Justia Public Benefits Opinion SummariesArticles Posted in US Court of Appeals for the Sixth Circuit
T.M. v. DeWine
Child foster care systems in this country are administered by state governments. The federal government reimburses states for “foster care maintenance payments” that the state makes to certified foster caregivers who meet federal-eligibility requirements. In Ohio, there are also foster caregivers (typically relatives) whom the state does not certify as meeting those federal requirements. Ohio withholds payments for those caregivers and provides these non-certified caregivers with less generous payments through a separate state program. The plaintiffs, foster caregivers whom Ohio has considered ineligible to receive the higher foster care maintenance payments, sued. The district court dismissed, finding that the caregivers did not have to meet the same licensing standards as licensed caregivers in Ohio and thus were not “foster family homes” as required by federal law.The Sixth Circuit affirmed. Title IV-E of the Social Security Act, 42 U.S.C. 671 (a), requires that all foster family homes eligible for payments under federal law meet the same licensing standards; the plaintiffs are subject to different standards than “licensed” caregivers are not “foster family home,” and are not eligible for the higher payments. View "T.M. v. DeWine" on Justia Law
J. B-K. v. Kentucky Cabinet for Health and Family Services
Under the Social Security Act’s Title IV-E program, states receive reimbursements for foster care maintenance payments (FCMPs), 42 U.S.C. 670–676. Title IV-E’s conditions include having a state plan approved by the Secretary of Health and Human Services (HHS); the removed child’s placement and care must be the responsibility of the state agency administering that plan. Kentucky's approved plan is administered by the Kentucky Cabinet for Health and Family Services. Under Kentucky law, a court may remove a child from her home “to the custody of an adult relative, fictive kin,” or other person or facility or can commit the child to the custody of the Cabinet. The Cabinet does not provide FCMPs to children placed by courts into the care of a relative or fictive kin, although that is a preferred outcome for the child.Caregivers brought a class action, accusing the Cabinet of denying FCMPs to eligible children without notice or a fair hearing, in a way that discriminated against relative caregivers. The district court certified a Children’s Class, a Caregivers’ Class, a Cabinet Custody Class, and a Notice and Hearing Class. The Sixth Circuit affirmed the dismissal of the suit except as to the Cabinet Custody Class. Under Kentucky law, the Cabinet did not have placement and care responsibility over children not in their custody; the Cabinet cannot change a child’s placement without a court order. Only Cabinet Custody Class members were eligible for FCMPs. View "J. B-K. v. Kentucky Cabinet for Health and Family Services" on Justia Law
Steigerwald v. Commissioner of Social Security
Class Counsel discovered the Social Security Administration's (SSA’s) systemic failure to perform “Subtraction Recalculations” and recovered over $106 million in past-due disability benefits. After performing the Subtraction Recalculations for all the claimants, the SSA argued that the district court did not have authority under the Social Security Act’s judicial-review provision, 42 U.S.C. 405(g), to order the Subtraction Recalculations and that Class Counsel cannot recover attorney fees under section 406(b) for representation of the claimants.The Sixth Circuit affirmed the award of $15.9 million in attorney fees to Class Counsel. SSA “may not hide behind” the statutory provisions merely because it erred at the end, rather than at the beginning, of the benefits-award process. The district court appropriately exercised judicial review under section 405(g), properly ordered the SSA to perform the Subtraction Recalculations, and properly awarded reasonable attorneys’ fees. The SSA failed to award claimants additional past-due benefits to which they were entitled. Counsel successfully sought judicial assistance to obtain those benefits. Congress did not create a statute that allows attorneys to recover fees when the SSA initially fails to award benefits, only to foreclose fee recovery when the SSA later unlawfully withholds additional benefits. View "Steigerwald v. Commissioner of Social Security" on Justia Law
Huscoal, Inc. v. Director, Office of Workers’ Compensation Programs, United States Department of Labor
Clemons worked as a coal miner for 10 years and smoked two packs per day for 30 years. Clemons suffered and died from COPD. His claims for federal black-lung benefits (30 U.S.C. 901) were denied. An ALJ awarded Mrs. Clemons survivor’s benefits after considering three medical opinions. Dr. Sikder diagnosed Clemons with legal pneumoconiosis in the form of COPD that resulted from both cigarette smoking and from coal-mine dust exposure. Doctros Habre and Broudy attributed Clemons’s COPD solely to his cigarette smoking. The ALJ credited Sikder’s opinion as well-documented, well-reasoned, and supported by substantial evidence, irrespective of the length of coal mine employment she considered, so that opinion was accorded “probative weight” while the other opinions did not sufficiently explain why Clemons’s coal-mine dust exposure did not contribute “at least in part” to his COPD. The Benefits Review Board affirmed, concluding that the evidence was sufficient to establish the presence of legal pneumoconiosis.The Sixth Circuit denied a petition for review, finding that the ALJ took the coal mine employment discrepancy into account when he weighed Dr. Sikder’s opinion, and acted within his discretion in explaining that the discrepancy was not so great as to detract from the opinion’s probative value. View "Huscoal, Inc. v. Director, Office of Workers’ Compensation Programs, United States Department of Labor" on Justia Law
Samons v. National Mines Corp.
After working underground in coal mines for three decades, Casey developed pneumoconiosis (black-lung disease). His widow, Mabel, sought benefits under the Black Lung Benefits Act, 30 U.S.C. 901–44. It took the Department of Labor 17 years to deny her claims. During this time, the claims bounced back and forth between an ALJ and the Benefits Review Board. In the last appeal, the Board also rejected one of Mabel’s main arguments, citing “law-of-the-case,” without reaching the merits. The Department of Labor then delayed things further by filing an incomplete and disorganized administrative record in the Sixth Circuit.The Sixth Circuit affirmed. While the government’s actions “perhaps could be described as poor customer service, they do not show any reversible legal error.” The Board could lawfully invoke the discretionary law-of-the-case doctrine to avoid reexamining an issue on which it had affirmed the ALJ years before. The credibility findings concerning the conflicting medical opinions concerning whether Casey was totally disabled or had only “moderate impairment” pass muster under the deferential “substantial evidence” test. View "Samons v. National Mines Corp." on Justia Law
Owsley v. Fazzi Associates., Inc.
Owsley. a nurse for Care Connection, a company providing home healthcare to Medicare patients, alleged that she observed, firsthand, documents showing that her employer had used fraudulent data from Fazzi to submit inflated claims for payment to the federal and Indiana state governments. She sued both companies under the False Claims Act, 31 U.S.C. 3729(a)(1)(A), (B), (C), (G), and an Indiana statute.The Sixth Circuit affirmed the dismissal of the suit. Owsley’s complaint provided few details that would allow the defendants to identify any specific claims—of the hundreds or likely thousands they presumably submitted—that she thinks were fraudulent, and did not meet the requirements of Civil Rule 9(b). While Owsley’s allegations describe, in detail, a fraudulent scheme: Fazzi fraudulently upcoded patient data, which Care then used to submit inflated requests for anticipated Medicare payments, that information does not amount to an allegation of “particular identified claims” submitted pursuant to the fraudulent scheme. View "Owsley v. Fazzi Associates., Inc." on Justia Law
Doucette v. Commissioner of Social Security
Attorney Conn represented Plaintiffs and thousands of other claimants in seeking disability benefits from the Social Security Administration. Conn bribed doctors to certify false applications and bribed an ALJ to approve those applications. After Conn’s scheme was uncovered, the SSA identified over 1,700 applications for redetermination of eligibility. Years of litigation ensued. Both Plaintiffs sought attorney’s fees under the Equal Access to Justice Act (EAJA), 28 U.S.C. 2412(d)(1)(A). Both courts awarded fees less than the amounts requested.The Sixth Circuit vacated the awards. Courts can award attorney’s fees for work performed during “all phases of successful civil litigation addressed by” the EAJA; one district court erred by holding that the EAJA does not authorize fees for work performed after the judgment becomes final. Both district courts abused their discretions by awarding below-market hourly rates. Plaintiffs’ unrefuted evidence established a market range of $205-500 but the courts concluded that the relative simplicity of the actions justified rates of only $125 and $150, although there is no evidence that any lawyer in the relevant communities would accept these rates for any kind of service. The complexity of the action is relevant to determine where the particular attorney’s representation lies along the spectrum of the market for legal services. It cannot be invoked to justify a rate below the established spectrum. View "Doucette v. Commissioner of Social Security" on Justia Law
Rahimi v. Rite Aid Corp.
Rite Aid’s “Rx Savings Program” provides generic prescription drugs at reduced prices. The program is free and widely available but excludes customers whose prescriptions are paid by publicly funded healthcare programs like Medicare or Medicaid. Federal regulations require pharmacies to dispense prescriptions for beneficiaries of those programs at their “usual and customary charge to the general public” (U&C rate). Rahimi alleged that Rite Aid overbilled the government programs because the amounts it charged did not take into account the lower Rx Savings Program prices. Rahimi claimed Rite Aid's submission of bills for those covered by publicly funded health insurance, representing the price to be the U&C rate, violated the False Claims Act, 31 U.S.C. 3729(a).The Sixth Circuit affirmed the dismissal of Rahimi’s claim. The Act’s public disclosure bar precludes qui tam actions that merely feed off prior public disclosures of fraud. From the beginning, communications about the Rx Savings Program have stated that publicly funded health care programs were ineligible for the discounted prices. Before Rahimi’s disclosures, Connecticut investigated membership discount prices; the Department of Health and Human Services announced that it would review Medicaid claims for generic drugs to determine the extent to which large chain pharmacies are billing Medicaid the usual and customary charges for drugs provided under their retail discount generic programs; and a qui tam action was unsealed in California, describing an identical scheme. View "Rahimi v. Rite Aid Corp." on Justia Law
River City Fraternal Order of Police v. Kentucky Retirement Systems
The plaintiffs retired from the Louisville Metropolitan police department and received free health insurance, administered by Kentucky Retirement Systems. Kentucky initially paid all of their healthcare costs. After the officers turned 65, Medicare became the primary payer, leaving Kentucky to cover secondary expenses. Each officer came out of retirement, joining county agencies different from the ones they served before retiring. They became eligible for healthcare benefits in their new positions. Kentucky notified them that federal law “mandate[d]” that it “cannot offer coverage secondary to Medicare” for retirees “eligible to be on [their] employer’s group health plan” as “active employees.” Some of the officers then paid for insurance through their new employers; others kept their retirement insurance by quitting or going part-time. The officers sued.The district court granted summary judgment to the officers, ordered Kentucky to reinstate their retirement health insurance, and awarded the officers some of the monetary damages requested. The Sixth Circuit affirmed. The officers have a cognizable breach-of-contract claim. Under Kentucky law, the Kentucky Retirement Systems formed an “inviolable contract” with the officers to provide free retirement health insurance and to refrain from reducing their benefits, then breached that contract. The Medicare Secondary Payer Act of 1980 did not bar Kentucky from providing Medicare-eligible police officers with state retirement insurance after they reentered the workforce and became eligible again for employer-based insurance coverage, 42 U.S.C. 1395y. View "River City Fraternal Order of Police v. Kentucky Retirement Systems" on Justia Law
Vitolo v. Guzman
The American Rescue Plan Act of 2021 allocated $29 billion for grants to help restaurant owners. The Small Business Administration (SBA) processed applications and distributed funds on a first-come, first-served basis. During the first 21 days, it gave grants only to priority applicants--restaurants at least 51% owned and controlled by women, veterans, or the “socially and economically disadvantaged,” defined by reference to the Small Business Act, which refers to those who have been “subjected to racial or ethnic prejudice” or “cultural bias” based solely on immutable characteristics, 15 U.S.C. 637(a)(5). A person is considered “economically disadvantaged” if he is socially disadvantaged and he faces “diminished capital and credit opportunities” compared to non-socially disadvantaged people who operate in the same industry. Under a pre-pandemic regulation, the SBA presumes certain applicants are socially disadvantaged including: “Black Americans,” “Hispanic Americans,” “Asian Pacific Americans,” “Native Americans,” and “Subcontinent Asian Americans.” After reviewing evidence, the SBA will consider an applicant a victim of “individual social disadvantage” based on specific findings.Vitolo (white) and his wife (Hispanic) own a restaurant and submitted an application. Vitolo sued, seeking a preliminary injunction to prohibit the government from disbursing grants based on race or sex. The Sixth Circuit ordered the government to fund the plaintiffs’ application, if approved, before all later-filed applications, without regard to processing time or the applicants’ race or sex. The government failed to provide an exceedingly persuasive justification that would allow the classification to stand. The government may continue the preference for veteran-owned restaurants. View "Vitolo v. Guzman" on Justia Law