Justia Public Benefits Opinion Summaries

Plaintiff-Appellants were eleven rural hospitals (the “Hospitals”) who challenged the methodology the U.S. Secretary of Health and Human Services (the “Secretary”) used to calculate their Medicare reimbursements. After the publication of the FY 2010 Final Rule, the Hospitals took issue with the Secretary’s methodology for calculating the hospital-specific rate for new base years. And dissatisfied with their reimbursements under that methodology, the Hospitals filed administrative appeals with the Provider Reimbursement Review Board, an independent panel authorized to hear appeals from the Secretary’s final determinations. The Hospitals then sued the Secretary in the district court, arguing: (1) the Secretary applied the same cumulative budget-neutrality adjustment twice—once by using inflated normalized diagnosis-related group weights as a divisor in step two and then again in step four; (2) the Secretary’s methodology yielded different payments than “would have been made had [he] . . . applied the budget-neutrality adjustments to the DRG weights themselves;" and (3) the Secretary acted arbitrarily and capriciously by not calculating the hospital-specific rate for new base years “based on 100 percent” of a hospital’s base-year “target amount." The district court held it would “not second-guess the Secretary’s policy” just because there may have been “other ways of calculating payments.” And so the court denied the Hospitals’ summary-judgment motion, granted the Secretary’s cross-motion, and entered final judgment.The Tenth Circuit Court of Appeals, in reviewing the Hospitals’ arguments, found that their arguments rested on "flawed assumptions. And the Secretary has long understood his methodology and explained it to the public." The Court concurred with the district court and affirmed its judgment. View "Hays Medical Center et al. v. Azar" on Justia Law

Attorney Ravin represented veteran Cook on a claim for past-due disability benefits. Their agreement provided for a contingent fee and contemplated that VA would withhold the fee from any past-due benefits awarded and pay that amount directly to Ravin under 38 U.S.C. 5904(d)(3). Within days of executing that agreement, Ravin sent a copy to the Board of Veterans’ Appeals, where it was date-stamped on December 11, 2009. No copy of the agreement was submitted to the Regional Office (RO) “within 30 days of the date of execution,” as required by 38 C.F.R. 14.636(h)(4). The RO awarded Cook past-due benefits in April 2010. On April 13, 2010, the RO’s Attorney Fee Coordinator searched for any attorney fee agreement and determined that “no attorney fee decision is required” and “[a]ll retroactive benefits may be paid directly to the veteran.” The RO paid the past-due benefits to Cook. On April 27, 2010, Ravin mailed a copy of Cook’s direct-pay fee agreement to the RO. The RO informed Ravin that it had not withheld his attorney’s fees because the agreement was “not timely filed.”The Veterans Court and Federal Circuit affirmed the Board’s denial of Ravin’s claim. Section 5904(d)(3) does not mandate withholding and direct payment; 38 C.F.R. 14.636(h)(4)'s submission requirement is valid. Ravin’s fees have not been forfeited; he may use all available remedies to obtain them from Cook, per their agreement. View "Ravin v. Wilkie" on Justia Law

Brett Woolley appealed an Idaho Industrial Commission (“Commission”) decision that found him ineligible for unemployment benefits. The Commission determined that Woolley was ineligible for benefits because he was a corporate officer whose claim for benefits was based on wages from a corporation in which he had an ownership interest. The Commission also determined Woolley willfully made a false statement by saying he had not received wages or performed services as a corporate officer. After review, the Idaho Supreme Court affirmed the Commission’s determination that Woolley was ineligible for benefits due to his status as a corporate officer because it was supported by substantial and competent evidence. However, the Court found Woolley did not willfully misrepresent his status as a corporate officer, "The statute makes no mention of a claimant’s performance of services as a corporate officer. To compound the confusion, IDOL provides no information in the unemployment handbook or on its website to explain why it is necessary for claimants to report their corporate officer status when filing a claim for benefits. To serve as the basis for a willful failure to report a material fact, the question to be answered by a claimant must be accurately grounded in the legal requirements of the statute." View "Woolley v. Idaho Dept. of Labor" on Justia Law

The First Circuit declared that exclusion of otherwise eligible residents of Puerto Rico from receiving the disability benefits that are granted to persons residing in the fifty States, the District of Columbia, and the Northern Mariana Islands under the Supplemental Security Income (SSI) provisions of Title XVI of the Social Security Act, 42 U.S.C. 1381-1383(f) is not rationally related to a legitimate government interest and is invalid.While residing in New York, Defendant became eligible and commenced receiving SSI disability benefits. The benefits were discontinued when the Social Security Administration became award that Defendant had moved to Puerto Rico. The United States subsequently brought suit against Defendant seeking to collect the amount the SSA claimed was owed by Defendant due to the allegedly improper payment of SSI benefits since Defendant's relocation to Puerto Rico. Defendant raised as an affirmative defense that the exclusion of Puerto Rico residents from the SSI program violated the Equal Protection Clause. The district court granted summary judgment for Defendant, holding that Congress's actions in this case failed to pass rational basis constitutional muster. The First Circuit affirmed, holding that the Fifth Amendment forbids the categorial exclusion of Puerto Rico residents from SSI coverage. View "United States v. Vaello-Madero" on Justia Law

In October 2012, Jeske, working at a cemetery, was carrying a heavy casket when she stumbled, injuring her back. Four years later, she applied for disability insurance benefits and supplemental security income based on disability; she claimed that back and spine problems, anxiety, depression, and suicidal tendencies made her unable to work. At a hearing, Jeske told the ALJ that she was 44 years old and lived with her husband and three sons. She changed the date on which she allegedly became disabled to more than a year after her injury because she had substantial gainful activity in 2013. She explained that she received treatment through a workers’ compensation program and her employer allowed her to work from home many days. When the doctor released her from treatment, Jeske’s boss no longer permitted her to work from home and she quit. Since then she has worked as a part-time security guard.The ALJ found Jeske not disabled under the Social Security Act, 42 U.S.C. 423(d), 1382c(3). The Seventh Circuit affirmed. The ALJ applied the proper standards and sufficiently explained the decision. Although the evidence showed Jeske suffered from limiting back pain, abundant evidence supports the ALJ’s determination that her condition lacked the requirements of a presumptively disabling impairment. The use of daily-living activities, to assess credibility and symptoms, was not improper. The evidence supported a conclusion that Jeske could perform light work with specific restrictions. View "Jeske v. Saul" on Justia Law

Plaintiff Steven Kientz spent many years as a "dual status" technician with the Kansas Army National Guard, where he worked as a mechanic on electronic measurement equipment. Plaintiff’s position required him to simultaneously serve as a member of the National Guard, a second job with separate pay and separate responsibilities. In retirement, Plaintiff receives a monthly pension payment under the Civil Service Retirement System based on his service as a dual status technician. Plaintiff also receives Social Security retirement benefits based on contributions he made to the Social Security system from his separate pay as a National Guard member. The issue this case presented for the Tenth Circuit's review centered on whether a dual status service technician’s civil service pension was “based wholly on service as a member of a uniformed service” under 42 U.S.C. 415(a)(7)(A). After review, the Court concluded Plaintiff's civil service pension is not “wholly” based on service as a member of a uniformed service, and his pension payments were therefore subject to the Windfall Elimination Provision ("WEP"). Plaintiff’s dual status technician work was at least partially distinct from the performance of his military duties. And Plaintiff received separate compensation and separate pensions for his performance of those distinct roles. The Court concurred with the district court and Social Security Administration that Plaintiff's Social Security retirement benefits were subject to the WEP. View "Kientz v. Commissioner, SSA" on Justia Law

An unsuccessful bidder on managed-care contracts for MississippiCAN, the state’s managed-care program, argued that the Division of Medicaid and its executive director violated multiple statutes and regulations in procuring the contracts. Mississippi True appealed the decision of the chancery court affirming the Division of Medicaid’s award of the contracts to three other companies and the chancery court’s order denying its motion to sever and transfer its damages claims to circuit court. The Mississippi Supreme Court "thoroughly reviewed the voluminous record" and concluded that Mississippi True has failed to prove any basis for reversal. "The decision of the DOM was supported by substantial evidence, was not arbitrary or capricious, was not beyond the DOM’s power to make, and did not violate Mississippi True’s statutory or constitutional rights." View "Mississippi True v. Dzielak et al." on Justia Law

Emard, age 33, was injured in a 2010 motorcycle accident. Emard had previously worked as a truck driver, assembler, and packager. He ceased working after the accident. His application for Social Security disability-insurance benefits claimed chronic low-back pain, chronic neck pain, cervical radiculopathy, lumbar radiculopathy, chronic migraine headaches, fatigue, mood swings, anxiety, and Crohn’s disease. An ALJ determined that Emard had not engaged in substantial gainful activity during his insured period; that Emard’s degenerative disc disease, asthma, obstructive sleep apnea, anxiety, and depression were severe impairments, but that his other conditions were mild impairments; that none of Emard’s impairments or any combination thereof met the criteria of any listed impairment; that Emard had the residual functional capacity to perform sedentary work; that Emard’s “subjective complaints exceed the available objective records,” particularly in light of Emard’s conservative course of treatment; that Emard could not perform past relevant work; and that Emard could perform jobs that existed in significant numbers in the national economy.The district court and Sixth Circuit affirmed the denial of benefits. The ALJ made no procedural error by declining to give weight to the opinion of a treating source offered after the claimant’s date last insured that did not relate back to the insured period. The ALJ complied with requirements to view Emard’s impairments in combination and to consider Emard’s ability to work on a sustained basis. View "Emard v. Commissioner of Social Security" on Justia Law

Until 2010, Reinaas, now in his mid‐fifties, worked as a machine operator. He injured his spine and tore his rotator cuff on the job, and underwent two neck fusion surgeries. Reinaas planned to return to work but continued to suffer from severe headaches (treated with hydrocodone), shoulder pain, and a decreased range of motion. A neurologist diagnosed him with cervicogenic headaches, and his family doctor diagnosed “long term nuchal headaches” and “[p]ermanent pain syndrome post cervical fusion.” Dr. Bodeau, a Mayo Clinic occupational physician, opined that Reinaas could not return to his factory job and suggested surgical intervention. In 2013, Reinaas had shoulder surgery and attended physical therapy; he took naproxen and Vicodin for pain.Reinaas applied for social security disability benefits. Benefits were denied after state‐retained physicians reviewed his records and concluded that Reinaas’s accounts of his symptoms were not fully credible. Dr. Bodeau opined that Reinaas had “deteriorated significantly” and was “highly unlikely to successfully regain employment at any physical demand level.” The ALJ concluded that Reinaas was not disabled. In determining Reinaas’s residual functional capacity, the ALJ afforded great weight to the opinions of the two non‐examining physicians and gave little weight to Dr. Bodeau’s opinion, explaining that Bodeau lacked knowledge of Social Security disability rules and that his report was based on subjective complaints of questionable credibility.The Seventh Circuit vacated. Substantial evidence does not support the ALJ’s decision to discount the treating physician’s opinion and the ALJ did not adequately evaluate Reinaas’s subjective complaints. View "Reinaas v. Saul" on Justia Law

This case involved an obligor father who never missed a child support payment to the obligee, mother for their minor child. The father retired and began collecting Social Security retirement benefits. As a result, the child became eligible to receive a derivative monthly children’s insurance benefit (CIB) from the Social Security Administration (SSA). The mother received four years of CIB payments in addition to regular monthly child support payments from the obligor; the law allowed the CIB payments to be credited against the child support obligation. However, neither parent notified the Alaska Department of Revenue, Child Support Services Division (CSSD) that they were receiving CIB payments for their daughter. After four years of overpayments, CSSD discovered the CIB payment from SSA and credited the father more than $47,000 in child support overpayment. The father filed suit, asking the superior court for a judgment against the mother for overpaid child support. He also requested reimbursement or credit for overpaid health insurance premiums. The superior court denied reimbursement for either overpayment, and the father appealed. After review, the Alaska Supreme Court affirmed, finding no reversible error in the superior court's judgment. View "Rosenbaum v. Shaw" on Justia Law