Articles Posted in Public Benefits

by
The California Legislature reduced Medicaid hospital payments 10 percent between 2008-2011; the federal agency administering the Medicaid program approved the rate reductions. Hospitals alleged the reductions violated the Medicaid Act (42 U.S.C. 1396), which sets out procedural and substantive requirements the state must follow when establishing reimbursement rates. Hospitals unsuccessfully sought to have the rates declared void and almost $100 million in recalculated rates. The court of appeal affirmed, concluding that healthcare providers alleging a violation of section 1396a(a)(30)(A) may not obtain a writ of mandate against state officials to contest Medicaid rates approved by the federal agency that administers the program. Their recourse is an administrative action against the federal agency that approved the rates. While plaintiffs may obtain a writ of mandate for violations of the procedural requirements of section 13(A), no such violation occurred here. View "Santa Rosa Memorial Hospital v. Kent" on Justia Law

by
In an issue of first impression, the Court of Appeals addressed whether Family Code section 4504(b) required derivative benefits received by the child of a disabled parent to be credited against a noncustodial obligor's child support. In this case, the Social Security Administration (SSA) took six years to approve Father's application. In 2015, it made a lump-sum payment for past-due derivative benefits to custodial parent Y.H. (Mother), as Daughter's representative payee. In the intervening six years, Father had continued to pay child support and was not in arrears. The Court of Appeals held section 4504 (b) indeed permitted retroactive child support credit from Daughter's lump-sum payment where there was no child support arrearage. View "Y.H. v. M.H." on Justia Law

by
Plaintiffs were 23 federally qualified health centers (FQHC’s) and rural health clinics (RHC’s) that served medically underserved populations (the Clinics). The dispute before the Court of Appeal centered on coverage for adult dental, chiropractic, and podiatric services the FQHC’s and RHC’s provided to Medi-Cal patients for a period between 2009 and 2013. Prior to July 1, 2009, the Department processed and paid claims for these services. In 2009, in a cost-cutting measure due to budget problems, the Legislature enacted Welfare and Institutions Code section 14131.101 to exclude coverage for these services (and others) “to the extent permitted by federal law.” After the Department stopped paying claims for these services, various FQHC’s and RHC’s challenged the validity of section 14131.10, claiming it conflicted with federal Medicaid law. In California Assn. of Rural Health Clinics v. Douglas, 738 F.3d 1007 (9th Cir. 2013), the Ninth Circuit held section 14131.10 was invalid to the extent it eliminated coverage for these services when provided by FQHC’s and RHC’s because the federal Medicaid Act imposed on participating states the obligation to cover these services by these providers. In response to CARHC, the Department announced it would reimburse FQHC’s and RHC’s for these services for dates of service only on or after September 26, 2013, the date of the Ninth Circuit’s mandate. Seeking reimbursement for services provided prior to September 26, 2103, the Clinics petitioned for a writ of mandate to compel the Department to accept, process, and pay claims for these services for the period July 1, 2009, to September 26, 2013. The trial court granted the petition in part and entered judgment for the Clinics. The Department appeals. Characterizing the Clinics’ writ petition as a suit for damages, it contended: (1) sovereign immunity barred the Clinics’ claims for retroactive payment; (2) the CARHC decision was retroactive because the Medicaid Act is spending clause legislation and its terms were not sufficiently clear as to the requirement to cover adult dental, chiropractic, and podiatric services provided by FQHC’s and RHC’s; and (3) retroactive relief violated the separation of powers doctrine because it forces the Legislature to appropriate money. The Court of Appeal disagreed with the Department’s characterization of the Clinics’ lawsuit. "Rather than a suit for damages, the lawsuit seeks an order to compel performance of a mandatory duty and did not result in a money judgment. Under well-settled California law, such a mandamus proceeding is not barred by sovereign immunity. The Department’s contentions based on spending clause legislation and separation of powers are new arguments raised for the first time on appeal. We exercise our discretion to consider only the spending clause argument. We reject it because the Department has not shown its obligations under Medicaid law, as determined by CARHC, came as a surprise. The separation of powers argument raises factual issues about appropriations that should have been presented in the trial court and we decline to consider this new argument." Accordingly, the Court affirmed the judgment. View "American Indian Health etc. v. Kent" on Justia Law

by
The IHSS program (Welf. & Inst. Code 12300) provides in-home services to elderly or disabled persons so that they may avoid institutionalization. For purposes of the state unemployment insurance system, IHSS service recipients are considered employers of their service providers if the providers are directly paid by the program or the recipient receives IHSS funds to pay their providers (Unemp. Ins. Code 683.) Generally, an employee of a close family member (child, parent or spouse) is excluded from unemployment insurance coverage. The California Unemployment Insurance Appeals Board ruled that, because a close-family-member IHSS service provider under the Direct Payment Mode is employed by the recipient, the provider is subject to the exclusion of Unemployment Insurance Code 631 (Caldera). Skidgel, an IHSS provider for her daughter, challenged the validity of Caldera, arguing government entities were joint employers with the recipient, thereby qualifying providers for unemployment insurance coverage despite the close-family-member exclusion. The court of appeal rejected the challenge, concluding that the Legislature, in enacting Unemployment Insurance Code section 683, intended to designate the recipient as the IHSS provider’s sole employer for purposes of unemployment insurance coverage. View "Skidgel v. California Unemployment Insurance Appeals Board" on Justia Law

by
Reilly and two daughters moved into a Novato apartment in 1998. They received Section 8 housing assistance payments. In 2004 one daughter moved out, but Reilly failed to inform the Marin Housing Authority (MHA) of her departure. Five years later, when Reilly told MHA that this daughter no longer lived with her, MHA informed Reilly that her failure to report the departure earlier was a violation of program rules and that she had to pay damages of $16,011. Reilly and MHA agreed to monthly payments; they revised the plan several times, eventually reducing Reilly’s obligation to $150 per month. Reilly missed multiple payments. Reilly requested that MHA recalculate her rent and exclude her income from the In-Home Supportive Services (IHSS) program, which compensates those who care for aged, blind, or disabled individuals incapable of caring for themselves. Reilly’s daughter suffers from a severe developmental disability. MHA proposed termination of her Section 8 voucher. Reilly argued that MHA improperly included her IHSS payments as income. A hearing officer upheld MHA’s decision to terminate Reilly’s housing voucher. The trial court and court of appeal affirmed. The IHSS money Reilly receives is “income” within the meaning of HUD regulations; MHA should include it in calculating Reilly’s housing assistance payment. View "Reilly v. Marin Housing Authority" on Justia Law

by
Six judges who were elected to the superior court in mid-term elections in 2012, but who did not take office until January 7, 2013, claimed entitlement to benefits under the Judges’ Retirement System II (JRS II) as in effect at the time they were elected, rather than at the time they assumed office. On January 1, 2013, JRS II became subject to the California Public Employees’ Pension Reform Act of 2013 (PEPRA), Government Code section 75500, which amended virtually all state employee retirement systems to address the state’s enormous unfunded pension liability and return these systems to actuarially sound footing. PEPRA increases employee contributions, provides for fluctuating contribution rates based on market performance and actuarial projections, and bases the amount of monthly pension payments on an employee’s final three years of compensation, rather than on only the final year. The court of appeal held that the judges did not obtain a vested right in JRS II benefits as judges-elect, but rather obtained a vested right to retirement benefits only upon taking office after PEPRA went into effect. PEPRA’s provisions pertaining to fluctuating pension contributions do not violate the non-diminution clause of the California Constitution nor do they impermissibly delegate legislative authority over judicial compensation. View "McGlynn v. State of California" on Justia Law

by
Brown worked for BCP for 10 years. BCP had permitted Brown to wear shirts with BCP patches, rather than a uniform shirt. After discovering that it could order larger-size uniform shirts, BCP purchased such shirts for Brown in 2011. He was fired in January 2012 for wearing the wrong shirt. The Employment Development Department (EDD) denied his application for unemployment benefits. The trial court granted Brown’s writ petition, concluding that Brown had not engaged in misconduct sufficient to disqualify him from benefits because he had offered to go home and change shirts and was terminated on his first violation. In August 2013, EDD responded that EDD had paid Brown “all the benefits for which he has been found eligible,” noting that it was requiring Brown to submit certification forms and that an eligibility issue would need to be resolved before further benefits could be paid. in October 2014, Brown sought enforcement, claiming that EDD had imposed improper conditions, caused extended delays, and continued to withhold benefits. The court found EDD’s failure to comply “without good cause,” levied a $1,000 fine, awarded attorney fees, and determined that the rate of interest for wrongfully withheld unemployment benefits was seven percent, the judgment interest rate (Government Code 965.5(a), (d)). The court of appeal reversed, remanding for calculation of interest at 10 percent under Civil Code 3289(b). EDD’s statutory obligations are like contractual promises, subject to the statutory contractual rate of prejudgment interest. Brown’s right to prejudgment interest gave way to his entitlement to post-judgment interest with the trial court’s order. View "Brown v. California Unemployment Insurance Appeals Board" on Justia Law

by
Johnson worked successively as a firefighter for South San Francisco (CSSF) and Pacifica. He developed nasopharyngeal cancer. Labor Code section 3212.11 establishes a presumption that cancer manifesting during and for a specified period following employment in certain public safety positions, including firefighters, arose out of and in the course of that employment. Section 5500.5(a) limits employer liability for a cumulative injury to the employer who employed the applicant during the one year preceding the earliest of the date of injury or the last date of injurious exposure to the hazards that caused the injury, so either CSSF or Pacifica would be potentially responsible for compensation for the entire injury. CSSF settled Johnson's workers’ compensation claim and sought contribution from Pacifica. An arbitrator denied the petition, ruling that evidence of the latency period for Johnson's cancer showed the injurious exposure occurred during Johnson’s earlier employment with CSSF. The Workers’ Compensation Appeals Board adopted the order. CSSF argued the Board erroneously utilized a more lenient preponderance evidentiary standard in applying section 5500.5(a), rather than the more stringent cancer presumption rebuttal standard of section 3212.1. The court of appeal affirmed; the evidence supports the award. Worker protection policies embodied in section 3212.1 are not implicated in the allocation of liability between employers. View "City of South San Francisco v. Workers' Compensation Appeals Board" on Justia Law

by
Guzman was operating a soil compactor on a hillside with a 45-degree slope when the compactor hit a rock. The compactor rose in the air, causing Guzman to fall backward, and then fell on top of him. The workers’ compensation judge determined that Guzman sustained an injury to his back and psyche and that the psychiatric injury was caused by a “sudden and extraordinary employment condition,” Lab. Code, 3208.3(d). The workers’ compensation carrier for Guzman’s employer unsuccessfully sought reconsideration by the Workers’ Compensation Appeals Board, arguing that Guzman failed to meet his burden of proving that his psychiatric injury was caused by a “sudden and extraordinary employment condition.” The court of appeal annulled the Board’s order denying reconsideration. Guzman did not provide any evidence establishing that it is “uncommon, unusual, and totally unexpected” for a rock to be in soil, for a compactor to rise when striking a rock, or for an operator to become unbalanced and to fall when the compactor rises on a 45-degree hillside. He did not introduce any evidence regarding what regularly or routinely happens if a compactor hits a rock on a slope. Guzman admitted that he had previously worked on flat surfaces only. View "State Compensation Insurance Fund v. Workers’ Compensation Appeals Board" on Justia Law

by
Under California’s workers’ compensation law, effective in 2013, an injured worker may challenge a decision denying medical treatment by requesting a determination of medical necessity from an independent medical review (IMR) organization. (Labor Code 139.5, 4610.5.1) The IMR organization, which is regulated by the Division of Workers’ Compensation and operates under contract with the Division, designates one or more medical professionals to review pertinent medical records, determine whether the disputed treatment is medically necessary, and prepare a written report including statutorily-required findings. The IMR organization is required to describe the qualifications of the medical professionals who prepare the determination of medical necessity and to keep the names of the reviewers confidential in all communications outside the IMR organization. The determination of the IMR organization is deemed to be the determination of the administrative director and is binding on all parties, subject to appeal on narrow statutory grounds. Zuniga availed himself of the IMR process and then petitioned the Workers’ Compensation Appeals Board to disclose the names of the reviewers. The Board declined to do so. The court of appeal upheld that decision. IMR determinations are not testimonial in character; IMR reviewers are not workers’ adversaries and are not subject to cross-examination. View "Zuniga v. Workers' Compensation Appeals Board" on Justia Law