Articles Posted in Public Benefits

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Bowling worked as a coal miner for 29 years, most recently for Island Fork. In 2002, Bowling unsuccessfully sought Black Lung Benefits Act (BLBA) benefits. In 2010, Bowling filed the current claim. In the meantime, the Affordable Care Act amended the BLBA to reinstate a rebuttable presumption that claimants with respiratory disabilities and 15 years or more of underground coal-mining work experienced those disabilities as a result of pneumoconiosis, 30 U.S.C. 921(c)(4). The District Director designated Island Fork as the responsible operator and awarded benefits. At a hearing, the ALJ learned that Island Fork and its insurer, Frontier were insolvent. Frontier declared insolvency after the Proposed Order issued. At the initial stages, if the District Director determines that an operator is not financially capable, the Director can select another operator—such as a previous employer—to be the responsible operator; once the claim reaches the ALJ, there is no mechanism to designate a different responsible operator. The Trust Fund, created by the BLBA, provides benefits when there are no responsible operators available, including when an operator is deemed at the ALJ stage not to be financially capable. KIGA, created by the Kentucky Insurance Guaranty Association Act, provides benefits when a member insurance company is insolvent. The ALJ decided that Island Fork was still the responsible operator because benefits could be paid by KIGA. The Sixth Circuit affirmed. The exclusions in the Guaranty Act do not apply; KIGA is liable. View "Island Fork Construction v. Bowling" on Justia Law

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Federal Medicaid funds are not available for state medical expenditures made on behalf of “any individual who is an inmate of a public institution (except as a patient in a medical institution),” 42 U.S.C. 1396d(a)(29)(A). "Inmate of a public institution" means a person who is living in a public institution. However, an individual living in a public institution is not an “inmate of a public institution” if he resides in the public institution “for a temporary period pending other arrangements appropriate to his needs.” Ohio submitted a proposed plan amendment aimed at exploiting this distinction: it sought to classify pretrial detainees under age 19 as noninmates, living in a public institution for only “a temporary period pending other arrangements appropriate to [their] needs,” for whom the state could claim Medicaid reimbursement. The Centers for Medicare and Medicaid Services rejected the amendment, finding that the inmate exclusion recognizes “no difference” between adults and juveniles, or convicted detainees and those awaiting trial. The Sixth Circuit denied a petition for review, agreeing that the involuntary nature of the stay is the determinative factor. The exception does not apply when the individual is involuntarily residing in a public institution awaiting adjudication of a criminal matter. View "Ohio Department of Medicaid v. Price" on Justia Law

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Critical Access Hospitals are reimbursed by Medicare for the reasonable and necessary costs of providing services to Medicare patients. The Medicaid program requires states to provide additional (DSH) payments to hospitals that serve a disproportionate share of low-income patients, 42 U.S.C. 1396a(a)(13)(A)(iv). In Kentucky, DSH payments are matched at 70% by the federal government. Kentucky’s contribution to DSH programs comes from payments from state university hospitals and Kentucky Provider Tax, a 2.5% tax on the revenue of various hospitals, including Appellants, The amount of DSH payments a hospital receives is unrelated to the amount of KP-Tax it paid. During the years at issue, DSH payments covered only 45% of Appellants' costs in providing indigent care. Appellants filed cost reports in 2009 and 2010 claiming their entire KP-Tax payment as a reasonable cost for Medicare reimbursement. Previously, they had received full reimbursement; for 2009 and 2010, however, the Medicare Administrative Contractor denied full reimbursement, offsetting the KP-Tax by the amount of DSH payments Appellants received. The Provider Reimbursement Review Board and Centers for Medicare and Medicaid Services upheld the decision. The Sixth Circuit affirmed, reasoning that the net economic impact of Appellants’ receipt of the DSH payment in relation to the cost of the KP-Tax assessment indicated that the DSH payments reduced Appellants’ expenses such that they constituted a refund. View "Breckinridge Health, Inc. v. Price" on Justia Law

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While implementing changes required by the Patient Protection and Affordable Care Act of 2010, Michigan experienced a systemic computer problem that erroneously assigned thousands of non-citizens, who may have been eligible for comprehensive Medicaid coverage, to Emergency Services Only (ESO) Medicaid. Plaintiffs, two eligible noncitizen residents of Michigan who were erroneously assigned ESO coverage, filed a class action complaint against the Director of the Michigan Department of Health and Human Services, alleging violations of the Medicaid statute and the Due Process Clause. The district court found that actions taken by the state since the complaint was filed had resolved all systemic errors, so that plaintiffs’ claims were moot. The Sixth Circuit reversed the summary judgment, noting that not one of the individuals identified as a named plaintiff or potential named plaintiff was granted relief on the basis of a systemic fix and that that it is not “absolutely clear the allegedly wrongful behavior could not reasonably be expected to recur.” Material questions of fact remain regarding claims that the state failed to provide comprehensive Medicaid coverage and a reasonable opportunity to verify immigration status, precluding summary judgment. View "Unan v. Lyon" on Justia Law

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Kentucky’s Health and Family Services commenced a Dependency, Neglect, and Abuse proceeding. The mother stipulated to neglecting her children. Kentucky placed both boys in foster care. R.O., the mother’s aunt, sought custody of the children. The state conducted a standard home evaluation and criminal background check on R.O. and eventually both children were placed in her home by court order. The family court closed the action and granted joint custody to the mother and R.O., though the boys remained living with R.O., who sought foster care maintenance payments. The family court declined to rule on the issue, “indicating that permanency had been achieved.” R.O. then sued the state, arguing that the federal Child Welfare Act, 42 U.S.C. 672(a), required the state to provide maintenance payments, and that the failure to make payments violated the Equal Protection and Due Process Clauses. The state removed the case to federal court. The district court dismissed, reasoning that the Child Welfare Act provides no privately enforceable rights, that the family lacked a property interest in the payments, and that Kentucky’s scheme rationally distinguished between relative and non-relative foster care providers. The Sixth Circuit reversed, finding that the Act creates a private right of action. View "D.O. v. Glisson" on Justia Law

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Clark sought attorney fees under the Equal Access to Justice Act (EAJA), 28 U.S.C. 2412(d)(2)(A): $6,790.52 in fees for 34.75 attorney hours at an hourly rate of $176.13, plus 6.70 paralegal hours at an hourly rate of $100. The rate exceeded the $125 rate set by the EAJA. Clark argued that her counsel should receive a cost of living adjustment, based on the U.S. Bureau of Labor Statistics Consumer Price Index (CPI) for “Midwest Urban Consumers.” The agency requested that the court award fees at no more than $140, "the current reasonable and customary rate for experienced Social Security practitioners in the Western District of Kentucky." In her reply, Clark attached a declaration from her attorney, stating that he had practiced disability law from his Syracuse, New York, office for several years and provided his firm’s non-contingent hourly rate. Clark cited 2014 Sixth Circuit precedent, concluding that the requested rate of $176.13 was modest and appeared to be reasonable; she argued that other courts have held that the CPI alone was sufficient to justify a rate above the statutory cap. The district court awarded fees at an hourly rate of $140. The Sixth Circuit affirmed; there must be some understanding of the rates charged locally before a court can adjust for cost of living or other factors. View "Clark v. Commissioner of Social Security" on Justia Law

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The Sixth Circuit declined to stay a preliminary injunction requiring the delivery of bottled water households served by the Flint water system that lack properly installed water filters. For many homes without a proper filter, safe drinking water is inaccessible due to the limited hours of the points of distribution and transportation issues. The cost of verifying and maintaining water filters and delivering bottled water to residents that are not part of the allegedly 96% of homes that have a functioning filter is "nowhere near $10.5 million" claimed by the defendants. There is still $100 million left of the $212 million that Michigan allocated to respond to the Flint water crisis. The court rejected an argument that delivering bottled water will slow down the recovery of Flint’s water system by decreasing the amount of water moving through the delivery lines. The defendants did not demonstrate a strong likelihood of success on their arguments, nor have they shown that portions of the preliminary injunction, including the provisions requiring the delivery of bottled water to non-exempt households, are overbroad. A stay would not support the public interest. Flint residents continue to suffer irreparable harm from the lack of reliable access to safe drinking water. View "Concerned Pastors for Social Action v. Khouri" on Justia Law

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Coursey’s application for Social Security benefits was denied. He sought judicial review. The district court granted a joint motion to reverse the decision. Coursey sought attorney fees. Although the Equal Access to Justice Act (EAJA), 28 U.S.C. 2412, sets the presumptive maximum hourly rate an attorney may recover at $125. Coursey sought $185.18 per hour. Coursey submitted the Bureau of Labor Statistics’ Consumer Price Index (CPI), which documents that the statutory amount would, when adjusted for the cost of living in the Midwest in 2015, be the equivalent of $185.18. The court concluded that the CPI and the attorney's affidavit were insufficient to justify the requested rate and approved an award of $140 per hour, consistent with recent cases in the district awarding that amount for EAJA attorney-fee requests in Social Security cases. The Sixth Circuit affirmed. A plaintiff seeking an attorney’s fee of greater than $125 per hour must show by competent evidence that the cost of living justifies a higher rate and that the fee is “in line with those prevailing in the community for similar services by lawyers of reasonably comparable skill, experience, and reputation.” The court properly relied on evidence, judicial findings in previous cases, that the prevailing market rate for similar services within its venue was $140 per hour. View "Coursey v. Commissioner of Social Security" on Justia Law

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In 2006, Congress amended 42 U.S.C. 1396p(c)(1)(F)(i), which permits individuals and married couples to dispose of their assets (to qualify for Medicaid) by purchasing an annuity, under which the state is named as the remainder beneficiary in the first position for the amount of medical assistance paid. The federal law initially contained a drafting error. It was subsequently amended. A corresponding Kentucky regulation, promulgated four months later, mistakenly included the pre-amendment language, stating that the state had to be the beneficiary for the amount of assistance paid on behalf of the annuitant, rather than the institutionalized spouse. The state agency enforced the corrected federal statute. The Singletons sought Medicaid benefits to support Claude’s full-time nursing home care; in purchasing an annuity, Mary wanted to name the state as a beneficiary for the value of care provided to her, rather than Claude, as the Kentucky regulation seemed to permit. Claude obtained Medicaid eligibility after the purchase of an annuity that complied with the federal regulation. The government paid $98,729.01 in medical expenses before Claude's death. Mary later died, leaving $118,238.41 in the annuity. In compliance with the federal rule, the government’s claim left $19,509.40 for the secondary beneficiaries. The Singleton children sued. The Sixth Circuit rejected their argument that the Medicaid statute gave the state discretion to be more generous concerning annuities and the general spend-down rules. The Kentucky regulation departed from the Medicaid statute’s clear instructions and was preempted. View "Singleton v. Commonwealth of Kentucky" on Justia Law

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Fleming had a sporadic work history in the coal industry. Between 1970 and 1991, Fleming worked for 25 different employers. In 2010, Fleming sought Black Lung Benefits Act payments. The DOL Office of Workers’ Compensation calculated that Fleming was employed as a miner for nine and one-quarter years and that he had contracted pneumoconiosis as a result of that employment. Aberry was designated as the employer responsible for payment of benefits. On appeal, an ALJ determined that Fleming could show he had worked 273.50 weeks in the industry (about 5.25 years), but that Fleming was credible and established that he had either been paid under the table or without proper records having been kept. Based on that determination, the ALJ found that Fleming engaged in coal-mine employment “for at least 15 years,” which entitled Fleming to the presumption of total disability under 30 U.S.C. 921(c)(4). The Benefits Review Board remanded, stating that the ALJ had neither explained how he resolved the conflict between Fleming’s “not [being] a good historian” and the ALJ’s crediting of Fleming’s testimony, nor resolved the conflicting evidence. The ALJ's second Decision again awarded benefits. finding that Fleming worked more than 15 years in coal-mine employment. The Sixth Circuit vacated. The evidence was insufficient to establish that Fleming had 15 years of employment. View "Aberry Coal, Inc. v. Fleming" on Justia Law