Justia Government & Administrative Law Opinion Summaries

Under the Medicaid program, the federal government offsets some state expenses for medical services to low-income persons; a state’s plan must cover medical assistance for specific populations, but a state may expand its Medicaid program by obtaining a waiver for an “experimental, pilot, or demonstration project.” In 1993, Tennessee obtained a waiver for TennCare, to cover uninsured and uninsurable individuals. Following approval, hospitals received reimbursement under the umbrella of TennCare. Because hospitals serving large numbers of low-income patients generally incur higher costs than Medicaid flat payment rates reflect, hospitals that treated a disproportionate share of low-income patients could apply for the “DSH” adjustment. A fiscal intermediary processed requests for reimbursement, including DSH adjustment payments. Due to discrepancies between the practices of fiscal intermediaries in different states, the Secretary issued a 2000 rule, providing that eligibility waiver patients were to be included as individuals “eligible for medical assistance” under Medicaid for purposes of DSH adjustment calculations. The 2005 Deficit Reduction Act ratified the rule. Adventist, a not-for-profit hospital network, provided more than 1,200 patient care days to TennCare expansion waiver patients 1995-2000. The fiscal intermediary did not include those days in calculating the adjustment. The Secretary’s Provider Reimbursement Review Board upheld the exclusion. The district court dismissed, concluding that section 1315 provided the Secretary discretion to exclude expansion waiver patient days from the DSH calculation. The Sixth Circuit affirmed. View "Adventist Health Sys./Sunbelt, Inc. v. Sebelius" on Justia Law

Providers brought suit against the State, asserting that the Adoption Assistance and Child Welfare Act of 1980 (CWA), 42 U.S.C. 670 et seq., gave them a privately enforceable right under 42 U.S.C. 1983 to receive payments from the State sufficient to cover the cost of certain statutorily enumerated components of foster care. At issue was whether Congress, in enacting the CWA, evinced a clear intent to grant foster care providers an individually enforceable right to foster care maintenance payments sufficiently large to cover the costs of each item enumerated in section 675(4)(A). The court held that Congress did not ambiguously confer such a right and, therefore, affirmed the district court's dismissal of the Providers' complaint for failure to state a claim. View "Midwest Foster Care, etc., et al v. Kincade, et al" on Justia Law

The North Dakota Department of Human Services appealed a district court order reversing and remanding the Department's order decreasing Plaintiff-Appellee Penne Nienow's monthly Supplemental Nutrition Assistance Program ("SNAP") benefits. The County determined Nienow received income from a prior mineral rights lease and, therefore, the 2011 payment was a recurring lump-sum payment. The County reduced Nienow's SNAP benefits to $16 per month. Nienow filed a request for hearing to the Department, and an evidentiary hearing was held. The County's representative testified Nienow stated that she leased the mineral rights and received income from the lease every five years and that she had leased the rights at least once before. After the hearing, the administrative law judge ("ALJ") concluded the County correctly determined Nienow's income and properly reduced her SNAP benefits. The Department adopted the ALJ's findings and conclusions. Nienow appealed the Department's order to the district court. The district court reversed and remanded, concluding Nienow's payment was a mineral leasing bonus, a nonrecurring lump-sum payment, and should not have been considered as income in determining Nienow's eligibility. Upon review of the matter, the Supreme Court reversed the district court order and reinstated the Department's final order reducing Nienow's SNAP benefits. View "Nienow v. Anderson" on Justia Law

MedQuest is a diagnostic testing company that operates more than 90 testing facilities in 13 states. In 2006 a former MedQuest employee, brought a qui tam suit against MedQuest alleging violations of the False Claims Act. The United States intervened and obtained summary judgment ($11,110,662.71) that MedQuest used supervising physicians who had not been approved by the Medicare program and the local Medicare carrier to supervise the range of tests offered at the Nashville-area sites, and after acquiring one facility, MedQuest failed to properly re-register the facility to reflect the change in ownership and enroll the facility in the Medicare program, instead using the former owner’s payee ID number. The Sixth Circuit reversed, stating that the Medicare regulatory scheme (42 U.S.C. 1395x) does not support FCA liability for failure to comply with the supervising-physician regulations. MedQuest’s failure to satisfy enrollment regulations and its use of a billing number belonging to a physician’s practice it controlled do not trigger the hefty fines and penalties created by the FCA. View "United States v. MedQuest Assocs, Inc." on Justia Law

Rohrer Towers is a housing facility for low-income elderly residents in Haddon Township, Camden County, New Jersey. Haddon leased Rohrer Towers to Housing Authority of the Township of Haddon, which entered into a housing assistance payments contract (HAP) with the U.S. Department of Housing and Urban Development (HUD) under the Housing Act of 1937, 88 Stat. 633, 662–66. Haddon sued in 2007 alleging that HUD breached the HAP Contract from 2001-2006 by requiring rent “comparability studies” to be submitted along with requests for annual rent adjustments and adopting a one-percent reduction of the annual adjustment factors for units occupied by the same tenants from the previous year. The Claims Court agreed and ordered rent adjustments for all years other than 2002. The government claimed that the complaint should have been dismissed on statute of limitations grounds and appealed the decision that regulatory imposition of a mandatory one-percent rent reduction for non-turnover units was arbitrary, and beyond HUD’s authority. The Federal Circuit reversed the holding that the prevention doctrine applied to the circumstances surrounding Haddon’s 2001 and 2003 rent adjustment, but affirmed the holdings with respect to the contract years 2002 and 2004-2006. View "Haddon Housing Assocs. v. United States" on Justia Law

Tennessee participates in Medicaid through “TennCare,” Tenn. Code 71-5-102. The Medicaid Act requires that TennCare administer an Early and Periodic Screening, Diagnosis, and Treatment program for all enrollees under age 21, 42 U.S.C. 1396a(a)(43), 1396d(r) and must provide outreach to educate its enrollees about these services. In 1998 plaintiffs filed a putative class action under 42 U.S.C. 1983, alleging that TennCare had failed to fulfill these obligations. The district court entered a consent decree that explained in detail the requirements that TennCare had to meet to “achieve and maintain compliance” with the Medicaid Act, based on the assumption that the Act created rights enforceable under section 1983. Eight years later, the Sixth Circuit held that one part of the Medicaid Act was unenforceable under section 1983. Following a remand, the district court vacated paragraphs of the decree that were based on parts of the Act that are not privately enforceable. After a thorough review of TennCare’s efforts, the court then vacated the entire decree, finding that TennCare had fulfilled the terms of the decree’s sunset clause by reaching a screening percentage greater than 80% and by achieving current, substantial compliance with the rest of the decree. The Sixth Circuit affirmed. View "John B. v.Emkes" on Justia Law

Gayheart applied for Social Security disability insurance benefits in 2005 due to manifestations of anxiety, panic disorder, bipolar disorder, and depression. After an initial denial and three separate hearings, an administrative law judge (ALJ) found that the limitations caused by Gayheart’s impairments did not preclude him from performing a significant number of jobs available in the national economy and denied Gayheart’s application. Gayheart’s request for an administrative appeal was denied. The Report and Recommendation issued by the federal court’s assigned magistrate judge concluded that the ALJ’s decision was not supported by substantial evidence and that Gayheart should be awarded benefits. But the district court sustained the Commissioner’s objections and affirmed the ALJ’s decision. The Sixth Circuit reversed and remanded, holding that the ALJ failed to weigh the medical opinions according to 20 C.F.R. 404.1527. View "Gayheart v. Comm'r of Soc. Sec." on Justia Law

Plaintiffs, teaching hospitals, received Medicare payments to offset the costs associated with training "full-time equivalent" residents and intern physicians (FTEs). In 1997, Congress capped those payments in such a way that the number of FTEs the hospitals trained in 1996 would dictate the maximum reimbursement in all future years. Although the parties agreed that the 1996 data was not accurate, the Secretary believed that this predicate fact could not be corrected outside the three-year reopening window. The court held that the reopening regulation allowed for modification of predicate facts in closed years provided the change would only impact the total reimbursement determination in open years. Alternatively, the court agreed with the district court that the Secretary had acted arbitrarily in treating similarly situated parties differently. The court rejected the Secretary's claim that the Medicare Act, 42 U.S.C. 1395 et seq., would not allow the intermediary to change the 1996 GME resident count without changing the corresponding reimbursement amount, which all parties conceded would constitute a reopening of an "Intermediary determination." Accordingly, the court affirmed the judgment. View "Kaiser Foundation Hospitals v. Sebelius" on Justia Law

Plaintiffs, thirteenth North Carolina residents who lost access to in-home personal care services (PCS) due to a statutory change, brought suit challenging the new PCS program. The district court granted plaintiffs' motions for a preliminary injunction and class certification. Defendants appealed, raising several points of error. The court agreed with the district court's conclusion that a preliminary injunction was appropriate in this case. The court held, however, that the district court's order failed to comply with Federal Rule of Civil Procedure 65 because it lacked specificity and because the district court neglected to address the issue of security. Accordingly, the court remanded the case. View "Pashby v. Delia" on Justia Law

Claimants appealed a district court judgment that affirmed Job Service of North Dakota's decision to deny them unemployment benefits. Upon review of the administrative record and the plain language of N.D.C.C. 52-06-02(4), the Supreme Court concluded that claimants were only disqualified from unemployment compensation for employee-initiated work stoppages due to labor disputes, not to locked out Claimants as in this case. Accordingly, the Court reversed the district court's judgment and remanded the case back to Job Service for further proceedings. View "Olson v. Job Service" on Justia Law