AGENCY FOR HEALTH CARE ADMINISTRATION, APPELLANT,
v.
DOROTHY MCGRIFF RILEY, AS PERSONAL REPRESENTATIVE OF THE ESTATE OF CAESAR RILEY, DECEASED, APPELLEE

Fla. 2d DCA | 2013-08-14
No. 2D11-3863
NORTHCUTT and WALLACE, JJ„ Concur.
119 So. 3d 514 Florida District Court of Appeal, Second District (2013) Negative Treatment
Cited by 12 cases

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Synopsis

The Florida Second District Court of Appeal reversed and remanded a trial court's determination of AHCA's Medicaid lien against a personal injury settlement, holding that a Medicaid recipient should be afforded an opportunity to rebut the statutory presumption of lien amount by demonstrating that the lien exceeds the portion of recovery attributable to medical expenses.


Holding

A plaintiff should be afforded an opportunity to seek reduction of a Medicaid lien amount established by the statutory default allocation by demonstrating, with evidence, that the lien amount exceeds the amount recovered for medical expenses. The statutory formula in section 409.910(11)(f) creates a rebuttable presumption rather than an absolute entitlement to full reimbursement.


Headnotes

[1] A Medicaid recipient may seek to reduce a Medicaid lien amount established by statutory default allocation by demonstrating, with evidence, that the lien amount exceeds t…

[2] A trial court must allow a Medicaid recipient an opportunity to present evidence to rebut the presumption regarding the amount of a Medicaid lien in a settlement.

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Key Quotes

“that a plaintiff should be afforded an opportunity to seek the reduction of a Medicaid lien amount established by the statutory default allocation by demonstrating, with evidence, that the lien amount exceeds the amount recovered for medical expenses.”

States the holding that recipients have a right to rebut the statutory presumption of lien amount through evidence

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Facts & Procedural History

Caesar Riley was shot by a third party and sued the property owner where the shooting occurred. Medicaid covered much of Riley's medical treatment, wi…

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Opinion of the Court
ALTENBERND, Judge.

ALTENBERND, Judge.

The Agency for Health Care Administration (AHCA) appeals an order of the trial court determining the portion of a personal injury settlement subject to AHCA’s Medicaid lien. For reasons further explained in this opinion, we reverse and remand.

Caesar Riley was shot by a third party who has not been involved in this litigation. Mr. Riley brought a personal injury lawsuit against the owner of the property on *515which the shooting occurred. Mr. Riley’s injuries were serious and much of his medical treatment was covered by Florida’s Medicaid program, which is administered by AHCA. The medical expenses for which AHCA claimed a Medicaid lien totaled somewhat in excess of $225,000. While Mr. Riley was still alive, he settled his case with the property owner.1 AHCA was not actively involved in that settlement and the details of the settlement are confidential.2

Following the settlement, Mr. Riley filed a motion to determine the Medicaid lien. In the trial court proceeding, AHCA refused to stipulate concerning the portion of the settlement attributable to medical expenses. Relying, in part, on our decision in Russell v. Agency for Health Care Administration, 23 So.3d 1266 (Fla. 2d DCA 2010), it maintained that it was entitled to full satisfaction of its lien. AHCA maintained that under Florida’s Medicaid Third-Party Liability Act, specifically section 409.910(ll)(f), Florida Statutes (2010), and consistent with this court’s decision in Russell, it was entitled to a full reimbursement of its Medicaid lien and that the trial court should not consider evidence presented by the Medicaid recipient that might rebut the application of the formula set forth in section 409.910(ll)(f).3 The trial court rejected this argument and allocated an amount that was less than the actual Medicaid payments made on behalf of the Medicaid recipient, Mr. Riley.

After the trial court made its ruling and while this case was pending on appeal, the United States Supreme Court decided Wos v. E.M.A., — U.S. -, 133 S.Ct. 1391, 185 L.Ed.2d 471 (2013), which severely undermined the reasoning of our decision in Russell. Also while this appeal was pending, the Fourth District issued a decision authorizing a trial court to conduct a hearing similar to the hearing conducted in this case. See Roberts v. Albertson’s Inc., 119 So.3d 457, 2012 WL 5232182 (Fla. 4th DCA 2012), reh’g and reh’g en banc denied, modified on reh’g, No. 4D10-2313 (Fla. 4th DCA June 26, 2013).

When Wos was released, this court ordered each party to submit a memorandum of law addressing the impact of Wos on this case. In its memorandum of law, AHCA modified its position and it now argues that section 409.910 should be read in such a way as to allow a recipient to attempt to rebut the presumption set forth in section 409.910(ll)(f).4 It now argues *516that Mr. Riley failed to present evidence that rebutted the presumption.

AHCA’s acknowledgement that a recipient should be afforded an opportunity to attempt to rebut the statutory presumption is consistent with the holding of the Fourth District in Roberts, which treats the statutory allocation as a “default allocation.” Roberts, 119 So.3d at 464. We conclude that the Fourth District’s holding in Roberts is correct. To avoid any confusion, we expressly adopt the holding of Roberts, which states

that a plaintiff should be afforded an opportunity to seek the reduction of a Medicaid lien amount established by the statutory default allocation by demonstrating, with evidence, that the lien amount exceeds the amount recovered for medical expenses.

Id. 5

Although the hearing conducted by the trial court in this case may be similar to the hearing contemplated by the Fourth District in Roberts and the United States Supreme Court in Wos, the trial court obviously had no ability to apply this new law during the hearing. AHCA had the right to rely on our Russell opinion at the time of that hearing. We conclude that Russell is no longer correct law. Recognizing that the trial court may ultimately make a decision similar to the decision that it has already made, we nevertheless conclude that the issue should be newly decided at a hearing at which both parties and the trial court will be guided by the decisions in Wos and Roberts. Accordingly, we reverse the order on appeal and remand for a supplemental hearing. The trial court is free to rely on evidence in the record from the prior hearing and, as needed, to consider additional evidence.

Reversed and remanded.

NORTHCUTT and WALLACE, JJ„ Concur.


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Citator

Cited By

  • Davis v. Roberts, 130 So. 3d 264 (Fla. 5th DCA 2013)
    …tion of a Medicaid lien amount by demonstrating, with evidence, that the lien amount [established by section 409.910(11X0 ] exceeds the amount recovered for medical expenses.” Smith, 24 So. 3d at 592; see also Agency for Health Care Admin. v. Riley, 119 So. 3d 514, 516 (Fla. 2d DCA 2013) (expressly adopting the fourth district’s holding in Roberts that a plaintiff should be afforded an opportunity to seek the reduction of a Medicaid lien amount established by the statutory default allocation by demonstrating,…
  • Iala Suarez v. Port Charlotte HMA, LLC, 171 So. 3d 740 (Fla. 2d DCA 2015)
    …§ 2, at 1718-19, Laws of Fla. Prior to the amendment, recipients were able to challenge the amount of a settlement designated as a recovery for past medical expenses by motion in the circuit court. See, e.g., Agency for Health Care Admin, v. Riley, 119 So. 3d 514, 515 (Fla. 2d DCA 2013). After the 2013 amendment, recipients must bring their challenges by petition to the Division of Administrative Hearings. See § 409.910(17)(b). Here, Suarez argues that the 2012 version of the statute should apply to her beca…
    1 / 2
  • Kaitlyn Harrell v. State, 143 So. 3d 478 (Fla. 1st DCA 2014)
    …hat three of five district courts in Florida have, when presented with the issue of whether section 409.910(ll)(f) has been preempted, uniformly changed course by issuing opinions consistent with Wos.1 See, e.g., Ag. for Health Care Admin, v. Riley, 119 So. 3d 514 (Fla. 2d DCA 2018) (applying Wos, abrogating Russell, and expressly adopting the holding in Roberts v. Albertson’s Inc., 119 So. 3d 457 (Fla. 4th DCA 2012)); see also Dillard v. Ag. for Health Care Admin., 127 So. 3d 820 (Fla. 2d DCA 2013) (holding…

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