34 Fla. L. Weekly D1533a
21 So. 3d 137
NOT FINAL VERSION OF OPINION
Subsequent Changes at 34 Fla. L. Weekly D2282a
Contracts — Insurance — Florida Kidcare Act — Health maintenance organization’s action for breach of contract, breach of implied covenant of good faith and fair dealing, and breach of fiduciary duty against Florida Healthy Kids Corporation, alleging that defendant erroneously determined that a special needs child could be enrolled in the FHKC program, with the result that plaintiff was obligated to provide child with medical costs exceeding $300,000 — Trial court misinterpreted controlling statutes when it concluded that defendant did not breach its contract with plaintiff by enrolling child in FHKC program — Child with special health care needs and family income exceeding 200% of federal poverty level is allowed to participate in Children’s Medical Services Network, a program specifically designed to cover children with special needs, and it was error to find that child was ineligible for CMS program due to her family’s income
HEALTH FIRST HEALTH PLAN #C, INC., Appellant, v. FLORIDA HEALTHY KIDS CORPORATION, Appellee. 5th District. Case No. 5D08-240. Opinion filed July 31, 2009. Appeal from the Circuit Court for Brevard County, John D. Moxley, Jr., Judge. Counsel: David C. Borucke and Steven L. Brannock of Holland & Knight LLP, Tampa, and Jerome W. Hoffman of Holland & Knight LLP, Tallahassee, for Appellant. Wilbur E. Brewton, Kelly B. Plante and Tana D. Storey of Brewton Plante, P.A., Tallahassee, for Appellee.
(PALMER, J.) Health First Health Plan C, Inc., (Health First) appeals the final order entered by the trial court granting summary judgment in favor of Florida Healthy Kids Corporation (FHKC). Determining that the trial court misinterpreted the controlling statutes in issuing its ruling, we reverse.
Health First filed an amended complaint against FHKC alleging claims of breach of contract, breach of the implied covenant of good faith and fair dealing, and breach of fiduciary duty. All claims arose out of Health First’s contract with FHKC.
In its amended complaint, Health First described itself as a health maintenance organization providing comprehensive health care services via a health insurance plan that covered 6,000 Brevard County children. FHKC was created by section 624.91 of the Florida Statutes to provide eligible children with health insurance coverage, and was one of the five components of the Florida KidCare Program.1 The overall coverage goal of the Florida KidCare Program was to ensure that uninsured children would receive health care provided through one of the following programs: (1) Medicaid, (2) Medikids, (3) employee sponsored group health-insurance plans, (4) the Children’s Medical Services Network (CMS), or (5) FHKC. Health First alleged that FHKC erroneously determined that a special needs child known as Child Doe #3 could be enrolled in the FHKC program because she was ineligible to be enrolled in the CMS program due to her family’s income.2 The CMS program was specifically designed to cover children with special needs. As a result of the allegedly erroneous determination by FHKC, Health First claimed it was obligated to provide Child Doe #3 with medical care at a cost in excess of $300,000.00.
FHKC filed a motion seeking summary judgment claiming that Child Doe #3 was eligible to be enrolled in the FHKC program. In response, Health First argued that Child Doe #3 should have been enrolled in the CMS program for children with special needs; not FHKC. The trial court granted FHKC’s motion, finding that FHKC did not breach its contract with Health First by enrolling Child Doe #3 in the FHKC program through Health First’s Health Plan under section 409.814(5), Florida Statutes, for the period beginning May 1, 2003 through April 30, 2004. We disagree.
Sections 409.814(3) & (5) of the Florida Statutes provide as follows:
409.814. Eligibility
A child whose family income is equal to or below 200 percent of the federal poverty level is eligible for the Florida Kidcare program as provided in this section.
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(3) A child who is eligible for the Florida Kidcare program who is a child with special health care needs, as determined through a medical or behavioral screening instrument, is eligible for health benefits coverage from and shall be referred to the Children’s Medical Services network.***
(5) A child whose family income is above 200 percent of the federal poverty level or a child who is excluded under the provisions of subsection (4) may participate in the Florida Kidcare program, excluding the Medicaid program, but is subject to the following provisions:
(a) The family is not eligible for premium assistance payments and must pay the full cost of the premium, including any administrative costs.
(b) The agency is authorized to place limits on enrollment in Medikids by these children in order to avoid adverse selection. The number of children participating in Medikids whose family income exceeds 200 percent of the federal poverty level must not exceed 10 percent of total enrollees in the Medikids program.
(c) The board of directors of the Florida Healthy Kids Corporation is authorized to place limits on enrollment of these children in order to avoid adverse selection. In addition, the board is authorized to offer a reduced benefit package to these children in order to limit program costs for such families. The number of children participating in the Florida Healthy Kids program whose family income exceeds 200 percent of the federal poverty level must not exceed 10 percent of total enrollees in the Florida Healthy Kids program.
(d) Children described in this subsection are not counted in the annual enrollment ceiling for the Florida Kidcare program. . .
§ 409.814(3) & (5), Fla. Stat. (2001).
In its order granting summary judgment in favor of FHKC, the trial court concluded that a child must meet the financial eligibility component and be a special needs child in order to be eligible for CMS. The trial court supported its decision based on the difference between the words “eligible” which appears in section 409.814(3), and “participate” which appears in section 409.814(5). However, the trial court’s conclusion is refuted by the language set forth in section 409.814(5) which states that a child with a family income above 200% of the federal poverty level may participate in all of the Florida Kidcare Programs, excluding only the Medicaid program. This language necessarily leads to the conclusion that the only component of the Florida Kidcare Program that a child with an income level above 200% of the federal poverty level could not participate in is the Medicaid program. If the legislature intended to exclude participation in CMS under 409.814(5) it could have specifically expressed that intent. When read together, sections 409.814(3) and (5) allow an eligible child with special health care needs and a family income exceeding 200% of the federal poverty level to participate in CMS. As such, Child Doe #3 should have been referred to CMS as a special needs child.
Accordingly, the final summary judgment entered in favor of FHKC is reversed and this case is remanded for further proceedings consistent with this opinion.
REVERSED and REMANDED. (TORPY and EVANDER, JJ., concur.)
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1See §409.812, Fla. Stat. (2001).
2Child Doe #3 is a child with special needs whose family income allegedly exceeded 200% of the federal poverty level.
