Co-payment for nursing home care can be a complex issue. A court recently held that the Florida Department of Children and Families (DCF) didn’t make a mistake in calculating an applicant’s co-payment for her Medicaid-covered nursing home care because it didn’t have to deduct more from her patient responsibility amount under Florida law than the three months of pre-eligibility nursing home expenses it already deducted.
Florida’s First District Court of Appeal heard the appeal of Gabrielle Goodwin. She claimed that the co-payment calculation made by the Florida Department of Children and Families (DCF) related to her Medicaid-covered nursing home care was in error.
Goodwin argued that federal law required the agency to deduct all unpaid nursing home bills she incurred before becoming Medicaid eligible from co-payment amounts she was responsible to pay after joining the program. But a DCF hearing officer rejected her argument.
Goodwin entered a skilled nursing facility in Tallahassee after a serious accident injured her spinal cord. She applied for Institutional Care Program (ICP) benefits through Florida’s Medicaid program to help cover her nursing home costs and became eligible in March 2012, retroactive to December 2011.
Management of Florida’s Medicaid Program
The federal and state government jointly manage Florida’s Medicaid program. The agencies create rules for Florida’s Medicaid program. The rules state that beneficiaries in Florida’s ICP must contribute to the cost of their care by remitting a monthly co-payment for nursing home care (known as the “patient responsibility amount” or “PRA”), based on their income.
Federal Medicaid law tells the states how to calculate PRAs. The formula begins with the beneficiary’s income but has some deductions for unpaid medical care expenses. After adding this into the equation, the program covers the difference between a beneficiary’s PRA and the facility’s monthly charge.
The smaller the PRA, the greater a beneficiary’s Medicaid benefit.
Goodwin’s PRA Calculation
DCF calculated Goodwin’s PRA at roughly $1000 a month with deductions, but she disputed the calculation. She argued that DCF should have deducted all her unpaid, pre-eligibility nursing care expenses, lowering her PRA. She asked DCF to recalculate it, deducting approximately $70,000 of these expenses incurred. But DCF disagreed with her legal interpretation and refused to make the recalculation.
Goodwin appealed to DCF’s Office of Appeal Hearings. She argued that the Social Security Act required DCF to deduct her outstanding, uncovered nursing home bills from her PRA. She also alleged that the State Plan didn’t authorize DCF’s methodology, and that it was “the [only] mechanism through which the State could place reasonable limits on the amount of expenses it deducted from the [PRA].”
A hearing officer issued an order, which concluded that the federal statute didn’t require DCF to deduct all of Goodwin’s pre-eligibility nursing home expenses from her PRA because they were “Medicaid compensable” and “non-recurring” expenses.
The DCF subsequently recalculated Goodwin’s PRA with this deduction, which DCF claimed mooted the appeal. But she disagreed, insisting that the Medicaid law required DCF to deduct all her medical expenses—almost a full year of additional expenses. Goodwin argued that DCF’s failure to deduct all her pre-eligibility nursing home bills from her Medicaid co-payment for nursing home care violated federal law. She also claimed that the order relied on a non-applicable state regulation, and that no administrative rule authorized DCF to limit her PRA deduction.
Court of Appeal Ruling on
Judge Timothy Osterhaus wrote in his opinion for the appellate court that federal and state Medicaid law establish mandatory PRA deductions. They include unpaid medical care expenses “not covered” under a state’s Medicaid plan. The judge explained that in Florida, the DCF made a regulation, in response to federal law, to address deductions:
medical expenses, not subject to payment by a third party, incurred by a Medicaid recipient for programs involving post eligibility calculation of a patient responsibility, as authorized by the Medicaid State Plan and in accordance with 42 CFR 435.725… The medical/remedial care service or item must meet all the following criteria: … Not be a Medicaid compensable expense.
Florida’s State Plan also says services covered and paid by Medicaid can’t be deducted. As a result, the court concluded that DCF shouldn’t deduct more from Goodwin’s PRA than the three months of pre-eligibility nursing home expenses that it has already deducted. The decision was affirmed. Goodwin v. Fla. Dep’t of Children & Families, 194 So. 3d 1042 (Fla. DCA 1st April 4, 2016)
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