Background
Edwardo Rosario sought Medicaid coverage for home health personal care services for his son, who has developmental disabilities and other health conditions requiring full-time assistance with activities of daily living. Children’s Medical Services denied the request and issued a Notice of Adverse Benefit Determination explaining that Rosario could pursue a plan appeal and, if dissatisfied with the result, request a Medicaid fair hearing.
Rosario initiated a plan appeal but requested a fair hearing before that appeal was resolved. The Office of Fair Hearings dismissed the hearing request without prejudice, concluding that completion of the plan appeal was a jurisdictional prerequisite. The Notice of Plan Appeal Resolution was not issued until 11 days after Rosario requested the fair hearing.
The Court’s Holding
The Third District affirmed. Applying de novo review without deferring to the agency’s legal interpretation, the court held that Florida Administrative Code Rule 59G-1.100(8)(e) requires an enrollee to initiate and complete a plan appeal before requesting a fair hearing.
A plan appeal is complete when the enrollee receives a Notice of Plan Appeal Resolution that does not resolve the appeal wholly in the enrollee’s favor, or when the plan fails to comply with applicable notice and timing requirements. Neither condition had occurred when Rosario requested his hearing, so the Office of Fair Hearings lacked jurisdiction to consider the request.
Key Takeaways
- A Medicaid enrollee must complete the plan-appeal process before requesting a fair hearing under Rule 59G-1.100(8)(e).
- A pending plan appeal is not complete merely because the enrollee has initiated it.
- Because Rosario’s request was dismissed without prejudice, he may submit a new coverage request and pursue the plan appeal and fair-hearing process anew.
Why It Matters
The decision underscores that Florida Medicaid enrollees must follow the prescribed sequence of administrative review. A fair-hearing request filed before the plan appeal is complete is premature and outside the Office of Fair Hearings’ jurisdiction.
The dismissal did not foreclose Rosario from seeking coverage again, but it requires him to restart the process and satisfy the plan-appeal prerequisite before pursuing a fair hearing.