Proposed Settlement of Florida Pediatric Society v. Dudek, No. 05-23037-CIV-
JORDAN/O’SULLIVAN (S.D. Fla.)
Florida Pediatric Society v. Dudek is a lawsuit, filed in 2005, challenging whether Florida’s Medicaid program for children complied with federal law. The Court in this case certified a class of all children who are or will be eligible for Medicaid in Florida.
The Plaintiffs (including representatives of the class of children described above, the Florida Chapter of the American Academy of Pediatrics, and the Florida Academy of Pediatric Dentistry) and the Defendants (the Secretaries of the Florida Agency for Health Care Administration (“AHCA”), Department of Children and Family Services (“DCF”), and Department of Health (“DOH”)) have proposed a settlement agreement resolving all issues in the case. The Plaintiffs have asked the Court to approve the proposed settlement. The terms of the proposed settlement are described briefly below. You may also review the complete text of the proposed settlement on this website.
Medical Care. To improve access to care, the Settlement Agreement provides a process to increase the reimbursement rates paid to physicians who treat children on Medicaid. AHCA will require the capitated Managed Medical Assistance (MMA) Plans to adopt an Incentive Plan under which Board-certified pediatricians and obstetricians, will have a reasonable opportunity to earn Medicare-equivalent reimbursement rates, starting in October 2016. AHCA may be obligated to seek additional funds if necessary to fund these increases. The Settlement commits AHCA to devote all of AHCA’s program savings from Medicaid Managed Care Plans until at least September 2019 to increasing reimbursement first for Board Certified Pediatricians and obstetricians, and then, to the extent cost savings allow, for other primary care providers treating children, general practitioners and family practitioners treating children, and pediatric specialists and sub-specialists.
Performance of the managed care plans will be evaluated on the following benchmarks: Plans must (1) achieve a participation ratio at least equal to the national mean on the CMS 416 report, a report that all state Medicaid programs must submit annually to the federal government; (2) achieve a participation ratio on the CMS 416 report of at least 75 percent for all aggregate age groups, on a weighted average basis, below the age of 10; and (3) achieve at least the national Medicaid mean for at least eight of nine specified HEDIS measures, including well-care visits in the first 15 months of life and in the third, fourth, five and sixth years of life, children’s access to primary care practitioners between the ages of 12 and 24 months, and the frequency of lead blood screening in children. Plans that do not meet these benchmarks will be required to take corrective action.
If the Florida MMA program statewide fails to meet the benchmarks within 30 months after implementation, then additional plan changes, including reimbursement increases are required to provide all pediatricians and pediatric specialists and sub-specialists the opportunity to earn Medicare service rates, and the Plans will be prohibited from using the old Medicaid rate schedule as a baseline to set rates.
Dental Care. The Settlement Agreement provides a similar process to improve children’s access to Medicaid dental services. AHCA, in collaboration with the MMA Plans and Plaintiffs’ representatives, will conduct a study to assess geographic accessibility, travel times, and other issues, and then it will incorporate any enhancements identified by the study into its 2016 contracts, which begin in October of 2016.
Again, objective benchmarks will be used to measure progress. The statewide MMA plan must meet the following benchmarks by September 30, 2021: (1) the 2014 national Medicaid mean for the HEDIS annual dental visit measure; (2) the 2014 national average for the Child Core Set PDENT score measuring preventative care visits; and (3) the 2014 national average for the CMS-416 Dental Treatment Service measure. If Florida fails to meet applicable interim benchmarks by 2019, or 2020, or the final benchmarks in 2021, then dental providers will receive a reasonable opportunity to earn reimbursement rates at least at the 50th percentile of commercial dental insurance rates for pediatric dental services in Florida. AHCA must seek increased funds if necessary to support those increased reimbursement rates on an actuarially sound basis.
Eligibility. The Settlement Agreement requires DCF to continue to improve the Medicaid eligibility process for the members of the class. The Settlement Agreement focuses on resolving various problems with the Medicaid eligibility process: improper terminations of children’s Medicaid eligibility, difficulties with the “baby of” process for immediately establishing newborns’ Medicaid eligibility, and the application process. A series of regular meetings between DCF and Plaintiffs’ representatives will address each of these problems, where Plaintiffs will provide examples of problems, and DCF will implement reasonable measures to further address these issues.
Remedy. If Plaintiffs believe that AHCA or DOH are not in compliance, or that the Florida legislature has failed to approve something the agencies were required to request, then Plaintiffs will provide written notice and an opportunity to cure. Forty-five days after providing such notice, if Plaintiffs believe any breach has not been cured, Plaintiffs may file a motion with the Court. Upon establishing non-compliance, Plaintiffs may seek declaratory or injunctive relief to remedy violations of the Medicaid Act. The federal court will retain jurisdiction of the case until September 2022.
Similarly, if Plaintiffs believe that prior to June 30, 2018, DCF has failed, without reasonable justification, to meet the goals set forth in the Settlement Agreement, Plaintiffs must give written notice and an opportunity to cure for 30 days. If Plaintiffs believe DCF is still in breach, Plaintiffs may seek declaratory and injunctive relief to remedy violations of the Medicaid Act.
Attorneys’ Fees. The agreement further specifies that Defendants will pay $12 million in attorneys’ fees and costs incurred by Plaintiffs’ counsel over the duration of the case through the date of the execution of the settlement agreement. That payment covers the fees of Boies, Schiller & Flexner LLP, the Public Interest Law Center, f/k/a the Public Interest Law Center of Philadelphia, and Louis Bullock, as well as the costs incurred in this action, and represents about 60% of Plaintiffs’ counsel fees in this action, at counsel’s normal rates.
If you have any questions, you may contact counsel for the plaintiffs, Pascual Oliu, of Boies, Schiller & Flexner, by phone at (954) 356-0011, by fax at (954) 356-0022, or by mail at 401 E. Las Olas Blvd., Suite 1200, Ft. Lauderdale, FL, 33301.
