Justia Public Benefits Opinion Summaries

A Massachusetts’ Medicaid beneficiary received services at Arbour, a mental health facility owned by Universal’s subsidiary. The teenager had an adverse reaction to a medication that a purported doctor prescribed after diagnosing her with bipolar disorder. She died of a seizure. Her parents discovered that few Arbour employees were licensed to provide mental health counseling or to prescribe medications without supervision. They filed a qui tam suit, alleging violations of the False Claims Act (FCA), which imposes penalties on anyone who “knowingly presents . . . a false or fraudulent claim for payment or approval” to the federal government, 31 U.S.C. 3729(a)(1)(A). They alleged an “implied false certification theory of liability,” which treats a payment request as an implied certification of compliance with relevant statutes, regulations, or contract requirements that are material conditions of payment. They cited Universal’s failure to disclose serious violations of Massachusetts Medicaid regulations and claimed that Medicaid would have refused to pay the claims had it known of the violations. The First Circuit reversed dismissal, in part. A unanimous Supreme Court vacated. The FCA does not define a “false” or “fraudulent” claim; the claims at issue may be actionable because they do more than merely demand payment. Representations that state the truth only so far as it goes, while omitting critical qualifying information, can be actionable misrepresentations. By conveying specific information about services without disclosing violations of staff and licensing requirements, Universal’s claims constituted misrepresentations. FCA liability for failing to disclose violations of legal requirements does not depend upon whether those requirements were expressly designated as conditions of payment. While statutory, regulatory, and contractual requirements are not automatically material, even if labeled as conditions of payment, a defendant can have “actual knowledge” that a condition is material even if the government does not expressly call it a condition of payment. View "Universal Health Servs., Inc. v. United States" on Justia Law

The issue before the New Jersey Supreme Court in this case was whether the 2011 suspension of State pension cost-of-living adjustments (COLAs) contravened a term of the contract right granted under the earlier enacted non-forfeitable right statute, L.1997, c.113 (codified as N.J.S.A.43:3C-9.5). Qualifying members of the State's public pension systems or funds were granted a non-forfeitable right to receive benefits as provided under the laws governing the retirement system or fund. By codifying that non-forfeitable right to receive benefits, the Legislature provided that the benefits program, for any employee for whom the right has attached, could not be reduced. Whether COLAs were part of the benefits program protected by N.J.S.A. 43:3C-9.5 depended on whether the Legislature, in enacting N.J.S.A. 43:3C-9.5(a) and (b), intended to create a contractual right to COLAs. The Supreme Court found in this instance, proof of unequivocal intent to create a non-forfeitable right to yet-unreceived COLAs was lacking. Although both plaintiff retirees and the State advanced plausible arguments on that question, "the lack of such unmistakable legislative intent dooms plaintiffs' position." The Court concluded that the Legislature retained its inherent sovereign right to act in its best judgment of the public interest and to pass legislation suspending further COLAs. Having determined that there was no contract violation, and because the additional arguments advanced by plaintiffs were not meritorious, the Court reversed the Appellate Division's judgment holding to the contrary. View "Berg v. Christie" on Justia Law

Plaintiff appealed the denial of his social security benefits. In a case of first impression, the court held that the law of the case doctrine and the rule of mandate apply to social security administrative remands from federal court in the same way they would apply to any other case. In this case, the court concluded that, given the new evidence - highly probative testimony about plaintiff's ability to perform his past work and a new finding supporting that testimony - the district court did not abuse its discretion in declining to apply the law of the case doctrine. Given the expansive remand orders in this case, the ALJ did not violate the rule of mandate. The court also held that the ALJ properly categorized plaintiff’s past work and correctly found that he was still able to perform that work as it is generally performed in the national economy. Accordingly, the court affirmed the judgment. View "Stacy v. Colvin" on Justia Law

In 2010-2011, the San Francisco Unified School District employed 11 substitute teachers who worked on an as-needed basis and 15 paraprofessional classified employees. Each of the 26 employees received a letter during the spring of the 2010-2011 school year advising that they had a reasonable assurance of employment for the following 2011-2012 school year. The 26 sought unemployment benefits for the period between the last date of the regular session of the 2010-2011 school year, May 27, 2011, and the first day of instruction for the 2011-2012 school year, August 15, 2011. The Employment Development Department denied benefits. The California Unemployment Insurance Appeals Board reversed. The trial court and court of appeals ruled in favor of the District: “in effect what the claimants ... are requesting is … a full year‘s income … they have agreed to work and be paid for only 41 weeks of each year. … school employees can plan for those periods of unemployment and thus are not experiencing the suffering from unanticipated layoffs that the employment-security law was intended to alleviate.” View "United Educators of San Francisco. v. Cal. Unemp. Ins. Appeals Bd." on Justia Law

Petitioner has been employed by the Raleigh County Board of Education as a physical therapist since 1987. Her initial “Teacher’s Probationary Contract of Employment” provided that she would be paid an annual salary “for an annual employment term of 120 days.” In 1989, petitioner executed a “Continuing Contract of Employment,” which likewise provided that she was to be employed “for an employment term of 120 days.” She requested enrollment in the Teachers’ Retirement System (TRS). Contributions on petitioner’s behalf were made to TRS continuously from 1987 through 1991, when she enrolled in the newly-created Teachers’ Defined Contribution System and froze her TRS contributions. In 1999, she transferred her TRS funds and service credit into TDC. In 2008, petitioner transferred back to the TRS. The Board ascertained that petitioner was ineligible to participate in either plan because she was only working 120 days a year and indicated that the money contributed would be returned to her and her employer. Petitioner testified that she believed that those working less than 200 days were not ineligible, but would merely receive fractional service credit for the year. The hearing examiner determined that West Virginia Code 18-7A-3 requires a 200-day contract before one may participate in TRS, but that there was no such 200-day requirement to participate in TDC. The circuit court affirmed. The Supreme Court of Appeals affirmed, stating that it was “sympathetic," but could not confer statutory eligibility where none exists. View "Ringel-Williams v. W.V. Consol. Pub. Retirement Bd." on Justia Law

In 2005, D.U., then three years old, was severely injured in a car accident. She qualified for Wisconsin Medicaid services on financial grounds and was provided extensive medical care until August 2013. After a change in family circumstances, D.U. no longer qualified on financial grounds. Wisconsin continued to provide the same services under its “Katie Beckett Program,” which funds Medicaid benefits for children who are otherwise ineligible because of the assets or income of their parents, 42 U.S.C. 1396a(e)(3). The state noted that D.U., whose condition had substantially improved over the years, was “borderline” for meeting the criteria to qualify for private duty nursing care and later informed D.U. and her father that D.U. no longer qualified for those services. D.U.filed a new request for 70 hours per week of private duty nursing and submitted additional information, but the request was denied. D.U. did not appeal the denial, but sought a preliminary injunction. The district court concluded that the evidence that D.U. submitted in support of her request for injunctive relief failed to demonstrate a likelihood of success on the merits. The Seventh Circuit affirmed, holding that D.U. failed to demonstrate that she will suffer irreparable harm if the injunction is denied. View "D. U. v. Rhoades" on Justia Law

Appellant James Corn appealed a circuit court order denying his petition to establish a special-needs trust pursuant to 42 U.S.C. 1396p(d)(4)(A). Corn was disabled because of a head injury from which he suffered short-term memory loss. Because of the severity of his injury, he received Social Security Disability (SSD) and Supplemental Security Income (SSI). Corn’s eligibility made him automatically eligible for Medicaid. However, SSI had an asset test which stated that Corn would become ineligible if he were to have assets of more than $2,000. Because of this, Corn’s partner, Ms. Yelvington, now deceased, established a special-needs trust for him. Yelvington also designated Corn as a beneficiary on life insurance policies and her bank accounts. There was approximately $260,000 that was not transferred into the special-needs trust created by Yelvington, and because Corn was designated as the beneficiary on these assets they would pass directly to Corn upon Yelvington’s death. Because these assets would be passing directly to Corn rather than through a special-needs trust, Corn would be ineligible to receive SSI benefits. In order to prevent this, Corn attempted to create a "D4A" trust. At the time of the circuit court hearing, Yelvington had passed away and her estate was in probate. Corn had not yet received any funds from her estate or from her beneficiary designations. In its order denying Corn’s motion for reconsideration, the circuit court found that the establishment of the trust would be against Arkansas public policy and that there was insufficient evidence presented to support that a special-needs trust should be established. The Supreme Court found that through his testimony at the hearing and by attaching letters from the Social Security Administration to his motion for reconsideration, Corn provided the circuit court with sufficient evidence of his disability. Therefore, the Court held that the circuit court erred in finding that there was insufficient evidence that Corn was disabled. The circuit court’s order was reversed and the case remanded for a determination of whether the proposed D4A trust met the requirements set forth in the statute. View "In re Corn" on Justia Law

Plaintiff alleged a disability due to gout, arthritis, back pain, diabetes, high blood pressure, and obesity. In this appeal, he challenged the denial of his application for disability insurance benefits under Title II of the Social Security Act, 42 U.S.C. 405. The ALJ found that plaintiff was capable of performing his past relevant work as a farm worker. The court concluded that the ALJ's determination that plaintiff's residual functioning capacity (RFC) to do medium work, with some limitations, is supported by substantial evidence and that the ALJ sufficiently developed the record. In this case, the objective medical findings do not support the degree of limitation alleged by plaintiff. Finally, the court rejected plaintiff's contention that the ALJ failed to adequately develop the record. Accordingly, the court affirmed the judgment. View "Buford v. Colvin" on Justia Law

Caring Hearts Personal Home Services, Inc. provided physical therapy and skilled nursing services to “homebound” Medicare patients. It sought reimbursement from Medicare for services provided. The definition of who qualified as "homebound" or what services qualified as "reasonable and necessary" was unclear, even to the Centers for Medicare & Medicaid Services (CMS). CMS has developed its own rules on both subjects that had been repeatedly revised and expanded over time. In an audit, CMS purported to find that Caring Hearts provided services to at least a handful of patients who didn’t qualify as “homebound” or for whom the services rendered weren’t “reasonable and necessary.” As a result, CMS ordered Caring Hearts to repay the government over $800,000. It was later found that in reaching its conclusions CMS applied the wrong law: the agency did not apply the regulations in force in 2008 when Caring Hearts provided the services in dispute. Instead, it applied considerably more onerous regulations the agency adopted years later, "[r]egulations that Caring Hearts couldn’t have known about at the time it provided its services." The Tenth Circuit found that Caring Hearts "[made] out a pretty good case that its services were entirely consistent with the law as it was at the time they were rendered" when CMS denied Caring Hearts' request for reconsideration. The Tenth Circuit reversed the district court's judgment affirming CMS' denial to Caring Hearts for reimbursement, and remanded for further proceedings. View "Caring Hearts v. Burwell" on Justia Law

In 2009 Crespo applied for Supplemental Security Income benefits for his mother, representing that she lived with him in Illinois and that he took care of her. He served as her representative payee. By signing the form, Crespo acknowledged that he could be held liable for any improper overpayments he caused. Crespo’s mother was not entitled to those benefits because she lived in Puerto Rico (20 C.F.R. 416.215), which Crespo hid from the Social Security Administration by falsely representing, in three subsequent reports as representative payee, that she lived with him. Airline records established that she resided in Puerto Rico; his mother was serving as representative payee for her own mother’s retirement benefits, declaring herself a resident of Puerto Rico. An ALJ imposed a $114,956 civil penalty on Crespo for misrepresentation. The Departmental Appeals Board of the Department of Health and Human Services dismissed his appeal as untimely. The Seventh Circuit affirmed. The Board did not abuse its discretion in rejecting Crespo’s untimely appeal and finding good cause lacking. Appeals are due 30 days after the ALJ’s initial decision is deemed served. A copy of the regulation is included when the decision is delivered. Crespo offered no reason why he did not request an extension. View "Crespo v. Colvin" on Justia Law