Justia Public Benefits Opinion Summaries

After Peggy Gheen died, her sons discovered quitclaim deeds Mrs. Gheen had executed to them for her interests in a residential property and a farm. The Gheen sons subsequently recorded the deeds. The State ex rel. Dep’t of Health, Div. of Healthcare Financing/Equitycare (Department) filed a lien against both properties to recover the cost of Medicaid benefits paid on behalf of Mrs. Gheen before her death. The Gheen sons filed a petition to remove a false lien and quiet title, claiming they were the rightful owners of the property. The Department moved for summary judgment, asserting that it had a valid lien because Mrs. Gheen owned the properties at the time of her death and the quitclaim deeds were not valid. The district court granted summary judgment for the Department. The Supreme Court affirmed, holding that the Department’s Medicaid lien was valid as to the properties.View "Gheen v. State ex rel. Dep’t of Health" on Justia Law

Spicer served on active duty in the Navy from 1984 until 1987. In 1986, Spicer fractured his left little finger when a door closed on his hand while aboard ship. The fracture required surgery, which resulted in the finger joint fusing. In 2007, a VA examiner diagnosed Spicer as having degenerative arthritis of the distal interphalangeal joint in that finger. A VA regional office denied Spicer a compensable rating. The Board of Veterans’ Appeals found that although Spicer’s left finger disability was manifested by pain and limitation of motion, he failed to meet the criteria for a compensable evaluation for a left finger disability under either Diagnostic Code (DC) 5227 or 5230. The Veterans Court rejected Spicer’s argument that DC 5003 assigns a 10% rating for either a single affected major joint or a group of affected minor joints and that 38 C.F.R. 4.45(f) does not mandate that multiple minor joints be involved. The Veterans Court stated that “the DIP joint is not a major joint or minor joint group for the purpose of rating disabilities from arthritis.” The Federal Circuit affirmed. View "Spicer v. Shinseki" on Justia Law

Martha Pierce applied for Medicaid assistance after her husband, Gordon Pierce, was admitted to a long-term-care facility. The Department of Human Services (DHS) included Martha’s IRA and 401(k) retirement accounts in calculating Gordon’s resources for purposes of Medicaid eligibility and denied the application. The circuit court reversed, concluding that DHS should not have counted against Gordon’s Medicaid eligibility the retirement accounts owned by Martha. DHS appealed. The Supreme Court reversed, holding that, under the Medicare Catastrophic Coverage Act, retirement accounts owned by a community spouse may be countable resources when determining Medicaid eligibility for an institutionalized spouse. Remanded. View " Ark. Dep't of Human Servs. v. Pierce" on Justia Law

Plaintiffs, Medicaid beneficiaries with near total disabilities, filed suit after being denied coverage for ceiling lifts under a categorical exclusion in the state's implementing Medicaid regulations. The district court granted summary judgment for the state. The court concluded that, under binding precedent, plaintiffs have an implied private cause of action under the Supremacy Clause to pursue their challenge; the state must comply with the requirements of the Medicaid Act, 42 U.S.C. 1396 et seq., but the Act does not preempt the state's categorical exclusions; and therefore, the court affirmed the grant of summary judgment and denied the motion to vacate.View "Detgen, et al. v. Janek" on Justia Law

The New Hampshire Department of Employment Security (DES) Appellate Board (board) appealed a decision that respondent Norman Coulombe was an employee of petitioner, Niadni, Inc. (d/b/a Indian Head Resort Motel) who was entitled to unemployment compensation benefits. Coulombe appeared as a musical entertainer at the resort in both solo and group performances beginning in approximately 1980. He also performed at other venues but testified that he performed at the resort nearly three hundred times in the last two years that he worked there. The resort and Coulombe negotiated a pay rate for Coulombe’s services, and he was paid weekly for his performances. He provided his own instruments and selected the songs he would play in his performances, though the resort asked him to perform new material prior to the end of his relationship with the resort. He reported that his last booking with the resort was in the summer of 2012, after which the relationship terminated. He subsequently filed for unemployment benefits with DES. Finding none of the Resort's arguments persuasive to reverse the Appellate Board's decision, the Supreme Court affirmed. View "Appeal of Niadni, Inc. d/b/a Indian Head Resort Motel" on Justia Law

An ALJ denied plaintiff's application for disability insurance benefits, concluding that she was not disabled because there were jobs she could have performed during the relevant period. The Appeals Council then denied review and plaintiff appealed the Commissioner's final decision to the district court. In this appeal, the government challenged the district court's reversal of the Commissioner's decision. The court reversed and affirmed the Commissioner's final decision, concluding that the ALJ's decision was supported by substantial evidence on the record.View "Turpin v. Colvin" on Justia Law

Petitioners were two medical providers whose patients included individuals insured by the State’s primary health benefit plan. The State Comptroller reviewed Petitioners’ billing records as part of an audit of billing practices in the health care industry for claims paid by the State. While Petitioners conceded that the State paid eighty percent of the costs of their services, Petitioners challenged the Comptroller’s authority to audit their books. Supreme Court concluded that the Comptroller lacked constitutional authority to audit Petitioners because Petitioners were “not a political subdivision of the State.” The Appellate Division modified Supreme Court’s orders to reinstate the audits. The Court of Appeals affirmed, holding that the State Constitution does not limit the Comptroller’s authority to audit, as part of its audit of State expenditures, the billing records of private companies that provide health care to beneficiaries of a State insurance program.View "Martin H. Handler, M.D., P.C. v. DiNapoli" on Justia Law

Holder was an Illinois correctional officer since 2006. His wife began to suffer from mental health problems relating to opiate dependency. The Family and Medical Leave Act (FMLA) entitles eligible employees to 12 work weeks of leave during a 12-month period to care for a spouse with a serious medical condition, 29 U.S.C. 2612(a)(1). In October 2007, Holder submitted an FMLA certification form. His wife’s psychiatrist indicated that it would “be necessary for the employee to take off work only intermittently or to work less than a full schedule as a result of the condition,” and that the need for leave would continue for an “unknown” duration. The request was approved. The state never asked for additional medical documentation and paid its share of his health insurance premium until April 18, 2008. About 130 days of absence were recorded on a day-by-day basis. On April 18, 2008, Holder was advised that his FMLA leave had expired and that additional leave would be under the Illinois Family Responsibility Leave program, which allows up to a year of unpaid leave; the state only covers insurance premiums for six months. In April-June 2008, Holder took 29 absences, citing the state program. The Warden disapproved requests for June 8-9 and on the denied form, Holder wrote “last one!!!” Eight months later Central Management Services informed Holder that the state had mistakenly paid for his health insurance premiums beyond his entitlement and began deducting 25% of his earnings until he had refunded $8,291.83. Holder sued, claiming interference with FLMA rights. The jury returned a verdict in favor of the state, but the judge entered judgment awarding Holder $1,222.10 for January 2008, but entered a judgment for the state for the rest of the months. The Seventh Circuit affirmed.View "Holder v. IL Dep't of Corrs." on Justia Law

In 2006, Michael Wilson, a former Bristol-Myers Squibb Co. (“BMS”) sales presentative, filed a complaint alleging that BMS engaged in off-label promotion of certain drugs, and that these actions caused false claims to be submitted to the government in violation of the False Claims Act (“FCA”). Wilson subsequently entered in a partial settlement agreement with BMS that concluded part of the case. In 2009, Wilson filed a second amended complaint expanding upon his earlier, not settled, allegations against BMS and adding Sanofi-Aventis, U.S., LLC as a defendant. In 2013, the district court dismissed Wilson’s federal FCA claims relating to Plavis and Pravachol because they violated the FCA’s first-to-file rule based on two complaints that were filed before Wilson filed his original complaint. Wilson appealed from the dismissal as well as from the denial of his motion to file a third amended complaint and from denial of his follow-up motion to reconsider. The First Circuit Court of Appeals affirmed, holding (1) the district court properly dismissed the remaining FCA claims because they ran afoul of the first-to-file rule; and (2) the district court was correct in rejecting the third amended complaint. View "United States ex rel. Wilson v. Bristol-Myers Squibb, Inc. " on Justia Law

In 1997, in response to Congress’s enactment of the Personal Responsibility and Work Opportunity Reconciliation Act, which narrowed the eligibility of non-citizens for Medicaid and other federal benefits, the state of Maine extended state-funded medical assistance benefits to certain legal aliens rendered ineligible for Medicaid. In 2011, the Maine Legislature terminated these benefits. Appellants moved for a preliminary injunction against enforcement of the 2011 legislation, alleging that the state violated their equal protection rights by providing state-funded medical assistance benefits to United States citizens while denying those benefits to similarly situated non-citizens due solely to their alienage. The district court denied Appellants’ motion for a preliminary injunction. The First Circuit Court of Appeals affirmed the district court’s denial of a preliminary injunction, holding that Appellants’ equal protection claim failed on the merits because the state of Maine was not obligated to extend equivalent state-funded benefits to Appellants in the first place, and therefore, the termination of those benefits did not violate the Equal Protection Clause.View "Bruns v. Mayhew" on Justia Law