J.W. v. Agency for Health Care Administration
J.W. v. Agency for Health Care Administration
Opinion of the Court
: Appellant, J.W. is .a Florida Medicaid recipient enrolled in Magellan Behavioral Health of Florida, Inc. (“Magellan”), a Managed Care Organization under contract with'the Agency for Health Care Administration (“AHCA”). On May 5, 2013, J.W. was admitted to Flagler Hospital under the Baker Act
Thereafter, Dawn Broun, an employee of Flagler Hospital, acting as J.W.’s authorized representative, submitted a fair hearing request on his behalf to the Department of Children and Families (“DCF”).
In Florida, Medicaid only authorizes and pays for those covered services deemed medically necessary. See Fla. Admin. Code R. 59G-1.010(166); see also 42 C.F.R. § 440.230(d) (providing that the state Medicaid agency “may place appropriate limits on a service based on such criteria as medical necessity or on utilization control procedures”). According to the Medicaid Provider Reimbursement Handbook, CMS-1500 (July 2008) (“Handbook”), incorporated by reference in Florida Administrative Code Rule 59G-4.001(1), certain services, including in-patient psychiatric services, require prior authorization — i.e., a determination before services are provided that they are medically necessary — before a provider can be reimbursed. See Handbook at 3-2. Under Federal law, a state must “provide for granting an opportunity for a fair hearing before the State [Medicaid] agency to any individual whose claim for medical assistance under the plan is denied or is not acted upon with reasonable promptness[.]” 42 U.S.C. § 1396a(a)(3); see also 42 C.F.R. 431.220(a)(2).(“The State [Medicaid] agency must grant an opportunity for a hearing to ... [a]ny beneficiary who requests it because he or she believes the agency has taken an action erroneously.”). Although AHCA is the Medicaid agency for Florida, see sections 409.901(2), 409. 902(1), Florida Statutes, DCF is responsible for conducting fair hearings. See §§ 409.285, 409.902(1), Fla. Stat.; Fla. Admin. Code R. 65-2.042 et seq.
Under this statutory and regulatory scheme, J.W., as a Medicaid beneficiary, was entitled to a fair hearing to challenge Magellan’s denial of prior authorization for Medicaid-covered inpatient psychiatric treatment after May 9, 2013. But then, before seeking such hearing, J.W. received the requested treatment from his health care provider — Flagler Hospital. DCF was correct to dismiss J.W.’s fair hearing request under these circumstances because, once he received the continued psychiatric treatment he’d asked for, he no longer needed agency review of Magellan’s
AFFIRMED.
. See § 394.467, Fla. Stat.
. AHCA asserts for the first time on appeal that the hearing request was untimely. We therefore do not address the argument. In any event, the record does not clearly establish the request was, in fact, untimely.
Case-law data current through December 31, 2025. Source: CourtListener bulk data.