Justia Public Benefits Opinion Summaries

Pursuant to federal law, California’s Medi-Cal program requires beneficiaries to use other health coverage (OHC) they may have before accessing Medi-Cal benefits. The state Department of Health Care Services (DHCS) maintains a database with codes that indicate whether a Medi-Cal beneficiary has OHC and, to some extent, the scope of that coverage. The codes are available to providers when a beneficiary seeks services. Medi-Cal beneficiaries filed suit. Because DHCS allegedly permits Medi-Cal providers to refuse nonemergency services to beneficiaries with OHC, and because the codes are not always correct and the information is limited, beneficiaries may be improperly denied service and referred to other providers even when there is no OHC available for the requested service; beneficiaries may experience delays in receiving nonemergency care and may be subject to a higher copayment than permitted under Medi-Cal. Plaintiffs argued that the assignment of an OHC code should trigger notice and a hearing. The trial and appeals courts rejected their arguments. Neither Welfare and Institutions Code 10950 nor regulation 50951 nor the California Constitution requires DHCS to provide a hearing or notice when it assigns an OHC code. Plaintiffs did not establish any violation of a ministerial duty subject to enforcement by a writ of mandate. View "Marquez v. Dept. of Health Care Servs." on Justia Law

Plaintiffs each applied for Medicaid institutional care coverage shortly after purchasing a short-term annuity. The Pennsylvania Department of Human Services (DHS) classified each of their annuities as a resource when determining Medicaid eligibility. This classification meant that the value of each annuity precluded them from receiving Medicaid assistance and resulted in a penalty period of ineligibility. The district court held that the plaintiffs’ purchases of the short-term annuities were sham transactions intended only to shield resources from Medicaid calculations, and affirmed DHS’s imposition of a period of Medicaid ineligibility, but held that, contrary to DHS’s arguments, a Pennsylvania statute that purported to make all annuities assignable was preempted by federal law. The Third Circuit affirmed in part, finding that the statute was preempted, but reversed in part, citing “safe harbor” provisions, under which, certain annuities are not considered resources for purposes of Medicaid eligibility, 42 U.S.C. 1396p(c)(1)(F). The court noted the qualifications for safe-harbor protection: the annuity must name the state as the remainder beneficiary, be irrevocable and nonassignable, be actuarially sound, and provide for payments in equal amounts during its term, with no deferral and no balloon payments. The court rejected the state’s argument that the annuities were “trust-like.” View "Zahner v. Sec'y Pa. Dept. of Human Servs." on Justia Law

Most Medicare recipients must pay monthly premiums in addition to various co-payments and deductibles, 42 U.S.C. 1395. States that receive federal Medicaid funds must assist certain low-income Medicare beneficiaries with payment of their out-of-pocket expenses related to the Medicare program. To be eligible for such assistance, a Medicare beneficiary must have income less than or equal to certain percentages of the federal poverty line “for a family of the size involved[.]” In calculating 74-year-old Turner’s family size to determine eligibility for assistance, the Ohio Department of Medicaid did not include Turner’s wife, who lives with him, and denied benefits. Ohio generally does not count a Medicare beneficiary’s spouse as a member of his “family.” The Sixth Circuit held that the Department’s use of an individual-need standard to deny applications and the state’s exclusion spouses in determining the size of a family, was contrary to federal law View "Wheaton v. McCarthy" on Justia Law

On April 25, 2011, Marcella Atkinson entered a long-term care facility. On June 16, 2011, Marcella and her husband Raymond submitted a Medicaid application for Marcella’s care. On August 9, 2011, Marcella transferred title to the house to Raymond. On September 28, 2011 the Knox County Department of Job and Family Services approved Marcella for Medicaid. The agency, however, delayed Medicaid benefits for Marcella until April 2012, asserting that the transfer of the home to Raymond was improper because it exceed the community-spouse resource allowance (CSRA) and was for less than fair market value. The Ohio Department of Job and Family Services upheld the determination. The Fifth District Court of Appeals affirmed. The Supreme Court affirmed, holding (1) during the period between an application for Medicaid benefits and the notice of Medicaid approval, Medicaid law allows an institutionalized spouse to transfer a home or equivalent assets to a spouse living in the community to the extent that it does not exceed the CSRA; and (2) in this case, the state may have imposed a penalty on Raymond that was not authorized by law. Remanded. View "Estate of Atkinson v. Ohio Dep’t of Job & Family Servs." on Justia Law

Hesseltine is “within the Borderline range of mental functioning.” She graduated from high school in 2003, reading at a sixth grade level. Hesseltine underwent several childhood surgeries to treat a leg impairment caused by Perthes disease, which cuts off blood flow to the hip. From 2004 to 2005, Hesseltine worked irregularly as a cook’s helper. From 2005 to 2007, Hesseltine worked part-time at a laundry business with the help of a job coach. In 2009, Hesseltine worked briefly as a casino housekeeper. In 2006, Hesseltine was diagnosed with polycystic ovarian syndrome, she manages her syndrome with medication. In 2007, a doctor observed limitation in flexion of her left hip and knee, “probably due to obesity.” Hesseltine lives with her husband and performs some household tasks, but reported that she could not walk more than a block without needing to rest and could lift a gallon of milk at a maximum. Hesseltine applied for disability insurance benefits. An ALJ denied the application, finding that her combination of impairments did not meet or medically equal a listed impairment in 20 C.F.R. 404, and that there were jobs in the economy that Hesseltine could perform. The Eighth Circuit remanded; the ALJ failed to sufficiently address whether her impairments medically equal Listing 12.05C. View "Hesseltine v. Colvin" on Justia Law

Alaura, age 22, was struck in the back of his head by an assailant wielding a bar stool. The blow shattered his skull, necessitating emergency surgery to remove part of his brain and place a metal plate in his skull. During this craniotomy Alaura had a seizure. Alaura has repeatedly seen neurologists, complaining of headaches, dizziness, and confusion, and has been diagnosed with post-traumatic headaches, cognitive impairment, and occipital neuralgia, an injury to or inflammation of nerves that run from the spinal cord at the base of the neck up through the scalp. It causes piercing or throbbing pain in the neck, the back of the head, and the front of the head behind the eyes. A year later, Alaura still complained of daily headaches, “absence-type” seizures several times a week, and back and neck pain. The Seventh Circuit reversed denial of Alaura’s claim for social security disability benefits as premature, stating that the “long list” of severe impairments “don’t sound like trivial obstacles to being able to hold full-time employment.” The administrative law judge’s explanations were “thin,” he made no effort to consider the combined effects on Alaura’s ability to work of all his impairments and limitations. View "Alaura v. Colvin" on Justia Law

Plaintiff-appellant Christopher J. Warner served as a municipal and then superior court judge from July 1996 until his retirement in October 2010. In November 2010, he applied for a disability retirement benefit under the Judges' Retirement System II Law (JRS II). Defendant-respondent California Public Employees' Retirement System (CalPERS) granted his application, and he was awarded a monthly retirement allowance, paying him an amount equal to 65 percent of his retirement-level salary. In May 2011, Judge Warner applied to CalPERS to receive a distribution of his monetary credits in the JRS II system, which totaled $572,407. CalPERS staff denied the request. Judge Warner appealed that decision to the CalPERS Board of Administration. After a hearing, the administrative law judge (ALJ) issued a proposed decision recommending the staff decision be affirmed. The Board adopted the ALJ's recommendation. In January 2013, Judge Warner filed a petition for writ of mandate in San Bernardino County Superior Court challenging the Board's decision. The Judicial Council assigned the case to Los Angeles County Superior Court, which later an order denying the petition. This appeal presented a matter of first impression for the Court of Appeal: a question of statutory interpretation regarding the JRS II. Judge Warner contended that under JRS II, he was entitled to receive both a disability retirement allowance and payment of the monetary credits he accrued during his service. CalPERS ruled JRS II entitles Judge Warner only to the disability retirement allowance. The trial court denied Judge Warner's petition for writ of mandate, which sought to reverse the agency's ruling. Finding no reversible error in the Superior Court's judgment, the Court of Appeal affirmed. View "Warner v. CalPERS" on Justia Law

This case arose from the Secretary’s decision in 2005 to change the boundaries of the geographic areas used to compute regional wage indices. A group of hospitals challenged the Secretary's decision to include wage data from Southcoast campuses outside the Boston-Quincy area in calculating the index for that area for fiscal years 2006 and 2007. The court concluded that the Secretary's treatment of Southcoast hewed to the existing administrative treatment of such multi-campus hospital groups; there were substantial informational and operational obstacles to implementing a different computational method quickly in 2006 or retroactively; appellants admit that the temporary effect of Southcoast’s multi-campus data on the wage index was a “one-off” occurrence arising from “unusual circumstances” that apparently did not affect any other multi-campus hospital group’s treatment; and nothing in the Medicare Act, 42 U.S.C. 1395 et seq., or established principles of administrative review mandate that the Secretary individually tailor one hospital’s reporting treatment to fit appellants' preferred computational outcome. Accordingly, the court affirmed the judgment. View "Anna Jacques Hospital v. Burwell" on Justia Law

The Defense Contract Management Agency within the Department of Defense (DOD) employed Vassallo as a computer engineer in 2012. That summer, it announced a vacancy for the position of Lead Interdisciplinary Engineer, stating that only certain individuals could apply: “[c]urrent [DCMA]” employees or “[c]urrent [DOD] [e]mployee[s] with the Acquisition, Technology, and Logistics . . . [w]orkforce who are outside of the Military Components.” Vassallo, a veteran, applied, but DCMA rejected his application. The Office of Personnel Management (OPM) determined that DOD was not required to afford him veterans employment preferences under the Veterans Employment Opportunities Act of 1998 (VEOA), 112 Stat. 3182. OPM defines the word “agency” in 5 U.S.C. 3304(f)(1) to mean “Executive agency” as defined in 5 U.S.C. 105 and concluded that DCMA was not required to give Vassallo an opportunity to compete under 5 U.S.C. 3304(f)(1) because the DOD— the agency making the announcement—did not accept applications from outside its own workforce. Vassallo sought corrective action from the Merit Systems Protection Board, which concluded that OPM’s regulation permissibly fills a gap in the governing statute. The Federal Circuit affirmed, rejecting arguments that the OPM regulation contradicts the plain terms of the statute and unreasonably undermines the purpose of the VEOA. View "Vassallo v. Dept. of Defense" on Justia Law

During the Vietnam War, herbicides were applied near the Korean DMZ in 1968-1969. The 2003 Veterans Benefits Act authorized benefits for children with spina bifida born to certain veterans, 38 U.S.C. 1821. In 2004, the VA amended its Manual to provide benefits for “individuals born with spina bifida who are the children of veterans who served with specific units … between September 1, 1967 and August 31, 1971” conceding that certain veterans who served in April 1968 to July 1969 were exposed to herbicides. The final rule, effective February, 2011, was applicable “to all applications for benefits that are received by VA on or after February 24, 2011 and to all applications … pending before VA,” the Veterans Court, or the Federal Circuit on February 24, 2011. McKinney filed a claim in 2010 for service connection based on exposure to Agent Orange during his DMZ service, which began in August 1969. The VA denied his claim. The period of presumed exposure expired one month before McKinney’s service. The VA finalized the 2011 regulation, which extended the presumed exposure period, and granted McKinney’s claim under that regulation, but denied him an effective date earlier than February 2011, so that he received benefits for the post-2011 portion of his claim. The Federal Circuit upheld the VA’s decision to assign the 2011 regulation a prospective effective date. View "McKinney v. McDonald" on Justia Law