Agency for Health Care Administration v. Riley
119 So. 3d 514
Fla. Dist. Ct. App.2013Background
- Caesar Riley was shot and sued the property owner where the shooting occurred; while his case was pending he settled with the property owner and the settlement terms were confidential.
- Riley received substantial medical care paid by Florida Medicaid; AHCA claimed a Medicaid lien for roughly $225,000.
- Riley (later substituted by his personal representative after his death) moved for a judicial determination of the Medicaid lien amount.
- AHCA relied on section 409.910(11)(f) and this court’s prior decision in Russell, arguing the statute established a presumptive/full lien amount and that Riley could not rebut that presumption.
- The trial court rejected AHCA’s position and allocated an amount less than the full Medicaid payments. AHCA appealed.
- After briefing, the U.S. Supreme Court decided Wos v. E.M.A., and the Florida Fourth District decided Roberts v. Albertson’s, which undermined Russell; AHCA revised its stance to concede recipients may attempt to rebut the statutory allocation.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether section 409.910(11)(f) bars a recipient from rebutting the statutory allocation of a Medicaid lien | Riley argued the trial court could consider evidence to reduce AHCA’s lien below the statutory default | AHCA initially argued the statute and Russell required full satisfaction of the lien without consideration of rebuttal; later conceded rebuttal is allowed but argued Riley failed to rebut | The court held the statute permits recipients to attempt to rebut the statutory default allocation; Russell is no longer good law and remand for a new hearing is required |
| Whether the trial court’s prior allocation should stand or be reconsidered under Wos/Roberts | Riley sought validation of the trial court’s reduction | AHCA argued the trial court must follow Russell or, post-Wos, that Riley failed to meet rebuttal burden | The court reversed and remanded for a supplemental hearing applying Wos and Roberts; the trial court may consider previous record evidence and additional proof |
Key Cases Cited
- Russell v. Agency for Health Care Administration, 23 So.3d 1266 (Fla. 2d DCA 2010) (previously endorsed a strict statutory recovery rule for Medicaid liens)
- Roberts v. Albertson’s Inc., 119 So.3d 457 (Fla. 4th DCA 2012) (treats statutory allocation as a default and allows evidentiary challenge to reduce lien)
- Wos v. E.M.A., 133 S. Ct. 1391 (2013) (U.S. Supreme Court decision limiting state rules that bar Medicaid recipients from introducing evidence to rebut a statutory presumption)