Justia Government & Administrative Law Opinion Summaries

Infant was born with severe brain damage. Respondent, Infant's mother, on behalf of Infant, applied for and received Medicaid benefits from the West Virginia Department of Health and Human Resources (DHHR). Respondent later filed a medical malpractice lawsuit on behalf of Infant. Subsequently, Respondent petitioned the circuit court for approval of the settlement, requesting that Medicaid not be reimbursed. DHHR intervened. The court granted the motion of Respondent for allocation of the $3,600,000 settlement, holding that, pursuant to Arkansas Department of Health and Human Services v. Ahlborn, a proportional reduction of DHHR's recovery was required based on the ratio of the settlement to the "full value" of the case among the various damages categories. Using this allocation method, the court reduced DHHR's statutory reimbursement from the requested amount of $289,075 to $79,040 and directed that the net settlement proceeds be placed in a special needs trust for the benefit of Infant. The Supreme Court reversed in part and affirmed in part, holding (1) a $500,000 cap on noneconomic damages was applicable in this case; and (2) under the formula applied in Ahlborn, the DHHR was entitled to approximately $98,080, less its pro rata share of attorney's fees and costs. Remanded.

Plaintiffs brought a putative class action challenging 62 Pa. Stat. 1414, which was enacted to regulate special needs trusts. The comprehensive Medicaid eligibility rules enacted by Congress generally mandate that trusts be counted as assets of those seeking Medicaid, but exempt special needs trusts, which are intended to provide disabled individuals with necessities and comforts not covered by Medicaid. Plaintiffs allege Section 1414 is preempted by 42 U.S.C. 1396p(d)(4). The district court held that all but one of the challenged provisions of Section 1414 was preempted, finding that plaintiffs had a private right of action under both Section 1983 and the Supremacy Clause. The court also held that Section 1414 was severable, certified a class, and appointed class counsel. The Third Circuit affirmed in part, agreeing that the case is justiciable and that plaintiffs have a private right of action. Section 1414's 50% repayment provision, "special needs" provision, expenditure provision, and age restriction are all preempted by federal law. The enforcement provision of Section 1414, however, when used to enforce provisions not otherwise preempted, is a reasonable exercise of the Commonwealth's retained authority to regulate trusts.

Plaintiff appealed an order of the district court affirming the Commissioner's final decision denying her disability benefits under Title II of the Social Security Act (SSA), 42 U.S.C. 401-434. At issue, among other things, was whether the district court should have considered evidence plaintiff did not submit to the ALJ but submitted for the first time to the Appeals Council, which accepted and considered the new evidence but declined to review the ALJ's decision. The court held that when a claimant submitted evidence for the first time to the Appeals Council, which considering that evidence in denying review of the ALJ's decision, the new evidence was part of the administrative record, which the district court must consider in determining whether the Commissioner's decision was supported by substantial evidence. Considering the record as a whole, the court concluded that the Commissioner's decision was not supported by substantial evidence. Accordingly, the court reversed and remanded for an immediate award of benefits.

Reeves served as a heavy mortar crewman during combat offensives, 1942-1945, and was awarded three Bronze Stars. In 1981, Reeves filed a claim seeking service-connected disability benefits, with a medical opinion, stating that Reeves had bilateral, nerve-type hearing loss in 1962, attributable to noise exposure or to treatment with quinine for malaria. He also submitted records of an audiogram and statements from officers with whom he had served. The board denied the claim, stating that hearing loss documented in 1962 was too remote from active service. Reeves did not appeal. In 2004, the board granted an application to re-open, citing new evidence of treatment from 1946 to 1954, and awarded him service-connected disability benefits, effective 2002. In 2006, Reeves sought revision to an earlier effective date. The board denied the motion. The Veterans Court affirmed, rejecting an assertion that the evidence of record in 1983 was such that the board had no choice but to resolve in his favor that his hearing disability was incurred in service. Reeves died in 2011; the Federal Circuit substituted his widow and reversed. The Veterans Court misinterpreted 38 U.S.C. 1154(b) in rejecting the clear and unmistakeable error claim.

Heinzelman, born in 1971, received a flu vaccine in 2003, and within 30 days, was hospitalized for Guillain-Barre syndrome, a disorder affecting the peripheral nervous system. She was previously employed full-time as a hairstylist earning $49,888 per year. Due to her injury, Heinzelman will never be able to work again and is eligible to receive SSDI benefits of approximately $20,000 per year. In 2007, she sought compensation under the National Childhood Vaccine Injury Act of 1986, 42 U.S.C. 300aa-1 to 300aa-34. A special master rejected the government’s argument that her eligibility for SSDI benefits should be considered in determining compensation under the Vaccine Act, finding that SSDI is not a "federal . . . health benefits program" within the meaning of section 300aa-15(g), and awarded $1,133,046.08, plus an annuity to cover future medical expenses. According to the government, Heinzelman's lost earnings award would have been roughly $316,000 less had the special master taken her anticipated SSDI benefits into account. The Claims Court and the Federal Circuit affirmed.

Petitioner, J.S., was a thirteen-year-old boy who suffered from cerebral policy. Through his mother, J.S. submitted an authorization request for a power wheelchair with fifty-five accessories to the respondent, the state department of health and human resources (DHHR), which administers the Medicaid program in West Virginia. DHHR denied Petitioner's request on the basis that it exceeded the Medicaid policy of providing only the most economical equipment to meet a recipient's basic health care needs. The DHHR board of review upheld the denial. The circuit court upheld the decision. The Supreme Court reversed, holding that the circuit court applied an erroneous standard of review to the decision of the DHHR board of review. Remanded to the circuit court with direction to make an independent review of both the law and the facts of this case.

This case stemmed from the denial of plaintiff's claim of social security disability benefits. At issue was whether the ALJ's handling of an ex parte contact was error, and if so, whether it was harmless. Because the ALJ erred by considering the ex parte evidence without allowing a supplementary hearing, the court was required to evaluate whether there was prejudice. The court concluded that there was no prejudice from the error where, considering the record as a whole, and the ALJ's explanation of his decision, the court was convinced that plaintiff had not demonstrated that the decision would have been any different without the ex parte communication. Accordingly, the court affirmed the judgment.

Respondent gave birth to twins conceived through in vitro fertilization using her deceased husband's frozen sperm. Respondent applied for Social Security survivors benefits for the twins, relying on 42 U.S.C. 416(e) of the Social Security Act, which defined child to mean, inter alia, "the child or legally adopted child of an [insured] individual." The Social Security Administration (SSA), however, identified subsequent provisions of the Act, sections 416(h)(2) and (h)(3)(C), as critical, and read them to entitle biological children to benefits only if they qualified for inheritance from the decedent under state intestacy law, or satisfied one of the statutory alternatives to that requirement. The Court concluded that the SSA's reading was better attuned to the statute's text and its design to benefit primarily those supported by the deceased wage earner in his or her lifetime. And even if the SSA's longstanding interpretation was not the only reasonable one, it was at least a permissible construction that garnered the Court's respect under Chevron U.S.A. Inc. v. Natural Resources Defense Council, Inc.

States both appealed the district court's grants of summary judgment in favor of HHS, which upheld HHS's disallowance of certain Medicaid claims for Federal Financial Participation (FFP) as ineligible for "medical assistance" under the "Institution for Mental Diseases" (IMD) exclusion set forth in section 1905(a) of 42 U.S.C. 1396 et seq. (Medicaid Statute). Because HHS correctly concluded that the disputed claims were not eligible for FFP under the plain language of the IMD exclusion and the under-21 exception, the court affirmed the judgment of the district court.

Plaintiff appealed the district court's grant of summary judgment to the Commissioner in its review of the Commissioner's denial of Social Security Disability Insurance (SSDI) and Social Security Income (SSI) benefits. Based on the rarity of the surveillance system monitor jobs, and considering plaintiff's physical and mental limitations, the court was compelled to find that the ALJ's decision was not supported by substantial evidence. Accordingly, the court reversed the district court's grant of summary judgment and remanded for further proceedings.