Justia Public Benefits Opinion Summaries

A 51-year-old man with a history of violent crime and drug abuse, applied for SSI (42 U.S.C. 1381). He alleged disability beginning in April 2002 due to bipolar disorder and anxiety. The application was denied in October 2006. An ALJ determined that petitioner was not disabled because he has been capable of making a successful adjustment to other work that exists in significant numbers in the national economy. The appeals council denied review. The district court upheld the decision and the Third Circuit affirmed. Any error in the district court's articulation of the standard of review was harmless, and the commissioner's determination was supported by substantial evidence.

Defendants are health service providers that receive reimbursement from Medicare and Medicaid under 42 U.S.C. 1395, 1396. Plaintiffs, former employees of defendants, filed a qui tam action, alleging violations of various federal laws. After investigation, the government declined to intervene. The district court dismissed. The Third Circuit affirmed dismissal of False Claims Act, 31 U.S.C. 3729 claims based on violation of Medicare marketing regulations and reversed with respect to allegations that the defendants submitted false claims to the government by violating the Anti-Kickback Statute, 42 U.S.C. 1320. Payment of Medicare claims was not conditioned on compliance with marketing regulations.

This appeal involved a putative class action filed by three Pennsylvania Medicaid beneficiaries subject to the Pennsylvania Department of Public Welfare's (DPW) liens against future settlements or judgments. At issue was whether state agencies responsible for administering the Medicaid program have the authority to assert such liens and, if so, whether Pennsylvania's statutory framework was consistent with the Supreme Court's decision in Arkansas Department of Health and Human Services v. Ahlborn. The court examined the text, structure, history, and purpose of the Social Security Act, 42 U.S.C. 301 et seq., and held that liens limited to medical costs were not prohibited by the anti-lien and anti-recovery provisions of the Act, 42 U.S.C. 1396p(a)-(b). Accordingly, the court upheld Pennsylvania's longstanding practice of imposing such liens. The court also held that Pennsylvania's current statutory framework, which afforded Medicaid recipients a right of appeal from the default allocation, was a permissible default apportionment scheme.

Under Medicaid, the federal government reimburses between 50% and 83% of state costs for patient care for eligible low-income individuals, including developmentally-disabled individuals receiving care in home- and community-based settings.42 U.S.C.1396n(c). In 2001 Pennsylvania obtained a waiver that authorized reimbursement of state expenses for "habilitation services" for developmentally-disabled individuals. Until 2006, Pennsylvania did not seek reimbursement for occupancy costs for Medicaid recipients living in nonprofit and county facilities, but paid for room and board using state funds and the residents' Supplemental Security Income. The Center for Medicare and Medicaid Services rejected the state's 2006 claim that more than 54 percent of the occupancy costs were for reimbursable habilitation services. The appeals board and district court upheld the denial. The Third Circuit affirmed, based on the plain meaining of the statutory exclusion of costs for "room and board," and noting consistent interpretation of the statute