Justia Public Benefits Opinion Summaries

An employee worked for Cowin & Company for nearly three decades, performing construction in coal mines and regularly being exposed to coal dust. Years after his employment ended, he filed a claim for benefits under the Black Lung Benefits Act, alleging total disability due to pneumoconiosis (“black lung disease”) caused by his coal mine work. The claimant relied on a regulatory presumption that applies to miners who have a disabling breathing impairment and at least fifteen years of qualifying coal mine employment. A key dispute in the case involved how to calculate a “year” of coal mine employment under Department of Labor regulations.An administrative law judge initially granted benefits, finding the claimant had at least fifteen years of qualifying employment, thus triggering the presumption. Cowin & Company appealed to the Benefits Review Board, which vacated the benefits award in part and instructed the judge to recalculate the length of coal mine employment, questioning the method used to credit years of employment. On remand, the judge again found more than fifteen years, but the Board disagreed with the method, holding that a claimant must prove both a 365/366-day period of employment and at least 125 working days during that period. Ultimately, after further proceedings, the administrative law judge found only 13.76 years of qualifying employment, and the Board affirmed the denial of benefits.The United States Court of Appeals for the Eleventh Circuit reviewed the Board’s decision. The court held that, under the plain text of the relevant regulation, a claimant establishes a “year” of coal mine employment by showing at least 125 working days in or around coal mines during a calendar year or partial periods totaling one year. The court granted the petition for review, vacated the Board’s decision, and remanded for further proceedings. View "Hayes v. Director, OWCP" on Justia Law

The United States brought a lawsuit against Florida alleging that the state was discriminating against children with medically complex conditions by failing to provide care in the most integrated setting as required under Title II of the Americans with Disabilities Act (ADA). The federal government claimed that Florida’s inadequate provision of at-home and group-home care forced some children into institutionalization and placed others at serious risk of institutionalization. Additionally, it argued that once children were institutionalized, Florida’s poor care coordination and deficient transition planning made it difficult for families to bring their children home.This litigation proceeded over many years, culminating in a bench trial in the United States District Court for the Southern District of Florida. Previously, the United States Court of Appeals for the Eleventh Circuit had determined that the United States had statutory authority to sue Florida under the ADA. After trial, the district court found that Florida’s Medicaid program failed to provide adequate private duty nursing (PDN) services and effective care coordination, resulting in unnecessary institutionalization of children or placing them at risk. The district court concluded that these failures constituted violations of the ADA as interpreted by Olmstead v. L.C. ex rel Zimring, and issued a permanent injunction requiring Florida to improve its services, with specific mandates regarding PDN, care coordination, transition planning, data collection, and appointment of a monitor.On appeal to the United States Court of Appeals for the Eleventh Circuit, Florida challenged the findings and scope of the injunction. The Eleventh Circuit held that the United States may seek injunctive relief for systemic ADA violations affecting a group of children, not just those who individually filed complaints. The court affirmed the district court’s findings that the United States established the elements required under Olmstead, that the violations were widespread, and that system-wide injunctive relief was warranted. The Eleventh Circuit affirmed the district court’s liability determinations and most provisions of the injunction, but vacated or modified some portions as overbroad. View "United States v. Florida" on Justia Law

Florida challenged a federal agency document known as the “Informational Bulletin” that interpreted Medicaid’s hold-harmless rule and threatened to claw back billions in Medicaid funds if certain state practices continued. Florida’s Medicaid funding system relies on a Directed Payment Program, under which local governments assess special fees on private hospitals, pool these fees, and transfer the funds to the state agency, which then uses them to secure additional federal matching funds. The state feared the new federal interpretation could jeopardize its program and moved to preliminarily enjoin the Bulletin’s implementation.The United States District Court for the Southern District of Florida, following a magistrate judge’s recommendation, denied Florida’s motion for a preliminary injunction and dismissed the case for lack of subject matter jurisdiction. The district court held that the Bulletin was not a “final agency action” under the Administrative Procedure Act (APA), and therefore not subject to judicial review.The United States Court of Appeals for the Eleventh Circuit reviewed the case and found that, contrary to the district court’s conclusion, the Bulletin was indeed a final agency action subject to judicial review under the APA. However, the Eleventh Circuit held that Florida was unlikely to succeed on the merits of its challenge, concluding that the Bulletin’s interpretation of the Medicaid hold-harmless rule was consistent with the statutory text, was not arbitrary or capricious, and did not require notice-and-comment rulemaking. The court thus reversed the dismissal of the complaint, affirmed the denial of the preliminary injunction, and remanded the case for further proceedings. View "Florida Agency for Health Care Administration v. Administrator for the Centers for Medicare & Medicaid Services" on Justia Law

An Army veteran serving a lengthy prison sentence in Florida applied for and received disability benefits for service-related post-traumatic stress disorder. Initially, the Veterans Benefits Administration approved his claim at a 70 percent rate, later increasing it to 80 percent. However, after his felony conviction and incarceration, the Administration reduced his monthly benefits to a 10 percent rate pursuant to 38 U.S.C. § 5313, which limits disability payments for veterans incarcerated for more than 60 days due to a felony.The veteran filed a pro se complaint in the United States District Court for the Middle District of Florida, naming the United States Congress as defendant. He alleged that the statute reducing his benefits violated the Bill of Attainder Clause and the Equal Protection component of the Fifth Amendment, seeking both prospective and retroactive relief. A magistrate judge recommended dismissal, assuming without deciding that the court had jurisdiction over facial constitutional challenges, but finding the claims frivolous. The district court adopted this recommendation, dismissing the complaint and declining to address the plaintiff’s general objections.On appeal, the United States Court of Appeals for the Eleventh Circuit reviewed the case. The court held that sovereign immunity barred the suit against Congress, as Congress has not waived immunity for constitutional claims arising from its enactment of legislation. The court further held that any amendment to name a different defendant would be futile because the Veterans’ Judicial Review Act provides an exclusive review scheme for challenges to veterans’ benefits decisions, channeling all such claims—including constitutional challenges—through the administrative process and ultimately to the Court of Appeals for Veterans Claims and the Federal Circuit. The Eleventh Circuit vacated the district court’s judgment and remanded with instructions to dismiss the case without prejudice for lack of jurisdiction. View "Johnson v. United States Congress" on Justia Law

Rachael Gorecki applied for disability benefits and received a hearing before an administrative law judge (ALJ) whose appointment was ratified by Nancy Berryhill during her second tenure as Acting Commissioner of the Social Security Administration. The ALJ denied Gorecki's benefits application, and the Social Security Administration's Appeals Council denied review, making the decision final. Gorecki then sued, arguing that the ALJ had no constitutional authority to issue a decision because Berryhill's second stint as Acting Commissioner violated the Federal Vacancies Reform Act (FVRA).The United States District Court for the Northern District of Alabama rejected Gorecki's argument, aligning with other appellate courts that had ruled on similar issues. The district court found that Berryhill's second tenure as Acting Commissioner was lawful under the FVRA.The United States Court of Appeals for the Eleventh Circuit reviewed the case and joined five other circuits in holding that the FVRA authorized Berryhill's second stint as Acting Commissioner. The court found that the plain text of the FVRA allowed Berryhill to serve again as Acting Commissioner once a nomination for the office was submitted to the Senate, regardless of whether the nomination occurred during the initial 210-day period. The court affirmed the district court's judgment, concluding that Berryhill's ratification of the ALJ's appointment was valid and that the ALJ had the authority to deny Gorecki's benefits application. The Eleventh Circuit thus affirmed the lower court's decision. View "Gorecki v. Commissioner, Social Security Administration" on Justia Law

The plaintiff, Afaf Beshay Malak, applied for disability insurance benefits (DIB) in 2021, citing several disabilities including pinched nerves, osteoarthritis, fibromyalgia, and chronic headaches. Her application was denied initially and upon reconsideration by disability examiners. Malak then had a hearing before an Administrative Law Judge (ALJ), who followed the five-step evaluation process for disability claims. The ALJ determined that Malak had severe impairments but did not meet the criteria for a listed impairment. The ALJ assessed Malak’s Residual Functional Capacity (RFC) and found she could perform sedentary work with certain limitations. The ALJ concluded that Malak could perform her past work as a financial institution manager and other jobs in the national economy, thus finding her not disabled.Malak appealed the ALJ’s decision to the Appeals Council, which denied her request for review, making the ALJ’s decision the final decision of the Commissioner of Social Security. Malak then appealed to the district court, which affirmed the ALJ’s denial of her DIB claim. Malak subsequently appealed to the United States Court of Appeals for the Eleventh Circuit.The Eleventh Circuit reviewed the case to determine if the ALJ’s decision was supported by substantial evidence. Malak argued that the ALJ failed to consider her medically related absences and the side effects of her treatments. The court held that the ALJ is not required to consider the time needed for medical appointments when determining RFC, as RFC assessments focus on functional limitations caused by medically determinable impairments. The court also found that the ALJ properly considered the effectiveness and side effects of Malak’s treatments, noting that the medical evidence showed positive responses to treatments without significant side effects. The Eleventh Circuit affirmed the district court’s decision, upholding the denial of Malak’s DIB claim. View "Malak v. Commissioner of Social Security" on Justia Law

The seven consolidated cases in this appeal all involve attempts by assignees of a health maintenance organization (HMO) to recover conditional payments via the Medicare Secondary Payer Act's (MSP Act), 42 U.S.C. 1395y(b)(2)(B)(ii), (b)(3)(A), private cause of action. At issue is whether a contractual obligation, without more (specifically, without a judgment or settlement agreement from a separate proceeding), can satisfy the “demonstrated responsibility” requirement of the private cause of action provided for by the MSP Act. The court held that a plaintiff suing a primary plan under the private cause of action in the MSP Act may satisfy the demonstrated responsibility prerequisite by alleging the existence of a contractual obligation to pay. A judgment or settlement from a separate proceeding is not necessary. Therefore, the court vacated the district courts' judgments and remanded for further proceedings. View "MSP Recovery LLC v. AllState Ins. Co." on Justia Law

The Secretary determined that Bayou Shores was not in substantial compliance with the Medicare program participation requirements, and that conditions in its facility constituted an immediate jeopardy to residents’ health and safety. The bankruptcy court assumed authority over Medicare and Medicaid provider agreements as part of the debtor’s estate, enjoined the Secretary from terminating the provider agreements, determined for itself that Bayou Shores was qualified to participate in the provider agreements, required the Secretary to maintain the stream of monetary benefit under the agreements, reorganized the debtor’s estate, and finally issued its Confirmation Order. The district court upheld the Secretary’s jurisdictional challenge and reversed the Confirmation Order with respect to the assumption of the debtor’s Medicare and Medicaid provider agreements. The court concluded that the statutory revision in this case does not demonstrate Congress's clear intention to vest the bankruptcy courts with jurisdiction over Medicare claims. Therefore, the court agreed with the district court that the bankruptcy court erred as a matter of law when it exercised subject matter jurisdiction over the provider agreements in this case. The bankruptcy court was without 28 U.S.C. 1334 jurisdiction under the 42 U.S.C. 405(h) bar to issue orders enjoining the termination of the provider agreements and to further order the assumption of the provider agreements. Accordingly, the court affirmed the judgment. View "Florida Agency for Health Care Admin. v. Bayou Shores" on Justia Law

VRC filed suit against HHS and the Secretary, seeking the recoupment of payments VRC returned to Medicare after it was issued notice of an overpayment. At issue is the reimbursement rate of the intravitreal injection of Lucentis. VRC did not follow the Lucentis label’s instructions limiting dosage to one per vial. Instead, VRC treated up to three patients from a single vial. Because VRC was extracting up to three doses from a single vial, it was reimbursed for three times the average cost of the vial and three times the amount it would have received had it administered the drug according to the label. The court affirmed the denial of recoupment, concluding that VRC's charge to Medicare did not reflect its expense and was not medically reasonable; the Secretary's decision was supported by substantial evidence; and VRC is liable for the overpayment. View "Vitreo Retinal Consultants v. U.S. Dep't of Health & Human Servs." on Justia Law

Plaintiff appealed the denial of her application for disability insurance benefits, contending in part that the district court should have remanded the case to the Commissioner for further proceedings to consider new evidence. The court agreed with the Sixth Circuit's rejection of the notion that the mere existence of a subsequent decision in the claimant's favor, standing alone, warranted reconsideration of the first application. In this case, the only “new evidence” plaintiff cites in support of her request for remand is the later favorable decision. The court concluded that the later decision is not evidence for purposes of 42 U.S.C. 405(g). Because plaintiff does not offer any other new evidence, she has not established that remand is warranted. The court also concluded that the ALJ's conclusion that plaintiff was able to perform light work was supported by substantial evidence and that the ALJ gave adequate weight to the opinion of her treating physician, finding it inconsistent with the medical records and other evidence. Accordingly, the court affirmed the judgment. View "Hunter v. SSA" on Justia Law