Maria Isabel Giraldo v. Agency for Health Care Administration
Maria Isabel Giraldo v. Agency for Health Care Administration
Opinion
We accepted review of the decision of the First District Court of Appeal in
Giraldo v. Agency for Health Care Administration
,
BACKGROUND
After Juan L. Villa suffered extreme injuries in an all-terrain vehicle accident, Florida's Medicaid program (administered by AHCA) paid $322,222.27 for Villa's medical care. Villa later settled with one of multiple alleged tortfeasors for $1 million. Claims against other alleged tortfeasers were still pending. Using the formula outlined in section 409.910(11)(f), Florida Statutes (2015), AHCA calculated the presumptively appropriate amount of its lien at $321,720.16, and asserted a lien in that amount against Villa's settlement. Section 409.910(17)(b) authorizes Medicaid recipients to contest the amount of a Medicaid lien at a hearing before the Division of Administrative Hearings (DOAH), by proving that "a lesser portion of the total recovery should be allocated as reimbursement for past and future medical expenses than the amount calculated by the agency pursuant to the formula set forth in paragraph (11)(f)." § 409.910(17)(b), Fla. Stat. (2015). Villa timely petitioned for this hearing.
At the DOAH hearing, Villa presented uncontested expert testimony establishing that only $13,881.79 of the $1 million tort recovery represented compensation for Villa's past medical expenses and argued that AHCA's lien should be limited to this amount. AHCA argued that the law authorizes recovery of Medicaid expenditures from third-party payments for past medical expenses and reasonably anticipated future medical expenses. Because Villa had the burden of rebutting the lien amount derived from the statutory formula-and put on no evidence to show that the lien exceeded the amount of his recovery properly allocated to his anticipated future medical expenses-AHCA argued that it should recover in the full amount of its lien.
Villa unexpectedly died weeks after the hearing, and his parents, as personal representatives of his estate, were properly substituted into this case as Petitioners. The ALJ's final order affirmed AHCA's lien amount and determined that Villa had failed to rebut the statutory formula because he did not establish that the lien exceeded the portion of his recovery allocated to future medical expenses. Petitioners appealed, and the First District affirmed the ALJ's final order, holding that Florida law 1 and the federal Medicaid Act allow AHCA to secure reimbursement for its Medicaid expenditures from the portions of Villa's third-party settlement recovery allocated to both past and future medical expenses. The Second District later reached the opposite conclusion in Willoughby , holding that the federal Medicaid Act prohibits AHCA from placing a lien on the future medical expenses portions of a recipient's recovery.
ANALYSIS
This case concerns interpretation of the federal Medicaid Act. Questions of statutory interpretation are reviewed de novo.
See
Borden v. East-European Ins. Co.
,
I. Overview
Medicaid is a joint federal-state cooperative program that helps participating states provide medical services to residents who cannot afford treatment.
Arkansas Dep't of Health & Human Servs. v. Ahlborn
,
II. Construing the Medicaid Act
We first examine the Act's plain language, applying the principle that "[w]hen the language of the statute is clear and unambiguous and conveys a clear and definite meaning, ... the statute must be given its plain and obvious meaning."
Holly v. Auld
,
The portion of the Medicaid Act defining the "ceiling"-the limitation on what portion of a recipient's tort recovery a state can be subject to a lien - reads in relevant part:
[T]o the extent that payment has been made under the State plan for medical assistance for health care items or services furnished to an individual, the State is considered to have acquired the rights of such individual to payment by any other party for such health care items or services.
42 U.S.C. § 1396a(a)(25)(H) (2012) (emphasis added). "Such health care items or services" is most naturally and reasonably read as referring to those "health care items or services" already "furnished" and for which "payment has been made under the State plan."
As explained by the Second District, this reading of the Act is consistent with the "majority view that the Medicaid lien does not attach to settlement funds allocable to future medical expenses,"
Willoughby
,
III. On Remand
Because we hold that the federal Medicaid Act prohibits AHCA from placing a lien on the future medical expenses portion of a Medicaid recipient's tort recovery, we remand with instructions that the First District direct the ALJ to reduce AHCA's lien amount to $13,881.79. Although a factfinder may reject "uncontradicted testimony," there must be a "reasonable basis in the evidence" for the rejection.
Wald v. Grainger
,
CONCLUSION
We quash the decision below in Giraldo , approve Willoughby , and hold that federal law allows AHCA to lien only the past medical expenses portion of a Medicaid beneficiary's third-party tort recovery to satisfy its Medicaid lien. We remand this case to the First District with instructions to direct the ALJ to reduce the awarded amount to $13,881.79 for satisfaction of AHCA's lien.
It is so ordered.
CANADY, C.J., and PARIENTE, LEWIS, QUINCE, and LABARGA, JJ., concur. POLSTON, J., concurs specially in part and dissents in part with an opinion.
POLSTON, J., concurring specially in part and dissenting in part.
I agree with the majority's conclusion that federal law only allows AHCA to place a lien on the past medical expenses portion of a Medicaid beneficiary's third-party tort recovery, but I reach this conclusion for a different reason. Additionally, I disagree with the majority's reduction of the amount of AHCA's lien on the settlement without a factfinder determining the portion of the settlement properly allocated to past medical expenses.
I.
Unlike the majority, I do not believe the federal Medicaid Act, considered as a whole, is clear and unambiguous regarding whether AHCA can place a lien on the portions of a settlement that represent past and future medical damages. For example, the general anti-lien provision of the Medicaid Act uses both the past and future tenses, while the provision requiring beneficiaries to assign to the states any rights to third-party payments does not use either the past or future tense, while the provision providing that states acquire rights to third-party payments uses only the past tense. Compare 42 U.S.C. § 1396p(a)(1) (2012) (employing both the past and future tenses when stating "paid or to be paid"), with 42 U.S.C. § 1396k(a)(1)(A) (2012) (requiring assignment to State "to payment for medical care from any third party"), with 42 U.S.C. § 1396a(a)(25)(H) (2012) (employing only the past tense of "has been made" along with "such health care items or services").
Instead, I believe the United States Supreme Court's opinion in
Arkansas Department of Health & Human Services v. Ahlborn
,
a declaration that the lien violated the federal Medicaid laws insofar as its satisfaction would require depletion of compensation for injuries other than past medical expenses. To facilitate the District Court's resolution of the legal questions presented, the parties, [including the state agency,] stipulated that Ahlborn's entire claim was reasonably valued at $3,040,708.12; that the settlement amounted to approximately one-sixth of that sum; and that, if Ahlborn's construction of federal law was correct, ADHS would be entitled to only the portion of the settlement ($35,581.47) that constituted reimbursement for medical payments made.
In the end, the United States Supreme Court held that "[f]ederal Medicaid law does not authorize [the state agency] to assert a lien on Ahlborn's settlement in an amount exceeding $35,581.47, and the federal anti-lien provision affirmatively prohibits it from doing so."
II.
Of course, the difference between this case and
Ahlborn
is that AHCA has not stipulated to the $4,817.56 allocation for past medical expenses outlined in the settlement at issue in this case (or to the testimony that $13,881.76 is a reasonable allocation of past medical damages here). And the United States Supreme Court in
Ahlborn
explained that this distinction may warrant procedural safeguards: "[T]he risk that parties to a tort suit will allocate away the State's interest can be avoided either by obtaining the State's advance agreement to an allocation or, if necessary, by submitting the matter to a court for decision."
To protect parties against such possible manipulation, the United States Supreme Court's subsequent decision in
Wos v. E.M.A.
,
Here, because there is no stipulation, judgment, or administrative finding regarding the portion of the settlement that represents past medical expenses, I dissent to the majority's declaration on appellate review that $13,881.79 is the proper allocation. The ALJ never found that $13,881.79 was the proper amount to allocate as past medical expenses in the settlement, and it is not proper that this Court do so on appellate review. While the beneficiary presented testimony of two expert witnesses to prove the valuation of total damages was $25,000,000, and that $13,881.79 was a reasonable allocation of past medical damages, the ALJ's final order noted that the testimony was questionable and based upon two-year-old hearsay reports. Therefore, I would remand this case to the First District with instructions that the ALJ determine the proper allocation for past medical expenses and that this allocation be awarded for satisfaction of AHCA's lien. 2
Accordingly, I concur specially in part and dissent in part.
The First District correctly observed that Florida law plainly contemplates recoupment of AHCA's expenditures on behalf of a Medicaid recipient from portions of the recipient's tort recovery "allocated as reimbursement for past
and future
medical expenses,"
Giraldo
,
AHCA stipulated that the beneficiary's death does not affect the case.
Reference
- Full Case Name
- Maria Isabel GIRALDO, Et Al., Petitioners, v. AGENCY FOR HEALTH CARE ADMINISTRATION, Respondent.
- Cited By
- 17 cases
- Status
- Published