Justia Public Benefits Opinion Summaries

Plaintiff filed suit alleging that the school district violated the Individuals with Disabilities Education Act (IDEA) by failing to develop and implement an Individual Education Plan (IEP) that was reasonably calculated to provide him with educational benefits appropriate to his circumstances.Assuming arguendo that plaintiff was able to challenge all of the IEPs that the school district designed and implemented, the Fifth Circuit ultimately held that there was no IDEA violation. The court held that the district court properly considered the four factor test articulated in Cypress-Fairbanks lndep. Sch. Dist. v. Michael ex rel. Barry F., 118 F.3d 245, 247 (5th Cir. 1997), and concluded that all factors weighed in favor of the school district. In this case, the school district expended a great amount of time and resources developing and implementing an IEP that was based on multiple in-depth evaluations of plaintiff's unique needs and abilities with significant input from plaintiff's parents and expert consultants, and plaintiff achieved at least some academic and nonacademic benefits as a result of his plan. Accordingly, the court affirmed the district court's grant of summary judgment against plaintiff on his IDEA claim and dismissal of his remaining claims. View "R. S. v. Highland Park Independent School District" on Justia Law

The Fourth Circuit affirmed the denial of Social Security disability benefits to plaintiff, who claims that she has been unable to engage in any substantial gainful employment since November 2013, due to a combination of her back and shoulder impairments and a lifelong learning disorder.The court held that the ALJ's findings and the mental limitation included in the residual functional capacity (RFC) are sufficiently explained and supported by substantial evidence in the record. In this case, the ALJ addressed plaintiff's lifelong, borderline intellectual disability, including her moderate limitations in concentration, persistence, or pace; explained why the psychological evidence and plaintiff's statements support a mental limitation to simple, routine, and repetitive tasks; and included the mental limitation in the hypothetical question posed to the vocational expert. The court also held that the ALJ's finding that plaintiff can perform light work despite her physical limitations was supported by substantial evidence in the record. View "Shinaberry v. Saul" on Justia Law

The Fifth Circuit reversed the denial of social security disability benefits to plaintiff. The court held that the denial of benefits was not supported by substantial evidence, because the ALJ failed to apply the SSA's rules regarding borderline-age situations and did not provide any explanation for putting her in a lower age category. Accordingly, the court remanded for further proceedings. View "Schofield v. Saul" on Justia Law

The Ninth Circuit affirmed the district court's decision upholding the SSA's denial of the claimant's application for disability benefits under Titles II and XVI of the Social Security Act. The panel held that the ALJ properly provided specific and legitimate reasons for discounting the opinions of claimant's physicians, correctly concluded that claimant's impairments did not meet a listing, and was entitled to rely on the vocational expert's testimony despite the expert's failure to provide information about the sources underlying the testimony. View "Ford v. Saul" on Justia Law

Kentucky and Arkansas residents sued the Secretary of Health and Human Services based on the approval under 42 U.S.C. 1315(a) of an “experimental, pilot, or demonstration projects which, in the judgment of the Secretary, is likely to assist in promoting the objectives” of Medicaid. The district court held that the Secretary failed to analyze whether the projects would promote the primary objective of Medicaid—to furnish medical assistance. Kentucky terminated its project and obtained voluntary dismissal.The D.C. Circuit affirmed with respect to the Arkansas Works program, which required beneficiaries aged 19-49 to “work or engage in specified educational, job training, or job search activities for at least 80 hours per month,” except beneficiaries who show they are medically frail or pregnant, caring for a dependent child under age six, participating in a substance treatment program, or are full-time students. Works proposed to eliminate retroactive coverage, to lower the income eligibility threshold from 133% to 100% of the federal poverty line, and eliminated using Medicaid funds to assist beneficiaries in paying the premiums for employer-provided health care coverage. Instead of analyzing whether the demonstration would promote the objective of providing coverage, the Secretary identified three alternative objectives. Congress has not conditioned the receipt of Medicaid benefits on fulfilling work requirements or taking steps to end receipt of governmental benefits View "Gresham v. Azar" on Justia Law

Of two people injured in a car wreck in April 2012, one was a Medicare beneficiary who received her benefits from an MAO-Florida Healthcare Plus, which later assigned its claims to appellant MSPA Claims 1, LLC. The other party involved in the accident was insured by appellee Kingsway Amigo Insurance. The Medicare beneficiary obtained medical treatment for her accident-related injuries between April 29, 2012 and July 26, 2012, and Florida Healthcare made $21,965 in payments on her behalf. On March 28, 2013, the beneficiary settled a personal-injury claim with Kingsway and received a $6,667 settlement payment. The issue this case presented for the Eleventh Circuit’s review centered on the timeliness requirement with which the government had to comply as a prerequisite to filing suit to seek reimbursements that it made on behalf of the Medicare beneficiary, and whether filing suit beyond a statutory three-year period beginning on the date on which medical services were rendered was fatal to the government’s claim. The district court held that MSPA’s claim was stale because it didn’t comply with what the court (somewhat confusingly) called “the three-year limitation requirement.” The Eleventh Circuit disagreed and reversed. “The Medicare Secondary Payer Act’s private cause of action, and our cases interpreting it lead us to conclude that the Act’s claims-filing provision, doesn’t erect a separate bar that private plaintiffs must overcome in order to sue. A closer look at the claims-filing provision’s text and the Act’s structure confirms that conclusion. Accordingly, the district court erred in granting Kingsway’s motion for judgment on the pleadings.” View "MSPA Claims 1, LLC v. Kingsway Amigo Insurance Company" on Justia Law

Central Mississippi Medical Center (CMMC) appealed a Chancery Court decision denying its appeal of a Division of Medicaid (DOM) hearing. The DOM had determined that CMMC owed it $1.226 million due to overpayment. The Mississippi Supreme Court recently decided a reimbursement dispute involving the DOM, Crossgates River Oaks Hosp. v. Miss. Div. of Medicaid, 240 So. 3d 385 (Miss. 2018). In Crossgates, the hospitals prevailed because the DOM had failed to adhere to the Medicare State Plan Agreement. Applying the same legal principles to this case, the Supreme Court ruled the DOM prevailed because the DOM adhered to the Plan. The chancellor found sufficient evidence to support the DOM’s decision, decreed that it was neither arbitrary nor capricious, and decreed that it did not exceed the DOM’s authority or violate any of CMMC’s statutory or constitutional rights. View "Central Mississippi Medical Center v. Mississippi Division of Medicaid" on Justia Law

The Court of Appeals confirmed the determination of a local services agency, confirmed by a state agency, that child support payments a parent receives, made for the benefit of her five children living at home, are included as "household" income in deciding whether the household is eligible for benefits under the Supplemental Nutrition Assistance Program (SNAP), holding that, for the purposes of SNAP, child support directly received by a parent is household income, even if it is used for the benefit of an ineligible college student living at home.The Suffolk County Department of Social Services (DSS) discontinued the household's benefits because its income exceeded the upper limit for the household. Because the two college children were ineligible for SNAP, DSS did not count them as household members but did include the full amount of child support in its calculation of household income. The mother appealed, arguing that the college children's pro rata share of the child support payment should be excluded from household income, rendering the household SNAP-eligible. The Office of Temporary and Disability Assistance (OTDA) upheld the determination. The Appellate Division confirmed the OTDA's determination. The Court of Appeals also confirmed, holding that the OTDA's interpretation of the relevant federal statutes was not irrational and was entitled to deference. View "Leggio v. Devine" on Justia Law

The Supreme Court affirmed the decision of the court of appeals affirming the determination of Scott County that Consumer Directed Community Support (CDCS) money that Cindy Ali, whose son was disabled, had allocated to herself as wages to care for her child was not excluded from the annual income calculation for the purpose of Section 8 eligibility, holding that amounts allocated to a parent to care for her disabled child are not excluded as income under 24 C.F.R. 5.609(c)(16).This dispute arose from the interplay between two public welfare programs, the state CDCS option for families with disabled members, and Section 8, an income-based federal housing program. Ali participated in the Section 8 housing program until Scott County, the local housing administrator, determined that the amounts Ali paid herself under the CDCS option were not excluded from her income when calculating her eligibility for Section 8 housing. As a result, Ali lost her Section 8 eligibility. The court of appeals affirmed. The Supreme Court affirmed, holding that the CDCS amounts Ali received as compensation for her services in caring for her child were correctly included as annual income when calculating Ali's Section 8 eligibility. View "In re Cindi Ali" on Justia Law

Under the Medicaid program, 42 U.S.C. 1396, states must ensure that certain medical assistance is available to all eligible beneficiaries. Illinois administers its Medicaid program through HFS. For managed care programs, HFS contracts with Medicaid managed care organizations (MCOs), which a flat monthly fee per patient. The MCOs pay providers for services rendered to Medicaid beneficiaries. Plaintiffs, consultants who offer business services to Illinois nursing homes and supportive living facilities, sued on behalf of a class of nursing home residents entitled to Medicaid benefits, alleging violations of Title XIX of the Social Security Act, the Americans with Disabilities Act, the Rehabilitation Act, and the Due Process and Equal Protection Clauses. They alleged that the MCOs failed to process timely payments for claims submitted by nursing homes—the plaintiff‐consultants’ clients—to the MCOs, putting the resident‐beneficiaries at risk of being discharged from the facilities. The Seventh Circuit affirmed the dismissal of the case for lack of subject matter jurisdiction. The regulation cited by plaintiffs does not permit authorized representatives to bring civil lawsuits on behalf of Medicaid beneficiaries so the plaintiffs lacked standing. The residents would be unlikely to benefit if the plaintiffs won; they apparently filed suit in an effort to push the state to pay outstanding bills owed to the consultants’ clients. View "Bria Health Services, LLC v. Eagleson" on Justia Law