Articles Posted in Public Benefits

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The Office of the Medicaid Inspector General (OMIG) may withhold payments to recover from Petitioner, the operator of a methadone clinic and provider of Medicaid-covered services, the full $1,857,401 in overpayments assessed following an audit. OMIG notified Petitioner than it had been overpaid $1,857,401 in claims from 2003 through 2007. OMIG informed Petitioner that it had twenty days to agree to settle these claims for a lower amount or OMIG would begin to withhold a percentage of Petitioner’s payments. When Petitioner did not agree to settle after twenty days and failed timely to commence an administrative appeal to challenge the audit findings, OMIG commenced withholding. Petitioner commenced this article 78 proceeding seeking to prohibit OMIG from liquidating the full amount in overpayments and a declaration that OMIG can collect only $1,460,914, the amount for which Petitioner declined to settle. The Court of Appeals held that OMIG was not precluded from seeking to withhold the full $1,857,401 amount. View "West Midtown Management Group, Inc. v. State" on Justia Law

Posted in: Public Benefits

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Aponte moved into his mother's one-bedroom New York City Housing Authority (NYCHA)-owned apartment and cared for her until she died in 2012. Two requests for Aponte to be granted permanent permission to live with his mother were denied. After she died, Aponte requested to be allowed to lease her apartment as a "remaining family member." NYCHA denied his request, finding that Aponte lacked permanent permission to reside in the apartment; management properly denied such permission because Aponte's presence would have violated occupancy rules for overcrowding. A person lacking permanent permission to reside in an apartment is not eligible for RFM status. The Court of Appeals upheld the denial. Under its rules, NYCHA could not have granted Aponte permanent permission to reside in his mother's apartment, and thus could not have granted his request for RFM status. NYCHA's rules contemplate that a tenant may require a live-in home-care attendant, either for a transient illness or the last stages of life, and expressly allow for such an attendant as a temporary resident, even if that permission will result in "overcrowding," regardless of whether the attendant is related to the tenant. NYCHA's policy is not arbitrary and capricious for not allowing Aponte to bypass the 250,000-household waiting line as a reward for enduring an "overcrowded" living situation while caring for his mother. View "Aponte v Olatoye" on Justia Law

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The question underlying these proceedings was whether the State must consider and pay claims submitted after the effective date of the legislative deadline for pre-2006 reimbursement claims set forth in Section 61 of the 2012 amendment to the Medicaid Cap Statute, which provides that no reimbursement claims shall be made for a category of Medicaid disability expenses paid by counties to the State prior to 2006. In these appeals, the latest round in a decade-long struggle between the counties and the State over Medicaid payments, several counties challenged the constitutionality of Section 61. The Court of Appeals held (1) Section 61 is constitutional; and (2) the State is under no obligation to address outstanding county reimbursement claims filed after April 1, 2012, and the State is not required to initiate an administrative review of its records to identify and pay for any pre-2006 claims. View "County of Chemung v. Shah" on Justia Law

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Beginning in 1989, Petitioner received public assistance from New York City Department of Social Services. Petitioner gave birth to a son, Michael, the next year. Michael was added to Petitioner’s public assistance case, and Petitioner assigned her right to child support for Michael. In January 2007, the Social Security Administration (SSA) determined that Michael was eligible to receive Supplemental Security Income (SSI), retroactive to September 2005. Because Michael’s eligibility for SSI made him ineligible for public assistance, the City removed him from Petitioner’s case in January 2007 but continued to collect child support arrears that had accrued prior to January 2007. In 2011, Petitioner requested a review from the City to determine whether she was owed any excess child support payments. The City determined that it owed no payments because it had not collected sufficient child support arrears to exceed the public assistance provided to Petitioner’s household. The State confirmed the City’s determination. Petitioner then commenced this N.Y. C.P.L.R. 78 proceeding challenging Respondents’ determinations as arbitrary, capricious and erroneous as a matter of law. Supreme Court denied the petition, and the Appellate Division affirmed. The Court of Appeals affirmed on the grounds that the City had not yet collected child support arrears that exceeded the unreimbursed benefits Petitioner’s family received. View "Hawkins v. Berlin" on Justia Law

Posted in: Public Benefits

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Plaintiff is a health insurance company that offers a choice of federal government-regulated alternatives to Medicare known as Medicare Advantage plans. These plans allow Medicare-eligible individuals to purchase health insurance from private insurance companies. Those companies are reimbursed by the government for health care services provided to the plans’ members. Before the Supreme Judicial Court was Plaintiff’s demand for indemnification to cover losses resulting from health care claims for unprovided services paid through Plaintiff’s computer system. At issue was the coverage available to Plaintiff pursuant to Rider #3 of a financial institution bond issued by Defendant. The bond insured Plaintiff against various losses, and the Rider amended the bond to provide indemnification specifically for computer systems fraud. When Plaintiff suffered more than $18 million in losses for payment for fraudulent claims for services never actually performed under its Medicare Advantage plans, Plaintiff sought payment from Defendant for its post-deductible losses. Defendant denied coverage, and Plaintiff sued. Supreme Court granted summary judgment for Defendant. The Court of Appeals affirmed, holding that the Rider applies to losses resulting directly from fraudulent access, not to losses from the content submitted by authorized users. View "Universal Am. Corp. v Nat’l Union Fire Ins. Co. of Pittsburgh, PA" on Justia Law

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Debtor lived in a rent-stabilized apartment for over forty years. Debtor filed for Chapter 7 bankruptcy and listed the value of her unexpired rent-stabilized lease as personal property exempt from the bankruptcy estate under N.Y. Debt. & Cred. Law 282(2) as a “local public assistance benefit.” The bankruptcy court struck the claimed exemption, concluding that the value of the lease did not qualify as an exempt local public assistance benefit. The district court affirmed. Debtor appealed, arguing that the value of her lease was a local public assistance benefit that was exempted from her bankruptcy estate. The Second Circuit certified a question to the New York Court of Appeals regarding the issue. The Court of Appeals answered that section 282(2) exempts a debtor-tenant’s interest in a rent-stabilized lease. View "Matter of Santiago-Monteverde" on Justia Law

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Petitioners were two medical providers whose patients included individuals insured by the State’s primary health benefit plan. The State Comptroller reviewed Petitioners’ billing records as part of an audit of billing practices in the health care industry for claims paid by the State. While Petitioners conceded that the State paid eighty percent of the costs of their services, Petitioners challenged the Comptroller’s authority to audit their books. Supreme Court concluded that the Comptroller lacked constitutional authority to audit Petitioners because Petitioners were “not a political subdivision of the State.” The Appellate Division modified Supreme Court’s orders to reinstate the audits. The Court of Appeals affirmed, holding that the State Constitution does not limit the Comptroller’s authority to audit, as part of its audit of State expenditures, the billing records of private companies that provide health care to beneficiaries of a State insurance program. View "Martin H. Handler, M.D., P.C. v. DiNapoli" on Justia Law

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The Office of the Medicaid Inspector General (OMIG) terminated a physician's participation in the Medicaid program on the basis of a Bureau of Professional Medical Conduct (BPMC) consent order, in which the physician pleaded no contest to charges of professional misconduct and agreed to probation. Supreme Court annulled the OMIG's determination. The Appellate Division affirmed, concluding (1) the agency acted arbitrarily and capriciously in barring the physician from treating Medicaid patients when the BPMC permitted him to continue to practice; and (2) the OMIG was required to conduct an independent investigation before excluding a physician from Medicaid on the basis of a BPMC consent order. The Court of Appeals affirmed but for another reason, holding (1) the OMIG is authorized to remove a physician from Medicaid in reliance solely on a consent order between the physician and the BMPC, regardless of whether BPMC chooses to suspend the physician's license or OMIG conducts an independent investigation; but (2) because OMIG did not explain why the BPMC consent order caused it to exclude the physician from the Medicaid program, the agency's determination was arbitrary and capricious. View "Koch v. Sheehan" on Justia Law

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The New York City Off-Track Betting Corporation (NYC OTB) was a public benefit corporation charged with operating an off-track pari-mutuel betting system within the City. Later, NYC OTB filed for bankruptcy and shut down. The City's Corporation Counsel then announced that NYC OTB retirees would lose coverage under the City's health insurance and welfare benefit plans because the Corporation was no longer able to reimburse the City. A union representing NYC OTB employees and retirees and others (collectively, Plaintiffs) brought suit against the State and City, seeking a judgment declaring that the failure of the State and City to fund, and the termination of retiree health insurance and supplemental benefits, violated the City Administrative Code and other express and implied obligations. Supreme Court rejected the four theories advanced by Plaintiffs to support State or City liability for NYC OTB retiree health benefits. The appellate division affirmed. The Court of Appeals affirmed, holding (1) Plaintiffs did not demonstrate a likelihood of success on the merits of their claim against the City; and (2) because NYC OTB had a legal identity separate from the State, Plaintiffs stated no viable theory under which the State could be held liable in this case. View "Roberts v. Paterson" on Justia Law

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Plaintiff represented psychiatrists who treated patients eligible for both Medicare and Medicaid and defendants were responsible for administering Medicaid in New York and for implementing and enforcing medicaid reimbursement rates. At issue was whether the 2006 amendment to the Social Services law found in a budget bill implementing a coinsurance enhancement for the benefit of psychiatrists who treat patients eligible for both Medicare and Medicaid was intended to be permanent or whether the amendment was intended only to provide a limited one-year enhancement. The court concluded that the Legislature only intended to provide for a one-time coinsurance enhancement, limited to the 2006-2007 fiscal year. View "New York State Psychiatric Assn., Inc. v New York State Dept. of Health" on Justia Law