Justia Public Benefits Opinion Summaries

The Supreme Judicial Court held that the six-year statute of limitations for contract actions governed this case and that the efforts of Executive Office of Health and Human Services, Office of Medicaid (MassHealth) to collect overpayments made to providers in the State Medicaid program were time barred.In 2005, MassHealth sent an audit notice to a provider, Suburban Home Health Care, Inc., but took no further action until 2016, when it initiated recovery proceedings. Suburban sought declaratory relief, arguing that the proceedings were barred under the statute of limitations for "actions of contract" in Mass. Gen. Laws ch. 260, 2. The superior court denied relief, concluding that the administrative proceedings to collect the overpayments could not be considered civil actions, and therefore, no statute of limitations applied. The Supreme Judicial Court reversed, holding that the six-year statute of limitations for contract actions applied and that MassHealth's action was time barred. View "Suburban Home Health Care, Inc. v. Executive Office of Health and Human Services, Office of Medicaid" on Justia Law

Attorney Conn represented Plaintiffs and thousands of other claimants in seeking disability benefits from the Social Security Administration. Conn bribed doctors to certify false applications and bribed an ALJ to approve those applications. After Conn’s scheme was uncovered, the SSA identified over 1,700 applications for redetermination of eligibility. Years of litigation ensued. Both Plaintiffs sought attorney’s fees under the Equal Access to Justice Act (EAJA), 28 U.S.C. 2412(d)(1)(A). Both courts awarded fees less than the amounts requested.The Sixth Circuit vacated the awards. Courts can award attorney’s fees for work performed during “all phases of successful civil litigation addressed by” the EAJA; one district court erred by holding that the EAJA does not authorize fees for work performed after the judgment becomes final. Both district courts abused their discretions by awarding below-market hourly rates. Plaintiffs’ unrefuted evidence established a market range of $205-500 but the courts concluded that the relative simplicity of the actions justified rates of only $125 and $150, although there is no evidence that any lawyer in the relevant communities would accept these rates for any kind of service. The complexity of the action is relevant to determine where the particular attorney’s representation lies along the spectrum of the market for legal services. It cannot be invoked to justify a rate below the established spectrum. View "Doucette v. Commissioner of Social Security" on Justia Law

After two administrative hearings, Brown was awarded disability insurance benefits and supplemental security income benefits by an ALJ, who concluded that, as of April 25, 2018, Brown was “disabled” within the meaning of the Social Security Act, 42 U.S.C. 416(i), 423(d), 1382c(a)(3)(A), but rejected Brown’s claim that he was disabled prior to that date. The district court upheld the ALJ’s decision.The Ninth Circuit remanded with instructions to set aside the ALJ’s determination and to conduct a new disability hearing before a different, and properly appointed ALJ. The ALJ who conducted Brown’s hearings was not appointed in conformity with the Appointments Clause of the Constitution. Because this proceeding did not arise from a direct appeal from a decision of one or more invalidly appointed officers, nor was it a direct petition for review that might similarly have brought the entirety of the administrative decision before the court, the Commissioner may not challenge the portions of that decision that are favorable to Brown. The court held that it had no authority under 42 U.S.C. 405(g). to set aside, or to disturb, the grant of benefits for the time period on or after April 25, 2018, View "Brown v. Kijakazi" on Justia Law

Larson served on active duty for training in the Navy Reserves in 1988 and on active duty in the Navy, 1989-1993. He gained a substantial amount of weight before, during, and after his active service. In 2009, Larson filed a claim for service connection for multiple conditions, including obesity and dysmetabolic syndrome (DMS). The VA denied the claims in 2010. The Board affirmed that denial in 2016, holding that neither DMS nor obesity was a disability because neither condition is ratable under the VA Schedule of Rating Disabilities. The Veterans Court affirmed the denial of service connection for DMS and obesity, holding that it lacked jurisdiction to review a Board determination of what constitutes a disability under 38 U.S.C. 1110 because such inquiry amounted to a review of the rating schedule, prohibited by 38 U.S.C. 7252(b).The Federal Circuit reversed, noting that it has previously held that the Veterans Court has jurisdiction to review a Board determination that a claimed condition did not constitute a disability for purposes of section 1110. Larson seeks only to establish a service connection for his conditions and is not asking the Veterans Court to invalidate or revise any portion of the rating schedule. View "Larson v. McDonough" on Justia Law

In this case involving the In-Home Supportive Services (IHSS) program the Supreme Court affirmed the judgment of the court of appeal concluding that sections 631 and 683 of the Unemployment Insurance Code exclude from coverage a provider who is the recipient's minor child, parent, or spouse under the state's unemployment insurance program, holding that the court of appeal did not err.The IHSS program authorized certain Californias, who were disabled or elderly, to receive in-home services from third parties or family members paid for with public funds. Under one program option, service recipients hire their own providers and the providers are paid either by a public entity or by the recipients with funds they have received from a public entity. At issue was whether such a provider qualified for unemployment benefits. The Supreme Court answered the question in the negative, holding that provider who is the recipient's minor child, parent, or spouse is not covered by the state's unemployment insurance program. View "Skidgel v. California Unemployment Insurance Appeals Board" on Justia Law

Molina Healthcare contracted with the Illinois Medicaid program to provide multiple tiers of medical-service plans with scaled capitation rates (fixed per-patient fees that cover all services within the plan’s scope). The Nursing Facility plan required Molina to provide Skilled Nursing Facility (SNF) services. Molina subcontracted with GenMed to cover that obligation. Molina received a general capitation payment from the state, out of which it was to pay GenMed for the SNF component. Molina breached its contract with GenMed. GenMed terminated the contract. After GenMed quit, Molina continued to collect money from the state for the SNF services, but it was neither providing those services itself nor making them available through any third party. Molina never revealed this breakdown, nor did it seek a replacement service provider.Prose, the founder of GenMed, brought this qui tam action under both the state and federal False Claims Acts, 31 U.S.C. 3729, alleging that Molina submitted fraudulent claims for payments from government funds. The district court dismissed the case. The Seventh Circuit reversed. The complaint plausibly alleges that as a sophisticated player in the medical-services industry, Molina was aware that these kinds of nursing facility services play a material role in the delivery of Medicaid benefits. View "Prose v. Molina Healthcare of Illinois," on Justia Law

The Ninth Circuit affirmed the district court's dismissal based on failure to exhaust administrative remedies of plaintiffs' action under the Individuals with Disabilities Education Act (IDEA). Plaintiffs claim that the district court is failing its responsibilities to students under the IDEA by not timely identifying and evaluating students with disabilities, and, after identifying them, by providing them with insufficiently individualized, "cookie-cutter" accommodations and services. Although plaintiffs argue that exhaustion was not required because they are challenging district-wide policies that only a court can remedy, plaintiffs are unable to identify such policies. The panel agreed with the district court that plaintiffs have not satisfied any of the limited exceptions recognized by caselaw to the exhaustion requirement contained in 20 U.S.C. 1415(l). In this case, plaintiffs challenged what amounted to failures in practice by the school district, rather than policies or practices of general applicability. View "Student A v. San Francisco Unified School District" on Justia Law

Decker employed Pehringer at its Montana open-pit surface mine, 1977-1999. There were periods when Pehringer did not work, including a roughly three-year-long strike. For most of his mining career, Pehringer was regularly exposed to coal dust while working primarily as a heavy equipment operator. After being laid off in 1999, Pehringer was awarded Social Security total disability benefits. He never worked again. In 2014 a month before his sixty-fifth birthday, Pehringer sought black lung benefits, citing his severe COPD, 30 U.S.C. 923(b). A physician determined that “Pehringer is 100% impaired from his COPD” and that coal “dust exposure and smoking are significant contributors to his COPD impairment.”The Benefits Review Board affirmed a Department of Labor (DOL) ALJ’s award of benefits. The Ninth Circuit affirmed, first rejecting a constitutional challenge to 5 U.S.C. 7521(a), which permits removal of an ALJ only for good cause determined by the Merits Systems Protection Board. DOL ALJ decisions are subject to vacatur by people without tenure protection; properly appointed, they can adjudicate cases without infringing the President’s executive power. The ALJ did not err in adjudicating Pehringer’s claim nor in rejecting untimely evidentiary submissions. Decker did not rebut the presumption of entitlement to benefits after a claimant established legal pneumoconiosis and causation, having worked for at least 15 years in substantially similar conditions to underground coal mines. View "Decker Coal Co. v. Pehringer" on Justia Law

UnitedHealthcare Medicare Advantage insurers challenged the Overpayment Rule, promulgated by the Centers for Medicare and Medicaid Services (CMS) under 42 U.S.C. 1301-1320d-8, 1395-1395hhh, in an effort to trim costs. The Rule requires that, if an insurer learns that a diagnosis submitted to CMS for payment lacks support in the beneficiary’s medical record, the insurer must refund that payment within 60 days. UnitedHealth claims that the Overpayment Rule is subject to a principle of “actuarial equivalence,” and fails to comply. Two health plans that pay the same percentage of medical expenses are said to have benefits that are actuarially equivalent.The D.C. Circuit rejected the challenge. Actuarial equivalence does not apply to the Overpayment Rule or the statutory overpayment-refund obligation under which it was promulgated. Reference to actuarial equivalence appears in a different statutory subchapter from the requirement to refund overpayments; neither provision cross-references the other. The actuarial-equivalence requirement and the overpayment-refund obligation serve different ends. The actuarial-equivalence provision requires CMS to model a demographically and medically analogous beneficiary population in traditional Medicare to determine the prospective lump-sum payments to Medicare Advantage insurers. The Overpayment Rule, in contrast, applies after the fact to require Medicare Advantage insurers to refund any payment increment they obtained based on a diagnosis they know lacks support in their beneficiaries’ medical records. View "UnitedHealthcare Insurance Co v. Becerra" on Justia Law

A False Claims Act, 31 U.S.C. 3729(a)(1)(A), “qui tam” lawsuit against SuperValu claimed that SuperValu knowingly filed false reports of its pharmacies’ “usual and customary” (U&C) drug prices when it sought reimbursements under Medicare and Medicaid. SuperValu listed its retail cash prices as its U&C drug prices rather than the lower, price-matched amounts that it charged qualifying customers under its discount program. Medicaid regulations define “usual and customary price” as the price charged to the general public. The district court held that SuperValu’s discounted prices fell within the definition of U&C price and that SuperValu should have reported them but held that SuperValu did not act with scienter.The Seventh Circuit affirmed, joining other circuits in holding that the Supreme Court’s 2007 “Safeco” interpretation of the Fair Credit Reporting Act’s scienter provision applies with equal force to the False Claims Act’s scienter provision. There is no statutory indication that Congress meant its usage of “knowingly,” or the scienter definitions it encompasses, to bear a different meaning than its common-law definition. SuperValu did not act with the requisite knowledge. SuperValu’s interpretation of “usual and customary price” was objectively reasonable under Safeco. View "Yarberry v. Supervalu Inc." on Justia Law