MEDICAID IN FLORIDA

Florida's Medicaid lien recovery warrants careful consideration. In Davis v. Roberts, 130 So. 3d 264 (Fla. 5th DCA 2013), the court affirmed that reductions in Medicaid liens are permissible under specific circumstances. A critical component of this mediation settlement was the unanimous, written agreement among all parties regarding a reasonable allocation of the plaintiff's past medical expenses, in addition to the projected total damages and the actual funds disbursed to the plaintiff due to mitigating conditions.

After the settlement, the plaintiff's attorneys filed two significant motions with the court: one seeking approval of the settlement for the minor plaintiff and another aimed at assessing the reasonableness of the allocations described.

The Fifth District Court established that a plaintiff retains the right to petition the court to demonstrate that the lien amount exceeds the amount recovered for past medical expenses. The court emphasized that its ruling is consistent with its earlier decision in Smith v. Agency for Healthcare Administration, 24 So. 3d 590 (Fla. 5th DCA 2009), although the factual scenarios involved differ markedly. In Smith, the plaintiff did not provide an allocation of the settlement nor offer evidence regarding which portion represented past medical expenses. Conversely, the plaintiffs in Davis presented a transparent allocation supported by ample evidence regarding its reasonableness. Consequently, the Fifth District concluded that when an allocation substantiated by evidence exists, a court may evaluate whether that allocation is reasonable, thereby limiting the Medicaid lien to the amount designated for past medical expenses.

Additionally, the Fifth District ruled that consistent with Wos v. E.M.A., 133 S. Ct. 1391 (2013), the federal anti-lien statute preempts the allocation default established in F.S. §409.910(11)(f), thereby preventing Medicaid from recovering any settlement funds beyond those allocated to past medical expenses. All parties acknowledged that the plaintiff in Davis recovered only 10 percent of her total damages, including 10 percent of her past medical expenses, due to various defenses and coverage issues. As a result, the case was reversed and remanded to the trial court, which now possesses the explicit authority to limit the Medicaid lien amount of $239,268.87 to $23,926.88, corresponding to the portion of the settlement allocated to past medical expenses.

In 2022, the Florida legislature enacted a Medicaid lien reduction formula to facilitate the state's recovery of funds. This formula generally permits lien reductions only under specific conditions. Refer to case 22-000782MTR, Darius Poupas vs. Agency For Health Care Administration, DOAH Final Order, dated August 24, 2022.

Darius Poupas (Petitioner) is a person for whom Medicaid paid $88,396.00 for treatment of his catastrophic injuries. The incident was the result of a shooting that took place in the parking lot of an apartment complex in Miami, where he was an innocent bystander.- Dade County, Florida. Respondent, Agency for Health Care Administration (Respondent), is the state agency that administers the Medicaid program in Florida. See § 409.902, Fla. Stat.

During the trial, Adam Finkel testified as an expert witness for Petitioner regarding the valuation of Petitioner's tort case. Finkel is an experienced trial attorney whose practice focuses on litigating significant personal injury cases, specializing in negligent security cases.

Finkel testified that he conservatively estimated the Petitioner's damages at $2,000,000.00. This amount was derived from the assessment of the Petitioner's pain and suffering, disfigurement, mental anguish, and diminished quality of life. Furthermore, the Petitioner's physicians have concluded that no further medical treatments are available to remedy or alleviate his injuries, meaning this case does not include economic damages for future medical expenses. Consequently, Finkel's valuation of the Petitioner's case primarily focused on non-economic damages.

Finkel further testified that considering the $2,000,000.00 valuation of the Petitioner's case and noting that the case settled for $400,000.00, the Petitioner recovered merely 20 percent of the total estimated value of his damages.

Utilizing the pro rata methodology for the settlement proceeds allocates 20 percent to all past medical expenses. In comparison, the remaining 80 percent was allocated to non-economic damages. Section 409.910(11)(f) outlines the statutory reduction for Florida's Medicaid lien. According to the statutory formula, "after attorney's fees and taxable costs as defined by the Florida Rules of Civil Procedure, one-half of the remaining recovery shall be paid to the agency up to the total amount of medical assistance provided by Medicaid."

In summary, Petitioner Poupos demonstrated, with clear and convincing evidence, that AHCA's Medicaid lien for past medical expenses should be adjusted based on a pro rata distribution of damages obtained by Petitioner in a third-party settlement.