Judge rules Fla. Medicaid program for kids violates several laws

By Donna Domino, DrBicuspid.com features editor

January 2, 2015 -- A federal judge has ruled that the 1.9 million children who depend on the Florida Medicaid program for medical and dental care are not receiving the care required by federal law.

Federal Judge Adalberto Jordan found violations of federal requirements with respect to dental care "based on the fact that 79% of the children enrolled in Medicaid are getting no dental services at all," he wrote in his 153-page opinion released on December 31.

Requirements that children receive preventative care have not been met, given that "approximately one-third of Florida children on Medicaid are not receiving the preventative medical care they are supposed to receive," according to the decision.

The class action case was filed 10 years ago by the Florida Academy of Pediatric Dentistry (FAPD) and the Florida Chapter of the American Academy of Pediatrics.

"Children on Medicaid have not been provided the [federal] guarantee of access to care for treatment of conditions based on the ... surveys showing serious shortages of specialist care for Medicaid," the judge wrote. "Children on Medicaid have to travel to other areas of the state and/or wait for several months to obtain care."

“A child is assigned to a certain medical plan ... but when we check, we find that they're no longer assigned to that primary care doctor, and neither the mom nor doctor knows.”
— Louis St. Petery, MD

One of the agencies named in the suit, the Agency for Health Care Administration (AHCA), said the ruling is a moot point. "The judge’s outdated observations pertain to a Medicaid program that no longer exists. Florida’s new statewide Medicaid managed care program is cost-effective and a working success," the AHCA wrote in an email to DrBicuspid.com.

Louis St. Petery, MD, a Tallahassee pediatrician who is the executive vice president of the Florida Pediatric Society, described the "switching" process, in which care providers for Medicaid children are changed without notifying the parents or doctors.

"A child is assigned to a certain medical plan, and they show up for care and they're sick, but when we check, we find that they're no longer assigned to that primary care doctor, and neither the mom nor doctor knows," Dr. St. Petery told DrBicuspid.com. "It happens by computer without anybody's knowledge. That's totally crazy."

He noted that reimbursements are less than what it costs doctors to provide care.

Dr. St. Petery recalled a recent situation in which his pediatrician wife, Julia St. Petery, MD, faced the same dilemma. "Her patient showed up, but the child had been reassigned to a doctor two-and-a-half hours away," he said. "The mom didn't know, and the girl was sick. So you do the right thing for the kid and 'eat' it. My wife treated the girl anyway but didn't get reimbursed."

Jordan agreed with plaintiffs that the low reimbursements for doctors and dentists seeing Medicaid patients is "by far the most important factor," and held "that a sufficient increase in reimbursement rates will lead to a substantial increase in provider participation and a corresponding increase in access to care."

Julie Russo, DMD, FAPD president, noted that Florida has one of the lowest Medicaid reimbursement rates in the country.

"Because of this, many children have not been able to receive the proper medical or dental care that they deserve," she told DrBicuspid.com. "With dental caries being the most common disease in children -- and so many of these children are not receiving care -- this is great news for the children of Florida. We also know there will still be more work ahead, but now we have the federal support needed to move forward."

The judge will conduct a further hearing to determine the remedy; however, he noted that evidence at trial showed that Medicaid rates need to be increased so they are close to rates paid under the Medicare program.

Attorney Stuart Singer, a partner at the law firm Boies, Schiller & Flexner, which litigated the case for the past decade, said the decision helps Florida's poor children.

"This decision provides improved access to medical and dental care for the 1.9 million children in Florida who depend on the state's Medicaid system," he told DrBicuspid.com.

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Last Updated dd 1/5/2015 4:30:59 PM

1 comment so far ...
1/17/2015 7:14:02 PM
This "switching" has been going on since Texas changed from TMHP to multiple companies. We now have Dentaquest and MCNA , Delta started, but dropped out. Weekly, we have children reassigned without notice or reason. Children that have never gone to another dentist are reassigned. We have to verify eligibility and main dental home prior to every appointment. Generally, a phone call from our office by the parent to the company can correct this, but the time and vigilance it takes to accomplish this, and the schedule delays prevent efficient care, and prevent complete care, because we usually can only accommodate part of the planned treatment due to the delay, and then we reappoint and have to go through it all again.