Justia Public Benefits Opinion Summaries

Articles Posted in US Court of Appeals for the District of Columbia Circuit
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Hospitals treating Medicare beneficiaries receive greater reimbursements to the extent that the beneficiaries are also entitled to supplemental security income benefits under Title XVI of the Social Security Act. The Secretary of Health and Human Services understands this population to include only patients receiving cash payments during the month in question. Various hospitals contend that this population also includes patients receiving a subsidy under Medicare Part D and vocational training. The district court disagreed and granted summary judgment to the Department of Health and Human Services (HHS).   The DC Circuit affirmed. The court explained that the hospitals argued that Empire compels their construction of the phrase “entitled to supplementary security income benefits.” The court wrote that this s argument misses key distinctions between the Part A and SSI schemes. First, Part A benefits extend well beyond payment for specific services at specific times. Moreover, the court explained that age or chronic disability makes a person eligible for Part A benefits “without an application or anything more,” and individuals rarely, if ever lose this eligibility over time.   Moreover, the court explained that the hospitals contend that HHS arbitrarily excluded patients whose SSI benefits were withheld under the so-called “cross-program recovery” scheme. The court reasoned that this assertion is mistaken. Next, the court explained that the hospitals contend that HHS unreasonably focused on whether patients receive SSI payments when hospitalized because the payments depend on income and resource levels from earlier months. But “eligibility” for the SSI benefit “for a month” depends on the individual’s income, resources, and other characteristics “in such month.” View "Advocate Christ Medical Center v. Xavier Becerra" on Justia Law

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Appellant applied for Supplemental Security Income based on disability. While her application was pending, the Social Security Administration promulgated rules with new criteria for demonstrating disability and made them applicable to pending claims like Appellant’s. An Administrative Law Judge subsequently found Appellant ineligible for benefits under those updated criteria. Appellant then filed suit in federal district court, and the court overturned the agency’s decision on the ground that application of the new criteria was impermissibly retroactive. The court ordered the agency to reconsider Appellant’s case under the criteria in place when she first filed her claim. The district court rejected all of Appellant’s other challenges to the agency’s decision. Both parties appealed.   The DC Circuit reversed the district court’s decision and remand for further proceedings. The court held that hat application of the new criteria to Appellant’s pending claim was not retroactive, but that the Administrative Law Judge erred in his analysis of evidence from Appellant’s treating physician. The court remanded with instructions to the district court to remand the matter to the Administration to reconsider Appellant’s claim while either according controlling deference to her treating physician’s opinion or offering a substantively reasonable explanation for not doing so. View "Angela Cox v. Kilolo Kijakazi" on Justia Law

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More than a decade ago, Medicaid recipients filed this suit alleging that in violation of the Due Process Clause, the District of Columbia is failing to provide them notice and an opportunity to be heard when denying them prescription coverage. The case is now before the DC Circuit for the third time. In the first two appeals, the DC Circuit reversed the district court’s dismissals for lack of standing and for failure to state a claim, respectively. On remand, the district court once more dismissed the case, this time for mootness.   The DC Circuit again reversed and remanded with instructions to proceed expeditiously with discovery and allow Plaintiffs to make their case. The court explained that Plaintiffs challenged the District’s failure to give Medicaid recipients reasons for denying their prescriptions and an explanation of how to appeal, and uncontested evidence demonstrates that, notwithstanding the transmittal memorandum, some number of Plaintiffs are still not receiving the information they claim they are entitled to under the Due Process Clause. Because it is not “impossible for [the district] court to grant any effectual relief,” the case is not moot. View "Elsa Maldonado v. DC" on Justia Law

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Petitioners PF Sunset Plaza, LLC (“Sunset Plaza”) and PF Holdings, LLC (“Holdings”) were each assessed monetary penalties by the Department of Housing and Urban Development (“HUD”) for violations of their duty to provide “decent, safe, and sanitary housing” to low-income families under Section 8. Petitioners petitioned to reverse ALJ decisions dismissing these HUD enforcement actions against them for lack of subject matter jurisdiction. At issue on appeal is whether the statute operates to bar the appeal of a civil monetary penalty should a respondent miss the fifteen-day deadline to request an administrative hearing?   The DC Circuit answered yes, and denied both petitions. The court explained that Petitioners claim that because the deadline falls under a subheading entitled “Final Orders,” a final order from HUD must occur before operation of the deadline commences. Petitioners argued that HUD’s issuance of a complaint is simply an invitation to engage in litigation, not a triggering of the fifteen-day deadline. Because HUD issued no final order here, they contest that the fifteen-day period never began. The court held that Petitioners misunderstand the statutory subheading. Congress entitled the section “Final Orders” because it enumerates two examples of how HUD’s penalties become final. View "PF Holdings, LLC v. HUD" on Justia Law

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In 2016, the Secretary of Health and Human Services (“HHS”) issued a final rule that implemented The Protecting Access to Medicare Act of 2014 (“PAMA” or “Act”), definition of “applicable laboratory” (“2016 Rule”). The American Clinical Laboratory Association (“ACLA”) filed a lawsuit challenging the 2016 Rule as arbitrary and capricious under the Administrative Procedure Act (“APA”) on the basis that it depresses Medicare reimbursement rates by excluding most hospital laboratories from PAMA’s reporting requirements. ACLA contended that because hospital laboratories tend to charge higher prices than standalone laboratories, their exclusion from reporting obligations results in an artificially low weighted median.   On remand, the parties cross-moved for summary judgment. The district court declined to reach the merits of ACLA’s APA challenge to the 2016 Rule, based on its determination that the Secretary had issued a new rule (“2018 Rule”) that superseded the 2016 Rule and mooted ACLA’s lawsuit.   The DC Circuit concluded that the case is not moot. Accordingly, the court reversed the district court’s dismissal for lack of subject matter jurisdiction and reached the merits of ACLA’s APA claim. The court explained that the 2016 Rule is arbitrary and capricious because the agency “failed to consider an important aspect of the problem.” The court wrote that PAMA provides that an applicable laboratory “means a laboratory that” receives “a majority” of its Medicare revenues from the Physician Fee Schedule or Clinical Laboratory Fee Schedule. Thus, hospital laboratories that provide outreach services may, in some instances, constitute “applicable laboratories” under PAMA. View "American Clinical Laboratory Association v. Xavier Becerra" on Justia Law

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UnitedHealthcare Medicare Advantage insurers challenged the Overpayment Rule, promulgated by the Centers for Medicare and Medicaid Services (CMS) under 42 U.S.C. 1301-1320d-8, 1395-1395hhh, in an effort to trim costs. The Rule requires that, if an insurer learns that a diagnosis submitted to CMS for payment lacks support in the beneficiary’s medical record, the insurer must refund that payment within 60 days. UnitedHealth claims that the Overpayment Rule is subject to a principle of “actuarial equivalence,” and fails to comply. Two health plans that pay the same percentage of medical expenses are said to have benefits that are actuarially equivalent.The D.C. Circuit rejected the challenge. Actuarial equivalence does not apply to the Overpayment Rule or the statutory overpayment-refund obligation under which it was promulgated. Reference to actuarial equivalence appears in a different statutory subchapter from the requirement to refund overpayments; neither provision cross-references the other. The actuarial-equivalence requirement and the overpayment-refund obligation serve different ends. The actuarial-equivalence provision requires CMS to model a demographically and medically analogous beneficiary population in traditional Medicare to determine the prospective lump-sum payments to Medicare Advantage insurers. The Overpayment Rule, in contrast, applies after the fact to require Medicare Advantage insurers to refund any payment increment they obtained based on a diagnosis they know lacks support in their beneficiaries’ medical records. View "UnitedHealthcare Insurance Co v. Becerra" on Justia Law

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In 2008, four long-term care hospitals that treat patients who are dually eligible for the Medicare and Medicaid programs were denied reimbursement by the Secretary of Health and Human Services for “bad debts,” unpaid coinsurances and deductibles owed by patients. The Secretary denied reimbursement on the grounds that the hospitals failed to comply with the “must-bill” policy, 42 C.F.R. 413.89(e)(2), which requires hospitals to bill the state Medicaid program to determine whether Medicaid will cover the bad debts first, and obtain a “remittance advice” indicating whether the state “refuses payment,” before seeking reimbursement under Medicare. uring the relevant time period, the hospitals were not enrolled in Medicaid and were unable to bill their state Medicaid programs; they claim they were previously reimbursed and that there was an abrupt policy change.The D.C. Circuit affirmed summary judgment for the Secretary, concluding that substantial evidence supported a finding that there was no change in policy. The court rejected arguments that the denial decision impermissibly required them to enroll in Medicaid, despite the fact that Medicaid participation is voluntary, and was arbitrary. View "New LifeCare Hospitals of North Carolina LLC v. Becerra" on Justia Law

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Saunders worked as a bus attendant for the Washington, D.C., school system, helping students with special needs and those in wheelchairs on and off the bus. On January 7, 2014, she slipped and fell on ice at work, suffering a hip contusion and back pain. Saunders never returned to work but filed a disability claim with the Social Security Administration six months after her fall. She obtained multiple opinions from Dr. Williams, her generalist, and Dr. Liberman, her neurologist. Saunders received disability benefits from the Washington, D.C., workers’ compensation board.After Saunders’s federal disability claims were denied an ALJ held a hearing and concluded that she was not disabled. The ALJ gave “some” weight to certain medical opinions but “no weight” to others, including Dr. Lieberman’s opinion that Saunders was permanently disabled. The ALJ placed considerable weight on the vocational expert’s testimony and found that someone with Saunders’s functional capacity could perform her past work as generally performed in the national economy. The district court affirmed. The D.C. Circuit remanded. The ALJ erroneously failed to consider certain medical opinions, particularly those of Saunders’s treating physician. View "Saunders v. Kijakazi" on Justia Law

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When Medicare overpays hospitals, it offsets that mistake by reducing future payments. By 2013, Medicare was out $11 billion because of new diagnostic codes and bookkeeping that did not keep up. Congress required that the Secretary of Health and Human Services recoup that amount by the end of fiscal year 2017 by reducing the base rate (standardized amount) paid for inpatient care and directed the Secretary to adjust the base rate by 0.5% each year through 2023, 129 Stat. 87, 163 (2015). Subsequently, while reviewing the 2017 budget, the Secretary realized that a -3.2% adjustment would leave the agency short of its $11 billion goal and announced a -3.9% adjustment. Congress then told the Secretary to increase the base rate by 0.4588% (not 0.5%) in 2018, 130 Stat. 1033, 1320 (2016). In 2017, the Secretary adjusted the base rate -3.9%. The agency met its goal. In 2018, the Secretary adjusted the base rate -3.4412%.Medicare providers sued, arguing that the Secretary should have reversed that expedient at the end of 2017 rather than carry it over into 2018, costing the hospitals $840 million in lost payments. The D.C. Circuit affirmed the dismissal of the suit. While the hospitals felt a “significant financial impact” from the -0.7% adjustment, Section 7(b)(5) bars judicial review of adjustments made under the Act. View "Fresno Community Hospital and Medical Center v. Cochran" on Justia Law

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Plaintiff filed suit alleging that DCPS failed to provide her son with a free appropriate public education (FAPE) based on his 2017 individualized education program (IEP). The DC Circuit affirmed the district court's dismissal of the claim as moot, holding that the case presents a fact-specific challenge to particular provisions in an inoperative IEP. Furthermore, the parties agreed to a subsequent IEP and plaintiff does not seek retrospective relief. The court also held that an exception to mootness does not apply where the voluntary cessation doctrine is inapplicable and plaintiff's claim fails to meet the capable of repetition prong because the challenge focuses on a fact-specific inquiry rather than a recurring legal question. View "J. T. v. District of Columbia" on Justia Law