Class action lawsuit seeks to stop Florida Agency for Health Care Administration from denying care to children based on its illegal Medicaid standard

For Immediate Release
August 6, 2021
Contact: Katy DeBriere, J.D., Legal Directo
debriere@floridahealthjustice.org, 904.356.8371, x. 333

ACKSONVILLE (Aug. 6) – The Florida Health Justice Project (FHJP), National Health Law Program (NHeLP), and attorney Joshua Norris have filed a federal class action lawsuit against the Florida Medicaid agency, the Agency for Health Care Administration (AHCA) on behalf of Medicaid beneficiaries, including two medically fragile Florida children. All under the age of 21, these children have been denied coverage for medically necessary services based on a standard that violates federal Medicaid law.

“States that participate in Medicaid programs must comply with federal Medicaid law,” said FHJP’s Katy DeBriere, the lead attorney representing the plaintiffs. “Specific federal requirements ensure that individual children get the healthcare that they need – as the federal Medicaid agency has said, the right care to the right child at the right time in the right setting. Our state Medicaid agency has refused to extend those protections to some of Florida’s most vulnerable children. Instead, Florida insists on applying the same criteria to infants and children with medically complex needs that it applies to adults.”

The two named plaintiffs in the lawsuit are a 1-year-old boy, W.B., with a genetic disorder called CHARGE syndrome, a condition so rare that it affects only 1 in 10,000 live births in the U.S., and an 11-year-old girl, A.W., whose medically complex conditions include quadriplegic cerebral palsy, global developmental delay, muscle spasticity and partial epilepsy.

The federal Medicaid program mandates coverage of “early and periodic screening, diagnostic and treatment services” (EPSDT) for Medicaid-enrolled children. Under EPSDT, states must provide all Medicaid-covered services necessary to “correct or ameliorate” physical or mental conditions of Medicaid beneficiaries under age 21, regardless of whether those services would be covered for adults.

W.B. has had multiple hospital admissions in his first year of life. His doctors believe that his intense medical needs can only be met at an out-of-state specialty clinic run by the Cincinnati Children’s Hospital. There, a multidisciplinary team of doctors who specialize in treating children with W.B’s unique diagnosis are ready to provide crucial interventions. Without this treatment, W.B. will suffer and likely have developmental delays and other medical problems.

A.W., who uses her feeding tube continuously at night, requires a special enclosed bed with an adjustable head, an IV pole, and access ports built into the foot and headboard for routing of medical tubing. The bed is built with an unbroken perimeter between the supportive mattress and the frame to reduce gaps and openings that can trap A.W. and lead to serious injury.

“It’s terrifying to think what could happen without the special bed my daughter needs,” said A.W.’s mother. “It’s so stressful and frustrating knowing that medical equipment that would keep her safe is not available to her because Florida Medicaid won’t cover it. They also did not consider her quality of life when they denied the equipment. My child, like all special needs children, deserves that consideration.”

AHCA denied each child’s claim, applying a standard that is narrower than federal Medicaid law allows.

“The EPSDT mandate is very broad and requires Florida to ensure that Medicaid eligible children like W.B. and A.W. have the care they need to improve or maintain their health, and to prevent the development of other adverse health outcomes,” Norris said. “By denying these claims for services, Florida is not fulfilling its duty under EPSDT to these children.”

“The Florida Medicaid agency is applying an illegal standard and in so doing putting the health of some of the youngest, most medically fragile Medicaid beneficiaries in Florida at risk,” said Sarah Somers, managing attorney of NHeLP’s North Carolina office and co-counsel in the lawsuit. “With this lawsuit, we are asking the federal court to require AHCA to once and for all to use a medical necessity standard for beneficiaries under age 21 required by federal Medicaid law, and then to ensure that they comply with it.”

A copy of the complaint can be accessed here

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