J.R., Appellant, v. CHILDREN MEDICAL SERVICES (2026)

Edwardo Rosario Appeals a final order dismissing his request for a Medicaid fair hearing in favor of Children's Medical Services (“CMS”). We have jurisdiction. See Fla. R. App. P. 9.030(b)(1)(C).

Rosario's son suffers from developmental disabilities and other health conditions that require full-time assistance with activities of daily living. Unable to provide that care alone, Rosario requested Medicaid coverage for home health personal care services. CMS denied his request and issued a Notice of Adverse Benefit Determination, which informed Rosario that he could file a “plan appeal” and, if dissatisfied with its resolution, request a Medicaid fair hearing. Rosario filed a plan appeal but requested a fair hearing before the plan appeal was resolved. The Office of Fair Hearings dismissed his fair hearing request without prejudice, concluding that completion of the plan appeal was a jurisdictional prerequisite.

“In interpreting a state statute or rule, a state court or an officer hearing an administrative action pursuant to general law may not defer to an administrative agency's interpretation of such statute or rule, and must instead interpret such statute or rule de novo.” Art. V, § 21, Fla. Const.; see § 120.68(7)(d), Fla. Stat. (“The court shall remand a case to the agency for further proceedings consistent with the court's decision or set aside agency action, as appropriate, when it finds that: ․ The agency has erroneously interpreted a provision of law and a correct interpretation compels a particular action[.]”); S.F. v. Agency for Persons with Disabilities, 394 So. 3d 96, 97 (Fla. 3d DCA 2024) (“We review an agency's conclusions of law de novo and we review the record to determine whether competent substantial evidence supports the agency's decision. In doing so, we give no deference to agency interpretations of statutes or rules.” (internal citation and quotation marks omitted)).

Florida Administrative Code Rule 59G-1.100(8)(e) requires an enrollee to “initiate and complete a plan appeal before making a fair hearing request.” A plan appeal is complete when either the enrollee receives a Notice of Plan Appeal Resolution or the plan fails to comply with the applicable notice and timing requirements. Fla. Admin. Code R. 59G-1.100(8)(e)1–2.¹ Rosario requested a fair hearing before either condition occurred. At the time of his request, his plan appeal remained pending—the Notice of Plan Appeal Resolution did not issue until 11 days later. We agree that the Office of Fair Hearings lacked jurisdiction to consider Rosario's request because he had not completed the plan appeal process before requesting a fair hearing. We emphasize that because the dismissal was without prejudice, Rosario remains free to submit a new coverage request and pursue the plan appeal and fair hearing process anew.

Affirmed.

FOOTNOTES

1.   Fla. Admin. Code Rule 59G-1.100(8)(e) states: “(e) An enrollee must initiate and complete a plan appeal before making a fair hearing request. The plan appeal is complete when: 1. The enrollee receives from the plan a NPAR indicating the plan appeal was not resolved wholly in the enrollee's favor, or 2. The plan fails to adhere to notice and timing requirements applicable to plan appeals.”

GORDO, J.