Justia U.S. 9th Circuit Court of Appeals Opinion Summaries

Plaintiffs appealed the Secretary's denial of their claims for Medicare coverage for dental services. Plaintiffs contended that this denial was premised on the Secretary's unreasonable interpretation of the Medicare Act, Pub. L. No. 89-97, 79 Stat. 286, which contravened the intent of Congress and violated plaintiffs' right to equal protection under the Fifth Amendment. The court concluded that, although the statutory provision for exclusion of dental services was ambiguous in the sense that plausible divergent constructions could be urged, the Secretary's interpretation of the statute was reasonable. The court also concluded that the Secretary's statutory interpretation warranted Chevron deference and the Secretary's statutory interpretation was reasonable. Accordingly, the court affirmed the judgment. View "Fournier v. Sebelius" on Justia Law

These are two appeals stemming from the government's immediate termination of a Medicare Part D services contract with a prescription drug insurance coverage provider, Fox. Fox subsequently filed actions in the district court challenging both the termination and an order for immediate repayment. The court affirmed the district court's holding that the contract was properly terminated; affirmed the district court's ruling that governing regulations authorized the government's demand for immediate repayment of a prorated share of the funds that had been paid to Fox at the beginning of the month and that Fox would not utilize after the contract's termination; and the government's actions were more than justified, as Fox had risked permanent damage to its enrollees by, inter alia, improperly denying coverage of critical HIV, cancer, and seizure medications, and having no compliance structure in place. View "Fox Ins. Co. v. Centers for Medicare and Medicaid" on Justia Law

Plaintiffs claimed that PacifiCare was not entitled to any reimbursement payments out of the wrongful death benefits paid by an insurance policy to them. PacifiCare counterclaimed, arguing that it was entitled to reimbursement under both the terms of its contract with the deceased (Count I) and directly under the Medicare Act (Count 11), 42 U.S.C. 1395. At issue was whether a private Medicare Advantage Organization (MAO) plan could sue a plan participant's survivors, seeking reimbursement for advanced medical expenses out of the proceeds of an automobile insurance policy. Because interpretation of the federal Medicare Act presented a federal question, the district court had subject matter jurisdiction to determine whether that act created a cause of action in favor of PacifiCare against plaintiffs. The district court properly dismissed the causes of action arising under the Medicare Act for failure to state a claim where section 1395y(b)(2) did not create a federal cause of action in favor of a MAO and where, under section 1395y(b)(3)(A), the Private Cause of Action applied in the case of a primary plan which failed to provide for primary payment, which was not applicable in this instance. The court affirmed the district court's dismissal of Count II for failure to state a claim as well as its decision to decline to exercise supplemental jurisdiction over Count 1. View "Parra v. Pacificare of Arizona" on Justia Law

This dispute arose from California's implementation of a change to Medicare in 2006. The Centers argued that California mishandled the shift in payment responsibility for dual-eligibles' prescription drug costs from state Medicaid programs to the new, federal Medicare Part D Program. The Centers brought suit for declaratory and injunctive relief. Among other things, the Centers urged the federal courts to declare unlawful California's "seizure" of the Centers' Medicare Part D funds, in excess of what would be owed under the per-visit rate for the Centers' expenses. The court concluded that the Eleventh Amendment barred the Centers' claims for retroactive monetary relief; the court affirmed the district court's dismissal of the Centers' claims to the extent that they sought money damages; however, the court reversed the district court and remanded to allow the district court to assess Ex parte Young's application to the Center's remaining claims. View "North East Medical Services v. CA Dept. of Health" on Justia Law

In the four cases giving rise to these eleven consolidated appeals, the Secretary of the Department of Health and Human Services (HHS) and the Director of the California Department of Health Care Services (DHCS), appealed the district court's grant of preliminary injunctions to plaintiffs, various providers and beneficiaries of California's Medicaid program (Medi-Cal). At issue was the implementation of Medi-Cal reimbursement rate reductions. The court held that Orthopaedic Hospital v. Belshe did not control the outcome in these cases because it did not consider the key issue here - the Secretary's interpretation of 42 U.S.C. 1396a(a)(30)(A); the Secretary's approval of California's requested reimbursement rates were entitled to Chevron deference; and the Secretary's approval complied with the Administrative Procedures Act, 5 U.S.C. 500 et seq. The court further held that plaintiffs were unlikely to succeed on the merits on their Supremacy Clause claims against the Director because the Secretary had reasonably determined that the State's reimbursement rates complied with section 30(A). The court finally held that none of the plaintiffs had a viable takings claim because Medicaid, as a voluntary program, did not create property rights. View "Managed Pharmacy Care, et al v. Sebelius, et al" on Justia Law

Tim Wilborn appealed the reduction of attorneys' fees he earned while representing plaintiff in a Social Security benefits claim. At issue was whether Wilborn received fees for the same work under the Equal Access to Justice Act (EAJA), 28 U.S.C. 2412, and the Social Security Act (SSA), 42 U.S.C. 406(b)(1). The court held that the $5,000 award under the EAJA was for the "same work" as the work for which Wilborn received the section 406(b)(1) award, and therefore the district court correctly offset the $5,000 from the 25% award. View "Parrish v. Commissioner Social Security" on Justia Law

Plaintiff sought review of the SSA's denial of his application for social security disability benefits. The federal magistrate judge who presided over plaintiff's action determined that the agency's decision improperly disregarded the opinions of an examining psychologist and remanded to the agency. Plaintiff sought reasonable attorney's fees pursuant to the Equal Access to Justice Act (EAJA), 28 U.S.C. 2412(d). The magistrate judge granted the request in part but determined that the 60.5 hours plaintiff's attorneys spent working on the case were excessive and subsequently reduced the number of hours by nearly one-third. The court held that it was improper for district courts to apply a de facto cap on the number of hours for which attorneys could be compensated under the EAJA in a "routine" case challenging the denial of social security benefits. Rather individualized consideration must be given to each case. Accordingly, the court reversed and remanded. View "Costa v. Commissioner of Social Security Admin." on Justia Law

Appellant applied for Social Security benefits, alleging that he became unable to walk because of a disability in 2005. Appellant's claim was denied in 2008. The ALJ held a hearing at Appellant's request and determined that Appellant's impairments notwithstanding, Appellant had the capacity to perform light work with specified limitations. The ALJ then concluded that Appellant was not disabled as defined in the Social Security Act. The Ninth Circuit Court of Appeals affirmed the ALJ's determination, holding (1) the ALJ conducted a full and fair hearing; (2) the ALJ properly documented his analysis of Appellant's psychiatric impairments, and his analysis was supported by the record; and (3) the ALJ's interpretation of the medical evidence was supported by the record, as was his credibility determination. View "Chaudry v. Astrue" on Justia Law

Appellant appealed a district court judgment affirming the Social Security Administration's (SSA) decision finding him disabled from September 26, 1997 through December 3, 1998, and concluding that the disability ended on December 4, 1998 due to medical improvement. Appellant contended that the ALJ's medical improvement finding was not supported by substantial evidence because she erred in relying on a single proposed rating decision from the Department of Veterans Affairs (VA) (the 2001 decision). Appellant also claimed that the ALJ erred by failing to mention the opinion of his treating physician. The Ninth Circuit Court of Appeals reversed, holding that the ALJ erred in relying solely on the 2001 decision, as (1) the 2001 only proposed changes while ignoring two other decisions that rejected the proposed changes recommended in the 2001 decision; and (2) the ALJ's misunderstanding led her to inaccurately conclude that her finding that Appellant's disability terminated on December 4, 1998 was consistent with the VA's ratings. View "Hiler v. Astrue" on Justia Law

Plaintiff filed for disability insurance benefits and supplemental security income under Title II and Title XVI of the Social Security Act. The Social Security Administration denied Hill's application. An ALJ also denied Plaintiff's application, and the appeals council denied Plaintiff's request for review. The district court granted summary judgment in favor of the Commissioner of Social Security and affirmed the ALJ's decision. The Ninth Circuit Court of Appeals reversed, holding (1) the ALJ failed to consider evidence favorable to Plaintiff and posed an improper hypothetical question to the vocational expert; and (2) therefore, substantial evidence did not support the ALJ's determination that Plaintiff was not disabled under the Social Security Act. View "Hill v. Astrue " on Justia Law