unlicensed and unsupervised personnel, in violation of state regulations, they brought a qui tam action against UHS under the False Claims Act (FCA), alleging that UHS had fraudulently submitted reimbursement claims to the Commonwealth despite knowing that it was in violation of state regulations (a theory of FCA liability known as the “implied false certification theory”). The district court dismissed the complaint, concluding that the regulatory violations were not conditions of payment as required for a claim to be actionable under the FCA. The First Circuit reversed, holding that the regulatory violations at issue were conditions for payment and that Relators appropriately stated a claim with particularity under the FCA. On certiorari, the Supreme Court held that the implied false certification theory can be a basis for FCA liability but remanded the case for further consideration of whether the complaint sufficiently alleged that the regulatory violations were material to the government’s payment decision. The First Circuit again reversed the district court’s grant of UHS’s motion to dismiss after applying the Supreme Court’s guidance on the question of whether UHS’s misrepresentations were material, holding that Relators’ complaint sufficiently stated a claim under the FCA. View "United States, ex rel. Escobar v. Universal Health Services, Inc." on Justia Law

Seven entities under contract to provide residential services to youth in the state (collectively, Petitioners) filed a petition for writ of mandamus requiring the West Virginia Department of Health and Human Services (DHHR), its Cabinet Secretary, the West Virginia Bureau for Medical Services (BMS), its Acting Commissioner, the Bureau for Children and Families (BCF), and its Commissioner (collectively, Respondents) to promulgate new or amended legislative rules prior to implementing changes to existing residential child care services policies. The Supreme Court granted a writ as moulded, finding it most appropriate to order this matter to be docketed in this circuit court as if it were an original proceeding in mandamus in that court. Remanded for further proceedings. View "State ex rel. Pressley Ridge v. W. Va. Department of Health & Human Resources" on Justia Law