Justia Public Benefits Opinion Summaries

Articles Posted in US Supreme Court
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The Medicare program offers additional payments to institutions that serve a “disproportionate number” of low-income patients, 42 U.S.C. 1395ww(d)(5)(F)(i)(I), calculated using the hospital’s “Medicare fraction.” The fraction’s denominator is the time the hospital spent caring for patients entitled to Medicare Part A benefits; the numerator is the time the hospital spent caring for Part-A-entitled patients who were also entitled to income support payments under the Social Security Act. Medicare Part C (Medicare Advantage) was created in 1997. Part C, beneficiaries may choose to have the government pay their private insurance premiums rather than pay for their hospital care directly. Part C enrollees tend to be wealthier than Part A enrollees, so counting them makes the fraction smaller and reduces hospitals’ payments. In 2014, the Medicare website indicated that fractions for fiscal year 2012 included Part C patients. Hospitals sued, claiming violation the Medicare Act’s requirement to provide public notice and a 60-day comment period for any “rule, requirement, or other statement of policy . . . that establishes or changes a substantive legal standard governing . . . the payment for services.” The Supreme Court affirmed the D.C. Circuit in agreeing with the hospitals. The government has not identified a lawful excuse for neglecting its statutory notice-and-comment obligations. The 2014 announcement established or changed a “substantive legal standard” not an interpretive legal standard. The Medicare Act and the Administrative Procedures Act do not use the word “substantive” in the same way. The Medicare Act contemplates that “statements of policy” can establish or change a “substantive legal standard." Had Congress wanted to follow the APA in the Medicare Act and exempt interpretive rules and policy statements from notice and comment, it could have cross-referenced the APA exemption, 5 U.S.C. 553(b)(A). View "Azar v. Allina Health Services" on Justia Law

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The Social Security Act permits judicial review of “any final decision . . . after a hearing” by the Social Security Administration (SSA), 42 U.S.C. 405(g). Claimants for Title XVI supplemental security income disability benefits must generally proceed through a four-step process before federal-court review: seek an initial determination of eligibility; seek reconsideration; request a hearing before an administrative law judge (ALJ); and seek review of the ALJ’s decision by the Appeals Council within 60 days of receiving the ALJ’s ruling. If the claimant misses that deadline and cannot show good cause for doing so, the Appeals Council dismisses the request. Smith’s claim for disability benefits was denied on initial determination, upon reconsideration, and on the merits by an ALJ. The Appeals Council dismissed Smith’s request for review as untimely. Smith sought judicial review of the dismissal. The Sixth Circuit affirmed dismissal for lack of jurisdiction, holding that the Appeals Council’s dismissal of an untimely petition is not a “final decision.” A unanimous Supreme Court reversed. An Appeals Council dismissal on timeliness grounds after a claimant has had an ALJ hearing on the merits qualifies as a “final decision . . . made after a hearing” under section 405(g). The Appeals Council’s dismissal is the final stage of review, 20 CFR 416.1472; Smith obtained the kind of hearing that section 405(g) most naturally suggests. The dismissal is not merely collateral but an end to a proceeding in which a substantial factual record has been developed. The Court noted that “Congress designed [the statute as a whole] to be ‘unusually protective’ of claimants” and “the strong presumption that Congress intends judicial review of administrative action.” View "Smith v. Berryhill" on Justia Law

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Biestek, a former construction worker, applied for social security disability benefits, claiming he could no longer work due to physical and mental disabilities. To determine whether Biestek could successfully transition to less physically demanding work, the ALJ heard testimony from a vocational expert regarding the types of jobs Biestek could still perform and the number of such jobs that existed in the national economy. The statistics came from her own market surveys. The expert refused Biestek’s attorney's request to turn over the surveys. The ALJ denied Biestek benefits. An ALJ’s factual findings are “conclusive” if supported by “substantial evidence,” 42 U.S.C. 405(g). The Sixth Circuit and the Supreme Court upheld the ALJ’s determination. A vocational expert’s refusal to provide private market-survey data upon the applicant’s request does not categorically preclude the testimony from counting as “substantial evidence.” In some cases, the refusal to disclose data, considered along with other shortcomings, will undercut an expert’s credibility and prevent a court from finding that “a reasonable mind” could accept the expert’s testimony; the refusal will sometimes interfere with effective cross-examination, which a reviewing court may consider in deciding how to credit an expert’s opinion. In other cases, even without supporting data, an applicant will be able to probe the expert’s testimony on cross-examination. The Court declined to establish a categorical rule, applying to every case in which a vocational expert refuses a request for underlying data. The inquiry remains case-by-case, taking into account all features of the expert’s testimony, with the rest of the record, and defers to the presiding ALJ. View "Biestek v. Berryhill" on Justia Law

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For representation in administrative proceedings, the Social Security Act provides that if a fee agreement exists, fees are capped at the lesser of 25% of past-due benefits or a set dollar amount—currently $6,000, 42 U.S.C. 406(a)(2)(A); absent an agreement, the agency may set any “reasonable” fee, section 406(a)(1). In either case, the agency is required to withhold up to 25% of past-due benefits for direct payment of fees. For representation in court proceedings, section 406(b) caps fees at 25% of past-due benefits; the agency may withhold benefits to pay these fees. Culbertson represented Wood in Social Security disability benefit proceedings before the agency and in court. The agency ultimately awarded Wood past-due benefits, withheld 25%, and awarded Culbertson fees under section 406(a) for representation before the agency. Culbertson sought a separate award under 406(b) for the court proceedings, requesting 25% of past-due benefits. The Eleventh Circuit held that 406(b)’s 25% limit applies to the total fees awarded under both sections. The Supreme Court reversed. Section 406(b)(1)(A)’s 25% cap applies only to fees for court representation, not to the aggregate fees awarded under 406(a) and (b). The subsections address different stages of the representation and use different methods for calculating fees. Applying 406(b)’s 25% cap on court-stage fees to 406(a) agency-stage fees, or the aggregate fees, would make little sense and would subject 406(a)(1)’s reasonableness limitation to 406(b)’s 25% cap—a limitation not included in the statute. The fact that the agency presently withholds a single pool of past-due benefits for payment of fees does not support an aggregate reading. The amount of past-due benefits that the agency can withhold for payment does not delimit the amount of fees that can be approved for representation before the agency or the court. View "Culbertson v. Berryhill" on Justia Law