Justia Public Benefits Opinion Summaries

Access Behavioral Health appeals from the district court’s judgment upholding an order of the Idaho Department of Health and Welfare that demanded recoupment of Medicaid payments made to Access. The Department sought to recoup certain payments made to Access because it failed to meet the Department’s documentation requirements. Following an audit of provider billings, the Department found Access billed Medicaid for two codes for services provided to the same patient on the same day without documentation to support its use of the codes. The Department concluded the documentation deficiencies violated IDAPA Rule 16.03.09.716 and the Handbook. The Idaho Supreme Court determined the Department had legal authority to issue recoupment demands to Access. Access failed to demonstrate an entitlement to payment of those funds sought to be recouped. The False Claims Act's materiality requirement was inapplicable to the Department’s administrative action. Finally, laches did not bar the Department’s administrative actions. Judgment was thus affirmed. View "Access Behavioral Health v. IDHW" on Justia Law

With the agreement of her supervisor, Johar, a salesperson, left work for about a week to care for a terminally ill relative. While she was away her employer (SWS) decided she had quit. Upon her return, SWS stated business was slow and gave her no new sales appointments. Johar sought unemployment benefits, citing a “temporary layoff.” SWS denied laying Johar off. While conceding that she left with her supervisor’s approval, SWS claimed that Johar’s failure to provide a return date or otherwise communicate with her supervisor while she was away amounted to a voluntary quit. The Employment Development Department agreed, found Johar ineligible for unemployment benefits, ordered reimbursement of benefits improperly paid, and imposed a penalty for willful misrepresentation. The California Unemployment Insurance Appeals Board (CUIAB) affirmed.After Johar sought judicial review, CUIAB confessed error for failing to consider new evidence discovered by Johar while the administrative appeal was pending. The court dismissed the case without reaching the merits. The court of appeal reversed. Johar was entitled to relief on the existing record. She left her job in emergency circumstances with the employer’s approval, thus for good cause; an employee who leaves work for good cause is presumed to have not voluntarily quit. SWS’ evidence did not establish that Johar positively repudiated her obligation to return in clear terms. View "Johar v. California Unemployment Insurance Appeals Board" on Justia Law

Jarnutowski sought Social Security disability benefits, claiming she could not work due to a foot condition, neck and leg pain, obesity, and mental health issues. Jarnutowski underwent multiple surgeries, X-rays, and CT scans on her foot between 2011-2015. An ALJ awarded Jarnutowski found that she was disabled during September 2013-January 2016, with only the ability to perform light work with some limitations; her foot condition, neck issues, and obesity were severe impairments; and, she was disabled by direct application of the Medical-Vocational Guidelines due to her age. The ALJ concluded that Jarnutowski’s disability ended when she regained the ability to perform medium work after her foot surgery and was again able to perform her past work as a store manager. The ALJ did not explicitly address Jarnutowski’s functional capabilities related to medium work, including Jarnutowski’s ability to lift objects weighing up to 50 pounds and frequently lift or carry objects weighing up to 25 pounds, emphasizing Jarnutowski’s ability to walk.The Seventh Circuit reversed. In Social Security disability determinations, the lifting and carrying weight requirements associated with medium work are more than double those of light work. The ALJ found that Jarnutowski’s “residual functional capacity” was limited to light work with some restrictions before her final foot surgery, but increased to medium work after the surgery without explaining how, after surgery, Jarnutowski could lift or carry objects more than twice the weight that she lifted or carried before surgery. View "Jarnutowski v. Kijakazi" on Justia Law

Class Counsel discovered the Social Security Administration's (SSA’s) systemic failure to perform “Subtraction Recalculations” and recovered over $106 million in past-due disability benefits. After performing the Subtraction Recalculations for all the claimants, the SSA argued that the district court did not have authority under the Social Security Act’s judicial-review provision, 42 U.S.C. 405(g), to order the Subtraction Recalculations and that Class Counsel cannot recover attorney fees under section 406(b) for representation of the claimants.The Sixth Circuit affirmed the award of $15.9 million in attorney fees to Class Counsel. SSA “may not hide behind” the statutory provisions merely because it erred at the end, rather than at the beginning, of the benefits-award process. The district court appropriately exercised judicial review under section 405(g), properly ordered the SSA to perform the Subtraction Recalculations, and properly awarded reasonable attorneys’ fees. The SSA failed to award claimants additional past-due benefits to which they were entitled. Counsel successfully sought judicial assistance to obtain those benefits. Congress did not create a statute that allows attorneys to recover fees when the SSA initially fails to award benefits, only to foreclose fee recovery when the SSA later unlawfully withholds additional benefits. View "Steigerwald v. Commissioner of Social Security" on Justia Law

A Social Security Administration ALJ, appointed by agency staff rather than by the Commissioner as required, reviewed and denied claimant’s initial claims. Without challenging the ALJ’s appointment, the claimant appealed to the district court and prevailed in part. The district court vacated the 2017 ALJ decision and ordered a new hearing because the ALJ failed to properly consider certain evidence. The case returned to the same ALJ, who by then had been properly ratified by the Acting Commissioner. The ALJ again denied benefits, and claimant appealed to the district court, raising the issue of an Appointments Clause violation. The district court affirmed the ALJ decision and denied the Appointments Clause claim because the 2017 decision had been vacated and the ALJ was properly appointed when she issued the 2019 decision.   Because the ALJ’s decision was tainted by a prior Appointments Clause violation, the Ninth Circuit vacated the district court’s decision affirming the Commissioner of Social Security’s denial of claimant’s application for benefits under the Social Security Act and remanded with instructions to the Commissioner to assign the case to a different, validly appointed ALJ to rehear and adjudicate claimant’s case de novo. The panel held that under Lucia, the claimant was entitled to a new hearing before a different ALJ. The panel concluded that claimants are entitled to an independent decision issued by a different ALJ if a timely challenged ALJ decision is tainted by a pre-ratification ALJ decision. View "BRIAN CODY V. KILOLO KIJAKAZI" on Justia Law

Air Force veteran Skaar was exposed to ionizing radiation while participating in a cleanup operation in Palomares, Spain following a 1966 midair collision involving a plane carrying nuclear weapons. In 1998, he was diagnosed with leukopenia. His doctor opined that exposure to ionizing radiation “appear[s] to be the positive agent” that historically causes leukopenia. Skaar filed an unsuccessful claim with the VA for service-connected benefits. Before the Veterans Court, he challenged the radiation dose estimates provided by the Air Force. The Veterans Court certified a class of similarly situated veterans who had participated in the Palomares cleanup operation, including veterans who had not received a Board decision but excluding veterans whose claims had been denied but not timely appealed.The Federal Circuit vacated. The Veterans Court lacked authority to certify a class that includes veterans who had not received a Board decision, a statutory prerequisite for the court’s jurisdiction, 38 U.S.C. 7252(a). Jurisdiction over Skaar’s individual claim did not create further jurisdiction over similarly situated veterans whose individual claims were beyond the court’s jurisdiction. The court rejected Skaar’s argument that the Veterans Court should have equitably tolled the appeal period for veterans whose claims had been denied but not timely appealed and should have included such veterans as members of the certified class. None of the claimants alleged the requisite due diligence in pursuing their rights. View "Skaar v. McDonough" on Justia Law

Clemons worked as a coal miner for 10 years and smoked two packs per day for 30 years. Clemons suffered and died from COPD. His claims for federal black-lung benefits (30 U.S.C. 901) were denied. An ALJ awarded Mrs. Clemons survivor’s benefits after considering three medical opinions. Dr. Sikder diagnosed Clemons with legal pneumoconiosis in the form of COPD that resulted from both cigarette smoking and from coal-mine dust exposure. Doctros Habre and Broudy attributed Clemons’s COPD solely to his cigarette smoking. The ALJ credited Sikder’s opinion as well-documented, well-reasoned, and supported by substantial evidence, irrespective of the length of coal mine employment she considered, so that opinion was accorded “probative weight” while the other opinions did not sufficiently explain why Clemons’s coal-mine dust exposure did not contribute “at least in part” to his COPD. The Benefits Review Board affirmed, concluding that the evidence was sufficient to establish the presence of legal pneumoconiosis.The Sixth Circuit denied a petition for review, finding that the ALJ took the coal mine employment discrepancy into account when he weighed Dr. Sikder’s opinion, and acted within his discretion in explaining that the discrepancy was not so great as to detract from the opinion’s probative value. View "Huscoal, Inc. v. Director, Office of Workers’ Compensation Programs, United States Department of Labor" on Justia Law

Plaintiff filed for Social Security benefits, but her application was denied by the Social Security Commissioner. The Appeals Council denied review, which made the Commissioner’s decision final. Plaintiff appealed that decision to the district court, which denied her motion and granted the Commissioner’s motion for judgment on the pleadings. Plaintiff appealed that judgment.   The Second Circuit affirmed in part and remanded in part. The court held the district court failed to properly assess Plaintiff’s Residual Functional Capacity (RFC) with regard to her ability to work consistently as well as her limitations regarding social interactions, and that substantial evidence accordingly does not support the determination that Plaintiff’s psychological impairments do not render her disabled. By contrast, the court held that substantial evidence does support the determination that Plaintiff’s physical impairments do not render her disabled. View "Rucker v. Kijakazi" on Justia Law

The Ninth Circuit reversed in part and vacated in part the district court’s grant of Defendants’ motion to dismiss, and remanded for further proceedings, in an action in which federally-qualified health centers operating in Arizona and their membership organization alleged that the Arizona Health Care Cost Containment System, which administers Arizona’s Medicaid program, and its director violated 42 U.S.C. Section 1396a(bb) and binding Ninth Circuit precedent by failing or refusing to reimburse Plaintiffs for the services of dentists, podiatrists, optometrists, and chiropractors.   First, the panel held that the court’s precedent in California Ass’n of Rural Health Clinics v. Douglas (“Douglas”), 738 F.3d 1007 (9th Cir. 2013), established that FQHC services are a mandatory benefit under Section 1396d(a)(2)(C) for which Plaintiffs have a right to reimbursement under Section 1396a(bb) that is enforceable under 42 U.S.C. Section 1983. The panel rejected Defendants’ interpretation of Section 1396d(a)(2)(C)’s phrase “which are otherwise included in the plan” as applying to both the phrases “FQHC services” and “other ambulatory services offered by a [FQHC.]” The panel, therefore, rejected Defendants’ assertion that Section 1396d(a)(2)(C) only required states to cover FQHC services that are included in the state Medicaid plan.   The panel recognized that Douglas held that the mandatory benefit of “FQHC services” under § 1396d(a)(2)(C) includes “services furnished by . . . dentists, podiatrists, optometrists, and chiropractors” as well as doctors of medicine and osteopathy. The panel held that Arizona’s categorical exclusion of adult chiropractic services violated the unambiguous text of the Medicaid Act as interpreted in Douglas. View "AACHC V. AHCCCS" on Justia Law

This dispute is about whether Texas must provide around-the-clock nursing services to a disabled individuals even though the expense of doing so exceeds the cost cap in the state’s Medicaid program. Plaintiff contends that the Americans with Disabilities Act and Rehabilitation Act require this service because the alternative of institutionalization would amount to discrimination. The district court issued a preliminary injunction requiring Texas to provide the nursing services.   The Fifth Circuit vacated the injunction. The court explained that with the scorecard lopsided in favor of exercising jurisdiction, it is unlikely the district court abused its discretion in declining to abstain. Further, although Plaintiff has shown that the district court should hear her claims, we conclude she is unlikely to succeed on one of them: her due process claim. The court found that because it is unlikely that Plaintiff has a property interest in the treatment she is seeking, a preliminary injunction was not warranted on her due process claim. Finally, on the current record, Plaintiff has not shown that she can prevail on an Olmstead claim seeking services that exceed the cost cap in Texas’s Medicaid waiver program. View "Harrison v. Young" on Justia Law