Articles Posted in Public Benefits

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The Hayes family is a low-income family whose rent is subsidized by enhanced voucher assistance under the Housing Act of 1937, 42 U.S.C. 1437f(t) (Section 8). Because an ordinary voucher does not cover a tenant’s rent to the extent that it exceeds the applicable payment standard, and, following a valid opt-out, property owners are no longer subject to limitations on what they may charge for rent, enhanced vouchers exist to enable residents to “choose” to continue renting the “dwelling unit in which they currently reside.” The Hayes family's eligibility to receive enhanced vouchers is contingent upon their continued tenancy in a unit currently owned by Harvey. Toward the end of their most recent lease term, Harvey notified the Hayes family that he would not renew their lease. The Hayes family refused to vacate the premises, arguing that as enhanced-voucher tenants, they have an enforceable “right to remain” in their unit as long as it is offered for rental housing. The district court granted Harvey summary judgment. The Third Circuit affirmed. The Act does not obligate property owners to renew enhanced-voucher tenancies after the initial lease term. View "Hayes v. Harvey" on Justia Law

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McGann, who is blind and deaf, requested from Cinemark an American Sign Language (ASL) tactile interpreter so that he could experience a movie in his local Cinemark theater during one of its regular showings. Cinemark denied his request. McGann filed suit under the Americans with Disabilities Act (ADA), 42 U.S.C. 12101 ADA. After a bench trial in which the parties stipulated to all relevant facts, the district court entered Judgment in favor of Cinemark. It reasoned that McGann’s requested tactile interpreter was not an auxiliary aid or service under the ADA and that the ADA did not require movie theaters to change the content of their services or offer “special” services for disabled patrons. The Third Circuit vacated. The tactile interpreter McGann requested is an “auxiliary aid or service.” A a public accommodation may avoid ADA liability for failure to provide an auxiliary aid or service only if it shows that the aid or service in question “fundamentally alter[s] the nature” of its goods or services, or “would result in an undue burden, i.e., significant difficulty or expense.” The court remanded for consideration of CInemark’s possible defense. View "McGann v. Cinemark USA Inc" on Justia Law

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Elliott worked in a coal mine until 1993 and developed a chronic cough. Three after his retirement, he developed more acute breathing problems. Elliott sought Black Lung Benefits Act, 30 U.S.C. 901–45, benefits in 2012. Helen Mining conceded it was the responsible employer, but challenged Elliott’s entitlement to benefits. The parties stipulated that Elliott had a totally disabling respiratory impairment. Because Helen Mining conceded disability and because Elliott demonstrated more than 15 years of employment, the ALJ determined that section 921(c)(4) applied and that the other elements, including causation, would be presumed, and shifted the burden to Helen Mining. Helen Mining offered the opinions of two doctors, attributing Elliott’s respiratory impairment to adult-onset asthma unrelated to coal dust exposure. The ALJ did not find their testimony persuasive, concluded that Helen Mining had failed to rule out coal dust-induced pneumoconiosis as a cause of Elliott’s disability, and awarded benefits. The Benefits Review Board upheld the award. The Third Circuit affirmed, upholding the application of the 2013 regulation, specifying the standard a coal mine operator must meet to rebut the presumed element of disability causation, 20 C.F.R. 718.305(d)(1). The regulation permissibly fills a statutory gap and Helen Mining did not meet that rebuttal standard. View "Helen Mining Co v. Elliott" on Justia Law

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Qui tam relator failed to satisfy the False Claims Act’s materiality requirement in alleging that the manufacturer of a widely-prescribed cancer drug, Avastin, suppressed data that caused doctors to certify incorrectly that Avastin was “reasonable and necessary” for certain at-risk Medicare patients. Avastin is FDA-approved and has accounted for $1.13 billion a year in Medicare reimbursements. The relator, formerly the head of healthcare data analytics for the manufacturer, claimed the company ignored and suppressed data that would have shown that Avastin’s side effects for certain patients were more common and severe than reported and that such analyses would have required the company to file adverse event reports with the FDA, and could have resulted in changes to Avastin’s FDA label. He claimed the company caused physicians to submit Medicare claims that were not “reasonable and necessary.” The Third Circuit affirmed dismissal of the claim, stating the allegations may be true but a False Claims Act suit is not the appropriate way to address them. The manufacturer followed all pertinent statutes and regulations. If those laws and regulations are inadequate to protect patients, it falls to the other branches of government to reform them. View "Petratos v. Genentech Inc" on Justia Law

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Morris worked as a coal miner for nearly 35 years, 19 years underground. Morris’s breathing difficulties caused him to leave work. In 2006, Dr. Cohen diagnosed him with pneumoconiosis (black lung disease). Eighty Four Mining’s physician also examined Morris, but determined that Morris’s breathing difficulties were caused by smoking and that there was no radiographic evidence of pneumoconiosis. In 2008, aPennsylvania Workers’ Compensation Judge denied benefits. Morris did not appeal. Morris’s breathing problems worsened; a doctor put him on oxygen nearly full-time. In 2011, Morris sought Black Lung Benefits Act (BLBA), 30 U.S.C. 901, benefits. He did not rely upon the 2006 report that had been discredited, but on a 2011 arterial blood gas study and pulmonary function testing that supported a finding of black lung disease. In 2013, an ALJ granted BLBA benefits, rejecting a timeliness challenge and reasoning that a denial of black lung benefits due to the repudiation of the claimant’s pneumoconiosis diagnosis renders that diagnosis a “misdiagnosis” and resets the three-year limitations period for subsequent claims. Morris sufficiently established the existence of pneumoconiosis through medical evidence obtained after 2010 and Eighty Four failed to adequately explain why Morris’s years of coal dust exposure were not a substantial cause of his impairment. The Benefits Review Board affirmed, citing judicial estoppel as precluding the timeliness argument. The Third Circuit denied a petition for review. View "Eighty Four Mining Co. v. Morris" on Justia Law

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Plaintiffs each applied for Medicaid institutional care coverage shortly after purchasing a short-term annuity. The Pennsylvania Department of Human Services (DHS) classified each of their annuities as a resource when determining Medicaid eligibility. This classification meant that the value of each annuity precluded them from receiving Medicaid assistance and resulted in a penalty period of ineligibility. The district court held that the plaintiffs’ purchases of the short-term annuities were sham transactions intended only to shield resources from Medicaid calculations, and affirmed DHS’s imposition of a period of Medicaid ineligibility, but held that, contrary to DHS’s arguments, a Pennsylvania statute that purported to make all annuities assignable was preempted by federal law. The Third Circuit affirmed in part, finding that the statute was preempted, but reversed in part, citing “safe harbor” provisions, under which, certain annuities are not considered resources for purposes of Medicaid eligibility, 42 U.S.C. 1396p(c)(1)(F). The court noted the qualifications for safe-harbor protection: the annuity must name the state as the remainder beneficiary, be irrevocable and nonassignable, be actuarially sound, and provide for payments in equal amounts during its term, with no deferral and no balloon payments. The court rejected the state’s argument that the annuities were “trust-like.” View "Zahner v. Sec'y Pa. Dept. of Human Servs." on Justia Law

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Hospitals that are disadvantaged by their geographic location may reclassify to a different wage index area for certain Medicare reimbursement purposes by applying for redesignation to the Medicare Geographic Classification Review Board. Section 401 of the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999, enacted 10 years after the Board was established, creates a separate mechanism by which qualifying hospitals located in urban areas “shall [be] treat[ed] . . . [as] rural” for the same reimbursement purposes. To avoid possible strategic maneuvering by hospitals, the U.S. Department of Health and Human Services issued a regulation providing that hospitals with Section 401 status cannot receive additional reclassification by the Board on the basis of that status, 42 C.F.R. 412.230(a)(5)(iii) (Reclassification Rule). Geisinger, a hospital located in an urban area, received rural designation under Section 401 but was unable to obtain further reclassification by the Board pursuant to the Reclassification Rule. Geisinger sued. The district court upheld the regulation. The Third Circuit reversed, finding that Section 401 is unambiguous: HHS shall treat Section 401 hospitals as rural for Board reclassification purposes, 42 U.S.C. 1395ww(d)(8)(E)(i) View "Geisinger Cmty. Med. Ctr. v. Sec'y United States Dep't of Health & Human Servs." on Justia Law

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Hansler was hired by Lehigh Valley in 2011. In 2013, Hansler began experiencing shortness of breath, nausea, and vomiting, of unknown origins. Hansler’s physician completed a medical certification form “requesting intermittent leave at a frequency of 2 times weekly starting on March 1, 2013 and lasting for a probable duration of one month.” Hansler submitted the certification as part of a formal request for leave under the Family Medical Leave Act, 29 U.S.C. 2601. Hansler was unable to work on March 13, 14, 23, 24, and 25. Without seeking further information from either Hansler or her physician, Lehigh terminated Hansler on March 28, citing absenteeism, including the five days she took off in March. Lehigh informed her, for the first time, that her leave request had been denied because her “condition presently does not qualify as a serious health condition under the criteria set forth by the [Act].” After her dismissal, Hansler received a diagnosis of diabetes and high blood pressure. The district court dismissed her suit under the Act, on the basis that the medical certification supporting Hansler’s request for leave was “invalid.” The Third Circuit reversed, finding that Lehigh violated the Act in failing to afford Hansler a chance to cure any deficiencies in her medical certification. View "Hansler v. Lehigh Valley Hosp. Network" on Justia Law

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Zirnsak was involved in a motor vehicle accident. She sustained head and lung injuries and skeletal fractures and was hospitalized from October 8 through November 14, 2001, temporarily on life support. Upon her discharge, she was sent to a rehabilitation facility, where she was treated from January 16, 2002 through October 18, 2005. In 2003, she suffered a seizure. She was prescribed medication and did not suffer any further seizures. Between January 5, 2005 and August 11, 2006, Zirnsak underwent plastic surgery for lipoma reductions. Zirnsak sought treatment from several medical professionals, including treatment for “traumatic brain injury, left hemiparesis cognitive impairments with short-term memory deficits, organic affective changes[,] and a seizure disorder.” In 2010, Zirnsak applied for Social Security Disability Insurance benefits alleging a disability commencing on May 11, 2006. Zirnsak’s date last insured was December 31, 2007. The SSA denied Zirnsak’s application, finding that Zirnsak was capable of performing certain jobs available in the national economy, so long as those jobs were sedentary and routine. The district court and Third Circuit affirmed. Substantial evidence supports Zirnsak’s ability to perform jobs widely available in the national economy: order clerk, food and beverage; charge account clerk; and telephone clerk. View "Zirnsak v. Colvin" on Justia Law

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Babaria, a licensed radiologist and medical director and manager of Orange Community MRI, an authorized Medicare and Medicaid provider, pleaded guilty to one count of making illegal payments (kickbacks), 42 U.S.C. 1320a-7b(b)(2)(A). From 2008 through 2011, he paid physicians to refer patients to Orange for diagnostic testing and billed Medicare and Medicaid for testing that was tainted by the corrupt referrals. Orange received $2,014,600.85 in payments that were directly traceable to the kickback scheme. There was no evidence that Babaria falsified patient records, billed Medicare or Medicaid for testing that was not medically necessary, or otherwise compromised patient care. Babaria objected to the PreSentence Investigation Report, which recommended a two-level adjustment for abuse of a position of trust (USSG 3B1.3) and a four-level adjustment for aggravating role (USSG 3B1.1(a)), resulting in a recommended Guidelines range of 70-87 months’ imprisonment. Ultimately, the Guidelines range was 60 months, capped by the statutory maximum for Babaria’s count of conviction. He argued that the correct range was 37 to 46 months. The court applied both adjustments but granted a downward variance and sentenced Babaria to 46 months’ imprisonment, a fine of $25,000, and forfeiture of the $2,014,600.85. The Third Circuit affirmed the sentence. View "United States v. Babaria" on Justia Law