Justia Public Benefits Opinion Summaries

After Insured sustained injuries in a car accident he sought MRIs from Virtual Imaging Services. Virtual Imaging obtained an assignment of personal injury protection (PIP) benefits under Insured's policy with GEICO and billed GEICO $3600 for the MRIs. GEICO paid the bill but limited its reimbursement to eighty percent of 200 percent of the applicable Medicare fee schedule in accordance with the formula described in Fla. Stat. 627.736(5)(a). This statutory provision became effective on January 1, 2008 as part of Florida's PIP statute. Virtual Imaging subsequently sued GEICO, alleging that GEICO's reimbursement was insufficient. The county court granted Virtual Imaging's motion for summary judgment. The court of appeal affirmed then certified a question of law to the Supreme Court, which answered by holding that GEICO was required to give notice to Insured by electing the permissive Medicare fee schedules in its policy before taking advantage of the Medicare fee schedule to limit reimbursements.View "Geico Gen. Ins. Co. v. Virtual Imaging Servs., Inc." on Justia Law

Plaintiffs, several nursing homes approved by the Iowa Department of Human Services (DHS) as Medicaid providers, submitted annual reports disclosing their income and expenses to DHS. DHS used the reports to calculate the Medicaid per diem reimbursement rates for the nursing homes. Some of the facilities' expenses were disallowed by DHS, and DHS reduced reimbursement rates accordingly. The facilities appealed the adjustments. The director of human services upheld the action. The district court affirmed. The court of appeals reversed, concluding that the DHS rules did not support its decision that the disputed costs were not allowable. The Supreme Court affirmed, holding that DHS's exclusion of the facilities' lab, x-ray, and prescription drug costs from the nursing homes' reports was based on an incorrect interpretation of its rules.View "Sunrise Ret. Cmty. v. Iowa Dep't of Human Servs." on Justia Law

In an earlier suit, fourteen Texas hospitals filed a declaratory relief action against the Texas Health and Human Services Commission and its Executive Commissioner (collectively HHSC), challenging a cutoff date used by HHSC to cap the collection of data used to calculate Medicaid reimbursement rates for inpatient services. The Supreme Court declared the cutoff-date rule invalid and enjoined its enforcement. The Court further remanded the cause to the district court, where the hospitals argued that the Court's judgment should apply retroactively to provide them a basis to reopen their earlier administrative appeals and to seek reimbursement for the underpayment of past Medicaid claims calculated under the invalid cutoff-date rule. The district court found in favor of the hospitals. The court of appeals reversed, determining that the injunction should only operate prospectively. The Supreme Court affirmed, holding that the court of appeals correctly concluded that the Court's earlier opinion and judgment did not purport to reopen past rate determinations or closed administrative proceedings.View "El Paso County Hosp. Dist. v. Tex. Health & Human Servs." on Justia Law

Claimant William Stewart appealed a decision of the appeal tribunal, as affirmed by the appellate board of the New Hampshire Department of Employment Security (DES) that denied his application for unemployment benefits. Stewart worked as the code enforcement director for the City of Laconia from March 14 to June 29, 2011. Following his termination, Stewart applied for unemployment benefits. A DES certifying officer denied the application. The officer determined that Stewart did not have annual earnings of at least $1,400 in two of four quarters of his alternate base period. Stewart appealed the decision to the tribunal. He argued that he had earnings of at least $1,400 in both the third and fourth quarters of his alternate base period. Following a hearing, the tribunal affirmed the decision denying Stewart’s claim. Stewart argued on appeal to the Supreme Court that the tribunal erred in concluding that he had insufficient quarterly earnings under RSA 282-A:25 to establish a claim for benefits. Upon review, the Supreme Court reversed and remanded, finding that DES’s reliance on its decision in "Appeal of Tennis" was misplaced. View "Appeal of William Stewart" on Justia Law

Several hospitals (Hospitals) sued Aetna, Inc. and Aetna Health, Inc. (collectively Aetna) for allegedly violating the Prompt Pay Statute. Aetna provided a Medicare plan (Plan) through an HMO called NYLCare. It delegated the administration of its Plan to North American Medical Management of Texas (NAMM), a third-party administrator. IPA Management Services (Management Services) provided medical services to Plan enrollees. Management Services entered into contracts with the Hospitals to secure hospital services for the Plan employees. Aetna was not a party to these contracts. The Hospitals submitted hospital bills to NAMM for payment. After NAMM and Management Services became insolvent, Aetna de-delegated NAMM and assumed responsibility for processing and paying claims. However, Aetna instructed the Hospitals to continue submitting their bills to NAMM. The Hospitals argued that Aetna was liable for NAMM's failure to timely pay claims and was responsible for $13 million in outstanding bills. The trial court granted summary judgment for Aetna. The court of appeals affirmed, concluding that because the Hospitals entered into contracts with Management Services and not with Aetna directly, the Hospitals had no viable prompt-pay claim. The Supreme Court affirmed, holding that the lack of privity between the Hospitals and Aetna precluded the Hospitals' suit.View "Christus Health Gulf Coast v. Aetna, Inc." on Justia Law

The North Dakota Department of Human Services appealed a district court order reversing and remanding the Department's order decreasing Plaintiff-Appellee Penne Nienow's monthly Supplemental Nutrition Assistance Program ("SNAP") benefits. The County determined Nienow received income from a prior mineral rights lease and, therefore, the 2011 payment was a recurring lump-sum payment. The County reduced Nienow's SNAP benefits to $16 per month. Nienow filed a request for hearing to the Department, and an evidentiary hearing was held. The County's representative testified Nienow stated that she leased the mineral rights and received income from the lease every five years and that she had leased the rights at least once before. After the hearing, the administrative law judge ("ALJ") concluded the County correctly determined Nienow's income and properly reduced her SNAP benefits. The Department adopted the ALJ's findings and conclusions. Nienow appealed the Department's order to the district court. The district court reversed and remanded, concluding Nienow's payment was a mineral leasing bonus, a nonrecurring lump-sum payment, and should not have been considered as income in determining Nienow's eligibility. Upon review of the matter, the Supreme Court reversed the district court order and reinstated the Department's final order reducing Nienow's SNAP benefits. View "Nienow v. Anderson" on Justia Law

Holline and William Parsons (Plaintiffs) were enrolled in Today's Option, a Medicare Advantage Plan sponsored by the Pyramid Life Insurance Company (Pyramid). After Plaintiffs were each disenrolled from their respective plans, they brought suit against Pyramid, asserting numerous state law claims. The circuit court granted Plaintiffs' motion for summary judgment in part declaring that the Medicare Act did not provide the exclusive remedy for Plaintiffs' claims in this case. Pyramid then moved for Ark. R. Civ. P. 54(b) certification and a stay pending appeal, requesting permission to file an interlocutory appeal on the issues of whether Plaintiffs' state-law claims arose under the Medicare Act and whether their claims, to the extent they did not arise under the Act, were expressly preempted by the Act. The circuit court certified this appeal pursuant to Rule 54(b). The Supreme Court dismissed the appeal without prejudice, holding that the finding supporting Rule 54(b) certification was in error. View "Pyramid Life Ins. Co. v. Parsons" on Justia Law

Claimants appealed a district court judgment that affirmed Job Service of North Dakota's decision to deny them unemployment benefits. Upon review of the administrative record and the plain language of N.D.C.C. 52-06-02(4), the Supreme Court concluded that claimants were only disqualified from unemployment compensation for employee-initiated work stoppages due to labor disputes, not to locked out Claimants as in this case. Accordingly, the Court reversed the district court's judgment and remanded the case back to Job Service for further proceedings.View "Olson v. Job Service" on Justia Law

Appellant, a forty-eight-year-old who lived independently for two decades, had "borderline intellectual functioning," an expressive language disorder, and a learning disorder. Appellant applied for Home and Community Based Services (HCBS), a federal-state Medicaid Waiver program that provides assistance to individuals with developmental disabilities. The South Dakota Department of Human Services (the Department) denied Appellant's application, determining that Appellant was not eligible for HCBS. After a hearing, an ALJ affirmed the Department's denial. The circuit court affirmed. The Supreme Court also affirmed, holding that the ALJ did not clearly err in finding that Appellant did not qualify for benefits, as the evidence indicated that Appellant was a generally independent client who was able to function with little supervision or in the absence of a continuous active treatment program.View "Nelson v. Dep't of Social Servs." on Justia Law

Appellant Habib Sadid, a former tenured professor of civil engineering at Idaho State University, appealed an Industrial Commission Order that reversed the Department of Labor Appeals Examiner's grant of unemployment benefits to Appellant after he was terminated by Idaho State University. Upon review, the Supreme Court concluded that the Commission's finding of misconduct was supported by substantial and competent evidence. As such, the Court affirmed the Industrial Commission's order.View "Sadid v. Idaho State University" on Justia Law