Justia Public Benefits Opinion Summaries

The Supreme Court reversed the decision of the court of appeal affirming the conclusion of the State Department of Health Care Services that the costs of outreach and education activities aimed at Medicaid-eligible patients were categorically nonreimbursable, holding that the chief administrative law judge's ruling was an abuse of discretion.Health care providers entitled to government reimbursement, including federally qualified health centers (FQHCs), for reasonable costs related to the care of Medicaid beneficiaries are required to offer outreach and education activities to members of underserved communities. The FQHC operator in this case sought reimbursement for the outreach and education costs, but the Department determined that the costs were nonreimbursable. The court of appeal affirmed. The Supreme Court reversed, holding that the Department's determination rested on a misunderstanding of relevant legal principles governing the reimbursement of medical provider costs. View "Family Health Centers of San Diego v. State Dep't of Health Care Services" on Justia Law

Following a 2013 car accident, Michelle Baptist, then 50 years old, began experiencing significant neck and shoulder pain, as well as headaches. She had one, possibly two, aneurysms. She applied for Disability Insurance Benefits and Supplemental Security Income the following year. After reviewing her medical records and conducting a hearing, an administrative law judge concluded that Baptist retained the capacity to perform light work and, therefore, was not disabled.The Seventh Circuit affirmed the decision as supported by substantial evidence. Despite initial complications from an aneurysm clipping procedure, Baptist’s medical records indicate that she made a full recovery and experienced no ongoing aneurysm-related symptoms. Two doctors reviewed Baptist’s 2018 MRI. Neither recorded any concerns nor did they observe any impact the MRI results would have on Baptist’s functional capacity. They noted that Baptist presented with full upper and lower extremity strength, normal reflexes, a normal gait, and “no overt weakness.” View "Baptist v. Kijakazi" on Justia Law

Grounds served in the Army from 1969-1972. He was charged with being AWOL during three periods in 1972 (less than 180 days). To avoid a court-martial. Grounds requested to be discharged “for the good of the service,” citing marital and financial problems and stating, if he were to remain in the Army, he would continue going AWOL. Grounds was discharged “[f]or the good of the [s]ervice” and “[u]nder conditions other than [h]onorable.”In 2013, Grounds applied for veterans' benefits. The VA found his multiple periods of AWOL constituted “willful and persistent misconduct,” rendering him ineligible for benefits under 38 C.F.R. 3.12(d)(4). The Board of Veterans Appeals agreed, concluding his discharge was considered “dishonorable” for VA benefits purposes. The Federal Circuit affirmed the Veterans Court's rejection of an argument that 38 U.S.C. 5303(a) controls and cannot be superseded by 38 C.F.R. 3.12(d)(4). Section 5303(a) provides that a veteran is not eligible for benefits if he was discharged by reason of court-martial on the basis of being AWOL for a continuous period of at least 180 days. Under Federal Circuit precedent, section 5303(a) is not the exclusive test for benefits eligibility; 38 C.F.R. 3.12(d)(4) is consistent with and authorized by statute. While Grounds’ misconduct did not constitute a statutory bar to VA benefits under section 5303. the Board did not clearly err in finding that his multiple periods of AWOL constituted a regulatory bar to benefits. View "Grounds v. McDonough" on Justia Law

The Supreme Court held that because Plaintiff's state-law claims were based on allegations that his father's health maintenance organization (HMO) plan and healthcare services administrator that managed his father's benefits (collectively, Defendants) breached state-law duties that incorporated and duplicated standards established under Medicare Part C, Part C's preemption provision preempted them.Plaintiff brought this action alleging a state statutory claim under the Elder Abuse Act and common law claims of negligence and wrongful death for the alleged maltreatment of his father, a Medicare Advantage (MA) enrollee who died after being discharged from a skilled nursing facility. Plaintiff alleged that the MA HMO and healthcare services administrator breached a duty to ensure his father received skilled nursing benefits to which he was entitled under his MA plan. Defendants demurred, arguing that the claims were preempted by Part C's preemption provision. The trial court sustained the demurrers, and the court of appeal affirmed. The Supreme Court affirmed, holding that because Plaintiff's state-law claims were based on allegations that Defendants breached state-law duties that incorporate and duplicate standards established under Part C, the claims were expressly preempted. View "Quishenberry v. UnitedHealthcare, Inc." on Justia Law

The Supreme Court held that a claim for reimbursement of emergency medical services may be maintained against a health care service plan when the plan is operated by a public entity and that the Government Claims Act, Cal. Gov. Code 810 et seq., did not immunize the County of Santa Clara from such a claim in this case.Two hospitals submitted reimbursement claims for the emergency medical services they provided to three individuals enrolled in a County-operated health care service plan. The hospitals sued for the remaining amounts based on the reimbursement provision of the Knox-Keene Act, and the trial court concluded that the hospitals could state a quantum merit claim against the County. The court of appeal reversed, determining that the County was immune from suit under the Government Claims Act. The Supreme Court reversed, holding that the County was not immune from suit under the circumstances of this case and that the hospitals' claims may proceed. View "County of Santa Clara v. Superior Court" on Justia Law

Crowell sought Supplemental Social Security Insurance benefits in 2010, alleging that she was unable to work due to ADHD, social anxiety, fibromyalgia, bipolar disorder, borderline personality disorder, chronic pain, panic attacks, arthritis, shoulder pain, back pain, OCD, anxiety, depression, insomnia, asthma, and COPD. The ALJ agreed that certain impairments were severe as defined under the regulations: fibromyalgia, depressive disorder, anxiety disorder, and impairments of her left shoulder which remained after surgical correction, and also considered Crowell’s claims that she suffered from asthma, back problems, substance abuse, and “absence” spells, but deemed that none of those conditions met the criteria of severe impairments. The Social Security Administration denied her application.After several appeals and remands, the district court upheld the denial of benefits. The Seventh Circuit affirmed. The ALJ appropriately followed the five-step process for evaluating whether a plaintiff is disabled, 20 C.F.R. 416.920, considering whether the claimant is currently employed, has a severe impairment or combination of impairments, has an impairment that meets or equals any impairment listed as being so severe as to preclude substantial gainful activity, has residual functional capacity that leaves her unable to perform past relevant work, and is unable to perform any other work existing in significant numbers in the national economy. View "Crowell v. Kijakazi" on Justia Law

The Supreme Court affirmed the decision of the district court entering summary judgment for the United States and rejecting the lawsuit brought by Appellant asking the district court to overturn the finding of the Food and Nutrition Service (FNS) of the United States Department of Agriculture that Appellant was disqualified from further participation in the supplemental nutrition assistance program (SNAP), holding that there was no error.FNS disqualified Appellant from further participation in SNAP after investigating evidence of unlawful trafficking in SNAP benefits. Thereafter, Appellant brought this action seeking to overturn the FNS's liability finding and asking the court to vacate the order of program disqualification as arbitrary and capricious. The district court entered summary judgment for the United States. The Supreme Court affirmed, holding (1) the district court did not err in entering summary judgment in favor of the United States on the liability issue; and (2) the sanction of the permanent disqualification order from the program was neither arbitrary nor capricious. View "AJ Mini Market, Inc. v. United States" on Justia Law

Plaintiff filed in the U.S. District Court for the Western District of Washington a pro se action to challenge the denial of his claim for disability benefits by the Social Security Administration. A magistrate judge of that court, acting with the full civil authority of that court, reversed and remanded the matter to the agency for rehearing after the government conceded that there was an error in the agency’s adjudication. Plaintiff appealed that decision.   The Ninth Circuit affirmed. The panel considered whether the magistrate judge had authority to exercise the full civil jurisdiction of the district court over Plaintiff’s claim. There is no doubt that the district court had jurisdiction over the case, but Plaintiff challenged whether he had given the consent that was required for a magistrate judge to exercise that jurisdiction. The panel held that it had jurisdiction to review the antecedent question of whether the magistrate judge validly entered judgment on behalf of the district court. The panel rejected Plaintiff’s contention that, as a pro se litigant, he believed he was consenting to the magistrate judge’s issuance of a report and recommendation, not a final judgment. The panel held that Plaintiff was fully informed of the district court’s conclusion that he had knowingly and voluntarily consented to the assignment to the magistrate judge. Further, the court wrote that Plaintiff was unable to show good cause or extraordinary circumstances to withdraw consent. The panel affirmed the district court’s conclusion that Plaintiff consented to magistrate judge jurisdiction. View "VICTOR WASHINGTON V. KILOLO KIJAKAZI" on Justia Law

Martinez applied for supplemental security income. An ALJ reviewed the record and found that Martinez suffered from severe impairments but could nonetheless “perform the requirements of representative unskilled occupations such as a checker, routing clerk, and mail sorter.” After the Appeals Council denied Martinez’s request to review the decision, Martinez filed suit, then notified the Commissioner that the administrative record (pages within exhibit B15F) included medical records regarding a different claimant. In filing the administrative record with the court, the Commissioner noted that it was the full record. The pages relating to the other claimant were removed and replaced with a placeholder reading: “THIS PAGE WAS REMOVED AS AN EXHIBIT BY THE APPEALS COUNCIL BECAUSE IT DOES NOT REFER TO THE CLAIMANT.” Neither Martinez nor the district court saw the omitted pages. The Commissioner refused to produce the pages. Martinez moved to compel the Commissioner to include the full exhibit in the administrative record. The district court denied that motion, stating that “[t]he ALJ [only] cited the third-party records in exhibit B15F … as additional potential evidence that Mr. Martinez had an impairment.” The district court then affirmed the denial as supported by substantial evidence.The Seventh Circuit reversed. The decision is not supported by substantial evidence because it relies on medical records belonging to someone other than Martinez; it is impossible to determine whether that error was harmless. View "Martinez v. Kijakazi" on Justia Law

The VA’s Schedule for Rating Disabilities includes diagnostic codes (DCs), each with a corresponding disability rating, 38 U.S.C. 1155. A particular veteran’s disability may not clearly fall under a delineated DC. VA regulations provide: When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected but the anatomical localization and symptomatology are closely analogous. The VA considers the functions affected by ailments, the anatomical localization of the ailments, and the symptomatology of the ailments.Webb served in the Army, from 1968-1970, receiving an honorable discharge. Webb later developed service-connected prostate cancer, the treatment for which caused him to develop erectile dysfunction (ED). In 2015, Webb was assigned a non-compensable (zero percent) rating for his ED. The Schedule did not then include a diagnostic code for ED. The VA rated Webb’s disability by analogy to DC 7522, which provides a 20 percent disability rating for “[p]enis, deformity, with loss of erectile power.” The Board explained that DC 7522 required Webb to show “deformity of the penis with loss of erectile power.” Without such a deformity, he was not entitled to a compensable disability rating. The Veterans Court affirmed. The Federal Circuit vacated. The listed disease or injury to which a veteran’s unlisted condition is being rated by analogy must be only “closely related,” not identical. View "Webb v. McDonough" on Justia Law