Justia Government & Administrative Law Opinion Summaries

This case arose from the cancellation of long-term-care Medicaid benefits for two claimants when an Oklahoma agency concluded that the claimants’ resources exceeded the regulatory cap for eligibility. One claimant, Idabelle Schnoebelen died, mooting her claim. The eligibility of the other claimant, Nelta Rose, turned on whether her resources included a 2018 promissory note. In 2017 and 2018, Rose loaned money to her daughter-in-law in exchange for three promissory notes. The daughter-in-law provided the first two promissory notes in 2017 (before Rose applied for Medicaid benefits). The Oklahoma Department of Human Services initially approved Rose for Medicaid, declining to regard the 2017 promissory notes as resources. In 2018, the daughter-in-law provided the third promissory note. But the Department of Human Services concluded that the 2018 promissory note: (1) was a resource because the payment to the daughter-in-law did not constitute a bona fide loan; and (2) was a deferral that turned the 2017 promissory notes into resources. The extra resources put Rose over the eligibility limit for Medicaid, so the Department of Human Services cancelled Rose’s benefits. A district court concluded that the agency’s conclusion did not conflict with federal law. In the Tenth Circuit's view, however, a reasonable factfinder could disagree. Summary judgment was reversed and the matter remanded for further proceedings. View "Baker, et al. v. Brown, et al." on Justia Law

Alliance alleged that County and City policies and inaction have created a dangerous environment in the Skid Row area, claiming that the County violated its mandatory duty to provide medically necessary care and that the municipalities have facilitated public nuisance violations by failing to clear encampments, violated disability access laws by failing to clear sidewalks of encampments, and violated constitutional rights by providing disparate services to those within the Skid Row area and by enacting policies resulting in a state-created danger to area residents and businesses. The district court issued a preliminary injunction, ordering the escrow of $1 billion to address homelessness, offers of shelter to all unhoused individuals in Skid Row within 180 days, and numerous reports. The court found that structural racism was behind Los Angeles’s homelessness crisis and its disproportionate impact on the Black community.The Ninth Circuit vacated. The plaintiffs lacked standing on all but their ADA claim; no claims were based on racial discrimination. The district court impermissibly resorted to independent research and extra-record evidence. There was no allegation that any individual plaintiff was Black nor that there was a special relationship between the City and unhoused residents nor that any individual plaintiff was deprived of medically necessary care or general assistance. Two plaintiffs who use wheelchairs and cannot traverse Skid Row sidewalks because of homeless encampments had standing to bring ADA claims but had not shown a likelihood of success on the merits. View "LA Alliance for Human Rights v. County of Los Angeles" on Justia Law

About 50 businesses that offer live adult entertainment (nude or nearly nude dancing) sought loans under the second round of the Paycheck Protection Program enacted to address the economic disruption caused by the Covid-19 pandemic. Congress excluded plaintiffs and other categories of businesses from the second round of the Program, 15 U.S.C. 636(a)(37)(A)(iv)(III)(aa), incorporating 13 C.F.R. 120.110. Plaintiffs asserted that their exclusion violated their rights under the Free Speech Clause of the First Amendment.The district court issued a preliminary injunction, prohibiting the Small Business Administration (SBA) from denying the plaintiffs eligibility for the loan program based on the statutory exclusion. The Seventh Circuit granted the government’s stay of the preliminary injunction and expedited briefing on the merits of the appeal. The SBA satisfied the demanding standard for a stay of an injunction pending appeal, having shown a strong likelihood of success on the merits. Congress is not trying to regulate or suppress plaintiffs’ adult entertainment. It has simply chosen not to subsidize it. Such selective, categorical exclusions from a government subsidy do not offend the First Amendment. Plaintiffs were not singled out for this exclusion, even among businesses primarily engaged in activity protected by the First Amendment. Congress also excluded businesses “primarily engaged in political or lobbying activities.” View "Camelot Banquet Rooms, Inc. v. United States Small Business Administration" on Justia Law

After two administrative hearings, Brown was awarded disability insurance benefits and supplemental security income benefits by an ALJ, who concluded that, as of April 25, 2018, Brown was “disabled” within the meaning of the Social Security Act, 42 U.S.C. 416(i), 423(d), 1382c(a)(3)(A), but rejected Brown’s claim that he was disabled prior to that date. The district court upheld the ALJ’s decision.The Ninth Circuit remanded with instructions to set aside the ALJ’s determination and to conduct a new disability hearing before a different, and properly appointed ALJ. The ALJ who conducted Brown’s hearings was not appointed in conformity with the Appointments Clause of the Constitution. Because this proceeding did not arise from a direct appeal from a decision of one or more invalidly appointed officers, nor was it a direct petition for review that might similarly have brought the entirety of the administrative decision before the court, the Commissioner may not challenge the portions of that decision that are favorable to Brown. The court held that it had no authority under 42 U.S.C. 405(g). to set aside, or to disturb, the grant of benefits for the time period on or after April 25, 2018, View "Brown v. Kijakazi" on Justia Law

Decker employed Pehringer at its Montana open-pit surface mine, 1977-1999. There were periods when Pehringer did not work, including a roughly three-year-long strike. For most of his mining career, Pehringer was regularly exposed to coal dust while working primarily as a heavy equipment operator. After being laid off in 1999, Pehringer was awarded Social Security total disability benefits. He never worked again. In 2014 a month before his sixty-fifth birthday, Pehringer sought black lung benefits, citing his severe COPD, 30 U.S.C. 923(b). A physician determined that “Pehringer is 100% impaired from his COPD” and that coal “dust exposure and smoking are significant contributors to his COPD impairment.”The Benefits Review Board affirmed a Department of Labor (DOL) ALJ’s award of benefits. The Ninth Circuit affirmed, first rejecting a constitutional challenge to 5 U.S.C. 7521(a), which permits removal of an ALJ only for good cause determined by the Merits Systems Protection Board. DOL ALJ decisions are subject to vacatur by people without tenure protection; properly appointed, they can adjudicate cases without infringing the President’s executive power. The ALJ did not err in adjudicating Pehringer’s claim nor in rejecting untimely evidentiary submissions. Decker did not rebut the presumption of entitlement to benefits after a claimant established legal pneumoconiosis and causation, having worked for at least 15 years in substantially similar conditions to underground coal mines. View "Decker Coal Co. v. Pehringer" on Justia Law

UnitedHealthcare Medicare Advantage insurers challenged the Overpayment Rule, promulgated by the Centers for Medicare and Medicaid Services (CMS) under 42 U.S.C. 1301-1320d-8, 1395-1395hhh, in an effort to trim costs. The Rule requires that, if an insurer learns that a diagnosis submitted to CMS for payment lacks support in the beneficiary’s medical record, the insurer must refund that payment within 60 days. UnitedHealth claims that the Overpayment Rule is subject to a principle of “actuarial equivalence,” and fails to comply. Two health plans that pay the same percentage of medical expenses are said to have benefits that are actuarially equivalent.The D.C. Circuit rejected the challenge. Actuarial equivalence does not apply to the Overpayment Rule or the statutory overpayment-refund obligation under which it was promulgated. Reference to actuarial equivalence appears in a different statutory subchapter from the requirement to refund overpayments; neither provision cross-references the other. The actuarial-equivalence requirement and the overpayment-refund obligation serve different ends. The actuarial-equivalence provision requires CMS to model a demographically and medically analogous beneficiary population in traditional Medicare to determine the prospective lump-sum payments to Medicare Advantage insurers. The Overpayment Rule, in contrast, applies after the fact to require Medicare Advantage insurers to refund any payment increment they obtained based on a diagnosis they know lacks support in their beneficiaries’ medical records. View "UnitedHealthcare Insurance Co v. Becerra" on Justia Law

The Montgomery County Council established the Emergency Assistance Relief Payment Program (EARP) in March 2020 to provide emergency cash assistance to County residents with incomes equal to or less than 50% of the federal poverty benchmark who were not eligible for federal or state pandemic relief. Although eligibility for EARP aid is not dependent on a person’s status as an undocumented immigrant, such individuals are eligible to receive EARP payments. To fund EARP, the County appropriated $10,000,000 from reserve funds to the County’s Department of Health and Human Services. Taxpayers filed suit in Maryland state court, asserting that EARP violated 8 U.S.C. 1621(a), which, with few exceptions, generally prohibits undocumented persons from receiving state and local benefits. Recognizing that Section 1621 does not authorize private enforcement, the plaintiffs cited the Maryland common law doctrine of taxpayer standing, which “permits taxpayers to seek the aid of courts, exercising equity powers, to enjoin illegal and ultra vires acts of [Maryland] public officials where those acts are reasonably likely to result in pecuniary loss to the taxpayer.” The case was removed to federal court based on federal question jurisdiction, 28 U.S.C. 1331. The court granted the County summary judgment. The Fourth Circuit affirmed. Congress has declined to authorize private parties to enforce Section 1621, a legislative decision that cannot be circumvented by invocation of a state’s law of taxpayer standing. View "Bauer v. Elrich" on Justia Law

This appeal arose from a district court order affirming the North Dakota Department of Human Services’ determination that Harold Ring was ineligible for Medicaid. In Ring v. North Dakota Department of Human Services, 2020 ND 217, 950 N.W.2d 142 (“Ring I”), the North Dakota Supreme Court remanded the case for the district court to determine whether a party should be substituted due to Ring’s death, which occurred before the court entered its order. On remand, the district court found substitution of a party was unwarranted and entered an order dismissing the case. The North Dakota Supreme Court affirmed the dismissal order. View "Ring v. NDDHS" on Justia Law

North Dakota Workforce Safety and Insurance (“WSI”) appealed a district court judgment reversing an administrative order sustaining a WSI order denying Bruce Bahmiller’s claim for workers’ compensation benefits. After review, the North Dakota Supreme Court affirmed the district court judgment, concluding the administrative law judge’s (“ALJ”) finding that Bahmiller failed to file a timely claim for benefits within one year of his work injury was not supported by the weight of the evidence. View "Bahmiller v. WSI, et. al." on Justia Law

Plaintiff Family Health Centers of San Diego operated a federally qualified health center (FQHC) that provided various medical services to its patients, some of whom are Medi-Cal beneficiaries. Section 330 of the Public Health Service Act authorized grants to be made to FQHC’s. In addition, FQHC’s could seek reimbursement under Medi-Cal for certain expenses, including reasonable costs directly or indirectly related to patient care. Plaintiff appealed a trial court’s order denying its petition for writ of mandate seeking to compel the State Department of Health Care Services (DHCS) to reimburse plaintiff for money it expended for outreach services. The Court of Appeal rejected plaintiff’s contention that the trial court and the DHCS improperly construed and applied applicable guidelines in the Centers for Medicare & Medicaid Services Publication 15-1, The Provider Reimbursement Manual (PRM). The Court concluded that the monies spent by plaintiff were not an allowable cost because they were akin to advertising to increase patient utilization of plaintiff’s services. View "Family Health Centers of S.D. v. State Dept. of Health Care Services" on Justia Law