Justia Public Benefits Opinion Summaries

The Centers for Medicare & Medicaid Services (CMS) terminated its Provider Agreement with Parkview Adventist Medical Center after finding that Parkview was no longer a “hospital” under the Medicare statute. Parkview, which had filed for bankruptcy, attempted to use the Bankruptcy Code to challenge the actions of CMS in terminating the agreement. Parkview filed a motion to compel post-petition performance of executory contracts, arguing that the Provider Agreement was an “executory contract” under 11 U.S.C. 365 and accordingly within the bankruptcy court’s jurisdiction and, as such, CMS’s termination of the agreement was a post-petition termination without court authority in violation of the Bankruptcy Code. Further, Parkview argued that CMS’s termination of the Provider Agreement violated the automatic stay in 11 U.S.C. 362(a)(3) and the non-discrimination provision in 11 U.S.C. 525(a). The bankruptcy court concluded that it lacked jurisdiction over the motion and that CMS had not violated either the automatic stay or the non-discrimination provision. The district court affirmed. The First Circuit affirmed, holding (1) the automatic stay did not bar CMS’s termination of the Provider Agreement; and (2) CMS’s termination of the Provider Agreement was not impermissible discrimination. View "Parkview Adventist Medical Center v. United States" on Justia Law

Relators’ daughter died of a seizure after receiving mental health treatment at Arbour Counseling Services, a facility in Massachusetts owned and operated by Universal Health Services (UHS). When Relators learned that Arbour had employed unlicensed and unsupervised personnel, in violation of state regulations, they brought a qui tam action against UHS under the False Claims Act (FCA), alleging that UHS had fraudulently submitted reimbursement claims to the Commonwealth despite knowing that it was in violation of state regulations (a theory of FCA liability known as the “implied false certification theory”). The district court dismissed the complaint, concluding that the regulatory violations were not conditions of payment as required for a claim to be actionable under the FCA. The First Circuit reversed, holding that the regulatory violations at issue were conditions for payment and that Relators appropriately stated a claim with particularity under the FCA. On certiorari, the Supreme Court held that the implied false certification theory can be a basis for FCA liability but remanded the case for further consideration of whether the complaint sufficiently alleged that the regulatory violations were material to the government’s payment decision. The First Circuit again reversed the district court’s grant of UHS’s motion to dismiss after applying the Supreme Court’s guidance on the question of whether UHS’s misrepresentations were material, holding that Relators’ complaint sufficiently stated a claim under the FCA. View "United States, ex rel. Escobar v. Universal Health Services, Inc." on Justia Law

Seven entities under contract to provide residential services to youth in the state (collectively, Petitioners) filed a petition for writ of mandamus requiring the West Virginia Department of Health and Human Services (DHHR), its Cabinet Secretary, the West Virginia Bureau for Medical Services (BMS), its Acting Commissioner, the Bureau for Children and Families (BCF), and its Commissioner (collectively, Respondents) to promulgate new or amended legislative rules prior to implementing changes to existing residential child care services policies. The Supreme Court granted a writ as moulded, finding it most appropriate to order this matter to be docketed in this circuit court as if it were an original proceeding in mandamus in that court. Remanded for further proceedings. View "State ex rel. Pressley Ridge v. W. Va. Department of Health & Human Resources" on Justia Law

This issue this case presented for the Supreme Court's review centered on whether the collateral source rule should apply when Medicaid pays for an injured party’s medical expenses. The Delaware Supreme Court held that, when Medicaid has paid an injured party’s medical expenses, the collateral source rule cannot be used to increase an injured party’s recovery of past medical expenses beyond those actually paid by Medicaid. "As with Medicare, the difference is unnecessary to make the injured party whole because it is paid by no one." Appellant Jennifer Smith, was injured in two car collisions. Although employed when her injuries occurred, Smith qualified for Medicaid coverage. At first, her treating physician sought to recover his standard charges of $22,911 from the proceeds of any personal injury settlement. But later, the treating physician opted to forego his original billed amount, and instead billed Medicaid for his charges. Medicaid paid the treating physician $5,197.71, and asserted a lien in that amount on the proceeds of any recovery by settlement or lawsuit. When all was netted out, the Superior Court entered judgment against the defendants jointly and severally for $49,911. Relying on the applicable case law, the trial court determined that “Delaware case law is clear that the collateral source rule does not apply to Medicaid or Medicare write-offs.” In its decision here, the Delaware Supreme Court refused to extend operation of the collateral source rule and affirmed the superior court's judgment. Also affirmed was the Superior Court’s ruling that future medical expenses were not subject to Medicaid reimbursement limitations. "Unlike Medicare, Medicaid coverage is income dependent, and might not be available if a plaintiff improves her financial position to a living wage and secures other insurance. Because of the uncertainty of future coverage, Medicaid benefits cannot be used to limit a plaintiff’s future medical expenses." View "Smith v. Mahoney" on Justia Law

Jessica Barr appealed an Idaho Industrial Commission (Commission) decision finding her ineligible for unemployment benefits and affirming the decision of an Appeals Examiner for the Idaho Department of Labor’s (IDOL) Appeals Bureau. The Commission found that Barr was discharged by her employer, Citicorp Credit Services, Inc. USA (Citicorp), for misconduct in connection with employment and determined that Barr was not eligible for benefits pursuant to Idaho Code section 72-1366(5). Barr argued that Citicorp representatives provided false information to the Appeals Examiner and her unemployment benefits should have been restored. Finding that the Commission's decision was supported by substantial and competent evidence, the Supreme Court affirmed the IDOL Appeals Examiner's decision. View "Barr v. CitiCorp Credit Svc" on Justia Law

The consolidated appeals in this case involved a dispute between the Secretary of Health and Human Services and a group of Maine hospitals about certain payments - called disproportionate share payments (DSH payments) - the hospitals had received in reimbursement from the federal government for charity care for fiscal years dating as far back as 1993. Generally speaking, the more low-income patients a hospital services, the higher the hospital’s DSH payment. In this case, the Secretary maintained that the Hospitals were overinclusive in their DSH payment calculations. An intermediary reassessed the DSH payments and recouped from the Hospitals approximately $22 million in alleged overpayments. The Provider Reimbursement Review Board, in turn, ordered the intermediary to restore approximately $17 million to the Hospitals. The Secretary reversed. The Hospitals sought judicial review, but neither side was satisfied with the district court’s ruling. On appeal, the First Circuit reversed in part and affirmed in part, holding (1) the Secretary properly reopened the disputed years and adequately demonstrated that the Hospitals had received substantial overpayments of DSH funds; and (2) the Hospitals’ defenses to repayment were unavailing. View "Maine Medical Center v. Burwell" on Justia Law

In the underlying litigation to this appeal, claimants were petitioners or represented petitioners who challenged legislation passed in 2013 that changed the pension benefits paid to certain members of the Public Employee Retirement System (PERS) by limiting the statutory cost-of-living adjustment (COLA) and eliminating a PERS income-tax offset for out-of-state retirees. In "Moro v. Oregon," (351 P.3d 1 (2015) (Moro I)), the Oregon Supreme Court largely agreed with petitioners’ argument that modifications to the COLA formula impaired petitioners’ contractual rights, thus violating Article I, section 21, of the Oregon Constitution. But the Court rejected petitioners’ similar challenge to the elimination of the income-tax offset. Petitioners, who were active and retired members of PERS, were the prevailing parties. Following the decision in Moro I, claimants petitioned for attorney fees and costs. State respondents and county/school district respondents filed objections. The Supreme Court referred those petitions to a special master for recommended findings of fact and conclusions of law. The special master reported his recommendations, and the parties subsequently filed objections and responses to those recommendations. The issues raised in those filings included which legal doctrines justified an award of attorney fees in this case; whether self-represented attorneys were eligible to receive an award of attorney fees; whether the fees sought by claimants were reasonable; and how to pay for an award of fees and costs. After review, the Oregon Supreme Court concluded that fees should be awarded based on the common-fund and substantial-benefit doctrines; that the self-represented attorneys were eligible to receive a fee award under those doctrines; that a reasonable fee award under the lodestar approach had to be based on reasonable hourly rates and reflect reductions to account for duplicative work and work on unsuccessful claims; and that an award in this case should be paid for as determined by the Public Employees Retirement Board (PERB) in a manner that was consistent with its statutory authority and fiduciary obligations. View "Moro v. Oregon" on Justia Law

The question underlying these proceedings was whether the State must consider and pay claims submitted after the effective date of the legislative deadline for pre-2006 reimbursement claims set forth in Section 61 of the 2012 amendment to the Medicaid Cap Statute, which provides that no reimbursement claims shall be made for a category of Medicaid disability expenses paid by counties to the State prior to 2006. In these appeals, the latest round in a decade-long struggle between the counties and the State over Medicaid payments, several counties challenged the constitutionality of Section 61. The Court of Appeals held (1) Section 61 is constitutional; and (2) the State is under no obligation to address outstanding county reimbursement claims filed after April 1, 2012, and the State is not required to initiate an administrative review of its records to identify and pay for any pre-2006 claims. View "County of Chemung v. Shah" on Justia Law

In 2001, Israel injured his back while digging posts for a porch. He worked while receiving treatments but his pain worsened; he stopped working in February 2003. He underwent a lumbar laminectomy and diskectomy, which did not resolve his pain Two surgeons determined that further surgery was not an option. Under the care of various doctors, Israel tried physical therapy, transcutaneous electrical nerve stimulation (TENS), a dorsal column stimulator, epidural injections, narcotic pain medications including Methadone and morphine, lidocaine patches, a muscle relaxer, an anti‐depressant, and drugs for nerve pain. Diagnosed with lumbar radiculopathy and post‐laminectomy pain syndrome, Israel continues to experience severely limiting pain. His doctor sought approval to implement an “intrathecal drug delivery system,” a pain pump that delivers medication directly to the spinal cord. Israel’s insurer refused to cover the cost. Israel sought Disability Insurance Benefits and Supplemental Security Income benefits in 2007. On remand, the Social Security Administration repeatedly denied benefits.The Commissioner conceded in the district court that her decision was not supported by substantial evidence and requested remand. Israel, frustrated with years of delay, sought a direct award of benefits. The district court remanded. The Seventh Circuit affirmed, finding that the district court did not abuse its discretion in ordering a remand; the agency should expedite proceedings so that the matter may be resolved. View "Israel v. Colvin" on Justia Law

W.C. was born in Guatemala in 1997. He lived with his grandparents because his mother was dead and his father missing. W.C. left Guatemala because of threats to his safety and came to the U.S. alone, in 2014. At the border, W.C. was taken into protective custody and placed with a distant relative in Oakland. The relative agreed to sponsor W.C. for asylum, but their relationship deteriorated. W.C. became homeless in October 2014. He started using drugs. Taken to a hospital for assessment after cutting himself at school, he was denied treatment because he lacked insurance. W.C. lived at a youth shelter for a while, then told social services he was living with a friend. Eventually, W.C. was suspended from school because he was under the influence of drugs, possessed a knife, and engaged in theft. W.C. requested protective custody. The court ordered him detained, with temporary placement and care provided by the agency. On May 1, 2015, W.C. turned 18. At a May 26 hearing, the agency recommended the dependency be dismissed because the juvenile court had made no legal determination on dependency. On July 7, the juvenile court dismissed the Welfare and Institutions Code section 300 petition. In February 2016, W.C. filed a Request to Return to Juvenile Court Jurisdiction and Foster Care, hoping to participate in job training. The court denied the request. The court of appeal affirmed, holding that a nonminor who was never found a dependent of the court could not reenter and be subject to juvenile court jurisdiction. View "In re W.C." on Justia Law