Justia Government & Administrative Law Opinion Summaries

Plaintiffs, Medicaid beneficiaries with near total disabilities, filed suit after being denied coverage for ceiling lifts under a categorical exclusion in the state's implementing Medicaid regulations. The district court granted summary judgment for the state. The court concluded that, under binding precedent, plaintiffs have an implied private cause of action under the Supremacy Clause to pursue their challenge; the state must comply with the requirements of the Medicaid Act, 42 U.S.C. 1396 et seq., but the Act does not preempt the state's categorical exclusions; and therefore, the court affirmed the grant of summary judgment and denied the motion to vacate. View "Detgen, et al. v. Janek" on Justia Law

Petitioners were found not responsible for crimes they committed by reason of mental disease or defect. Petitioners were eventually released from confinement into the community, subject to a five-year order of conditions. The New York State Office of Mental Health (OMH) later requested that the supervising court extend the order of conditions. In its proposed order, OMH asked the court to include an effective-evaluation provision, which would allow the OMH to seek judicial approval of a mandatory psychiatric evaluation in a secure facility if Petitioners failed to comply with the conditions of their release and refused to undergo voluntary examination. Petitioners sought writs of prohibition barred enforcement of the effective-evaluation provisions, arguing that the provisions were inconsistent with N.Y. Crim. Proc. Law 330.20(14)’s specific procedure for recommitment orders. The Appellate division granted the petitions, concluding that the effective-evaluation provision was barred by the recommitment provisions in section 330.20(14). The Court of Appeals reversed, holding that section 330.20(14) does not prohibit inclusion of an effective-evaluation provision in an order of conditions. View "Allen B. v. Sproat" on Justia Law

Plaintiff sought insurance coverage for gastric lap band surgery. Defendant, a health-care insurer that covered Plaintiff by virtue of Plaintiff’s husband’s employment with the federal government, refused to cover the full cost of the surgery. Plaintiff brought tort and breach of contract claims against Defendant in the Puerto Rico Court of First Instance. Defendant removed the action to the federal district court, asserting, inter alia, that the Federal Employees Health Benefits Act of 1959 (FEHBA) completely preempted Plaintiff’s local-law claims, thus conferring original jurisdiction on the federal court. Defendant then moved to dismiss the case, arguing that the FEHBA demanded exhaustion of administrative remedies. Plaintiff, in the meantime, requested that the district court remand the case to the Court of First Instance. The district court (1) denied Plaintiff’s motion to remand, holding that the FEHBA completely preempted Plaintiff’s claims and, thus, federal jurisdiction attached; and (2) dismissed the action for Plaintiff’s failure to exhaust administrative remedies. The First Circuit Court of Appeals reversed the district court’s judgment of dismissal and its order denying remand, holding that the court erred in concluding that the FEHBA afforded complete preemption. View "Lopez-Munoz v. Triple-S Salud, Inc. " on Justia Law

Petitioner worked as a charge nurse at a facility of the State’s Department of Health and Social Services (DHSS). After an incident with a patient who later died, DHSS concluded that Petitioner should be dismissed for patient neglect, failure to perform a thorough assessment of the patient’s condition, and unprofessional and unacceptable behavior. Petitioner’s employment was governed by a collective bargaining agreement (CBA) between a union and HDSS. After arbitration as prescribed by the CBA, the arbitrator concluded there was just cause for Petitioner’s dismissal. Petitioner brought this action challenging the arbitrator’s decision. The Court of Chancery granted summary judgment in favor of DHSS, holding that the arbitrator (1) correctly held DHSS to its burden to demonstrate good cause for termination in reaching his decision; (2) applied the correct standard of care as to the definition of “neglect”; and (3) necessarily rejected Petitioner’s effort to obtain back pay. View "AFSCME, Council 81, Registered Nurses Unit, Local 2305 v. State, Dep't of Health & Soc. Servs." on Justia Law

Petitioners were two medical providers whose patients included individuals insured by the State’s primary health benefit plan. The State Comptroller reviewed Petitioners’ billing records as part of an audit of billing practices in the health care industry for claims paid by the State. While Petitioners conceded that the State paid eighty percent of the costs of their services, Petitioners challenged the Comptroller’s authority to audit their books. Supreme Court concluded that the Comptroller lacked constitutional authority to audit Petitioners because Petitioners were “not a political subdivision of the State.” The Appellate Division modified Supreme Court’s orders to reinstate the audits. The Court of Appeals affirmed, holding that the State Constitution does not limit the Comptroller’s authority to audit, as part of its audit of State expenditures, the billing records of private companies that provide health care to beneficiaries of a State insurance program. View "Martin H. Handler, M.D., P.C. v. DiNapoli" on Justia Law

Cameron returned to Kentucky after serving as a Marine in Iraq and applied for VA Medical Benefits, but did not include verification of service (DD-214). Four months later, the VA verified his service, but its record did not reflect combat service or other eligibility; his status was “Rejected.” A week later, Cameron’s records were updated and he was retroactively enrolled. Cameron had been involved in killing a civilian family. His parents had contacted the Lexington VA mental health department and urged their son to seek help. Tiffany, his wife, told him that she and their baby would not continue to live with him unless he sought help. Days before his enrollment was corrected Cameron went to the Leestown VA. The intake clerk recognized that Cameron was in urgent need of help and talked to him for 40 minutes, despite not finding his enrollment. She concluded that Cameron was suicidal. No mental health professional was available at Leestown. She sent him to Cooper Drive VA. Cameron called his father later, stating that he had been turned away from Cooper Drive because he did not have his DD-214. Cameron drove home. He and Tiffany searched for the form. Cameron became frustrated and threatened Tiffany, who called 911. While on the phone, she heard a shot. Her husband had committed suicide. His family asserted claims under the Federal Tort Claims Act. The district court dismissed, holding that it did not have jurisdiction over a “benefits determination,” Veterans’ Judicial Review Act, 38 U.S.C. 511.The Sixth Circuit reversed. Whether the clinics had a duty to care for Cameron is an improper question for this stage. The government failed to show that the actions of the VA employees satisfied the test of the FTCA’s discretionary function exception. View "Anestis v. United States" on Justia Law

PAMC appealed the district court's affirmance of the Secretary's decision denying PAMC its full Medicare Annual Payment Updated for the fiscal year 2009. PAMC claimed that the Department acted arbitrarily and capriciously when it refused to excuse PAMC's late filing of the required Reporting Hospital Quality Data for Annual Payment Updated (RHQDAPU) program data by the admittedly applicable deadline. The court concluded that PAMC neither pointed to any contrary or antithetical decisions by the Department under similar circumstances, nor otherwise demonstrated that the Board acted arbitrary or capriciously when it denied equitable relief. The court rejected PAMC's argument that the Board should have used the contract doctrine of substantial performance to excuse PAMC's failure to submit data at the proper time. The court did not view the Board's adherence to the policy of strict compliance with a deadline as arbitrary and capricious. Accordingly, the court affirmed the judgment of the district court. View "PAMC, LTD. v. Sebelius" on Justia Law

Bryn Mawr Chicago nursing home, a Medicaid provider, is subject to Illinois Department of Public Health (IDPH) inspections. In 2010, IDPH inspected the facility following allegations that a resident had been sexually assaulted. Bryn Mawr was eventually cited for three deficiencies, 42 C.F.R. 488.301, two based on sexual abuse and one based on failure to sufficiently monitor a resident. Bryn Mawr challenged the findings by Informal Dispute Resolution, which involved exchange of written information without a live hearing. IDPH simultaneously conducted internal review and found that the deficiencies based on allegations of sexual abuse were not sufficiently supported by credible evidence, but the third party upheld the deficiency findings. Ultimately IDPH maintained the deficiency findings. Meanwhile, Bryn Mawr also engaged in a parallel process to “correct” deficiencies. At the follow-up inspection, IDPH determined that the deficiencies had been corrected, so that remedies would not be imposed. IDPH passed the deficiency findings on to the Centers for Medicare and Medicaid Services, which published them on its website and factored them into its 5-Star Rating System. Bryn Mawr’s rating was supposed to fall from five to four stars because of the deficiencies, but CMS mistakenly reduced it to two stars. Regardless of a partial correction, Bryn Mawr was displeased that it had not had the opportunity to challenge the findings at a hearing and sued to compel a hearing. The district court granted summary judgment to defendants. The Seventh Circuit affirmed. View "Bryn Mawr Care, Inc. v. Sebelius" on Justia Law

Petitioners, a group of hospitals that serve a significant number of elderly, very low-income patients, filed suit challenging the Secretary's issuance of a rule concerning the "disproportionate share percentage" calculation of supplemental payments for low-income Medicare patients. When the Secretary published reimbursement calculations for FY 2007, petitioners learned that their payments would decrease by tens of millions of dollars per year. The rule change had an enormous financial consequence on hospitals. The court held that the Secretary did not provide adequate notice and opportunity to comment before promulgating its 2004 rule, and so affirmed the portion of the district court's opinion vacating the rule. The court reversed only the portion of the district court's opinion directing the Secretary to recalculate the hospitals' reimbursements using the alternate methodology. View "Allina Health Services, et al. v. Sebelius" on Justia Law

In enacting comprehensive welfare reform in 1996, Congress rendered various groups of aliens ineligible for federal benefits and also restricted states' ability to use their own funds to provide benefits to certain aliens. As a condition of receiving federal funds, Congress required states to limit eligibility for federal benefits, such as Medicaid, to citizens and certain aliens. Plaintiffs filed suit claiming that Basic Health Hawai'i violated the Equal Protection Clause of the Fourteenth Amendment because it provided less health coverage to nonimmigrant aliens residing in Hawai'i (COFA Residents) than the health coverage that Hawai'i provided to citizens and qualified aliens who are eligible for federal reimbursements through Medicaid. The court concluded that Congress has plenary power to regulate immigration and the conditions on which aliens remain in the United States, and Congress has authorized states to do exactly what Hawai'i had done here - determine the eligibility for, and terms of, state benefits for aliens in a narrow third category, with regard to whom Congress expressly gave states limited discretion. Hawai'i has no constitutional obligation to fill the gap left by Congress's withdrawal of federal funding for COFA Residents. Accordingly, the court vacated the district court's grant of a preliminary injunction preventing Hawai'i from reducing state-paid health benefits for COFA Residents because Hawai'i is not obligated to backfill the loss of federal funds with state funds and its decision not to do so was subject to rational-basis review. View "Korab v. Fink" on Justia Law