Justia U.S. 6th Circuit Court of Appeals Opinion Summaries

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

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

Hilleger, suffering from dementia, heart problems, and arthritis, moved into a Cincinnati assisted-living facility. For four years, Hilleger paid the center’s $4,300 monthly fee. When she ran out of money, her daughters paid the fee while Hilleger applied for Medicaid assistance through Ohio’s assisted-living waiver program. When the agency determined that Hilleger was financially eligible, Medicaid began paying for her care. Saunders suffered a fall. Her stress fractures and dementia prevented her from returning home. She moved to an Ironton assisted-living center and applied for Medicaid assistance The agency authorized benefits 18 days later. Saunders’s daughter paid the costs for those 18 days. Hilleger and Saunders filed a putative class action, alleging that Ohio’s omissions of Medicaid coverage for the first 18 days of Saunders’s assisted-living costs and for the first three months of Hilleger’s costs violated 42 U.S.C. 1396a(a)(34); violation of the notice requirements of 42 U.S.C. 1396a(a)(3) and failure to provide Medicaid assistance with reasonable promptness (42 U.S.C. 1396a(a)(8)). The district court certified the proposed class and granted plaintiffs summary judgment. The Sixth Circuit reversed. The plaintiffs had standing to pursue only their claim with respect to retroactive benefits; other claims could not be redressed by the relief sought. Section 1396n(c)(1) permits Medicaid funding only for assisted-living services that are authorized by a preceding service plan. View "Price v. Medicaid Dir." on Justia Law

Brookdale Senior Living hired Prather to review documentation related to thousands of Brookdale residents who had received home-health services from Brookdale. Medicare claims regarding those patients were on hold and Brookdale faced possible recoupment of payments it had received if it did not review and submit final Medicare claims. Prather noticed that the required certifications stating that the doctor had decided that the patient needed home-health services, established a plan of care, and met with the patient, were signed long after care was provided. Prather repeatedly raised this issue, but was rebuffed. Brookdale, facing financial disaster, began paying doctors to complete the paperwork months after treatment was provided. Prather thought that Brookdale was not just asking treating physicians to complete forgotten paperwork, but had provided the services without physician involvement and then found doctors willing to validate the care after-the-fact. Prather's suit under the False Claims Act, 31 U.S.C. 3729, was dismissed. The Sixth Circuit reversed as to unlawful retention of payments. Completing certifications months after the fact was not “as soon as possible” after the plan was established, as required by regulations. Prather provided a detailed description of the alleged fraudulent scheme and her personal knowledge. Affirming dismissal of her false-records claim, the court concluded that Prather failed to plead with particularity the use of government forms to certify falsely that care had been provided under a doctor’s orders, or that unnecessary care had been provided. View "Prather v. Brookdale Senior Living Communities, Inc." on Justia Law

The Supplemental Nutrition Assistance Program (SNAP), overseen by the USDA, is administered by the states, 7 U.S.C. 2011–2036c. An individual is ineligible for SNAP benefits if he is “fleeing to avoid prosecution, or custody or confinement after conviction . . . for a crime, or attempt to commit a crime, that is a felony under the law of the place from which the individual is fleeing.” Michigan’s implementation barred assistance to anyone “subject to arrest under an outstanding warrant arising from a felony charge against that individual.” Michigan had an automated program that compared the list of public-assistance recipients with a list of outstanding felony warrants maintained by the Michigan State Police; when the program identified a match, it automatically closed the recipient’s file and generated a notice of the termination of benefits. In 2015 the Secretary of Agriculture promulgated 7 C.F.R. 273.11(n), clarifying disqualification of fugitive felons. Plaintiffs challenged Michigan's automatic disqualification and notice process. The court certified a class, held that Michigan policy violated the SNAP Act and the Constitution, and issued an injunction requiring Michigan to refrain from automatic disqualifications based solely on the existence of a felony warrant and to provide adequate notices of valid disqualification. The Sixth Circuit affirmed, rejecting claims that the plaintiffs lacked standing, of mootness, that there is no SNAP Act private right of action, and that Michigan's methods were valid. View "Barry v. Lyon" on Justia Law

For more than 40 years, participants in the Tennessee Valley Authority Retirement System (TVARS) received cost-of-living adjustments on top of their investment returns, pension benefits, and supplemental benefits. In 2009, with the system’s financial health in jeopardy, the TVARS board amended the rules that govern the system to cap or eliminate cost-of-living adjustments for the years 2010–2013, increase the eligibility age for cost-of-living adjustments, and lower the interest rate on a savings fund. The participants sued. None of their claims survived summary judgment. According to the district court, the plaintiffs did not have a private right of action to enforce the board’s compliance with the TVARS rules, and a Takings claim failed on the merits. The Sixth Circuit affirmed in part; cost-of-living adjustments are not vested, the agencies were also entitled to summary judgment on the merits of the claim that the board violated TVARS rules by reducing vested benefits. The court remanded remaining claims alleging violations of the TVARS rules because those claims are judicially reviewable in the context of this case. View "Duncan v. Muzyn" on Justia Law

Under the 2000 Energy Employees Occupational Illness Compensation Program Act a “covered employee” (or her survivor) is entitled to a lump sum payment of $150,000 “for the disability or death of that employee from that employee’s occupational illness,” 42 U.S.C. 7384s(a)(1). The claim adjudication process culminates in a final decision by the Final Adjudication Branch (FAB), which may be challenged in court. A claimant may request to reopen his claim after a final decision by submitting new evidence of covered employment or exposure to a toxic substance or identifying a change in medical guidelines. Berry sought benefits based on his father’s employment. After FAB denied his application for lack of proof that his father worked at a covered facility, Berry did not seek reconsideration or judicial review; 10 years later, Berry filed a request to reopen, stating that he had new evidence of employment. The request was denied. Berry sued under the Administrative Procedure Act. The district court dismissed, find the refusal to reopen “not a final agency action,” 5 U.S.C. 704. The Sixth Circuit affirmed. While the decision not to reopen satisfied the Supreme Court’s test for “final agency action,” and was not the type of decision that Court has recognized as “committed to agency discretion,” the court properly dismissed because the request was not actually based on new evidence, but alleged a material error in the initial decision. Under Supreme Court precedent, reopening requests based on material error are “committed to agency discretion” and unreviewable. View "Berry v. Dept. of Labor" on Justia Law

The amount of additional Medicare reimbursements that a hospital is entitled to receive for serving a disproportionate share of low-income patients depends, in part, on the number of days that the hospital served patients who were “eligible for medical assistance under a State plan approved under [the Medicaid statute].” 42 U.S.C. 1395ww(d)(5)(F)(vi)(II). Kentucky hospitals contend that because Kentucky has chosen in its Medicaid plan to award additional Medicaid funds to hospitals based on how many days they treat patients who are eligible for the Kentucky Hospital Care Program (KHCP), a state program that provides medical coverage to low-income individuals who do not qualify for Medicaid, KHCP patient days should be counted in the calculation of the additional Medicare reimbursements. The Sixth Circuit affirmed rejection of the state’s argument on summary judgment, stating that the statutory term “eligible for medical assistance under a State plan approved under [the Medicaid statute]” is synonymous with “eligible for Medicaid” and KHCP patients are, by definition, not eligible for Medicaid. View "Owensboro Health, Inc. v. United States Dept. of Health & Human Servs." on Justia Law

Minor suffers from migraine headaches, injuries from a serious car accident, fibromyalgia, and depression. Minor previously appealed the Social Security Commissioner’s decision to deny her disability claims; in 2013, the Sixth Circuit remanded with instructions to award benefits. The district court, calculating attorney fees under the Equal Access to Justice Act (EAJA), 28 U.S.C. 2412, substantially reduced Minor’s requested hourly rate and number of hours. While fees awarded under the Social Security Act, 42 U.S.C. 406(b) are deducted from a claimant’s award of past-due Social Security benefits, the government must pay fees awarded under the EAJA out of government funds, so the issue was, essentially, whether the government had to reimburse Minor for some or all of the attorney fees to be deducted from her benefit award. The Sixth Circuit vacated, stating that the district court provided little explanation for drastically reducing the requested EAJA fee award. View "Minor v. Comm'r of Social Sec." on Justia Law

A class of Tennessee residents who applied for Medicaid sought declaratory and injunctive relief, alleging that the delays they have experienced in receiving eligibility determinations on their applications violate 42 U.S.C. 1396a(a)(8) of the Medicaid statute, and that the state’s failure to provide a fair hearing on their delayed applications violates that statute and the Due Process Clause. Regulations implementing the statute provide that “the determination of eligibility for any applicant may not exceed” 90 days for those “who apply for Medicaid on the basis of disability” and 45 days for all other applicants. The district court certified a class and granted a preliminary injunction, which requires the state to grant a fair hearing on delayed applications to class members who request one. The Sixth Circuit affirmed the preliminary injunction, holding that the matter is not moot and that the federal government is not a required party. The court noted that the federal government submitted an amicus brief, supporting plaintiffs’ position. Despite the passage of the Affordable Care Act, states remain ultimately responsible for ensuring their Medicaid programs comply with federal law. View "Wilson v.Gordon" on Justia Law