Roberts v. Albertson's Inc.
119 So. 3d 457
Fla. Dist. Ct. App.2012Background
- Roberts, a Medicaid recipient, was quadriplegic from a side-view mirror impact and received Medicaid medical care totaling $343,452.83.
- AHCA, the Medicaid administrator, placed a lien on third-party settlement proceeds.
- All defendants except Albertson’s settled; Albertson’s settled for $2,735,000 with no allocation between medical and non-medical damages.
- Albertson’s settlement did not involve AHCA, which did not participate in the settlement.
- Roberts moved to determine the equitable Medicaid lien amount and asked for a hearing to allocate settlement proceeds to medical expenses.
- The trial court applied the statutory formula in §409.910(11)(f), denying an evidentiary hearing and enjoining a full lien for medical expenses only, prompting appellate review.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether Florida's framework allows judicial allocation of a settlement for Medicaid lien purposes. | Roberts seeks judicial determination of the medical-expense portion. | AHCA relies on §409.910 to set the lien amount by formula without a hearing. | Yes; plaintiff may seek judicial allocation. |
| Whether Ahlborn limits Florida's statutory allocation and precludes full lien without stipulation. | Ahlborn limits lien to medical-expense portion absent stipulation. | Ahlborn does not invalidate Florida’s default allocation. | Ahlborn does not preclude Florida’s default allocation. |
| Whether §409.910(11)(f) is a valid default allocation that can be challenged judicially. | Default allocation can be disproved if lien exceeds medical expenses. | Statutory allocation controls absent stipulation. | Default allocation permissible but subject to challenge. |
| Whether Roberts was entitled to an evidentiary hearing to prove the lien exceeds medical expenses. | Evidence needed to show lien exceeds medical expenses. | No evidentiary hearing required. | Plaintiff entitled to evidentiary hearing on lien extent. |
| Whether conflict should be certified with Garcon and Russell based on proper allocation approach. | Support for claim that plaintiff can prove lien exceeds medical costs. | Garcon/Russell align with default allocation; no evidence override. | Conflict certified; plaintiff allowed to challenge lien. |
Key Cases Cited
- Arkansas Dept. of Health & Human Servs. v. Ahlborn, 547 U.S. 268 (U.S. 2006) (limits lien to payments for medical expenses; sets allocation framework; federally governed)
- Russell v. Agency for Health Care Administration, 23 So.3d 1266 (Fla. 2d DCA 2010) (discussed Ahlborn; Florida statutory allocation rule; conflict with Ahlborn cautioned)
- Garcon v. Agency for Health Care Administration, 96 So.3d 472 (Fla. 3d DCA 2012) (holds section 409.910(1) fully effective; allocation rule challenged)
- Smith v. Agency for Health Care Administration, 24 So.3d 590 (Fla. 5th DCA 2009) (opined plaintiff entitled to challenge lien amount when excess of medical costs; supports evidentiary hearing)
- Tristani v. Richman, 652 F.3d 360 (3d Cir. 2011) (federal regime allows challenge to allocation; discusses anti-lien/anti-recovery)
- E.M.A. v. Cansler, 674 F.3d 290 (4th Cir. 2012) (requires process for challenging default allocation; supports judicial input)