Articles Posted in US Court of Appeals for the Sixth Circuit

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Bowling worked as a coal miner for 29 years, most recently for Island Fork. In 2002, Bowling unsuccessfully sought Black Lung Benefits Act (BLBA) benefits. In 2010, Bowling filed the current claim. In the meantime, the Affordable Care Act amended the BLBA to reinstate a rebuttable presumption that claimants with respiratory disabilities and 15 years or more of underground coal-mining work experienced those disabilities as a result of pneumoconiosis, 30 U.S.C. 921(c)(4). The District Director designated Island Fork as the responsible operator and awarded benefits. At a hearing, the ALJ learned that Island Fork and its insurer, Frontier were insolvent. Frontier declared insolvency after the Proposed Order issued. At the initial stages, if the District Director determines that an operator is not financially capable, the Director can select another operator—such as a previous employer—to be the responsible operator; once the claim reaches the ALJ, there is no mechanism to designate a different responsible operator. The Trust Fund, created by the BLBA, provides benefits when there are no responsible operators available, including when an operator is deemed at the ALJ stage not to be financially capable. KIGA, created by the Kentucky Insurance Guaranty Association Act, provides benefits when a member insurance company is insolvent. The ALJ decided that Island Fork was still the responsible operator because benefits could be paid by KIGA. The Sixth Circuit affirmed. The exclusions in the Guaranty Act do not apply; KIGA is liable. View "Island Fork Construction v. Bowling" on Justia Law

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Federal Medicaid funds are not available for state medical expenditures made on behalf of “any individual who is an inmate of a public institution (except as a patient in a medical institution),” 42 U.S.C. 1396d(a)(29)(A). "Inmate of a public institution" means a person who is living in a public institution. However, an individual living in a public institution is not an “inmate of a public institution” if he resides in the public institution “for a temporary period pending other arrangements appropriate to his needs.” Ohio submitted a proposed plan amendment aimed at exploiting this distinction: it sought to classify pretrial detainees under age 19 as noninmates, living in a public institution for only “a temporary period pending other arrangements appropriate to [their] needs,” for whom the state could claim Medicaid reimbursement. The Centers for Medicare and Medicaid Services rejected the amendment, finding that the inmate exclusion recognizes “no difference” between adults and juveniles, or convicted detainees and those awaiting trial. The Sixth Circuit denied a petition for review, agreeing that the involuntary nature of the stay is the determinative factor. The exception does not apply when the individual is involuntarily residing in a public institution awaiting adjudication of a criminal matter. View "Ohio Department of Medicaid v. Price" on Justia Law

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Critical Access Hospitals are reimbursed by Medicare for the reasonable and necessary costs of providing services to Medicare patients. The Medicaid program requires states to provide additional (DSH) payments to hospitals that serve a disproportionate share of low-income patients, 42 U.S.C. 1396a(a)(13)(A)(iv). In Kentucky, DSH payments are matched at 70% by the federal government. Kentucky’s contribution to DSH programs comes from payments from state university hospitals and Kentucky Provider Tax, a 2.5% tax on the revenue of various hospitals, including Appellants, The amount of DSH payments a hospital receives is unrelated to the amount of KP-Tax it paid. During the years at issue, DSH payments covered only 45% of Appellants' costs in providing indigent care. Appellants filed cost reports in 2009 and 2010 claiming their entire KP-Tax payment as a reasonable cost for Medicare reimbursement. Previously, they had received full reimbursement; for 2009 and 2010, however, the Medicare Administrative Contractor denied full reimbursement, offsetting the KP-Tax by the amount of DSH payments Appellants received. The Provider Reimbursement Review Board and Centers for Medicare and Medicaid Services upheld the decision. The Sixth Circuit affirmed, reasoning that the net economic impact of Appellants’ receipt of the DSH payment in relation to the cost of the KP-Tax assessment indicated that the DSH payments reduced Appellants’ expenses such that they constituted a refund. View "Breckinridge Health, Inc. v. Price" on Justia Law