G.R., ETC.
v.
MOLINA HEALTHCARE OF FLORIDA, INC.
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G.R. sought a fair hearing challenging Molina Healthcare's denial of additional personal care services under Medicaid. The court affirmed dismissal of his request because he failed to timely file a plan appeal (internal review) within 60 days of the adverse benefit determination notice, as required by federal regulation.
G.R. is foreclosed from obtaining a fair hearing because he did not timely file his plan appeal within 60 days from the date on the adverse benefit determination notice, as required by 42 C.F.R. § 438.402(c)(2)(ii). However, G.R. remains free to request additional personal care services again in the future and pursue timely plan appeals if those requests are denied.
[1] A request for a "plan appeal" under Medicaid regulations must be filed within 60 days from the date of the adverse benefit determination notice, not the date of receipt.
[2] Failure to timely file a "plan appeal" forecloses an enrollee from obtaining a fair hearing before a hearing examiner.
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Join FLexlaw to unlock all legal intelligence“Following receipt of a notification of an adverse benefit determination by an MCO, PIHP, or PAHP, an enrollee has 60 calendar days from the date on the adverse benefit determination notice in which to file a request for an appeal to the managed care plan.”
Establishes the governing federal regulation requiring timely filing of plan appeals within 60 days from the date of notice, not receipt.
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Join FLexlaw to unlock all legal intelligenceG.R. requested additional personal care services from Molina Healthcare of Florida, Inc., his Medicaid provider. Molina Healthcare denied the request.…
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Third District Court of Appeal State of Florida Opinion filed February 25, 2026. Not final until disposition of timely filed motion for rehearing. No. 3D25-1158 Lower Tribunal No. AНСА 25-FH061 G.R., etc., Appellant, vs. Molina Healthcare of Florida, Inc., Appellee. An Administrative Appeal from the State of Florida, Agency for Health Care Administration. G.R., in proper person. Lombard Law, and Eduardo S. Lombard and Melissa Hedrick (Tallahassee), for appellee. Before SCALES, C.J., and LOGUE and GOODEN, JJ.
PER CURIAM.
Under the regulations governing Medicaid, we have no choice but to affirm the dismissal by the Florida Agency for Health Care Administration hearing officer of G.R.'s request for a “fair hearing." G.R. properly made the request for additional personal care services to Molina Healthcare of Florida, Inc., his Medicaid provider. As the hearing officer found, however, after Molina Healthcare denied the request, G.R.'s attempt to obtain a "plan appeal" (that is, an internal review) by Molina Healthcare of its denial was untimely filed. G.R.'s request for a "plan appeal" had to be filed (not merely mailed) within 60 days from the date of the adverse benefit determination notice (not the receipt of the denial).
See 42 C.F.R. § 438.402(c)(2)(ii) ("Following receipt of a notification of an adverse benefit determination by an MCO, PIHP, or PAHP, an enrollee has 60 calendar days from the date on the adverse benefit determination notice in which to file a request for an appeal to the managed care plan.” (emphases added)).
Because G.R. did not timely file the “plan appeal,” G.R. is foreclosed from obtaining a fair hearing before a hearing examiner. In affirming the dismissal, we note that Molina Healthcare acknowledged in its brief that: > G.R. is not precluded from again seeking additional > personal care services. Long Term Care enrollees > can ask for increased services at any time; > accordingly, G.R. is free to request personal care > services again if he believes those services are > necessary. If his request is denied and he timely > pursues a plan appeal, G.R. will be able to seek > another fair hearing.
Affirmed.