Source: http://openjurist.org/961/f2d/1578/91/1995
Timestamp: 2015-10-07 06:38:28
Document Index: 681812738

Matched Legal Cases: ['§ 1395', '§ 1395', '§ 1396', '§ 1396', '§ 433', '§ 1395', '§ 424', '§ 424']

961 F2d 1578 Michigan Department of Social Services v. W Sullivan | OpenJurist
961 F. 2d 1578 - Michigan Department of Social Services v. W Sullivan Home
961 F2d 1578 Michigan Department of Social Services v. W Sullivan 961 F.2d 1578
MICHIGAN DEPARTMENT OF SOCIAL SERVICES, Plaintiff-Appellant,v.Louis W. SULLIVAN, Secretary, United States Department ofHealth & Human Services, Defendant-Appellee.
No. 91-1995.
Before KENNEDY and BOGGS, Circuit Judges; and KRUPANSKY, Senior Circuit Judge.
This is an appeal from the district court's denial of a motion for relief from judgment under Rule 60(b)(2) and 60(b)(6), Fed.R.Civ.P. We affirm the district court's denial of relief from judgment because no extraordinary circumstance or newly discovered evidence was presented as required under Rule 60(b)(2) and (6).
* In the action below, plaintiff Michigan Department of Social Services ("MDSS") sought declaratory relief to invalidate a policy of the Secretary of the Department of Health & Human Services ("HHS" or "Secretary"). The policy prevents MDSS in some cases from appealing HHS's denials of Medicare coverage for recipients for whom MDSS has already paid Medicaid benefits. The district court dismissed the action, ruling that it did not have subject matter jurisdiction because MDSS has not exhausted administrative remedies and because the matter was not ripe under 42 U.S.C. §§ 1395ff and 405(g). MDSS did not appeal that ruling. Rather, it filed a motion for relief from judgment on April 1, 1991. The trial court denied this motion on July 26, 1991, finding no extraordinary circumstances or new evidence had been presented by MDSS that would warrant a reversal. MDSS appeals the denial of its motion.
This is a dispute between two governmental agencies, both of which provide public funds for medical care for aged patients in nursing homes. These patients are eligible for benefits under both Medicaid and Medicare. Medicare is the federally-funded health insurance program for the aged and disabled established by Title XVIII of the Social Security Act, 42 U.S.C. §§ 1395 et seq. The Secretary of HHS is responsible for the program's administration, which is carried out through the Health Care Financing Administration ("HCFA") and its agents. These agents, called "fiscal intermediaries," include insurance companies that are responsible for the routine administration of the Medicare program.
Medicaid, established by Title XIX of the Social Security Act, 42 U.S.C. §§ 1396 et seq., is a jointly-funded, cooperative federal-state program, which pays the costs of necessary medical expenses for recipients whose income and resources are insufficient to meet these costs. Under Medicaid, the state is required to determine if the service is covered by a liable third party, 42 U.S.C. § 1396(a)(25); 42 C.F.R. § 433.138(a), and may not make payments if it establishes that a probability that third party liability exists. Under state law, Mich.Comp.Laws. 400.106(b)(ii), when MDSS pays Medicaid benefits to a nursing home, it is subrogated to any claim the patient may have for reimbursement from a responsible third party, including Medicare. Thus, when Medicare should pay, MDSS may first pay under the Medicaid program, thus incurring state expense, and then recover from Medicare.
Medicare will cover the cost of extended skilled care at skilled nursing facilities ("SNFs" or "nursing homes"). The SNFs, applying the Medicare guidelines, make the first determination as to whether an individual patient's care is covered by Medicare. 42 U.S.C. § 1395(a)(2)(B); 42 C.F.R. § 424.20. Medicare will only cover nursing home patients who have just been released from a hospital and require a heightened level of care called "skilled care."
If the nursing home initially determines that Medicare does not cover the service provided to a particular patient, that patient must be notified, and may file an initial claim for benefits. See 42 C.F.R. §§ 424.32 and 424.34. If the beneficiary is "physically or mentally incapable" of making the claim, it may be signed by a legal guardian, relative, or "a rep