Justia Public Benefits Opinion Summaries

In response to secretly recorded videos released by the Center for Medical Progress depicting conversations with Planned Parenthood employees elsewhere, LDHH terminated PPGC Louisiana Medicaid provider agreements. PPGC and the Individual Plaintiffs filed suit against LDHH under 42 U.S.C. 1983, alleging violations of 42 U.S.C. 1396a(a)(23) and the First and Fourteenth Amendments of the U.S. Constitution. The Individual Plaintiffs, three women who are Medicaid beneficiaries and who receive medical care from one of PPGC’s Louisiana facilities, seek to continue receiving care from PPGC’s facilities. The Individual Plaintiffs contend that LDHH’s termination action will deprive them of access to the qualified and willing provider of their choice, PPGC, in violation of Medicaid’s free-choice-of-provider provision. The district court entered a preliminary injunction against LDHH’s termination of PPGC’s Medicaid provider agreements. The court held that the Individual Plaintiffs met their burden to show their entitlement to a preliminary injunction; the district court did not abuse its discretion in preliminarily enjoining LDHH’s termination of PPGC’s provider agreements; and thus the court affirmed the district court's preliminary injunction, remanding for further proceedings. View "Planned Parenthood v. Gee" on Justia Law

In 2012, the Wood plaintiffs, who were recipients of health coverage under Arizona's Medicaid demonstration project, filed suit against the Secretary challenging her approval of a new Arizona project that raised copayments for medical visits and medications and that permitted healthcare providers to refuse non-emergency services based on an inability to pay. At issue on appeal is whether the members of the class action were the prevailing parties for purposes of attorneys’ fees under the Equal Access to Justice Act (EAJA), 28 U.S.C. 2412. The court applied the factors in Buckhannon Bd. & Care Home, Inc. v. W. Va. Dep’t of Health & Human Res., holding that under the EAJA, the Wood plaintiffs are the prevailing party in their procedural Administrative Procedure Act (APA), 5 U.S.C. 706(2)(A), challenge against the Secretary. The court noted that the dispositive question is not whether the plaintiff ultimately obtained some form of substantive relief, but rather whether there is a lasting alteration in the legal relationship between the parties. The court concluded that there was a material alteration in the legal relationship of the parties, to the benefit of the Wood plaintiffs. Finally, the court concluded that the retention of jurisdiction for practical and equitable reasons did not undermine the reality that the Wood plaintiffs were a prevailing party. Therefore, the court reversed and remanded to the district court to consider whether the government’s position was “substantially justified” under the EAJA. View "Wood v. Burwell" on Justia Law

Aldridge served on active duty in the U.S. Marine Corps, 1984-1992, and was denied a disability rating higher than 10% for patellofemoral syndrome on his knees in 2013. The Board of Veterans Appeals informed Aldridge that he had 120 days to file a notice of appeal with the Veterans Court, 38 U.S.C. 7266(a), by April 23, 2014. The Veterans Court received his notice on October 27, 2014. Aldridge acknowledged that his appeal was late, but argued that deaths in his family and his resulting depressive state prevented him from timely filing. His mother died on September 27, 2013; his daughter gave birth to a stillborn child on December 16; and his sister died on January 14, 2014. He asked the court to apply the doctrine of equitable tolling. The court determined that Aldridge had failed to demonstrate that his family’s losses “themselves directly or indirectly affected the timely filing of his appeal,” noting that Aldridge closed the estates of his deceased mother and sister, became his father’s primary caregiver, maintained his job at a Veterans Affairs hospital, and attempted to hire a lawyer during the time at issue. The Federal Circuit affirmed, upholding the Veterans Court’s application of a legal standard that required proof of causation. View "Aldridge v. McDonald" on Justia Law

John Boman appealed the grant of summary judgment in favor of the City of Gadsden. Boman worked as a Gadsden police officer from 1965 until he retired in 1991. Following his retirement, Boman elected to pay for retiree health coverage through a group plan offered by Gadsden to retired employees. This retired-employee-benefit plan was also administered by Blue Cross and provided substantially similar benefits to those Boman received as an active employee. In 2000, however, Gadsden elected to join an employee-health-insurance-benefit plan ("the plan") administered by the State Employees' Insurance Board ("the SEIB"). When Boman turned 65 in 2011, he was receiving medical care for congestive heart failure and severe osteoarthritis of the spine. After his 65th birthday, Blue Cross began denying his claims for medical treatment based on the failure to provide Blue Cross with a "record of the Medicare payment." However, Boman had no Medicare credits. Boman was hired before March 31, 1986, and, although Gadsden did begin participation in the Medicare program in 2006, Boman's employee group had not opted to obtain Medicare coverage before Boman retired. Consequently, Boman never paid Medicare taxes and did not claim to have Medicare coverage. The SEIB ultimately determined that the plan was the secondary payer to Medicare. Boman sued Gadsden, asserting that it had broken an agreement, made upon his employment, to provide him with lifetime health benefits upon his retirement. Boman also sued the members of the SEIB charged with administering the plan, challenging the SEIB's interpretation of the plan. Finding no reversible error in the grant of summary judgment to Gadsden, the Supreme Court affirmed. View "Boman v. City of Gadsden" on Justia Law

L.J.’s mother filed suit in federal district court to require the school district to provide L.J. with an Individualized Education Plan (IEP) to provide specialized services to assist with what she contends are serious disabilities. The district court reviewed the record and found that L.J. was disabled under three categories defined by the Individuals with Disabilities Education Act (IDEA), 20 U.S.C. 1400 et seq. Nevertheless, the district court concluded that an IEP for specialized services was not necessary because of L.J.’s satisfactory performance in general education classes. The court concluded that L.J. clearly exhibited behavioral and academic difficulty during the snapshot period where he threatened and attempted to kill himself on three occasions in 2012; in the fall, he frequently acted out at school, and continued to have needs associated with his medication regimen; and the district court should not have discounted these facts. The court concluded that they demonstrate that L.J. required special education services. Because L.J. is eligible for special education, the school district must formulate an IEP. The court also concluded that the school district clearly violated important procedural safeguards set forth in the IDEA. In this case, the school district failed to disclose assessments, treatment plans, and progress notes, which deprived L.J.’s mother of her right to informed consent. The school district also failed to conduct a health assessment, which rendered the school district and IEP team unable to evaluate and address L.J.’s medication and treatment related needs. Accordingly, the court reversed and remanded. View "L. J. V. Pittsburg U.S.D." on Justia Law

Presser, who has 20 years of experience as a Wisconsin nurse and a nurse practitioner, began working with Acacia in 2011, providing psychiatric evaluations, managing patient medication, and providing other medical services. Presser alleges that Acacia and its owner, Freund, engaged in “upcoding,” provided unnecessary medical procedures, and then charged the federal and state governments for those expenses. The district court dismissed Presser’s qui tam action under the False Claims Act, 31 U.S.C. 3729 and the Wisconsin False Claims Act. Citing the need for particularity in pleading, the court noted Presser did not allege that the defendants actually sent any of the alleged claims or made any of the alleged statements to the state or federal governments. The Seventh Circuit affirmed that judgment except with respect to the claims regarding the use of an improper billing code, which were stated with sufficient particularity. Presser otherwise provided no medical, technical, or scientific context which would enable a reader of the complaint to understand why Acacia’s alleged actions amount to unnecessary care forbidden by the statute. View "Presser v. Acacia Mental Health Clinic, LLC" on Justia Law

Alvarado was born in 1967. In 1993 he was granted childhood disability benefits and Supplemental Security Income. The Social Security Act requires the Social Security Administration to periodically review whether a recipient remains disabled. Alvarado’s eligibility was reviewed and affirmed in 1999. In a 2004 review, the Administration determined that his disability had ended, so his benefits were discontinued. After a remand, a hearing officer and ALJ each upheld the decision, finding that Alvarado continued to suffer from a severe learning disorder, which prevented him from performing many jobs, but which did not prevent him from doing simple jobs that did not require interaction with the public and that a significant number of such jobs exist in Illinois,. The Appeals Council denied review. The district judge and Third Circuit affirmed, finding the denial supported by substantial evidence. The court noted evidence evidence that Alvarado: had a driver’s license and drove regularly, including long trips; used public transportation; had obtained an associate’s degree and was only a few credits short of a bachelor’s degree; had lived alone, in a different state from his family; assisted at his mother’s flower shop; performed chores at home; and used the internet. View "Alvarado v. Colvin" on Justia Law

The seven consolidated cases in this appeal all involve attempts by assignees of a health maintenance organization (HMO) to recover conditional payments via the Medicare Secondary Payer Act's (MSP Act), 42 U.S.C. 1395y(b)(2)(B)(ii), (b)(3)(A), private cause of action. At issue is whether a contractual obligation, without more (specifically, without a judgment or settlement agreement from a separate proceeding), can satisfy the “demonstrated responsibility” requirement of the private cause of action provided for by the MSP Act. The court held that a plaintiff suing a primary plan under the private cause of action in the MSP Act may satisfy the demonstrated responsibility prerequisite by alleging the existence of a contractual obligation to pay. A judgment or settlement from a separate proceeding is not necessary. Therefore, the court vacated the district courts' judgments and remanded for further proceedings. View "MSP Recovery LLC v. AllState Ins. Co." on Justia Law

The Supplemental Nutrition Assistance Program (SNAP), overseen by the USDA, is administered by the states, 7 U.S.C. 2011–2036c. An individual is ineligible for SNAP benefits if he is “fleeing to avoid prosecution, or custody or confinement after conviction . . . for a crime, or attempt to commit a crime, that is a felony under the law of the place from which the individual is fleeing.” Michigan’s implementation barred assistance to anyone “subject to arrest under an outstanding warrant arising from a felony charge against that individual.” Michigan had an automated program that compared the list of public-assistance recipients with a list of outstanding felony warrants maintained by the Michigan State Police; when the program identified a match, it automatically closed the recipient’s file and generated a notice of the termination of benefits. In 2015 the Secretary of Agriculture promulgated 7 C.F.R. 273.11(n), clarifying disqualification of fugitive felons. Plaintiffs challenged Michigan's automatic disqualification and notice process. The court certified a class, held that Michigan policy violated the SNAP Act and the Constitution, and issued an injunction requiring Michigan to refrain from automatic disqualifications based solely on the existence of a felony warrant and to provide adequate notices of valid disqualification. The Sixth Circuit affirmed, rejecting claims that the plaintiffs lacked standing, of mootness, that there is no SNAP Act private right of action, and that Michigan's methods were valid. View "Barry v. Lyon" on Justia Law

Charles Wimberly filed an application for disability retirement benefits with the Kentucky Retirement Systems (KERS). A hearing officer recommended that Wimberly's application be denied and, before KERS could render a final decision, Wimberly filed a second application pursuant to Kentucky Revised Statute (KRS) 61.600(2). Following the recommendation of another hearing officer, KERS denied that application. Wimberly sought judicial review; the circuit court reversed KERS. KERS appealed to the Court of Appeals, which affirmed the circuit court. The Supreme Court granted discretionary review to address the parties' arguments regarding the application of the doctrine of res judicata and to determine whether the consumption of alcohol was or could be a pre-existing condition. Having reviewed the record and the arguments of the parties, the Supreme Court affirmed. View "Kentucky Retirement Systems v. Wimberly" on Justia Law