An autistic child, through his mother, appealed from an order of the Department of Children and Families' Office of Appeal Hearings, affirming a decision of the Agency for Health Care Administration (AHCA) reducing the Medicaid-funded personal care assistance (PCA) hours requested by the child's pediatrician.
The Florida Appeals Court determined the hearing officer reviewed the pediatrician's request for unskilled PCA using the incorrect medical necessity standard for skilled nursing, rather than the standard of care for PCA. Therefore, the hearing officer's decision that the autistic child was not entitled to Medicaid coverage for PCA hours spent transporting the child to and from therapy sessions was not supported by substantial evidence.
The court found the services would be covered under the regulations relating to Early Periodic Screening, Diagnosis, and Treatment (EPSDT), which were never mentioned at the hearing, and the decision was based in part on testimony that the AHCA had changed its approach to caring for autistic children, which contradicted the AHCA's assurance that it was not changing its rules regarding PCA for autistic children.
See: I.B., ex rel. R.B. v. State, Agency for Health Care Admin., 2012 WL 637911 (Fla.App. 3 Dist. Feb 29, 2012) (not designated for publication).