Justia Public Benefits Opinion Summaries

On appeal from a federal appellate court's decision that the Federal Medicare scheme prohibits State Medicaid agencies, including MassHealth, from receiving funds from Medicare, the Supreme Judicial Court ordered that this case be remanded for modification of the declaratory judgment, holding that MassHealth demonstrated a sufficient change in circumstances to warrant modification to allow MassHealth to seek reimbursement where the liable third party is Medicare.In Atlanticare Medical Center v. Commissioner of the Division of Medical Assistance, 439 Mass. 1, 3, 5 (2003) (Altanticare I), the Supreme Judicial Court concluded that the Federal Medicaid scheme tasked the State Medicaid agency, not individual providers, with seeking reimbursement from liable third-party insurers, including Medicare. When the Center for Medicare & Medicaid Services (CMS) refused to issue reimbursements from Medicare to MassHealth, MassHealth brought suit. In 2011, the United States Court of Appeals for the First Circuit held that the Federal Medicare scheme prohibited MassHealth from receiving funds from Medicare. Therefore, a Federal Medicare regulation was amended to acknowledge the practice of State Medicaid agencies obtaining Medicare reimbursements through providers, rather than seeking such reimbursements directly from Medicare. MassHealth sought to modify the declaratory judgment and restore its ability to obtain reimbursements from providers, rather than liable third parties. The Supreme Judicial Court remanded the case for modification of the judgment, holding that changed circumstances required modification. View "Atlanticare Medical Center v. Division of Medical Assistance" on Justia Law

The California State Teachers’ Retirement System (CalSTRS) determined that Ernest Moreno’s retirement benefits had been incorrectly calculated and initiated proceedings to adjust Moreno’s retirement benefits and collect the overpayment. The trial court denied Moreno’s petition for writ of administrative mandamus challenging the CalSTRS actions. Moreno appealed, contending: (1) CalSTRS’s adjustment of his retirement benefits and collection of the overpayment were barred by the statute of limitations found in Education Code section 22008 (c) because CalSTRS was on inquiry notice of the problem as early as 2008; and (2) CalSTRS should have been equitably estopped from adjusting his retirement benefits and collecting the overpayments. After review, the Court of Appeal concluded: (1) CalSTRS was not on inquiry notice of the reporting error that led to overpayment until December 2014 when it began an audit of Moreno’s retirement benefits, and, therefore, CalSTRS’s adjustments to Moreno’s retirement benefits and collection of overpayments were not barred by the statute of limitations; and (2) CalSTRS was not equitably estopped because CalSTRS was not apprised of (or on notice about) the overpayments until December 2014. View "Moreno v. Cal. State Teachers' Retirement System" on Justia Law

The Ninth Circuit affirmed the Commissioner's reduction of claimant's social security retirement benefits pursuant to the Windfall Elimination Provision (WEP) of the Social Security Act. The WEP applies to retirees who, like claimant, are entitled to social-security benefits and pension benefits from employment not covered by social security.The panel held that the text of the uniformed-services exception is ambiguous as applied to dual-status technicians. However, because the Commissioner's interpretation of the uniformed-services exception is reasonable, it is entitled to Skidmore deference. View "Larson v. Saul" on Justia Law

While serving in the Navy 1968-1970, Simmons experienced feelings of depression and homesickness. A VA physician diagnosed Simmons with situational depression but no permanent disability. Another VA physician diagnosed him with immature personality disorder and recommended he be discharged. In 1972, the VA awarded Simmons a non-service-connected pension on his polyarthritis claim. In 1974, Simmons sought additional compensation, asserting that his arthritis was service-connected and that he also had a nervous condition that justified compensation. The VA denied the claim. In 2005, after receiving a total disability rating for an unrelated asbestosis-based claim, Simmons claimed that there was clear and unmistakable error (CUE) in the 1974 decision, with respect to the denial of service connection, citing the presumptions of soundness and service connection in 38 U.S.C. 105(a) and 1111.The Board found that Simmons’s current psychiatric disorder was due to his non-service-connected arthritis and that the presumptions did not apply. The Veterans Court affirmed, finding that although the Board erred in analyzing the presumptions, that error was harmless because Simmons’s current disability was not causally related to his in-service condition. The Federal Circuit affirmed, rejecting an argument that a failure to apply an evidentiary presumption is per se prejudicial. A per se rule of prejudice for failure to apply the presumptions would undo any proper VA finding that the claimant had failed to establish a causal nexus. View "Simmons v. Wilkie" on Justia Law

While serving in the Navy, 1972-1073, Merritt sustained a concussion in an automobile accident. In 2006, a VA psychologist prepared a note. stating that Merritt had “[s]ymptoms of bipolar disorder[, which] first began ... on active duty,” and that Merritt’s “work performance began to suffer” after the in-service accident. In 2010, Merritt sought disability benefits for bipolar disorder, anxiety, and personality disorders. The Board determined that Merritt’s psychiatric disorders were not service-connected, relying solely on an independent medical expert opinion. On remand, the Board again denied Merritt’s claim, stating that the VA psychology note was entitled to little probative weight, apparently because there was no evidence that the VA psychologist had access to Merritt’s records, and there was a discrepancy between that note and Merritt’s treatment records as to the length of time that Merritt was unconscious following the automobile accident. The Veterans Court affirmed, finding the Board’s error in not following the remand order harmless because the VA note “described no symptoms that . . . supported . . . a retrospective diagnosis” of bipolar disorder, and “there [was] no possibility that the Board could have awarded service connection based on [the note].”Merritt died; Mrs. Merritt was allowed to substitute herself as the surviving spouse. The Federal Circuit subsequently dismissed her appeal as moot. Mrs. Merritt did not preserve her claim by filing a formal claim with the VA within one year of Merritt’s death as required. View "Merritt v. Wilkie" on Justia Law

Sellers served in the Navy in 1964-1968, and in the Army, 1981-1996. He suffers from major depressive disorder (MDD). Sellers has a 2009 effective date for his disability benefits. He seeks an effective date of March 1996, the date of his formal claim seeking compensation for specific injuries to his leg, knee, back, finger, and ears. On his application, under “Remarks,” Sellers wrote “Request for s/c [service connection] for disabilities occurring during active duty service.” Sellers contends that the law in effect in 1996 requires his remarks to be understood as a claim for compensation for his MDD, although his claim in no way refers to MDD. The Veterans Court agreed with Sellers. The Secretary of Veterans Affairs challenged that decision.The Federal Circuit reversed, finding that Sellers is not entitled to an earlier effective date. A legally sufficient formal claim must identify, at least at a high level of generality, the current condition upon which the veteran’s claim is based. The Secretary’s duty to assist begins upon receipt of a formal claim that identifies the medical condition for which benefits are sought, which triggers the Secretary’s duty to obtain the veteran’s medical records, 38 U.S.C. 5103A(c)(1)(A), and then to fully develop the stated claim. Until the Secretary comprehends the condition on which the claim is based, the Secretary does not know where to begin to develop the claim. View "Sellers v. Wilkie" on Justia Law

Jones served on active duty with the Army in 1967-1974 and in the Army National Guard in 1987-1990. In 1994, he sought disability benefits for a nervous disorder and a leg wound. A VA regional office granted service connection for a leg scar but found that disability non-compensable and denied the claim for a nervous condition. Jones did not appeal. In 2002, Jones filed a request to reopen his claim, asserting that he was assaulted by muggers while stationed in Germany, which resulted in his developing PTSD. The regional office denied his request. In 2008, the Board of Veterans’ Appeals granted the request to reopen, directing the regional office to obtain additional information from two individuals with knowledge of the assault. In 2010, the regional office granted Jones service connection for PTSD and a schizoaffective disorder, with a 100% disability rating effective from October 2002, when he sought to reopen his claim. Jones sought to have the effective date made retroactive to 1994. In 2016, after Jones’s death, the Board held that the effective date was 2002. The Veterans Court and the Federal Circuit affirmed, citing 38 C.F.R. 3.156(c); the decision in Jones’s favor was based on evidence created in 2003 and 2008, which did not exist in 1994. View "Jones v. Wilkie" on Justia Law

The Eighth Circuit affirmed the denial for disability insurance benefits and supplemental security income to plaintiff. The court held that the ALJ properly weighed the opinions of medical professionals, including a physician's assistant, and gave partial weight to the opinion of a certain medical expert. The court also held that sufficient evidence in the record supported the ALJ's decision, including clinical notes that plaintiff lost weight from moving around so much, left a clinical appointment with a brisk walk and no cane, and stated he was doing well after a total hip replacement. Finally, the court held that a hypothetical question given to the vocational expert captured the concrete consequences of plaintiff's impairments, and the court need not consider plaintiff's Appointments Clause challenge. View "Hilliard v. Saul" on Justia Law

In this case requiring the Supreme Court to determine the scope of the authority of the Wisconsin Department of Health Services (DHS) to recoup payments made to Medicaid service providers the Supreme Court held that DHS does not have the authority to enforce its recoupment policy.Plaintiffs, Kathleen Papa and Professional Homecare Providers, Inc. (collectively, PHP), challenged DHS's recoupment policy as it had been enforced against PHP nurses to recover payments made for services they provided to Medicaid patients. PHP claimed that DHS recoups payments nurses earned and received for their Medicaid services because the nurses' supporting records contained documentation shortcomings. The Supreme Court held (1) DHS may recoup Medicaid payments from service providers only in cases where DHS cannot verify certain facts; and (2) DHS's recoupment policy exceeds its authority. View "Papa v. Wisconsin Department of Health Services" on Justia Law

Hargett, born in 1965, has a high-school education and previously worked as a semi-truck driver, municipal worker, maintenance mechanic, and industrial cleaner. He last worked in March 2015. Hargett applied for disability insurance benefits; he had high blood pressure, type-two diabetes, curvature of the spine, and COPD. Hargett’s primary care physician, Lucardie, referred Hargett to a physical therapist for a functional capacity evaluation (FCE), which indicated that Hargett had a maximum lifting capacity of 35 pounds and maximum carrying capacity of 20 pounds--the “medium strength” category-- but that Hargett could continuously stand for no more than five minutes; could continuously walk for no more than 0.1 miles; could never balance while standing, crouching, or walking; and could never crouch, stoop, or crawl. Lucardie reviewed and signed the FCE.An ALJ denied Hargett’s claim, finding that Hargett retained the residual functional capacity to perform light work. The ALJ gave only “partial weight” to the FCE, discounting its indication that Hargett’s ability to stand or walk did not meet any standard for work activity. The Sixth Circuit vacated. The ALJ should have considered the FCE as a treating-source opinion, which, in 2015, had to be given controlling weight if “well-supported by medically acceptable clinical and laboratory diagnostic techniques” and “not inconsistent with the other substantial evidence.” The error was not harmless. View "Hargett v. Commissioner of Social Security" on Justia Law