Justia Public Benefits Opinion Summaries

This case involved the interplay between the Medicare Secondary Payer Statute (MSP), 42 U.S.C. 1395y(b), and Texas workers' compensation law. At issue was whether the MSP preempted a state law that required a workers' compensation claimant to obtain preauthorization from the relevant carrier before incurring certain medical expenses. The court held that it did not. The court concluded that Congress intended the MSP to complement, no supplant, state workers' compensation rules. This included the preauthorization requirement that plaintiff failed to meet before he filed suit. The court rejected plaintiff's claim that Medicare's conditional payment for his surgeries - which equated to a determination that his surgeries were medically unnecessary - rendered the state-law preauthorization requirement "moot" because preauthorization likewise depended on a showing of medical necessity. Accordingly, the court affirmed the district court's dismissal of plaintiff's claim for failure to state a claim under Rule 12(b)(6). View "Caldera v. The Ins. Co. of the State of PA" on Justia Law

These are two appeals stemming from the government's immediate termination of a Medicare Part D services contract with a prescription drug insurance coverage provider, Fox. Fox subsequently filed actions in the district court challenging both the termination and an order for immediate repayment. The court affirmed the district court's holding that the contract was properly terminated; affirmed the district court's ruling that governing regulations authorized the government's demand for immediate repayment of a prorated share of the funds that had been paid to Fox at the beginning of the month and that Fox would not utilize after the contract's termination; and the government's actions were more than justified, as Fox had risked permanent damage to its enrollees by, inter alia, improperly denying coverage of critical HIV, cancer, and seizure medications, and having no compliance structure in place. View "Fox Ins. Co. v. Centers for Medicare and Medicaid" on Justia Law

Plaintiffs, a class of Medicaid beneficiaries who suffered from severe developmental disabilities, sued the NCDHHS, PBH, and the director of PBH, alleging that defendants violated their rights under the Medicaid statute and the Due Process Clause of the Fourteenth Amendment by reducing their health care services without notice and an opportunity for a hearing. On appeal, PBH and the director challenged the district court's entry of a preliminary injunction. However, the NCDHHS did not join the appeal. Given that the NCDHHS had decided not to litigate the appeal, the court concluded that the Medicaid statute, 42 U.S.C. 1396a(a)(5), and accompanying regulations precluded PBH from appealing in the absence of the NCDHHS. Accordingly, the court dismissed the appeal. View "K.C. v. Shipman" on Justia Law

Defendant appealed a district court order adding to her previously imposed sentence a new requirement that she apply all tax refunds and other money she received from any "anticipated or unexpected financial gains" toward an outstanding restitution obligation imposed on her as a part of her sentence. Defendant was convicted of theft of government property because she received Supplementary Security Income (SSI) from the Social Security Administration after her eligibility for such payments had ended. Defendant had been receiving the money on behalf of her special-needs daughter but failed to notify the government when she subsequently married and her husband's income made her ineligible for SSI. The court concluded that the district court abused its discretion by later amending the original sentence in the absence of evidence of the impact the amendment would have on defendant's ability to support herself and her family and, therefore, the court vacated the order. View "United States v. Grant" on Justia Law

Parks served in Vietnam 1964-1966. Along with 6,000 other soldiers, Parks volunteered for “Project 112” and was intentionally exposed to chemical warfare agents. In 2000 and in 2002, Parks sought service connection for diabetes type II with peripheral neuropathy and heart disability. The Regional Office denied the claims. While appeal was pending, the government declassified details about chemicals used in Project 112. The Department of Defense reported that it did not know of any long-term effects caused by exposure to the chemicals, but the Veterans Health Administration required the VA to provide to Project 112 veterans “a thorough clinical evaluation,” enhanced access to the VA health care system, and free care for any illness possibly related to their participation” and 38 U.S.C. 1710(e)(1)(E) provides specific services for veterans who participated in Project 112. The VA sent Parks a letter identifying the chemicals to which he had been exposed and providing instructions on how to obtain additional medical examinations. Ultimately, the Veterans’ Court denied a service connection. The Federal Circuit affirmed, upholding reasoning that a nurse practitioner is able to provide a medical examination that meets the regulatory requirements of competent medical evidence and refusal to consider information found on the Internet. View "Parks v. Shinseki" on Justia Law

Kyhn served in the U.S. Army 1945-1946. In 1998, he filed a claim for service-connected hearing loss, which was denied by the regional office. Kyhn submitted a Notice of Disagreement, with medical evidence from his private audiologist and asserted that he was seeking service connection for tinnitus. The RO granted service connection for hearing loss at a 50% rating, but denied service connection for tinnitus. Kyhn did not appeal. The decision became final. In 2004, Kyhn sought to reopen his tinnitus claim and presented another letter from his private audiologist. Although the RO declined to reopen the tinnitus claim, the Board found the private audiologist’s statement constituted new and material evidence and remanded. Kyhn failed to appear and the Board denied service connection, based on the evidence of record. The Veterans Court found the VA had a regular practice to provide veterans with notice of their VA examinations and applied the presumption of regularity to presume the VA had properly notified Kyhn in accordance with this practice and affirmed the denial. The Federal Circuit vacated because of the lower court’s reliance on affidavits that were not part of the record before the Board. View "Kyhn v. Shinseki" on Justia Law

Dotson died in August 1998. An administrative law judge determined that his wife was entitled to survivor’s benefits under the 2010 Black Lung Amendments, Pub. Law 111-148, 1556(a)–(c). The Sixth Circuit denied the company’s petition for review of the Benefits Review Board decision. The company filed a petition for rehearing, arguing that its case involved an additional issue: whether an award of benefits should commence the month the miner died. The Sixth Circuit denied the petition. The regulation says: “Benefits are payable to a survivor who is entitled beginning with the month of the miner’s death, or January 1, 1974, whichever is later.” 20 C.F.R. 725.503(c). This language was clear before Congress enacted the Amendments, and, by its terms, the widow is entitled to benefits beginning with the month of the miner’s death: August 1998. Rejecting an argument concerning retroactive application, the court stated that “imposition of liability for the effects of disabilities bred in the past is justified as a rational measure to spread the costs of the employees’ disabilities to those who have profited from the fruits of their labor—the operators and the coal consumers.” View "McCoy Elkhorn Coal Corp. v. Dotson" on Justia Law

Southwest appealed the district court's dismissal of its claim regarding the Medicare Part D statute, 42 U.S.C. 1395w-101 et seq., for lack of subject matter jurisdiction. Citing Shalala v. Illinois Council on Long Term Care, Southwest argued that its claim provided a narrow exception to 42 U.S.C. 405(h)'s requirement that required a plaintiff to exhaust administrative remedies before filing a claim in federal court. The court concluded that caselaw interpreting the application of section 405(h) to Medicare claims emphasized that the Illinois Council exception was extremely narrow and appropriately applied only in cases where judicial review would be entirely unavailable through the prescribed administrative procedures. Because Southwest has not carried its heavy burden of showing that the Illinois Council exception applied, the court affirmed the district court's order dismissing the suit. View "Southwest Pharmacy Solutions, Inc. v. Centers for Medicare & Medicaid, et al" on Justia Law

Figueroa received the flu vaccine in 2008. Within 20 days, he developed numbness in his face, impaired speech, and weakness. He was diagnosed with Guillain-Barré Syndrome, a sometimes fatal nervous system disorder. Because GBS is not listed on the Vaccine Injury Table, 42 U.S.C. 300aa-14(a), it requires proof of causation, although flu vaccine GBS cases have been compensated under the National Childhood Vaccine Injury Act. Figueroa had 36 months from the onset of symptoms to file a petition under the Act (until November, 2011), but, in 2010, he died of pancreatic cancer. His widow timely sought compensation for the vaccine-related neurological injuries suffered prior to his death. A special master dismissed, reasoning that because Figueroa had died of pancreatic cancer, a non-vaccine-related cause, Ms. Figueroa lacked standing to seek injury compensation. The Court of Federal Claims affirmed. The Federal Circuit reversed, interpreting a section that provides: “any person who has sustained a vaccine-related injury, the legal representative of such person if such person is a minor or is disabled, or the legal representative of any person who died as the result of the administration of a vaccine ... may ... file a petition for compensation,” 42 U.S.C. 300aa-11(b)(1)(A) View "Figueroa v. Sec'y of Health & Human Servs." on Justia Law

Kentucky provided medical care to its poorest citizens through Medicaid (42 U.S.C. 1396-1) using a traditional fee-for-service model until 2011, when it transitioned to a managed-care program and awarded Coventry a contract to administer Medicaid services in southeastern Kentucky. Coventry entered into a temporary agreement with Appalachian, the dominant hospital care provider in that area, to provide members in-network hospital care and other services. Coventry soon realized it was losing money, partly because its network included Appalachian, whose patients, on average, were sicker and more expensive to treat. Coventry learned that its competitors were not required to contract with Appalachian and unsuccessfully sought an increase in payment rates. Coventry then noticed termination of Appalachian’s contract, which would have made thousands of Medicaid recipients unable to access healthcare providers at Appalachian’s facilities without first paying fees. Appalachian sued Coventry and state defendants. The district court required Coventry to keep Appalachian in its network for four months longer than the contract specified (until November 1, 2012) and denied Coventry’s motion to require Appalachian to post a security bond. The Sixth Circuit affirmed with respect to the bond and otherwise dismissed an appeal as moot because no recognized exception permits review of an expired injunction. View "Appalachian Reg'l Healthcare, Inc. v. Coventry Health & Life Ins. Co." on Justia Law