Justia U.S. Supreme Court Opinion SummariesArticles Posted in Public Benefits
Azar v. Allina Health Services
The Medicare program offers additional payments to institutions that serve a “disproportionate number” of low-income patients, 42 U.S.C. 1395ww(d)(5)(F)(i)(I), calculated using the hospital’s “Medicare fraction.” The fraction’s denominator is the time the hospital spent caring for patients entitled to Medicare Part A benefits; the numerator is the time the hospital spent caring for Part-A-entitled patients who were also entitled to income support payments under the Social Security Act. Medicare Part C (Medicare Advantage) was created in 1997. Part C, beneficiaries may choose to have the government pay their private insurance premiums rather than pay for their hospital care directly. Part C enrollees tend to be wealthier than Part A enrollees, so counting them makes the fraction smaller and reduces hospitals’ payments. In 2014, the Medicare website indicated that fractions for fiscal year 2012 included Part C patients. Hospitals sued, claiming violation the Medicare Act’s requirement to provide public notice and a 60-day comment period for any “rule, requirement, or other statement of policy . . . that establishes or changes a substantive legal standard governing . . . the payment for services.”The Supreme Court affirmed the D.C. Circuit in agreeing with the hospitals. The government has not identified a lawful excuse for neglecting its statutory notice-and-comment obligations. The 2014 announcement established or changed a “substantive legal standard” not an interpretive legal standard. The Medicare Act and the Administrative Procedures Act do not use the word “substantive” in the same way. The Medicare Act contemplates that “statements of policy” can establish or change a “substantive legal standard." Had Congress wanted to follow the APA in the Medicare Act and exempt interpretive rules and policy statements from notice and comment, it could have cross-referenced the APA exemption, 5 U.S.C. 553(b)(A). View "Azar v. Allina Health Services" on Justia Law
Smith v. Berryhill
The Social Security Act permits judicial review of “any final decision . . . after a hearing” by the Social Security Administration (SSA), 42 U.S.C. 405(g). Claimants for Title XVI supplemental security income disability benefits must generally proceed through a four-step process before federal-court review: seek an initial determination of eligibility; seek reconsideration; request a hearing before an administrative law judge (ALJ); and seek review of the ALJ’s decision by the Appeals Council within 60 days of receiving the ALJ’s ruling. If the claimant misses that deadline and cannot show good cause for doing so, the Appeals Council dismisses the request. Smith’s claim for disability benefits was denied on initial determination, upon reconsideration, and on the merits by an ALJ. The Appeals Council dismissed Smith’s request for review as untimely. Smith sought judicial review of the dismissal. The Sixth Circuit affirmed dismissal for lack of jurisdiction, holding that the Appeals Council’s dismissal of an untimely petition is not a “final decision.”A unanimous Supreme Court reversed. An Appeals Council dismissal on timeliness grounds after a claimant has had an ALJ hearing on the merits qualifies as a “final decision . . . made after a hearing” under section 405(g). The Appeals Council’s dismissal is the final stage of review, 20 CFR 416.1472; Smith obtained the kind of hearing that section 405(g) most naturally suggests. The dismissal is not merely collateral but an end to a proceeding in which a substantial factual record has been developed. The Court noted that “Congress designed [the statute as a whole] to be ‘unusually protective’ of claimants” and “the strong presumption that Congress intends judicial review of administrative action.” View "Smith v. Berryhill" on Justia Law
Biestek v. Berryhill
Biestek, a former construction worker, applied for social security disability benefits, claiming he could no longer work due to physical and mental disabilities. To determine whether Biestek could successfully transition to less physically demanding work, the ALJ heard testimony from a vocational expert regarding the types of jobs Biestek could still perform and the number of such jobs that existed in the national economy. The statistics came from her own market surveys. The expert refused Biestek’s attorney's request to turn over the surveys. The ALJ denied Biestek benefits. An ALJ’s factual findings are “conclusive” if supported by “substantial evidence,” 42 U.S.C. 405(g).The Sixth Circuit and the Supreme Court upheld the ALJ’s determination. A vocational expert’s refusal to provide private market-survey data upon the applicant’s request does not categorically preclude the testimony from counting as “substantial evidence.” In some cases, the refusal to disclose data, considered along with other shortcomings, will undercut an expert’s credibility and prevent a court from finding that “a reasonable mind” could accept the expert’s testimony; the refusal will sometimes interfere with effective cross-examination, which a reviewing court may consider in deciding how to credit an expert’s opinion. In other cases, even without supporting data, an applicant will be able to probe the expert’s testimony on cross-examination. The Court declined to establish a categorical rule, applying to every case in which a vocational expert refuses a request for underlying data. The inquiry remains case-by-case, taking into account all features of the expert’s testimony, with the rest of the record, and defers to the presiding ALJ. View "Biestek v. Berryhill" on Justia Law
Culbertson v. Berryhill
For representation in administrative proceedings, the Social Security Act provides that if a fee agreement exists, fees are capped at the lesser of 25% of past-due benefits or a set dollar amount—currently $6,000, 42 U.S.C. 406(a)(2)(A); absent an agreement, the agency may set any “reasonable” fee, section 406(a)(1). In either case, the agency is required to withhold up to 25% of past-due benefits for direct payment of fees. For representation in court proceedings, section 406(b) caps fees at 25% of past-due benefits; the agency may withhold benefits to pay these fees. Culbertson represented Wood in Social Security disability benefit proceedings before the agency and in court. The agency ultimately awarded Wood past-due benefits, withheld 25%, and awarded Culbertson fees under section 406(a) for representation before the agency. Culbertson sought a separate award under 406(b) for the court proceedings, requesting 25% of past-due benefits. The Eleventh Circuit held that 406(b)’s 25% limit applies to the total fees awarded under both sections.The Supreme Court reversed. Section 406(b)(1)(A)’s 25% cap applies only to fees for court representation, not to the aggregate fees awarded under 406(a) and (b). The subsections address different stages of the representation and use different methods for calculating fees. Applying 406(b)’s 25% cap on court-stage fees to 406(a) agency-stage fees, or the aggregate fees, would make little sense and would subject 406(a)(1)’s reasonableness limitation to 406(b)’s 25% cap—a limitation not included in the statute. The fact that the agency presently withholds a single pool of past-due benefits for payment of fees does not support an aggregate reading. The amount of past-due benefits that the agency can withhold for payment does not delimit the amount of fees that can be approved for representation before the agency or the court. View "Culbertson v. Berryhill" on Justia Law
Universal Health Servs., Inc. v. United States
A Massachusetts’ Medicaid beneficiary received services at Arbour, a mental health facility owned by Universal’s subsidiary. The teenager had an adverse reaction to a medication that a purported doctor prescribed after diagnosing her with bipolar disorder. She died of a seizure. Her parents discovered that few Arbour employees were licensed to provide mental health counseling or to prescribe medications without supervision. They filed a qui tam suit, alleging violations of the False Claims Act (FCA), which imposes penalties on anyone who “knowingly presents . . . a false or fraudulent claim for payment or approval” to the federal government, 31 U.S.C. 3729(a)(1)(A). They alleged an “implied false certification theory of liability,” which treats a payment request as an implied certification of compliance with relevant statutes, regulations, or contract requirements that are material conditions of payment. They cited Universal’s failure to disclose serious violations of Massachusetts Medicaid regulations and claimed that Medicaid would have refused to pay the claims had it known of the violations. The First Circuit reversed dismissal, in part. A unanimous Supreme Court vacated. The FCA does not define a “false” or “fraudulent” claim; the claims at issue may be actionable because they do more than merely demand payment. Representations that state the truth only so far as it goes, while omitting critical qualifying information, can be actionable misrepresentations. By conveying specific information about services without disclosing violations of staff and licensing requirements, Universal’s claims constituted misrepresentations. FCA liability for failing to disclose violations of legal requirements does not depend upon whether those requirements were expressly designated as conditions of payment. While statutory, regulatory, and contractual requirements are not automatically material, even if labeled as conditions of payment, a defendant can have “actual knowledge” that a condition is material even if the government does not expressly call it a condition of payment. View "Universal Health Servs., Inc. v. United States" on Justia Law
Texas Dep’t of Hous, & Cmity Affairs v. Inclusive Communities Project, Inc.
The federal government provides low-income housing tax credits that are distributed to developers by state agencies, including the Texas Department of Housing and Community Affairs. The Inclusive Communities Project (ICP), which assists low-income families in obtaining affordable housing, brought a disparate-impact claim under Fair Housing Act sections 804(a) and 805(a), alleging that allocation of too many credits to housing in predominantly black inner-city areas and too few in predominantly white suburban neighborhoods resulted in continued segregated housing patterns. Relying on statistical evidence, the district court ruled in favor of ICP. While appeal was pending, HUD issued a regulation interpreting the FHA to encompass disparate-impact liability and establishing a burden-shifting framework. The Fifth Circuit held that disparate-impact claims are cognizable under the FHA, but reversed, concluding that the court had improperly required proof of less discriminatory alternatives. The Supreme Court affirmed and remanded. Disparate-impact claims are cognizable under the FHA. The Court noted that the statute shifts emphasis from an actor’s intent to the consequences of his actions. Disparate-impact liability must be limited so that regulated entities can make practical business choices that sustain the free-enterprise system. Before rejecting a business justification—or a governmental entity’s public interest—a court must determine that a plaintiff has shown “an available alternative . . . that has less disparate impact and serves the [entity’s] legitimate needs.” A disparate-impact claim relying on a statistical disparity must fail if the plaintiff cannot point to a policy causing that disparity. Policies, governmental or private, are not contrary to the disparate-impact requirement unless they are “artificial, arbitrary, and unnecessary barriers.” When courts find disparate impact liability, their remedial orders must be consistent with the Constitution and should concentrate on eliminating the offending practice. Orders that impose racial targets or quotas might raise difficult constitutional questions. View "Texas Dep't of Hous, & Cmity Affairs v. Inclusive Communities Project, Inc." on Justia Law
Armstrong v. Exceptional Child Ctr., Inc.
Providers of “habilitation services” under Idaho’s Medicaid plan are reimbursed by the state Department of Health and Welfare. Section 30(A) of the Medicaid Act requires Idaho’s plan to “assure that payments are consistent with efficiency, economy, and quality of care” while “safeguard[ing] against unnecessary utilization of . . . care and services,” 42 U.S.C. 1396a(a)(30)(A). Providers of habilitation services claimed that Idaho reimbursed them at rates lower than section 30(A) permits. The district court entered summary judgment for the providers. The Ninth Circuit affirmed, concluding that the Supremacy Clause gave the providers an implied right of action, under which they could seek an injunction requiring compliance. The Supreme Court reversed, concluding that there is no private right of action. The Supremacy Clause instructs courts to give federal law priority when state and federal law clash, but it is not the source of any federal rights and does not create a cause of action. The suit cannot proceed in equity. The power of federal courts of equity to enjoin unlawful executive action is subject to express and implied statutory limitations. The express provision of a single remedy for a state’s failure to comply with Medicaid’s requirements, the withholding of Medicaid funds by the Secretary of Health and Human Services, 42 U.S.C. 1396c, and the complexity associated with enforcing section 30(A) combine to establish Congress’s “intent to foreclose” equitable relief. View "Armstrong v. Exceptional Child Ctr., Inc." on Justia Law
Sebelius v. Cloer
The National Childhood Vaccine Injury Act of 1986 established a no-fault compensation system to stabilize the vaccine market and expedite compensation to injured parties. Under the Act, a proceeding for compensation is “initiated” by service upon the Secretary of Health and Human Services and “the filing of a petition containing” specified documentation with the clerk of the Court of Federal Claims, who forwards the petition for assignment to a special master. 42 U. S. C. 300aa–11(a)(1). An attorney may not charge a fee for services in connection with such a petition, but a court may award attorney’s fees and costs incurred by a claimant in any proceeding on an unsuccessful petition, if that petition was brought in good faith. In 1997, shortly after receiving her third Hepatitis-B vaccine, Cloer began to experience symptoms that led to a multiple sclerosis (MS) diagnosis in 2003. In 2004, she learned of a link between MS and the Hepatitis-B vaccine, and in 2005, she filed a NCVIA claim. The special master concluded that Cloer’s claim was untimely because the Act’s 36-month limitations period began to run when she had her first MS symptoms in 1997.The Federal Circuit agreed. Cloer then sought attorney’s fees and costs. The Federal Circuit ruled in Cloer’s favor. The Supreme Court affirmed. Nothing in the attorney’s fees provision suggests that the reason for the subsequent dismissal of a petition, such as untimeliness, nullifies the initial filing. An NCVIA petition delivered to the court clerk, forwarded for processing, and adjudicated before a special master is a “petition filed under section 300aa–11.” The government’s contrary position is inconsistent with the fees provision’s purpose, which was to avoid limiting petitioners’ ability to obtain qualified assistance by making awards available for “non-prevailing, good-faith claims.” View "Sebelius v. Cloer" on Justia Law
Wos v. E. M. A.
The Medicaid statute’s anti-lien provision, 42 U. S. C. 1396p(a)(1), pre-empts state efforts to take any portion of a tort judgment or settlement not “designated as payments for medical care.” A North Carolina statute requires that up to one-third of damages recovered by a beneficiary for a tortious injury be paid to the state to reimburse it for payments made for medical treatment on account of the injury. E. M. A. suffered serious birth injuries that require her to receive 12 to 18 hours of skilled nursing care per day and that will prevent her from working or living independently. North Carolina’s Medicaid program pays part of the cost of her ongoing care. E. M. A. and her parents filed a medical malpractice suit against the physician who delivered her and the hospital where she was born and settled for $2.8 million, due to insurance policy limits. The settlement did not allocate money among medical and nonmedical claims. The state court placed one-third of the recovery into escrow pending a judicial determination of the amount owed by E. M. A. to the state. While that litigation was pending, the North Carolina Supreme Court held in another case that the irrebuttable statutory one-third presumption was a reasonable method for determining the amount due the state for medical expenses. The federal district court, in E.M.A.’s case, agreed. The Fourth Circuit vacated. The Supreme Court affirmed. The federal anti-lien provision pre-empts North Carolina’s irrebuttable statutory presumption that one-third of a tort recovery is attributable to medical expenses. North Carolina’s irrebuttable, one-size-fits-all statutory presumption is incompatible with the Medicaid Act’s clear mandate View "Wos v. E. M. A." on Justia Law
Sebelius v. Auburn Reg’l Med. Ctr.
Reimbursement providers for inpatient services rendered to Medicare beneficiaries is adjusted upward for hospitals that serve disproportionate numbers of patients who are eligible for Supplemental Security Income. The Centers for Medicare & Medicaid Services annually submit the SSI fraction for eligible hospitals to a “fiscal intermediary,” a Health and Human Services contractor, which computes the reimbursement amount and sends the hospitals notice. A provider may appeal to the Provider Reimbursement Review Board within 180 days, 42 U. S. C. 1395oo(a)(3). The PRRB may extend the period, for good cause, up to three years, 42 CFR 405.1841(b). A hospital timely appealed its SSI fraction calculations for 1993 through 1996. The PRRB found that errors in CMS’s methodology resulted in a systematic under-calculation. When the decision was made public, hospitals challenged their adjustments for 1987 through 1994. The PRRB held that it lacked jurisdiction, reasoning that it had no equitable powers save those granted by legislation or regulation. The district court dismissed the claims. The D. C. Circuit reversed. The Supreme Court reversed. While the 180-day limitation is not “jurisdictional” and does not preclude regulatory extension, the regulation is a permissible interpretation of 1395oo(a)(3). Applying deferential review, the Court noted the Secretary’s practical experience in superintending the huge program and the PRRB. Rejecting an argument for equitable tolling, the Court noted that for nearly 40 years the Secretary has prohibited extensions, except as provided by regulation, and Congress not amended the 180-day provision or the rule-making authority. The statutory scheme, which applies to sophisticated institutional providers, is not designed to be “unusually protective” of claimants. Giving intermediaries more time to discover over-payments than providers have to discover underpayments may be justified by the “administrative realities” of the system: a few dozen intermediaries issue tens of thousands of NPRs, while each provider can concentrate on its own NPR. View "Sebelius v. Auburn Reg'l Med. Ctr." on Justia Law