Justia Government & Administrative Law Opinion Summaries

Plaintiffs, individuals living with HIV/AIDS who have employer-sponsored health plans, and who rely on those plans to obtain prescription drugs, filed suit alleging that CVS's program violates the anti-discrimination provisions of the Affordable Care Act (ACA), the Americans with Disabilities Act (ADA), and the California Unruh Civil Rights Act (Unruh Act); denies them benefits to which they are entitled under the Employee Retirement Security Act (ERISA); and violates California's Unfair Competition Law (UCL). The district court granted defendants' motion to dismiss.The Ninth Circuit held that Section 1557 of the ACA does not create a healthcare-specific anti-discrimination standard that allowed plaintiffs to choose standards from a menu provided by other anti-discrimination statutes. Because plaintiffs claim discrimination on the basis of their disability, to state a claim for a Section 1557 violation, they must allege facts adequate to state a claim under Section 504 of the Rehabilitation Act. Applying the section 504 framework, the panel concluded that plaintiffs adequately alleged that they were denied meaningful access to their prescription drug benefit under their employer-sponsored health plans because the program prevents them from receiving effective treatment for HIV/AIDS. Therefore, plaintiffs have stated a claim for disability discrimination under the ACA.However, plaintiffs have failed to establish a claim of disability discrimination under the ADA, because they have not plausibly alleged that their benefit plan is a place of public accommodation. Finally, the panel upheld the district court's denial of plaintiffs' claims under ERISA and their cause of action under California's Unfair Competition Law. The panel affirmed in part, vacated in part, and remanded. View "Doe v. CVS Pharmacy, Inc." on Justia Law

Dr. Korban and his medical practice Delta, practice diagnostic and interventional cardiology. In 2007, Dr. Deming filed a qui tam action under the False Claims Act (FCA), 31 U.S.C. 3729(a)(1)(A)–(C), (G) against Korban, Jackson Regional Hospital, and other Tennessee hospitals, alleging “blatant overutilization of cardiac medical services.” The United States intervened and settled the case for cardiac procedures performed in 2004-2012. Korban entered into an Integrity Agreement with the Office of Inspector General, effective 2013-2016 that was publicly available and required an Independent Review Organization. The U.S. Department of Justice issued a press release that detailed the exposed fraudulent scheme and outlined the terms of Korban’s settlement. In 2015, Jackson Regional agreed to a $510,000 settlement. The Justice Department and Jackson both issued press releases.In 2017, Dr. Maur, a cardiologist who began working for Delta in 2016, alleged that Korban was again performing “unnecessary angioplasty and stenting” and “unnecessary cardiology testing,” paid for in part by Medicare. In addition to Korban and Jackson, Maur sued Jackson’s corporate parent, Tennova, Dyersburg Medical Center, and Tennova’s corporate parent, Community Health Systems. The United States declined to intervene. The district court dismissed, citing the FCA’s public-disclosure bar, 31 U.S.C. 3730(e)(4). The Sixth Circuit affirmed. Maur’s allegations are “substantially the same” as those exposed in a prior qui tam action and Maur is not an “original source” as defined in the FCA. View "Maur v. Hage-Korban" on Justia Law

Alleging debilitating pain in her back, legs, and hands, Zoch sought disability insurance benefits, 42 U.S.C. 413, 423. An ALJ denied the application, finding that, based on the opinions of three of her four treating physicians, a consulting physician, and the objective medical evidence, she could perform sedentary work.The district court and Seventh Circuit affirmed, rejecting Zoch’s arguments that the ALJ improperly discounted her assertions and an opinion by a physician who relied on those assertions. Substantial evidence supports the ALJ’s decision. Zoch’s testimony of incapacitating pain conflicted with the objective medical evidence, including normal test results: lumbar MRI, wrist x-rays, range of motion, straight-leg raising, strength in extremities, and pressure on her nerves. Zoch’s testimony that she usually walked with a cane conflicted with the doctors’ reports that at all but one appointment she walked normally. Zoch’s testimony that she could not raise her arms or bend over to dress conflicted with a doctor’s observation that Zoch could comfortably bend over to touch her fingertips to her knees. Zoch’s hearing testimony that she could not perform the usual activities of daily living was inconsistent with her assertions in her application. View "Zoch v. Saul" on Justia Law

The en banc court held that 42 U.S.C. 1396a(a)(23) does not give Medicaid patients a right to challenge, under 42 U.S.C. 1983, a State's determination that a health care provider is not "qualified" within the meaning of section 1396a(a)(23). The en banc court vacated the preliminary injunction issued by the district court prohibiting the termination of the Providers' Medicaid provider agreements.The Providers provide family planning and other health services to Medicaid patients, and each of the Providers is a member of Planned Parenthood. This case stemmed from a pro-life organization's release of video recordings of conversations at Planned Parenthood (PP) Gulf Coast headquarters. The videos depict two individuals posing as representatives from a fetal tissue procurement company discussing the possibility of a research partnership with PP Gulf Coast. The release of the videos prompted congressional investigations, which ultimately led to the OIG sending each Provider a Notice of Termination of its respective Medicaid provider agreement. The Providers and Individual Plaintiffs filed suit alleging that the terminations violated rights conferred by section 1396a(a)(23) and sought relief under section 1983.The en banc court held that the Individual Plaintiffs may not bring a section 1983 suit to contest the State's determination that the Providers were not "qualified" providers within the meaning of section 1396a(a)(23). The en banc court rested its decision primarily on two independent bases: (1) the Supreme Court's decision in O'Bannon v. Town Court Nursing Center, 447 U.S. 773 (1980), and (2) the text and structure of section 1396a(a)(23), which does not unambiguously provide that a Medicaid patient may contest a State's determination that a particular provider is not "qualified." Rather, the court held that whether a provider is "qualified" within the meaning of section 1396a(a)(23) is a matter to be resolved between the State (or the federal government) and the provider. In so holding, the en banc court overruled Planned Parenthood of Gulf Coast, Inc. v. Gee, 862 F.3d 445 (5th Cir. 2017), which held that a state agency or actor cannot legitimately find that a Medicaid provider is not "qualified" unless under state or federal law the provider would be unqualified to provide treatment or services to the general public, including Medicaid patients who paid for the care or services with private funds. View "Planned Parenthood of Greater Texas Family Planning and Preventative Health Services, Inc. v. Kauffman" on Justia Law

The Second Circuit originally resolved the motions that are the subject of this opinion in an order entered November 9, 2020. Except in unusual circumstances, the court resolves such motions by order, not opinion. The court converted the original order and the dissent into opinions per the dissent's request.These appeals challenge Governor Andrew Cuomo's issuance of an executive order directing the New York State Department of Health to identify yellow, orange, and red "zones" based on the severity of COVID-19 outbreaks and imposing correspondingly severe restrictions on activity within each zone. Appellants, Agudath Israel and the Diocese, each challenged the executive order as a violation of the Free Exercise Clause of the First Amendment. After the district court denied appellants' motion for a preliminary injunction against enforcement of the order, appellants moved for emergency injunctions pending appeal and to expedite their appeals.Preliminarily, the Second Circuit concluded that Agudath Israel did not move first in the district court for an order granting an injunction while an appeal is pending before filing with this court its present motion for an injunction pending appeal. Rather, Agudath Israel moved for a preliminary injunction pending the district court’s final judgment. Furthermore, Agudath Israel has not explained or otherwise justified its failure to comply with the straightforward requirement of Federal Rule of Appellate Procedure 8(a). Agudath Israel has also failed to demonstrate that moving first in the district court would be impracticable, or even futile, particularly in light of the fact that a full eleven days elapsed after the district court's ruling before Agudath Israel sought relief from this court. Therefore, the court denied Agudath Israel's motion for procedural reasons.The court also denied the Diocese's motion, concluding that appellants cannot clear the high bar necessary to obtain an injunction pending appeal. The court stated that, while it is true that the challenged order burdens appellants' religious practices, the order is not substantially underinclusive given its greater or equal impact on schools, restaurants, and comparable secular public gatherings. To the contrary, the executive order extends well beyond isolated groups of religious adherents to encompass both secular and religious conduct. View "Agudath Israel of America v. Cuomo" on Justia Law

Hospitals, in calculating their Medicaid fractions -- the proportion of treatment a hospital provided to Medicaid patients -- sought to include days of care funded by Florida's Low Income Pool, an approved Medicaid demonstration project. The Secretary refused to allow the Hospitals to include these patients in their Medicaid fraction, on the ground that the patients were treated out of charity rather than as designated beneficiaries of a demonstration project.The DC Circuit affirmed the district court's judgment in favor of the Hospitals, and agreed with the district court that the Secretary's own regulation states that, for the purposes of calculating the Medicaid fraction, "hospitals may include all days attributable to populations eligible for [Medicaid] matching payments through a [demonstration project]" so long as the services provided under the demonstration project include "inpatient hospital services." In this case, it was "obvious to the [c]ourt that uninsured and underinsured patients received inpatient hospital services" through the Low Income Pool, because (1) the Secretary authorized federal matching funds to reimburse hospitals for these services, and (2) the hospitals rigorously documented the services provided using funds from the Pool. Furthermore, the Fifth Circuit's opinion in Forrest Gen. Hosp. v. Azar, 926 F.3d 221 (2019), supported this conclusion. View "Bethesda Health, Inc. v. Azar" on Justia Law

Plaintiff-appellant Terri Baker appealed the dismissal of this putative class action for lack of standing. She sued on behalf of herself and her son, S.F.B., to challenge Kansas laws and school district policies that: (1) required children to be vaccinated to attend school and participate in child care programs; and (2) provided a religious exemption from these requirements. She claimed these immunization laws and policies violated various federal and state constitutional provisions and statutes. Baker argued she and S.F.B. had standing because the immunization requirements and religious exemptions injured them in two ways: (1) the District misapplied Kansas law when it granted a religious exemption for S.F.B. to attend preschool despite being unvaccinated - her fear that the District would revoke S.F.B.'s religious exemption was an injury in fact that established standing; and (2) Baker "would like the option" of placing S.F.B. in a non-accredited private school (i.e., home school), school programs, or licensed child care - she contended Kansas law inhibited her from exercising these options and caused an injury in fact because she would be unable to secure a religious exemption for S.F.B. if she tried. Finding no reversible error in the district court's dismissal, the Tenth Circuit affirmed. View "Baker v. USD 229 Blue Valley" on Justia Law

Community Mental Health modified the methodology through which it allocated funding to individuals with disabilities receiving community living support services under a Medicaid waiver received by Michigan. Individuals receiving those services, together Advocacy, challenged that methodology as violating the Medicaid Act, 42 U.S.C. 1396a(a)(8), (a)(10)(A), (a)(10)(B), 1396n(c)(2)(A) and (C); Title II of the Americans with Disabilities Act (ADA), 42 U.S.C. 12132; section 504 of the Rehabilitation Act, 29 U.S.C. 794; the Michigan Mental Health Code; and the terms of Michigan’s Medicaid Habilitation Supports Waiver and the contracts implementing it. The district court dismissed the claims in full.The Sixth Circuit reversed, first holding that the plaintiffs have standing, that the defendants are not entitled to Eleventh Amendment immunity, that the plaintiffs were not required to exhaust their administrative remedies provided by the state under the Medicaid Act, and that the plaintiffs have a private right of action under sections 1396a(a)(8) and (a)(10). The plaintiffs’ allegations suffice to state plausible claims that they are being denied sufficient necessary medical services; that feasible alternatives that provide them a meaningful choice between institutionalized and at-home or community-based care exist and are not being ensured; and that they face a serious risk of institutionalization. View "Waskul v. Washtenaw County Community Mental Health" on Justia Law

The Ninth Circuit affirmed the district court's dismissal based on lack of jurisdiction of an action brought by Sensory NueroStimulation, a medical device supplier, seeking Medicare coverage of its product. The panel held that the district court correctly held that 42 U.S.C. 405(h)'s administrative channeling requirement applied and that it therefore had no subject matter jurisdiction to hear Sensory's claims. In this case, the lawsuit is subject to Medicare's administrative channeling requirements; Sensory has not met those requirements; there exists a way to satisfy those requirements; and these conclusions do not completely preclude judicial review so as to trigger a key exception to the channeling requirements. View "Sensory NeuroStimulation, Inc. v. Azar" on Justia Law

Plaintiff filed suit challenging the Affordable Care Act (ACA), seeking retrospective and prospective relief for myriad alleged violations of the United States Constitution and the Religious Freedom Restoration Act. The Fifth Circuit declined to reach the merits of plaintiff's claims. The court held that, given the altered legal landscape and the potential effects of plaintiff's request for prospective relief, a mootness analysis must precede the merits. In this case, a year after plaintiff filed his lawsuit, Congress passed and President Trump signed the Tax Cut and Jobs Act, which reduced the shared responsibility payment (imposed on individuals who fail to purchase health insurance) to $0. In the same year, the Department of Health and Human Services created new exemptions to the contraceptive mandate, including an exemption for individuals like plaintiff. These exemptions were enjoined until the Supreme Court's recent decision in Little Sisters of the Poor Saints Peter and Paul Home v. Pennsylvania. Therefore, the court vacated the district court's dismissal of plaintiff's claims and remanded for the district court to conduct a mootness analysis in the first instance. The court also remanded to allow plaintiff to amend his complaint where the parties agreed that the district court incorrectly dismissed plaintiff's claim for retrospective relief. View "Dierlam v. Trump" on Justia Law