K.H. v. Agency for Health Care Administration

First DCA

K.H. v. Agency for Health Care Administration
1st DCA
4/12/23, Judge Osterhaus
Topics: Medicaid Lien

Appellant settled a lawsuit for more than $350,000 after being seriously injured by a criminal act committed at a commercial property. By the time of the settlement, AHCA had paid over $120,000 for Appellant’s medical care under the Medicaid program. ACHA then asserted a statutory lien to recoup the $120,000. There is a statutory formula for this under section 409.910(11)(f), Fla. Stat., though a recipient can show reasons why a lesser amount should be paid if he or she can satisfy the standard under section 409.910(17)(b). The recipient did that, but an Administrative Law Judge denied the petition and applied the normal statutory formula. She appealed.

Her first argument was that a “Letter of Understanding” between herself and the commercial property she sued limited the lien to 5% of the settlement, which would just be $13,000. The agreement was between the parties to the civil suit, not the State, though. Medicaid and AHCA never agreed to a 5% limitation. Thus, the letter did not rob ACHA of its right to seek full reimbursement.

Appellant’s second argument was that the ALJ erred by rejecting the pro rata method of proportioning medical expenses. The pro rata method is a way of reducing the repayment amount of medical expenses from a lawsuit settlement by which an injured party establishes the overall value of the lawsuit compared to the settlement amount and applies that same proportion to the total medical expenses paid with Medicaid funds. The ALJ found that the pro rata argument wasn’t raised at the hearing, thus it wasn’t preserved. Even if it had been, the record was insufficient to establish the overall value of the lawsuit because there wasn’t a transcript of the hearing.

https://supremecourt.flcourts.gov/content/download/865894/opinion/download%3FdocumentV ersionID=2029358e-599d-4163-9a4a-bfc93d1881c7

Terry P. Roberts
Director of Appellate Practice Fischer Redavid PLLC
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