vs. ) CASE NO. 84-0462RP
Respondent. )
Pursuant to notice, the Division of Administrative Hearings, by its duly appointed Hearing Officer, R. T. Carpenter, held hearings in this cause on March 20, 1984, in Jacksonville, Florida, and on April 3, 1984, in Tallahassee, Florida. The issue for determination in this proceeding is whether Respondent's proposed Rule 10C-7.65, Florida Administrative Code (F.A.C.) constitutes an invalid exercise of delegated legislative authority.
For Petitioners: Marilyn G. Rose, Esquire
Amy E. Hirsch, Esquire Jacksonville Area Legal Aid 5566 Avenue "B"
For Respondent: Theodore E. Mack, Esquire
Office of the General Counsel 1323 Winewood Boulevard Building One, Suite 407 Tallahassee, Florida 32301
Petitioners challenge the validity of Respondent's proposed Rule 10C-7.65, F.A.C., which establishes a program of recipient case management in the Florida Medicaid Program. The procedures will allow Respondent to screen frequent users of Medicaid services for possible abuses. Those selected for case management would receive counseling and supervision over their utilization of health care services. The challenged rule and economic impact statement were published in the Florida Administrative Weekly on January 27, 1984.
In support of their position of invalidity, Petitioners presented the testimony of Charles W. Smithers, Jr., accepted as an expert certified public accountant, specifically in the field of hospital financing and reimbursement; John Patrick Plumlee, Ph.D., accepted as an expert in the field of public administration; Margaret Mary McKibben, M.D.; and Annie Elizabeth Kearse, Petitioner.
Respondent, Department of Health and Rehabilitative Services presented the testimony of James Conn, M.D.; Erwin Peter Bodo, Ph.D., its Medicaid Program Integrity Administrator who was accepted as an expert in statistics, specifically in the area of cost benefit analysis as it relates to economic impact statements, and also as an expert in Medicaid management, utilization and reimbursement; and Jane McLeod, a Senior Human Services Program Specialist in the Medicaid Program and the project director for Medicaid recipient case management.
Both Petitioners are recipients of Medicaid benefits who have medical problems requiring medical care for which reimbursement will be sought under the Medicaid program. Neither has been identified for recipient case management, but both are frequent users and thus are potentially eligible for supervision under the proposed rule.
Petitioner Annie Elizabeth Kearse is a 67 year old woman who suffers with heart, diabetes, and thyroid problems. She takes between seven and ten different prescribed drugs plus a prescription for insulin syringes, and had not, at the time of the hearing, filled an additional prescription because she lacked the money to pay for it and her alternative source for prescription drugs (University Hospital) could not provide it. During a recent six week period she used physician office services on eight occasions, and was treated on these occasions by more than one physician. She has used the hospital outpatient department on a weekend for services which are "medically necessary" but would not qualify as "emergency" under the definition in the proposed rule.
Petitioner Christina Youngblood is a 39 year old woman, confined to a wheelchair, who suffers from the present effects of polio as a child, has had 16 operations, has diabetes, and suffers with serious kidney problems. She takes at least nine different prescribed drugs, requiring at least ten prescriptions, and has at least three different physicians. She needs special transportation to obtain medical services, and has experienced difficulty in the past obtaining such transportation.
In 1970, the State of Florida began its participation in Medicaid, a joint federal and state program to provide medical services to the indigent. The Medicaid program is voluntary for the State, the providers who agree to participate, and those recipients who receive benefits. Once a state agrees to participate in the program, it must provide specified services and abide by certain regulations.
As a part of the federal requirements, the state is required to maintain the Office of Program Integrity to assure that the funds are expended on behalf of recipients for appropriate services in a proper manner, to detect fraud and abuse, and to educate providers and recipients through those efforts.
Program Integrity looks at the quality and quantity of services and the appropriateness of those services. Determinations are made on the basis of medical necessity. As a part of this review, the federal government requires Program Integrity to study recipient utilization patterns, identify those outside the norm, and assist those recipients who need help.
Although the Florida Medicaid Program has long had a surveillance and utilization review subsection (SURS) to monitor the utilization patterns, it lacked the funds and positions to assist recipients. Only in certain areas such as early periodic screening and diagnostic treatment for children was case management put into effect. Overall recipient case management was carried out on a limited basis by referring recipients to district offices for unspecified assistance.
Even though its ability to assist recipients was restricted by funding limitations, the Medicaid Program had considered the possibility of recipient case management for some time. In 1981, the federal government, in an attempt to control escalating costs of public assistance, implemented the Omnibus Reconciliation Act which allowed increased state flexibility and authorized the Secretary of the Department of Health and Human Services (HHS) to waive certain requirements to allow the states to implement innovative approaches to control utilization. In accordance with this authorization, the Health Care Financing Administration (HCFA) of HHS sponsored a request to the states for proposals. The Florida Medicaid Program responded with the Alternative Health Plan. In that plan, "Module B" was presented which set forth recipient case management.
HHS accepted Florida's Alternative Health Plan and established a grant to fund recipient case management. That grant paid for one of three proposed demonstration sites and personnel located at the headquarters office. The other sites are to be funded with marching state and federal funds. In order to receive the required waivers for implementation, the Medicaid Program submitted a detailed Protocol to HCFA which in essence is a performance contract. In accepting the Protocol, HCFA granted the requested waivers of statewideness, freedom of choice, and confidentiality.
Respondent thereafter proposed the challenged rule to meet state requirements and set forth the guidelines for recipient case management. In developing this rule, discussions were held with various affected groups, including the Medicaid Advisory Council which contains recipients and the Florida Medical Association. Although questions were raised by community mental health providers, those questions were answered with apparent satisfaction and no one requested a public hearing.
At present, the three demonstration sites proposed are Hillsborough, Duval, and Orange counties. Although these demonstration sites will be managed differently, each will have registered nurses as case managers and each will have physician consultants. One-hundred recipients will be selected for each site with a one-hundred recipient comparison group being referred throughout the state to districts without demonstration sites,
In choosing the recipients to be selected for recipient case management, SURS statistical data is being used to look for recipients whose utilization is above the norm in certain categories of benefits. The parameters set forth in the rule for this first stage of selection are sufficiently high to except out only those recipients in the ninety-ninth percentile of each group. For example, the average recipient has less than one physician office visit per quarter, but the computer will except out only recipients who have nine or more
office visits per quarter. To further assist in the process of narrowing the possible candidates for recipient case management, the computer ranks and weighs the exceptors and prints out summary profiles. Recipients may also be initially identified by other referrals.
Working from the computer list which has narrowed the candidates down to a manageable number, recipient analysts will look for a pattern of questionable utilization in the summary profiles which may indicate a lack of medical necessity. Costs screened by the recipient analysts will be reviewed by a registered nurse consultant and a physician consultant for medical necessity. Recipients picked by this process are enrolled in the program and referred to local case managers who review the data and discuss the matter with the recipient. If at this stage the recipient's utilization is justified, the recipient is dis-enrolled from the program. If inappropriate utilization is verified, the recipient remains in level one of recipient case management.
Level one consists of education and counselling to assist the recipient in obtaining only medically necessary services. Should the recipient fail to respond to such education and counselling, he or she is then moved to level two for more intensive counselling and may be required to pick up the Medicaid card at the case manager's office in order to assure the recipient's presence for such counselling.
Should counselling fail to alter the recipient's pattern of misutilization, the recipient is moved to level three which is referred to as "prior authorization". At this level, while the recipient still retains a freedom of choice of providers, he or she must contact the case manager prior to obtaining medical services in order to receive Medicaid reimbursement. The recipient continues to make his own health care decisions, but the case manager attempts to guide him in making appropriate decisions. To obtain payment authorization for the services, the provider must. also contact the case manager. Emergency services require no prior authorization. If care is sought when the case manager cannot be reached, the provider may contact the case manager later to obtain payment authorization.
Should prior authorization fail to correct the recipient's misutilization, the recipient is moved to level four of recipient case management in which he or she is "locked in" to a primary care provider. The primary care provider will either provide the necessary care or refer the recipient to other providers. The recipient must go through the primary care provider for services in order to receive Medicaid reimbursement. The primary care provider concept is medically recognized but there is no strict limitation on who may act as a primary care provider. Under the rule, all primary care providers will be physicians, have physicians on staff, or act under the direction of a physician.
Change of status from one level to the other and enrollment or dis- enrollment from the program are based upon recommendations of the case manager with the final decision resting with the program office. Decisions are based upon a pattern of utilization of medically necessary services. At the initial enrollment into the case management program and at all changes from level to level, the recipient is informed of his or her hearing rights in accordance with the Department of Health and Rehabilitative Services' procedures.
Currently, thirty-nine states have recipient case management of one type or another. Thirty-seven have lock-in which is the easiest to administer. Only two or three states rely on prior authorization which is difficult to administer. Florida's proposed system is unique since it applies all facets of case management. Prior authorization is not new to Florida's Medicaid Program since at one time all Medicaid reimbursement in Florida had to be authorized in advance. Currently, elective surgery, excess drug grants and new procedures must be authorized in advance. Limited prior authorization exists in every state Medicaid Program.
Medicaid is a self-referral system with no limitation on the number of different providers a recipient may see. This can cause problems where a recipient does not make appropriate judgments regarding his or her medical care. If a person is seeing more than one physician, for example, and has informed neither physician of that fact, duplication of drugs or the prescription of contraindicated drugs may result. The misutilization of emergency rooms for
non-emergency care is another example of a potential problem in a self-referral system.
Recipient case management is basically a limitation on the payment for medical services once a recipient reaches levels three and four. Such limitations occur throughout Medicaid and are authorized by federal regulations. For instance, Medicaid will only reimburse for one physician visit per day. If the recipient wishes to make other physician visits in a single day, the recipient is responsible for payment. Under recipient case management a recipient may receive all of the medical care he or she wants. Medicaid, however, will not be responsible for payment of those services that are not medically necessary.
Although recipient case management is intended to assist both over and under utilizers of medical services, there is no specific proposal to detect underutilization. Overutilizers are to be addressed by the program first, with development of methods to detect and assist underutilizers to follow.
Respondent's economic impact statement is deficient in the area of program costs as well as program savings. With respect to the latter, Respondent cites a savings in Minnesota "in excess of $5,000 per year for enrolled recipients." (Petitioner's Exhibit 6). This figure is erroneous in that the claimed savings in Minnesota were for a two year period and were thus only 50 per cent of the amount cited by Respondent.
Respondent's use of "the most conservative Texas estimate of $1,200 .
. . " is likewise erroneous. The figure claimed by Texas was $1,065, which Respondent arbitrarily increased to $1,200 because of the additional Florida components. Further, Respondent's reliance on claimed savings in other states was not based on any detailed analysis of such data.
The projected savings to the State of $159,192 is misleading and not an acceptable representation of anticipated benefits. Respondent's estimated cost to the State is $74,935 (25 per cent of the total $302,000 cost), while the savings is estimated to be $159,192 (44 per cent of the total $350,000 savings). Thus, these figures indicate that the State is "saving" substantially more than net program savings which are only estimated to be $58,000. This anomaly apparently results from the federal grant which would apply to the initial phase of this program.
Respondent included the estimated salaries for only those personnel who will be primarily employed in this project. No additional costs were recognized for the support to be provided by others, such as secretaries and supervisors, who are now in place. The additional costs for analysts and medical consultants at the headquarters office were omitted.
Respondent stated only those costs involved in setting up the demonstration program (Orange, Duval and Hillsborough counties) However, the program may become statewide and Respondent has already requested legislative authority to expand the program to Dade and Broward counties.
The additional cost to medical providers was not addressed in the Economic Impact Statement. Such costs would include the additional time required to obtain prior authorization for services and the documenting of emergency care. In some instances this added cost may discourage providers from further participation in the Medicaid Program. However, this is unlikely given the small percentage of Medicaid patients who would be so involved.
Costs to recipients in time and transportation to attend counselling and education sessions were not reflected in the Economic Impact Statement. However, Respondent did consider such costs and correctly determined they would not be significant.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over the subject matter of, and the parties to, this proceeding. Section 120.54, Florida Statutes.
Section 120.54(4)(a), Florida Statutes, provides that:
Any person substantially affected by a rule may seek an administrative determination of the invalidity of the rule on the ground that the rule is an invalid exercise of delegated legislative authority.
Petitioners demonstrated they are persons likely to be identified and subjected to recipient case management because of their use of multiple providers, frequency of medical treatment and substantial use of prescription drugs. If so selected, their freedom of provider choice could be reduced and they could be subjected to the inconvenience of traveling to counselling sessions and obtaining prior authorization, for medical treatment.
Sections 409.026 and 409.266, Florida Statutes control the conduct of the Respondent, Department of Health and Rehabilitative Services, in carrying out the Medicaid program in the State of Florida. Specifically, Section 409.026(1) states:
The department shall conduct, supervise, and administer all social and economic services within the state which are or will be carried on by the use of Federal or state funds or funds from any other source and receive and distribute food stamps and commodities donated by the United States or any agency thereof. . . .
Section 409.026(6)(b) further states:
(b) The department may:
(6) Act as agent of, or contract with, the Federal Government, state government, or any county or municipal government in the conduct and administration of social and economic services activities in securing the benefits of any public assistance that is available from the Federal Government or any of its agencies and in the disbursement of funds received from the Federal Government, state government, or any county or municipal government for social and economic services purposes within the state, . . .
Regarding medical assistance, Section 409.266 states:
The department is designated at the state agency responsible for the administration of Medicaid funds under Title XIX of the Social Security Act and, to the extent monies are appropriated, is authorized
to provide payment for medical services to any person . . .
* * *
The department is authorized to:
(a) Enter into such agreements with appropriate agents, other state agencies, or any agency of the Federal Government and accept such duties in respect to social welfare or public aid as may be necessary or needed to implement the provisions of Title XIX of the Social Security Act pertaining to medical assistance.
The above powers authorize the Department to implement its Medicaid program and disburse benefits in the way it deems appropriate, so long as it is in compliance with federal law.
Where federal law is controlling, the rule in question must be in accord with the federal statutes. See, Farmworkers Rights Organization, Inc. v. State Department of Health and Rehabilitative Services, 430 So.2d 1 (Fla. 1st DCA 1983). In the instant case, applicable federal law is contained in Title XIX of the Social Security Act entitled Grants to States for Medical Assistance Programs, 42 United States Code 1396. Pursuant to this law, a state is required to meet certain minimum requirements before its plan for medical assistance is approved for participation in the Medicaid program. In implementing the federal law, the Federal Government has promulgated rules setting forth the requirements for medical assistance (42 Code of Federal Regulations, Chapter 4). Florida's State Plan has been approved as evidenced by its participation in the Medicaid Program and Florida must therefore comply with the federal regulations.
In 1981 the Federal Government enacted the Omnibus Budget Reconciliation Act (Public Law 97-35) which, in part, amended portions of the Social Security Act and increased flexibility for states to implement programs
under Medicaid. As a result of these changes, the federal regulations were also amended. Specifically, the amendments allowed exceptions to certain state plan requirements and authorized the waiver of certain Medicaid requirements upon request. In order to implement its recipient case management system under an approved federal grant, the Florida Medicaid Program applied for and was granted waivers of the following regulations:
Section 431.50 Statewide operation.
Basis and purpose. This section implements section 1902(a)(1) of the Act, which requires a State plan to be in effect throughout the State, and Section 1915, which permits certain exceptions.
State plan requirements. A State plan must provide that the fol- lowing requirements will be met:
The plan will be in operation statewide through a system of local offices, under equitable standards for assistance and administration
that are mandatory throughout the State.
If administered by political subdivisions of the State, the plan
will be mandatory on those subdivisions.
The agency will assure that the plan is continuously in operation in all local offices or agencies . . .
Section 431.51 Free choice of providers.
Basis and purpose. This section implements section 1902(a)(23) of the Act, which provides that recipients may obtain services from any qualified Medicaid provider, and section 1915 of the Act, which provides that a State shall not be found out of compliance with section 1902(a)(23) solely by reason of certain specified allowable restrictions of this free choice (see paragraph (c) of this section and
Section 431.54) and which authorizes the Secretary to waive the requirements of section 1902(a)(23), and other provisions of the Act, in certain circumstances (see Section 431.55)
State plan requirement. Except as provided in paragraph (c) of this section, a State plan (except in Puerto Rico, the Virgin Islands, and Guam) must provide that any recipient may obtain
Medicaid services from any institution, agency, pharmacy, person, or organization that is qualified to perform the services, including an
organization that provides these services or arranges for their availability on a prepayment basis.
* * *
Section 431.306 Release of information.
The agency must have criteria specifying the conditions for release and use of information about applicants and recipients.
Access to information concerning- applicants or recipients must be re- stricted to persons or agency repre- sentatives who are subject to standards of confidentiality that are comparable to those of the agency.
The agency must not publish names of applicants or recipients.
The agency Thust obtain permission from a family or individual, whenever possible, before responding to a request for information from an outside source. If, because of an emergency situation, time does not permit obtaining
consent before release, the agency must notify the family or individual immediately after supplying the information.
The agency's policies must apply to all requests for information from outside sources, including governmental bodies, the courts, or law enforcement officials.
If a court issues a subpoena for a case record or for any agency repre- sentative to testify concerning an applicant or recipient, the agency
must inform the court of the applicable statutory provisions, policies, and regulations restricting disclosure of information.
In implementing its recipient case management system, Florida's Medicaid Program is operating under the following pertinent sections of 42 Code of Federal Regulations:
Section 456.-23 Post-payment review process.
The agency must have a post-payment review process that -
Allows State personnel to develop and review -
Recipient utilization profiles;
Provider service profiles; and
Exceptions criteria; and
Identifies exceptions so that the agency can correct misutilization practices of recipients and providers.
Section 431.54 Exceptions to certain State plan requirements.
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(e) Lock-in of recipients who over- utilize Medicaid services. If a Medicaid agency finds that a recipient has utilized Medicaid services or items at a frequency or amount that is not
medically necessary, as determined in accordance with utilization guidelines established by the State, the agency may restrict that recipient for a reasonable period of time to obtain Medicaid services or items from designated providers only. The agency may impose these restrictions provided that:
The agency gives the recipient notice and opportunity for a hearing (in accordance with procedures established by the agency) before such restrictions are imposed.
The agency assures that the recipient has reasonable access (taking into account geographic location and reasonable travel time) to Medicaid services of adequate quality.
The restrictions will not apply to emergency services furnished to the recipient.
Section 431.55 Waiver of other Medicaid requirements.
* * *
Case-management system. Waivers of appropriate requirements of sections 1902 and 1903(m)(as permitted
under paragraph (h) of this section) of the Act may be authorized for a State to implement a primary care case-
management system or specialty physician services arrangements which restricts the provider from or through whom a recipient can obtain medical care services (other than in emergency cir- cumstances) provided that those restrictions do not substantially
impair access to such services of ade- quate quality where medically necessary.
Under a primary care case-management system the agency assures that a specific person or persons or agency will be responsible for locating, coordinating,
and monitoring all primary care or primary care and other medical care and rehabilitative services on behalf of a recipient.
A specialty physician services arrangement allows States to restrict recipients of specialty services to designated providers of such services, even in the absence of a primary care case-management system.
Section 440.230 Sufficiency of amount, duration, and scope.
* * *
The agency may place appropriate limits on a service based on such criteria as medical necessity or on utilization control procedures.
Under 42 U.S.C. Section 1396a(b), state plans are subject to federal approval to assure compliance with federal requirements. Testimony produced at the hearing in this cause showed that the proposal being challenged was submitted to, and approved by, the federal regulating agency.
Petitioners failed to carry their burden of showing that Respondent exceeded its authority under the federal regulations given the fact that certain specific waivers of those regulations were granted to implement recipient case management. Likewise, Petitioners failed to prove that the requirements of the rule are not reasonably related to the purpose of the enabling legislation, that is, correction of misutilization practices through restrictions and limitations of services.
What the Petitioners are actually challenging here is the wisdom of the methods chosen by the Department to correct misutilization of health services reimbursed by Medicaid. The fact that the methods chosen may be imperfect, unwise or even out of harmony with a particular school of thought is not grounds for invalidating the discretionary action of an agency which is otherwise acting within its authority.
It is apparent from the state statutes, federal statutes and federal regulations that the challenged rule is consistent with the Respondent's delegated legislative authority. As limitations on the services which Medicaid will provide, the requirements set forth in the rule are no more restrictive than other limitations and exclusions implemented by the Florida Medicaid Program and authorized by the federal government. Petitioners specifically questioned the requirement of prior authorization and the selection of primary care providers.
Concerning prior authorization, testimony presented at hearing revealed that prior authorization is used in all state Medicaid programs, was once in effect for all services in the State of Florida, and is currently in use, pursuant to federal regulations, for approval of reimbursement for certain services in the Florida program. Furthermore, 42 U.S.C. Section 1396a specifically states that a state plan for medical assistance must:
. . . (4) provide (A) such methods of administration . . . as are found by the Secretary to be necessary for the proper
and efficient operation of the plan . . . and:
. . . (30) provide such methods and procedures relating to the utilization of, and the payment for, care and services available under the plan as may be nec- essary to safeguard against unnecessary utilization of such care and service. . .
Prior authorization has been generally accepted as a recognized method, of carrying out these requirements and Florida's use of prior authorization has been specifically accepted by the Secretary of HHS through the Federal Government's approval of the Florida Medicaid Program's system of recipient case management.
Concerning the qualifications of those persons or agencies selected as primary care providers, the federal regulations place no requirement on who may be a primary care provider. 42 CFR Section 431.54(e), merely refers to "designated providers." That regulation only requires that recipients receive notice and opportunity for a hearing (which the rule provides for at 10C-7.65
(14) F.A.C.), that the recipient have reasonable access (geographically to adequate services (which the rule provides for at 10C-7.65(8)(d) 2), and that restrictions not apply to emergency services (which the rule exempts at 10C- 7.65(8) 11).
In evaluating the reasonableness of the rule's requirements for primary care providers, the evidence shows that all primary care providers will either be physicians, have physicians on staff (Medicaid Rule 10C-7.51(3)(a)3
F.A.C. requires a physician on the staff of a rural health clinic; Medicaid Rule 10C-7.525(3)(a) F.A.C. requires a psychiatrist on staff or under contract with a community mental health services provider) or be under the supervision of a physician (Medicaid Rule 10C-7.52(3)(a) F.A.C. requires an advanced registered nurse practitioner to be working in collaboration' with a physician).
The fact that a physician will either be the primary care provider or working with the primary care provider is reasonable and allows the Medicaid program flexibility to insure that the recipients who are locked in to primary care providers will receive the care necessary to meet their specific needs. In addition, since 42 CFR Section 431.54(e)(2) requires geographic accessibility, a broader range of primary care providers will allow the Medicaid program to meet that requirement.
Petitioner's due process and right to privacy arguments are without merit. The proposed rule provides ample hearing opportunities in addition to those available under Section 120.57(1), Florida Statutes. Exceptions to privacy and confidentiality of patient medical information are the subject of waivers granted by the federal, government and are limited to those essential to implement recipient case management.
42 CFR s. 431.55(b) requires data on the cost effectiveness of a project where, as here, waivers are required. Section 120.54 (2)(a) Florida Statutes, requires each agency to prepare a detailed economic impact statement as a condition to promulgation of any rule. This section further provides:
The economic impact statement shall include:
An estimate of the cost to the agency of the implementation of the proposed
action, including the estimated amount of paperwork;
An estimate of the cost or the eco- nomic benefit to all persons directly affected by the proposed action;
An estimate of the impact of the pro- posed action on competition and the open market for employment, if applicable; and
A detailed statement of the data and method used in making each of the above estimates.
Respondent's Economic Impact Statement lacks the detail and thoughtful preparation contemplated by Section 120.54(2), Florida Statutes. See State Department of Health v. Framat Realty, Inc., 407 So.2d 238, 242 (Fla. 1st DCA 1981). However, Petitioners have not demonstrated that deficiencies in the Economic Impact Statement have impaired the fairness of the proceedings or the correctness of the action proposed. Therefore, such deficiencies as exist constitute harmless error. See Department of Health and Rehabilitative Services v. Wright, 439 So.2d 937, 940 (F1a. 1st DCA 1983).
Petitioners have failed to establish that Department of Health and Rehabilitative Services proposed Rule 10C-7-65, Florida Administrative Code, constitutes an invalid exercise of delegated legislative authority, and the Petition for Determination of Invalidity of Rule is accordingly DISMISSED.
DONE and ORDERED this 31st day of May, 1984, in Tallahassee, Florida.
R. T. CARPENTER Hearing Officer
Filed with the Clerk of the Division of Administrative Hearings this 31st day of May, 1984.
Marilyn G. Rose, Esquire Jacksonville Area Legal Aid 604 Hogan Street
Amy E. Hirsch, Esquire Jacksonville Area Legal Aid 5566 Avenue "B"
Theodore E. Mack, Esquire Office of the General Counsel 1323 Winewood Boulevard Building One, Suite 407 Tallahassee, Florida 32301
