Justia Public Benefits Opinion Summaries

Taylor owned a convenience store. In 2008, the store received authorization to redeem benefits through the Supplemental Nutrition Assistance Program, a federally funded program providing nutritional assistance to needy individuals. In 2010-2011, the USDA conducted an undercover operation. Taylor allowed undercover police officers and confidential informants working under USDA special agents to redeem SNAP benefits for cash that Taylor knew would be used to purchase illegal drugs. Taylor once exchanged a firearm for SNAP benefits. Taylor pled guilty to conspiracy to defraud the U.S., SNAP fraud, drug distribution, and being a felon in possession of a firearm. Based on the firearm conviction and Taylor’s criminal history, the probation officer recommended an enhanced sentence under the Armed Career Criminal Act, 18 U.S.C. 924(e), resulting in a Guidelines range of 188 to 235 months. The district court sentenced Taylor to 188 months. Graves, a friend of Taylor’s, worked in the store and would stand outside the store and either sell drugs to people who redeemed benefits for cash or tell them where to find drugs. Graves also sold an informant a firearm and split the proceeds with Taylor’s wife. The district court sentenced Graves to 200 months. The Sixth Circuit affirmed. View "United States v. Taylor" on Justia Law

In 2004, Illinois enacted Hospital Provider Funding Legislation imposing a tax on hospital providers, except for certain categories of exempt hospitals, for fiscal years 2004 and 2005, 305 ILCS 5/5A-2(a). The Centers for Medicare and Medicaid Services disallowed the reimbursement of Medicare expenses (42 U.S.C. 1395f(b)(1)) to a group of Illinois hospitals, finding that the amount of a tax assessment paid by the hospitals was a reasonable cost, but was subject to offset by any payments those hospitals received from an Illinois State fund. The district court and Seventh Circuit affirmed, finding that the decision was not inconsistent with established policy. The court rejected an argument that the hospitals incurred the full cost of the tax, as they were billed by and wrote checks to the state, reasoning that the argument ignored the real net impact of the tax and of Access Payments by the state.View "Abraham Lincoln Mem'l Hosp. v. Sebelius" on Justia Law

Plaintiff appealed from the judgment of the district court affirming the Social Security Administration's (SSA) denial of her application for Supplemental Security Income disability benefits on the basis of her alleged intellectual disability. The court held that evidence of a petitioner's cognitive limitations as an adult established a rebuttable presumption that those limitations arose before petitioner turned 22, as was required by SSA regulations. The court further held that a petitioner must make separate showings of deficits in cognitive and adaptive functioning in order to be considered intellectually disabled under SSA regulations. Because the agency's finding that petitioner did not suffer from qualifying deficits in adaptive functioning was supported by substantial evidence, the court affirmed the judgment. View "Talavera v. Commissioner of Social Security" on Justia Law

In his 40s, Kastner had worked as a truck driver and as a delivery manager. Having suffered injuries following a fall and subsequent heavy lifting at work, he suffered from a degenerative disc disorder and pain in various parts of his body, and sought disability insurance benefits under 42 U.S.C. 423(d). An administrative law judge determined that, though Kastner’s impairments are severe, they do not meet listed requirements for a presumptively disabling condition and that Kastner has residual capability to perform certain jobs in the economy. The Appeals Council denied review and the district court affirmed. The Seventh Circuit reversed and remanded, holding that the ALJ did not adequately explain why Kastner had not met the requirements for a presumptive disability. View "Kastner v. Astrue" on Justia Law

A dialysis provider created a wholly-owned subsidiary, RCGSC, which supplied dialysis equipment for home use, to take advantage of the Medicare reimbursement scheme and increase profits. In 2005 former employees filed a qui tam action under the False Claims Act, 31 U.S.C. 3729-33, alleging that RCGSC was not a legitimate and independent durable medical equipment supply company, but a “billing conduit” used to unlawfully inflate Medicare reimbursements. The United States intervened and the relators’ claim was voluntarily dismissed. The government alleged that defendants submitted claims, knowing that RCGSC was a sham corporation created solely for increasing Medicare reimbursements; knowing that RCGSC was not in compliance with Medicare rules and regulations; knowing that RCGSC was misleading patients over their right to choose between Method I and Method II reimbursements; and for facility support charges for services rendered to home dialysis patients who had selected Method II reimbursements. The government also brought common law theories of payment by mistake and unjust enrichment. The district court granted summary judgment in favor of the United States. The Sixth Circuit reversed on all counts and remanded some. Defendants did not act with reckless disregard of the alleged falsity of their submissions to Medicare.View "United States v. Renal Care Grp., Inc." on Justia Law

Tasis and his brother ran a sham medical clinic, recruited homeless Medicare recipients who had tested positive for HIV, hepatitis or asthma, paid the “patients” small sums in exchange for their insurance identification, then billed Medicare for infusion therapies that were never provided. During four months in 2006, the Center billed Medicare $2,855,785 and received $827,000 in return. The scheme lasted 15 months, during which Tasis and his collaborators submitted $9,122,159.35 in Medicare claims. An auditor notified the FBI. After an investigation, prosecutors indicted Tasis on fraud and conspiracy claims. Over Tasis’s objection, co-conspirator Martinez testified that she and Tasis had orchestrated a a similar scam in Florida. The court instructed the jury to consider Martinez’s testimony about the Florida conspiracy only as it related to Tasis’s “intent, plan and knowledge.” The jury found Tasis guilty, and the trial judge sentenced him to 78 months in prison and required him to pay $6,079,445.93 in restitution. The Sixth Circuit affirmed, rejecting various challenges to evidentiary rulings. View "United States v. Tasis" on Justia Law

Plaintiff, through his wife and attorney-in-fact, filed an application for Medicaid benefits with the Connecticut Department of Social Services to cover the cost of his nursing home care. At issue was whether a non-assignable annuity contract that provided the spouse of an institutionalized person with monthly payments counted as an excess resource that must be spent down before the institutionalized person could receive Medicaid benefits under the Medicare Catastrophic Coverage Act of 1988 (MCCA), 42 U.S.C. 1396r-5. The court held that the payment stream for non-assignable annuity was not a resource for purposes of determining Medicaid eligibility. Accordingly, the court affirmed the judgment of the district court granting plaintiff's motion for summary judgment. View "Lopes v. Dept. of Social Services" on Justia Law

Bontrager filed a putative class action complaint challenging Indiana’s $1,000 annual limit for dental services covered by Medicaid, 42 U.S.C. 1396. The district court granted a preliminary injunction, holding that Indiana is required to cover all medically necessary dental services, irrespective of the monetary cap. The Seventh Circuit affirmed. Bontrager has an enforceable federal right capable of redress through Section 1983. The monetary cap, which excludes medically necessary treatment, is not a utilization control procedure, but allows a state to shirk its primary obligation to cover medically necessary treatments. The court acknowledged that Bontrager’s victory may be short-lived if the state decides to end coverage for all dental services. View "Bontrager v. IN Family & Soc. Servs." on Justia Law

Plaintiff-Appellant Pennie Keyes-Zachary appealed a district court order that affirmed the Commissioner's decision denying her applications for Social Security disability and Supplemental Security Income benefits. Plaintiff alleged disability based on, among other things, neck, back, shoulder, elbow, wrist, hand, and knee problems, accompanied by pain; hearing loss; urinary frequency; anger-management problems; depression; and anxiety. The ALJ upheld the denial of her application for benefits. The Appeals Council denied her request for review of the ALJ's decision, and she then appealed to the district court. The district court remanded the case to the ALJ for further consideration. After the second hearing, the ALJ determined that Plaintiff retained residual functional capacity to perform light work with certain restrictions, but that she was not disabled within the meaning of the Social Security Act. The Appeals Council declined jurisdiction, and the ALJ's decision was then deemed the Commissioner's final decision. On appeal Plaintiff raised two issues: (1) that the ALJ "failed to properly consider, evaluate and discuss the medical source evidence;" and (2) the ALJ "failed to perform a proper credibility determination." Upon review, the Tenth Circuit found no error in the ALJ's decision and affirmed the Commission's final determination in Plaintiff's case. View "Keyes-Zachary v. Astrue" on Justia Law

Until 2003, Hagans worked as a security guard and as a sanitation worker. At 44 years old, Hagans required open-heart surgery. Hagans claims additional medical problems relating to his cerebrovascular and respiratory systems, hypertension and dysphagia, insomnia, and back pain. He has been diagnosed with depression. Hagans began receiving disability benefits as of January 30, 2003. In September, 2004, pursuant to an updated Residual Function Capacity assessment showing his condition had improved, SSA determined that Hagans was no longer eligible for benefits. The ALJ considered several evaluations of Hagans’s condition, most of which were completed in mid-2004, and found that he was capable of engaging in substantial gainful activity, although he could not perform his past relevant work. The Appeals Council denied review; the district court affirmed. The Third Circuit affirmed, after determining that “relatively high” deference should be afforded to SSA’s Acquiescence Ruling interpreting the cessation provision of 42 U.S.C. 423(f) as referring to the time of the SSA’s initial disability determination. SSA correctly evaluated Hagans’s condition as of the date on which the agency first found that Hagans’s eligibility for disability benefits ceased. Substantial evidence supported the conclusion that Hagans was not fully disabled as of that date. View "Hagans v. Comm'r of Soc. Sec." on Justia Law