Justia Public Benefits Opinion Summaries

Claimant argued that the administrative law judge (“ALJ”) erred by rejecting the uncontested opinion of a non-examining physician, that supported her claim. Under the pre-2017 regulations that apply to the claim, ALJs are required to give greater weight to certain medical opinions. To reject the uncontested opinion of an examining or treating doctor, an ALJ must provide “clear and convincing” reasons supported by substantial evidence.   The Ninth Circuit affirmed the district court’s decision affirming the denial of claimant’s application for disability benefits under Title II of the Social Security Act. The panel held that the “clear and convincing” standard did not apply to the physician’s opinion because he never treated or examined claimant. Rather his opinion was based solely on a review of claimant’s medical records. The panel held that nothing in the relevant regulations required an ALJ to defer to an opinion from a non-treating, non-examining medical source. In rejecting the physician’s opinion, the ALJ cited specific contradictive medical evidence in the record. In making these findings, the ALJ cited the record at length. The panel concluded that this satisfied the requirements of Sousa v. Callahan, 143 F.3d 1240, 1244 (9th Cir. 1998), the relevant regulations, and the substantial evidence standard. Further, the panel concluded that the district court properly concluded that the ALJ’s denial of benefits was supported by substantial evidence View "RUTH FARLOW V. KILOLO KIJAKAZI" on Justia Law

A Social Security Administration ALJ, appointed by agency staff rather than by the Commissioner as required, reviewed and denied claimant’s initial claims. Without challenging the ALJ’s appointment, the claimant appealed to the district court and prevailed in part. The district court vacated the 2017 ALJ decision and ordered a new hearing because the ALJ failed to properly consider certain evidence. The case returned to the same ALJ, who by then had been properly ratified by the Acting Commissioner. The ALJ again denied benefits, and claimant appealed to the district court, raising the issue of an Appointments Clause violation. The district court affirmed the ALJ decision and denied the Appointments Clause claim because the 2017 decision had been vacated and the ALJ was properly appointed when she issued the 2019 decision.   Because the ALJ’s decision was tainted by a prior Appointments Clause violation, the Ninth Circuit vacated the district court’s decision affirming the Commissioner of Social Security’s denial of claimant’s application for benefits under the Social Security Act and remanded with instructions to the Commissioner to assign the case to a different, validly appointed ALJ to rehear and adjudicate claimant’s case de novo. The panel held that under Lucia, the claimant was entitled to a new hearing before a different ALJ. The panel concluded that claimants are entitled to an independent decision issued by a different ALJ if a timely challenged ALJ decision is tainted by a pre-ratification ALJ decision. View "BRIAN CODY V. KILOLO KIJAKAZI" on Justia Law

The Ninth Circuit reversed in part and vacated in part the district court’s grant of Defendants’ motion to dismiss, and remanded for further proceedings, in an action in which federally-qualified health centers operating in Arizona and their membership organization alleged that the Arizona Health Care Cost Containment System, which administers Arizona’s Medicaid program, and its director violated 42 U.S.C. Section 1396a(bb) and binding Ninth Circuit precedent by failing or refusing to reimburse Plaintiffs for the services of dentists, podiatrists, optometrists, and chiropractors.   First, the panel held that the court’s precedent in California Ass’n of Rural Health Clinics v. Douglas (“Douglas”), 738 F.3d 1007 (9th Cir. 2013), established that FQHC services are a mandatory benefit under Section 1396d(a)(2)(C) for which Plaintiffs have a right to reimbursement under Section 1396a(bb) that is enforceable under 42 U.S.C. Section 1983. The panel rejected Defendants’ interpretation of Section 1396d(a)(2)(C)’s phrase “which are otherwise included in the plan” as applying to both the phrases “FQHC services” and “other ambulatory services offered by a [FQHC.]” The panel, therefore, rejected Defendants’ assertion that Section 1396d(a)(2)(C) only required states to cover FQHC services that are included in the state Medicaid plan.   The panel recognized that Douglas held that the mandatory benefit of “FQHC services” under § 1396d(a)(2)(C) includes “services furnished by . . . dentists, podiatrists, optometrists, and chiropractors” as well as doctors of medicine and osteopathy. The panel held that Arizona’s categorical exclusion of adult chiropractic services violated the unambiguous text of the Medicaid Act as interpreted in Douglas. View "AACHC V. AHCCCS" on Justia Law

An Administrative Law Judge (“ALJ”) denied Plaintiff benefits based on the testimony of a vocational expert (“VE”) that there were an estimated 72,000 “Table worker,” 65,000 “Assembler,” and 32,000 “Film touch up inspector” jobs in the national economy that claimant could perform. After the ALJ issued her decision, claimant’s attorney submitted to the Social Security Administration (“SSA”) Appeals Council different estimates for those same jobs, allegedly using the same software program used by the VE. The Appeals Council considered the new evidence but denied claimant’s request for review.The Ninth Circuit reversed the district court’s decision granting summary judgment to the Commissioner of Social Security and affirming the denial of Plaintiff’s claim for Supplemental Security Income (“SSI”) benefits, and remanded to the district court with directions that the case be remanded to the agency for further proceedings. The court held that under Buck v. Berryhill, 869 F.3d 1040 (9th Cir. 2017), remand was required to allow the ALJ to address claimant’s evidence of widely discrepant job number estimates.The claimant estimated—using SkillTRAN Job Browser Pro and the same DOT codes the VE had used—that there were 2,957 table worker, 0 assembler, and 1,333 film tough-up inspector jobs in the national economy. The discrepancy between the VE and the claimant’s estimates was comparable to the discrepancy in Buck. View "TYRONE WHITE V. KILOLO KIJAKAZI" on Justia Law

Plaintiff hospices exceeded their aggregate caps in the 2013 fiscal year, and three Silverado hospices also exceeded their aggregate caps in the 2014 fiscal year. Plaintiffs appealed their cap determinations to the Provider Reimbursement Review Board (“PRRB”), arguing that their MAC had failed to calculate the aggregate cap using the “actual net amount of payment received by the hospice provider.” The Ninth Circuit affirmed the district court’s summary judgment in favor of the government.   The court held that CMS correctly concluded that the Budget Control Act required it to reduce the total annual amounts paid to hospices, not only the periodic reimbursements, and that the agency’s chosen method for implementing sequestration was consistent with the Medicare statute. The court further held that the agency was not required to undertake notice-and-comment rulemaking before implementing the Budget Control Act’s sequestration mandate. The agency’s sequestration method, as reflected in the TDL and the PRRB’s decisions, did not amount to the “establish[ment]” or “change[]” of a substantive legal standard governing payment for services under Medicare, within the meaning of 42 U.S.C. Section 1395hh. Rather, Congress enacted the Budget Control Act’s sequestration requirements, and the President implemented sequestration when the statutory conditions were triggered. View "SILVERADO HOSPICE, INC. V. XAVIER BECERRA" on Justia Law

Appellants, Medicaid providers and former members of public-sector unions, challenge the district courts’ dismissals of two cases, consolidated on appeal. When Appellants joined the unions, they authorized the California State Controller to deduct union dues from their Medicaid reimbursements. Appellants now contend that, when the Controller made these deductions, she violated the “anti-reassignment” provision of the Medicaid Act, which prohibits state Medicaid programs from paying anyone other than the providers or recipients of covered services.   The Ninth Circuit affirmed the district court’s dismissal. The court explained that California uses some of its Medicaid funding to provide assistance with daily activities to elderly and disabled beneficiaries under a program called In-Home Support Services (IHSS). The recipients of these services are responsible for employing and overseeing the work of their IHSS providers, who are often family members. The Controller makes a variety of standard payroll deductions, including for federal and state income tax, unemployment compensation, and retirement savings. California law also authorizes the Controller to deduct union dues from the paychecks of IHSS providers.   Thus, the court held that the Medicaid Act’s anti-reassignment provision, 42 U.S.C. Section 1396a(a)(32), does not confer a right on Medicaid providers enforceable under Section 1983. The text and legislative history of the anti-reassignment provision make clear that Congress was focused on preventing fraud and abuse in state Medicaid programs rather than on serving the needs of Medicaid providers. Because Congress did not intend to benefit Medicaid providers, the anti-reassignment provision did not confer a right as enforceable under Section 1983. View "DELORES POLK V. BETTY YEE" on Justia Law

In denying Plaintiff’s request for Social Security disability benefits, an Administrative Law Judge (ALJ) relied on the testimony of a vocational expert to conclude that a person with Plaintiff’s limitations, age, education, and work experience could still perform jobs that exist in significant numbers in the national economy. On appeal, Plaintiff claimed that the ALJ erred in not addressing competing job numbers that her counsel provided using his own methodology.   The Ninth Circuit affirmed the district court’s judgment upholding the Commissioner of Social Security’s denial of a claimant’s application. The court held in the context of similar challenges to ALJ decisions that an ALJ need only explain his rejection of significant probative evidence. The court reasoned that in accordance with Social Security Act regulations, an administrative law judge (“ALJ”) is entitled to rely on a vocational expert’s testimony to support a finding that the claimant can perform occupations that exist in significant numbers in the national economy.     The court reasoned that to engage in a meaningful review of a disability claim, an ALJ may not ignore significant probative evidence that bears on the disability analysis, but an ALJ need not discuss all evidence that was presented.  Here, Plaintiff’s attorney did not replicate the VE’s methodology, and Plaintiff’s different approach led to different numbers. There is no basis to conclude that these results qualified as significant probative evidence that the ALJ was required to address. View "SARAHROSE KILPATRICK V. KILOLO KIJAKAZI" on Justia Law

Plaintiff filed a lawsuit alleging state law claims arising from SelectHealth’s administration of her deceased husband’s MA plan and his death. Under Part C of the Medicare Act, beneficiaries can enroll in an MA plan and receive Medicare benefits through private MA organizations instead of the government. SelectHealth removed the action to federal court on the basis of diversity jurisdiction.   The Ninth Circuit affirmed the district court’s summary judgment in favor of SelectHealth, Inc. because the Medicare Act’s express preemption provision, 42 U.S.C. Section 1395w-26(b)(3), barred Plaintiff’s state law claims.   The court held that Section 1872 of Title XVIII of the SSA provides that Section 205(h) is applicable to cases under the Medicare Act to the same extent as in cases under Title II. The court concluded that enrollees in an MA plan must likewise first exhaust their administrative remedies before seeking judicial review of a claim for benefits.   Next, the court concluded that Plaintiff’s claims were not subject to the SSA’s exhaustion requirement because the dispute was not whether Plaintiff’s husband received a favorable outcome from the internal benefits determination process but rather whether he should have received the services earlier.   Further, the court held that Plaintiff’s claim that SelectHealth breached a duty to process timely her husband’s October 7, 2016, appeal was expressly preempted. Because the standards established under Part C supersede any state law duty that would impose obligations of MA plans on the same subject. View "NAOMI AYLWARD V. SELECTHEALTH, INC." on Justia Law

Plaintiff was civilly confined by court order pursuant to California’s Sexually Violent Predator Act (“SVPA”), after a probable cause hearing, but before a full civil commitment trial. While confined by court order in a state hospital, Plaintiff applied for Social Security disability benefits. The Social Security Administration (SSA) approved his application, and he received benefits.   In May 2014, the SSA notified Plaintiff that these benefits had been issued in error, and required him to refund the benefits previously paid. Plaintiff challenged that determination and requested a hearing before an Administrative Law Judge (ALJ). After a hearing, the ALJ determined that Section 402(x)(1)(A)(iii) made Plaintiff ineligible for benefits, and ordered him to repay the benefits to the SSA. Plaintiff sought judicial review of the ALJ’s decision and the district court concluded that Plaintiff was not eligible for disability benefits   The Ninth Circuit affirmed and held that the Commissioner did not err in concluding that Plaintiff was not eligible for benefits. The court reasoned the Social Security Act provides that no monthly benefits shall be paid to individuals who are confined at public expense, including someone who “immediately upon completion of confinement” for a criminal sexual offense “is confined in an institution at public expense pursuant to a finding that the individual is a sexually dangerous person or a sexual predator or a similar finding.”  Here, the state trial court’s confinement order in Plaintiff’s case was pursuant to a finding that he was a sexually dangerous person or a sexual predator or a similar finding. View "GEORGE ALLEN V. KILOLO KIJAKAZI" on Justia Law

Plaintiff, who receives two government pensions, one from noncovered employment and one from covered employment, alleged that the Government Pension Offset (“GPO”) should not apply to his benefits. During Plaintiff’s administrative proceedings, the Social Security Administration (“SSA” or the “agency”) agreed with Plaintiff and paid him spousal benefits without applying any offset. Ultimately, though, the agency decided that the GPO should apply. The agency then temporarily withheld Plaintiff’s spousal benefits to recoup approximately $15,000 in overpayments to him, and it reduced his spousal benefits going forward. On appeal, the parties disputed whether the GPO applies to Plaintiff’s spousal benefits and if it does apply, whether the agency was entitled to recoup the overpayment.   The Ninth Circuit held that the GPO applies to Plaintiff’s spousal benefits but that a remand to the agency is necessary to determine whether SSA was entitled to recoupment. The court reasoned that under both the old and new version of Social Security regulation 20 C.F.R. Sec 404.408a, the existence of Plaintiff’s pension earned through noncovered employment triggered the GPO’s application to his spousal benefits notwithstanding his later covered employment in a job with a different pension plan.  Further, the court held that the ALJ’s finding of Plaintiff’s fault for the overpayment was not supported by substantial evidence and that on remand the agency could consider whether any evidence in the record beyond that relied on by the ALJ supported the proposition that Plaintiff was at fault for the overpayment and, if so, whether recoupment would be appropriate. View "PAUL MISKEY V. KILOLO KIJAKAZI" on Justia Law