VIRGINIA CABELLO, APPELLANT,
v.
AGENCY FOR HEALTH CARE ADMINISTRATION, ETC., APPELLEE
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Virginia Cabello appealed an AHCA administrative order reducing home health care hours for her autistic daughter from 992 requested hours to 329 approved hours. The court affirmed the reduction, holding that AHCA properly determined the services were not medically necessary under Medicaid's Home Health Services Program because the daughter's diagnoses were psychiatric in nature, which are not covered services.
The court affirmed AHCA's denial, holding that the Hearing Officer's ruling was supported by substantial and competent evidence showing the services were not authorized as medically necessary under Medicaid's Home Health Services Program, which does not cover psychiatric services.
[1] Medicaid Home Health Services coverage does not extend to services primarily intended for the convenience of the recipient or caretaker.
[2] A provider's prescription or recommendation of medical services does not, in itself, establish medical necessity or coverage under Medicaid.
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Join FLexlaw to unlock all legal intelligence“based on our standard of review we must affirm the Hearing Officer's ruling, as it was based on substantial and competent evidence in the record showing that the services provided were not authorized as medically necessary, such as to meet the requirements of Medicaid's Home Health Services Program”
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Join FLexlaw to unlock all legal intelligenceVirginia Cabello's 15-year-old autistic daughter, J.C., receives Medicaid assistance and requires constant supervision and assistance with daily activ…
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Virginia Cabello appeals from a final order from the Agency for Health Care Administration (“AHCA” or “Agency”) reducing home health care hours. Based on our standard of review, we must affirm.
Virginia Cabello is J.C.’s mother. J.C. is fifteen years old, autistic, and needs constant supervision, as well as assistance with her activities of daily living. J.C. receives Medicaid assistance, and attends school from 7:30 a.m. until 3:00 p.m., Monday through Friday. Cabello works full time, is the primary caregiver for her household, and cares for J.C. during her home hours and weekends; she must also care for her two other children, ages two and twelve. In November 2010, J.C.’s primary care physician requested Medicaid home health care assistance for J.C.’s personal needs, as well as skilled nursing visits to the home. The home health agency in turn requested a Certified Nurse Assistant to provide care for J.C Monday through Sunday for a total of 992 hours over the 180-day coverage period. The hours were initially approved by the first physician consultant for AHCA. On January 29, 2011, a second physician consultant issued a correction, concluding that the hours should be denied because J.C.’s diagnoses were not supported by Medicaid Home Health Services coverage as they were psychiatric in nature. AHCA then denied a total of 663 home health hours and approved only 329 hours for the coverage period (December 2, 2010, through January 30, 2011). Cabello appealed. At the administrative appeals hearing, AHCA’s witness testified that there was no evidence that the home health agency knew that J.C. was diagnosed with autism, and that all of J.C.’s issues are related to mental health and psychiatric services, which are not covered under Medicaid’s Home Health Services. Cabello’s witness testified that J.C.’s primary diagnosis is autism, and that all of the physician’s orders were for needs associated with autism. The Agency reconsidered and agreed to allow limited weekly home health services to assist J.C. with personal care for the remainder of the service period. The Hearing Officer denied Cabello’s appeal from the Agency’s denial of the additional 663 hours.
Although we share Cabello’s concerns for the care and well-being of her child, based on our standard of review we must affirm the Hearing Officer’s ruling, as it was based on substantial and competent evidence in the record showing that the services provided were not authorized as medically necessary, such as to meet the requirements of Medicaid’s Home Health Services Program. Fla. Admin. Code R. 59G-1.010(166)(a).1 AHCA has encour*125aged Cabello to seek out other Medicaid and community programs that are available to meet J.C.’s mental health needs.
Affirmed.