G.R., etc., Appellant, v. MOLINA HEALTHCARE OF FLORIDA INC (2026)

Under the regulations governing Medicaid, we have no choice but to affirm the dismissal by the Florida Agency for Health Care Administration hearing officer of G.R.’s request for a “fair hearing.” G.R. properly made the request for additional personal care services to Molina Healthcare of Florida, Inc., his Medicaid provider. As the hearing officer found, however, after Molina Healthcare denied the request, G.R.’s attempt to obtain a “plan appeal” (that is, an internal review) by Molina Healthcare of its denial was untimely filed. G.R.’s request for a “plan appeal” had to be filed (not merely mailed) within 60 days from the date of the adverse benefit determination notice (not the receipt of the denial). See 42 C.F.R. § 438.402(c)(2)(ii) (“Following receipt of a notification of an adverse benefit determination by an MCO, PIHP, or PAHP, an enrollee has 60 calendar days from the date on the adverse benefit determination notice in which to file a request for an appeal to the managed care plan.” (emphases added)). Because G.R. did not timely file the “plan appeal,” G.R. is foreclosed from obtaining a fair hearing before a hearing examiner.

In affirming the dismissal, we note that Molina Healthcare acknowledged in its brief that:

G.R. is not precluded from again seeking additional personal care services. Long Term Care enrollees can ask for increased services at any time; accordingly, G.R. is free to request personal care services again if he believes those services are necessary. If his request is denied and he timely pursues a plan appeal, G.R. will be able to seek another fair hearing.

Affirmed.

PER CURIAM.