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Case Name Florida Pediatric Society v. Levine PB-FL-0017
Docket / Court 1:05-cv-23037-AJ ( S.D. Fla. )
State/Territory Florida
Case Type(s) Public Benefits / Government Services
Attorney Organization Public Interest Law Center (PILCOP)
Case Summary
On November 28, 2005, the Florida Pediatric Society, the Florida Chapter of the American Academy of Pediatrics, the Florida Academy of Pediatric Dentistry, Inc., and certain named individual children who were eligible to receive medical and dental care through Medicaid filed this class action ... read more >
On November 28, 2005, the Florida Pediatric Society, the Florida Chapter of the American Academy of Pediatrics, the Florida Academy of Pediatric Dentistry, Inc., and certain named individual children who were eligible to receive medical and dental care through Medicaid filed this class action lawsuit in the U.S. District Court for the Southern District of Florida. The plaintiffs, represented by attorneys from private practice and from the Public Interest Law Center of Philadelphia, brought this suit under 42 U.S.C. § 1983 against the Florida Agency for Health Care Administration ("AHCA"); the Florida Department of Children and Families ("DCF"); the Surgeon General; and the Florida Department of Health ("DOH"). The plaintiffs sought declaratory and injunctive relief, claiming that the defendants systematically failed to administer the state's Medicaid program in compliance with federal law. Specifically, they alleged that the defendants violated Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq. (also known as the Medicaid Act), by failing to provide essential medical and dental services to eligible children in Florida. The plaintiffs sought to certify a class consisting of all children who now, or in the future will, reside in Florida and who are, or will be, eligible under Title XIX of the Act for Early and Periodic Screening, Diagnosis and Treatment Services.

The complaint included four counts. In Count I, the plaintiffs alleged that the defendants violated 42 U.S.C. §§ 1396a(a)(8) and (a)(10) by failing to provide "medical assistance . . . with reasonable promptness to all eligible individuals." Count II claimed that the defendants violated 42 U.S.C. § 1396a(a)(30)(A) by failing to afford equal access to medical care through a Medicaid program that ensured that reimbursement rates for providers were high enough to guarantee children access to care that equaled the access of their peers in other geographical areas. Count III charged that the defendants violated 42 U.S.C. §1396u-2(b)(5), which requires that states obtain assurances that the HMO contractors offer a suitable range of services and access to preventive and primary care services for the population expected to be enrolled and maintain a sufficient number, mix, and geographic distribution of providers. Finally, Count IV alleged that the defendants violated 42 U.S.C. § 1396a(a)(43) by failing to effectively inform the plaintiffs and their caretakers of the availability of child health care services.

On January 12, 2007, Judge Adalberto Jordan issued an order granting in part and denying in part the defendants' motion to dismiss. The Court refused to dismiss the case on the theory that the organizational plaintiffs lacked standing, holding that it did not need to answer this question given that the individual plaintiffs clearly had standing. The District Court proceeded to reject in large part the argument that the statutes under which the plaintiffs sued do not confer individually enforceable rights. Adopting the Supreme Court's test in Gonzaga University v. Doe, 536 U.S. 273 (2002), the District Court held that the statutes from Counts I, II, and IV evinced an "unmistakable focus on the benefitted class" and therefore created private rights of action. The statute in Count III, by contrast, was held not to create a privately enforceable right because it is "aggregate and systemwide in nature" rather than focused on the needs of a particular class of people. The defendants filed a motion asking the Court to reconsider this decision and certify certain issues as immediately appealable to the Eleventh Circuit, but Judge Jordan rejected that request on April 24, 2007.

The parties then engaged in extensive discovery. On March 20, 2009, Judge Jordan granted in part and denied in part two partial motions for summary judgment filed by DCF and the Surgeon General. For its part, DCF challenged the plaintiffs' standing, and the Court determined that at least one plaintiff had suffered an injury in fact because the child experienced an eighteen-month delay for an appointment in violation of Count I and because he failed to receive information about his rights to medical care in violation of Count IV. The Court further held that each of these violations could be traced to DCF. The plaintiffs did, however, fail to satisfy the causation element for Count II because DCF lacked authority to set or modify reimbursement rates, an authority that state law reposes in AHCA. Having concluded that at least one plaintiff had standing, the District Court turned to the merits of the summary judgment motion. It denied the motion with respect to the first prong of Count I (42 U.S.C. § 1396a(a)(8)) and Count IV, holding that issues of material fact existed about whether DCF unlawfully prevented children from obtaining health care services and whether the agency failed to inform the plaintiffs about their rights to medical care. But the Court did rule for the defendants and grant summary judgment on the second prong of Count I (§ 1396a(a)(8)). It held that the plaintiffs had failed to produce any evidence showing that DCF afforded them unequal treatment compared to other Medicaid recipients or people not on Medicaid. As a result, summary judgment was proper on this part of Count I.

The District Court then evaluated the Surgeon General's motion for summary judgment, which raised substantially the same issues as DCF's motion. The Court held that at least one plaintiff had standing on Counts I and II. Because this plaintiff's surgery was delayed by a year, he was denied medical care with reasonable promptness in violation of the first prong of Count I. The Surgeon General also violated prong two of Count I because the plaintiffs received deficient medical assistance compared to the assistance afforded other individuals. As for Count II, the District Court determined that medical care and services were not available to the plaintiffs to the same extent they were available to the rest of the population in the geographic area. The Court then held that the causation requirement was satisfied, explaining that DOH has at least some control over the Medicaid reimbursement rates paid to providers. On Count IV, however, the Court held that the plaintiffs lacked standing because they failed to allege facts showing that DOH was responsible for any lack of information concerning available medical services. The Court then denied the Surgeon General's summary judgment motion on Counts I and II because of the plaintiffs' factual showings on DOH's failure to provide medical services with reasonable promptness and to ensure that payments to providers were sufficiently high to guarantee quality care as compared with that received by other children.

The parties tried mediation for the next few months, but on June 9, 2009, they reached an impasse. On June 25, Magistrate Judge Chris McAliley issued a recommendation that the District Court grant the plaintiffs' motion for class certification. Judge Jordan then issued an order on September 30 adopting the magistrate's report and granting in part the motion for certification. After concluding that the plaintiffs had standing to pursue Counts I, II, and IV against AHCA, the Court certified a class consisting of all children under the age of 21 who now, or in the future will, reside in Florida and who are, or will be, eligible under Title XIX of the Social Security Act for Early Periodic Screening, Diagnosis and Treatment Services.

Also on September 30, 2009, Judge Jordan issued an order denying the defendants' motions for summary judgment. The Court again rejected the argument that the statutes at issue do not confer individually enforceable rights. It also rejected the defendants' contention that the term "medical assistance" in §§ 1396a(a)(8) and 1396a(a)(10) is narrowly defined and precludes relief for failure to provide medical services.

After more discovery, a bench trial began on December 9, 2009. The trial consisted of 94 sessions and ended in January 2012. On November 21, 2012, the District Court (Judge Jordan) issued an order requiring the parties to submit memoranda of law explaining whether the new Affordable Care Act provisions moot or otherwise affect the issues in this case. These provisions, which took effect on January 1, 2013, require Medicaid to match Medicare's rate of payment for primary care treatment for any services performed over the next two years.

On March 18, 2013, Judge Jordan denied the defendants' request to dismiss certain claims as moot because of Florida's state plan amendment, which gave to Medicaid providers Medicare's higher reimbursement rates. The Court explained that the Centers for Medicare & Medicaid Services had yet to approve the amendment, which means that medical providers in the state still have not been paid the higher rates that the plaintiffs demanded. As a result, the claims in the case remain viable. Judge Jordan again rejected the defendants' mootness arguments in an order issued on July 10, 2014. The Court held that a temporary two-year increase of Medicaid reimbursement rates to Medicare levels did not moot the case given the uncertainty about whether the state legislature would keep funding the rate increases past their expiration date on December 31, 2014. Moreover, Florida's decision to place 98 to 99 percent of children eligible for Medicaid in managed care similarly did not render the case moot because of the 1 to 2 percent of excluded children and because the managed care system would not be live until October 1, 2014.

On November 25, 2014, Judge Jordan denied the defendants' request to reopen the record for trial on liability and their suggestion of mootness. In declining to reopen the record, the Court explained that allowing more discovery and trial sessions would cause substantial prejudice and would improperly prolong the process of determining liability. The Court then rejected the defendants' mootness arguments. Even though DCF made significant changes in its system for determining Medicaid eligibility, including implementing a new computer system with new income eligibility standards and a new streamlined Medicaid application, the Court held that because these changes were relatively recent it remained unclear whether they would fully resolve all of the plaintiffs' complaints.

About a month later, on December 30, 2014, Judge Jordan issued its findings of fact and conclusions of law in an opinion that spanned more than 150 pages. The Court began by reaffirming its pretrial determination that the individual plaintiffs have standing to bring this case. (It declined to reach the organizational plaintiffs' standing but reserved the right to do so in a future revised order.) The Court also reaffirmed its pretrial class-certification ruling and its determination that the statutes underlying Counts I, II, and IV confer individually enforceable rights under which the plaintiffs can bring this action. After making extensive factual findings, the District Court held that Florida's Medicaid program violated federal law in several respects. The program has failed to compensate physicians and specialists at rates that are competitive with those of Medicare or private insurers. Specifically, the state's system for reimbursing physicians prioritizes budget neutrality and fails to consider statutory mandates like ensuring that reimbursement rates are sufficiently high to incentivize physicians to treat Medicaid patients. As a result, about one-third of Florida children on Medicaid do not receive the preventative care to which they are entitled, a violation of the Early Periodic Screening, Diagnosis and Treatment requirements for preventative medical care under §§ 1396a(a)(8) and (a)(10). The District Court held that the defendants violated these requirements for specialty care as well. On the issue of dental care, the Court reached similar conclusions, holding that children in Florida are not receiving such care with reasonable promptness and that dental reimbursement rates are too low. The Court then identified the defendants' additional violations of federal law, including those relating to outreach efforts.

On March 31, 2015, Judge Jordan issued amended findings of fact and conclusions of law in response to a motion filed by the defendants. The Court's changes related primarily to the expiration of a state statute that had delegated to DCF certain outreach responsibilities. Given the statute's expiration, the Court held that DCF could no longer be sued under Count IV for failing to perform these duties, although AHCA and DOH remained subject to liability. The Court's other changes involved the standing of some of the individual plaintiffs.

After a scheduling conference, the district court informed the parties that the next phase of the case would focus on whether there remains an ongoing controversy to justify awarding any declaratory or injunctive relief. The court directed the parties to file their respective offers of proof in preparation for a hearing to be held on April 24, 2015. The defendants argued that a recent case, Armstrong v. Exceptional Child Care Center, required that the court dismiss all of the plaintiffs' claims. However, on May 1, 2015, the Court dismissed only Count II based on the new case law.

After several months of settlement discussions, the court approved a final settlement agreement on June 28, 2016. The state agreed to implement an incentive program providing rate increases to eligible medical services providers upon achievement of certain objectively measurable patient access and outcome measures. The state also agreed to increase access to and utilization of pediatric dental services. The agreement calls for at least quarterly meetings between state agencies and the plaintiffs to address plan changes, changes in primary care provider assignments, and timely activation and enrollment of newborn babies with Medicaid coverage from birth. The state also agreed to ensure that communications are made through various media and non-media channels to inform parents and guardians of enrolled Medicaid children of available EPSDT services and to inform parents and guardians of unenrolled children of the availability of the Medicaid program. Finally, the state agreed to improve the Medicaid eligibility process for children by making all reasonable efforts to minimize wrongful terminations of Medicaid eligibility, monitor files on eligible unborn babies, evaluate the application process. The parties agreed to quarterly meetings to monitor the Medicaid eligibility process.

The Court has jurisdiction over the litigation until September 30, 2022. The defendants agreed to pay the plaintiffs $12,000,000 to cover attorneys' fees and costs. As of January 6, 2019, the docket reflects no further activity, but the term of the Court's jurisdiction is still ongoing.

Brian Tengel - 04/07/2015
Eva Richardson - 01/05/2019


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Issues and Causes of Action
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Issues
Benefit Source
Medicaid
Defendant-type
Hospital/Health Department
Jurisdiction-wide
General
Government Services (specify)
Payment for care
Plaintiff Type
Non-profit NON-religious organization
Private Plaintiff
Causes of Action 42 U.S.C. § 1983
Defendant(s) Florida Agency for Health Care Administration
Florida Department of Children and Family Se rvices ;
Florida Department of Health
Plaintiff Description The Florida Pediatric Society, the Florida Chapter of the American Academy of Pediatrics, the Florida Academy of Pediatric Dentistry, Inc., and certain named individual children who were eligible to receive medical and dental care through Medicaid.
Indexed Lawyer Organizations Public Interest Law Center (PILCOP)
Class action status sought Yes
Class action status granted Yes
Filed Pro Se No
Prevailing Party None Yet / None
Public Int. Lawyer No
Nature of Relief Attorneys fees
Injunction / Injunctive-like Settlement
Source of Relief Settlement
Form of Settlement Court Approved Settlement or Consent Decree
Order Duration 2016 - 2022
Filing Year 2005
Case Ongoing Yes
Additional Resources
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Docket(s)
1:05-cv-23037-AJ (S.D. Fla.)
PB-FL-0017-9000.pdf | Detail
Date: 07/20/2016
Source: PACER [Public Access to Court Electronic Records]
General Documents
Complaint- Class Action [ECF# 1]
PB-FL-0017-0001.pdf | Detail
Date: 11/28/2005
Source: PACER [Public Access to Court Electronic Records]
Order On Motion To Dismiss [ECF# 40] (S.D. Fla.)
PB-FL-0017-0002.pdf | Detail
Date: 01/12/2007
Source: PACER [Public Access to Court Electronic Records]
Order Denying Motion To Reconsider Motion To Dismiss And To Certify Issues As Immediately Appealable [ECF# 58] (S.D. Fla.)
PB-FL-0017-0003.pdf | Detail
Date: 04/24/2007
Source: PACER [Public Access to Court Electronic Records]
Amended Complaint- Class Action [ECF# 77]
PB-FL-0017-0004.pdf | Detail
Date: 06/05/2007
Source: PACER [Public Access to Court Electronic Records]
[Proposed] Order On Partial Motion To Dismiss Count III Of The Amended Complaint [ECF# 148] (S.D. Fla.)
PB-FL-0017-0005.pdf | Detail
Date: 02/14/2008
Source: PACER [Public Access to Court Electronic Records]
Order on Motions for Summary Judgment [ECF# 1236] (S.D. Fla.)
PB-FL-0017-0009.pdf | Detail
Date: 03/20/2009
Source: PACER [Public Access to Court Electronic Records]
Report and Recommendation on Plaintiffs' Motion for Class Certification [ECF# 613]
PB-FL-0017-0010.pdf | Detail
Date: 06/25/2009
Source: PACER [Public Access to Court Electronic Records]
Order Granting in Part the Plaintiffs' Motion for Class Certification [ECF# 671] (S.D. Fla.)
PB-FL-0017-0011.pdf | Detail
Date: 09/30/2009
Source: PACER [Public Access to Court Electronic Records]
Order Denying the Defendants' Motions for Summary Judgment [ECF# 672] (S.D. Fla.)
PB-FL-0017-0007.pdf | Detail
Date: 09/30/2009
Source: PACER [Public Access to Court Electronic Records]
Order Denying Motion to Dismiss [ECF# 1236] (S.D. Fla.)
PB-FL-0017-0008.pdf | Detail
Date: 03/18/2013
Source: PACER [Public Access to Court Electronic Records]
Order on Defendants' Suggestion of Mootness [ECF# 1270] (S.D. Fla.)
PB-FL-0017-0012.pdf | Detail
Date: 07/10/2014
Source: PACER [Public Access to Court Electronic Records]
Order on Defendants' Motion Reopen the Record for Trial on Liability and Suggestion of Mootness [ECF# 1293] (S.D. Fla.)
PB-FL-0017-0013.pdf | Detail
Date: 11/25/2014
Source: PACER [Public Access to Court Electronic Records]
Findings of Fact and Conclusions of Law [ECF# 1294] (S.D. Fla.)
PB-FL-0017-0015.pdf | Detail
Date: 12/31/2014
Source: PACER [Public Access to Court Electronic Records]
Order on Defendants' Motion to Amend or Alter Findings of Fact [ECF# 1310] (S.D. Fla.)
PB-FL-0017-0014.pdf | Detail
Date: 03/25/2015
Source: PACER [Public Access to Court Electronic Records]
Amended Findings of Fact and Conclusions of Law [ECF# 1314] (S.D. Fla.)
PB-FL-0017-0006.pdf | Detail
Date: 04/01/2015
Source: PACER [Public Access to Court Electronic Records]
Settlement Agreement [ECF# 1399-1]
PB-FL-0017-0016.pdf | Detail
Date: 06/17/2016
Source: PACER [Public Access to Court Electronic Records]
show all people docs
Judges Jordan, Adalberto Jose (S.D. Fla., Eleventh Circuit) show/hide docs
PB-FL-0017-0002 | PB-FL-0017-0003 | PB-FL-0017-0005 | PB-FL-0017-0006 | PB-FL-0017-0007 | PB-FL-0017-0008 | PB-FL-0017-0009 | PB-FL-0017-0011 | PB-FL-0017-0012 | PB-FL-0017-0013 | PB-FL-0017-0014 | PB-FL-0017-0015 | PB-FL-0017-9000
McAliley, Chris M. (S.D. Fla.) [Magistrate] show/hide docs
PB-FL-0017-0010 | PB-FL-0017-9000
O'Sullivan, John J. (S.D. Fla.) [Magistrate] show/hide docs
PB-FL-0017-9000
Plaintiff's Lawyers Boruchow, Sashi Bach (Florida) show/hide docs
PB-FL-0017-9000
Bullock, Louis Werner (Oklahoma) show/hide docs
PB-FL-0017-0001 | PB-FL-0017-0004 | PB-FL-0017-9000
Eiseman, James Jr. (Pennsylvania) show/hide docs
PB-FL-0017-0001 | PB-FL-0017-0004 | PB-FL-0017-9000
Geffen, Benjamin D. (Pennsylvania) show/hide docs
PB-FL-0017-9000
Gilhool, Thomas K. (Pennsylvania) show/hide docs
PB-FL-0017-0001 | PB-FL-0017-0004 | PB-FL-0017-9000
Goldfarb, Carl Edward (Florida) show/hide docs
PB-FL-0017-0001 | PB-FL-0017-0004 | PB-FL-0017-9000
Gonzalez, Mauricio (Florida) show/hide docs
PB-FL-0017-9000
Kunz, Paul Bernard (Florida) show/hide docs
PB-FL-0017-9000
Marshall, Damien J. (Florida) show/hide docs
PB-FL-0017-0001 | PB-FL-0017-0004 | PB-FL-0017-9000
Riley, Joshua P. (District of Columbia) show/hide docs
PB-FL-0017-9000
Singer, Stuart Harold (Florida) show/hide docs
PB-FL-0017-0001 | PB-FL-0017-0004 | PB-FL-0017-0016 | PB-FL-0017-9000
Verkuil, Paul R. (New York) show/hide docs
PB-FL-0017-9000
Defendant's Lawyers Bowden, Albert III (Florida) show/hide docs
PB-FL-0017-9000
Daniel, Stephanie A. (Florida) show/hide docs
PB-FL-0017-9000
Figlio, Erik Matthew (Florida) show/hide docs
PB-FL-0017-0016 | PB-FL-0017-9000
Giurato, Gerald Anthony (Florida) show/hide docs
PB-FL-0017-9000
Jimenez, Marcos Daniel (Florida) show/hide docs
PB-FL-0017-9000
Landon, Robert Donald Wike (Florida) show/hide docs
PB-FL-0017-9000
Martin, Paul Jeffrey (Florida) show/hide docs
PB-FL-0017-9000
Smith, Chesterfield Jr. (Florida) show/hide docs
PB-FL-0017-9000

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