TALLAHASSEE – In a case that has far-reaching ramifications for elderly and poor Medicaid recipients who receive nursing home care in the state, the 1st District Court of Appeal recently rejected Gabrielle Goodwin's appeal on Florida Department of Children and Families' (DCF) co-payment calculations and also ruled that she did not have standing to bring a class-action lawsuit against the department.
Goodwin was involved in an accident that injured her spinal cord. She is disabled and confined to a wheelchair. Due to her injuries and other medical issues, she now lives in a Tallahassee nursing home. She became eligible for the Institutional Care Program (ICP) through the state Medicaid program in March 2012, with benefits retroactive to December 2011.
Under Medicaid rules, Goodwin has a co-pay, known as a patient responsibility amount (PRA), that is based on her Social Security and long-term disability benefits. DCF determined that her PRA was approximately $1,000 per month, after determining her monthly income and deducting allowable expenses. Allowable deductions include a personal needs allowance, health insurance premium and unpaid medical expenses. ICP then pays the difference between the PRA and the nursing home charges.
| hin255/shutterstock.com
Goodwin disagreed with DCF's calculation and requested that it deduct the approximately $70,000 in unpaid nursing home expenses that accrued between November 2010 to November 2011. DCF refused to recalculate the expenses, as nursing home care is not considered a medical expense.
Goodwin submitted an appeal to the DCF Office of Appeal Hearings and argued that the Social Security Act required DCF to deduct the unpaid nursing home bills from her PRA. According to court documents, the hearing officer's August 2012 decision stated that, "the federal statute did not require DCF to deduct all of Ms. Goodwin’s pre-eligibility nursing home expenses from her PRA because they were 'Medicaid compensable' and 'non-recurring' expenses."
Goodwin appealed the hearing officer's ruling in 2012, but then requested a stay on the appeal. She and her attorneys filed a class-action lawsuit in the 2nd Judicial Circuit Court for Leon County, naming the Florida Agency for Health Care Administration (AHCA), AHCA Secretary Elizabeth Dudek, DCF and DCF Secretary David Wilkins as defendants.
Goodwin sought class-action status on behalf of herself and other elderly and poor Medicaid recipients who received long-term nursing home care in the past four years and those who will receive nursing home care in the future. The case alleges that the calculations used by DCF to determine the PRA "unlawfully restrict the (pre-eligibility medical expenses) PEME deduction to non-nursing home medical expenses."
The circuit court denied the class-action lawsuit. The case was appealed, and DCF motioned to dismiss the appeal to the 1st District Court of Appeal, however, the court denied the motion. After hearing both the administrative and class-action cases, the court upheld the hearing officer's decision as well as circuit court's ruling.
The 12-page court ruling on the administrative case, written by Judge Timothy Osterhaus, stated: "Here, we defer to DCF’s reasonable interpretation and enforcement practice because it is the enforcing agency. Its interpretation of Medicaid law prevails, irrespective of which interpretation we might prefer, because it is reasonable, and not clearly erroneous or contrary to law."
Goodwin's lawyer is hopeful that the latest ruling isn't the last word in the case.
"We have a pending motion for rehearing either by the panel, or by the entire 1st District Court of Appeal, in both cases," Goodwin's attorney Cyril V. Smith recently told the Florida Record. "We look forward to the court’s decision on that motion."