vs. ) CASE NO. 84-0806
Respondent. )
A final hearing was held in this case in Tallahassee, on January 14, 1986. The issue is whether certain expenditures made by Petitioner, Marvin Brownlee, are covered and payable by the State of Florida under the Employees' Group Health Insurance Program administered by Respondent, Department of Administration.
For Respondent: Augustus D. Aikens, Jr., Esquire
Petitioner, Marvin Brownlee is a former State employee who was totally disabled in approximately June 1975 as a result of a spinal cord injury. As a result of the injury, Brownlee is paraplegic and suffers intermittent pain and incontinence of the bowels and bladder. Brownlee consequently retired on disability.
After completion of treatment of Brownlee's acute condition, Brownlee went to a rehabilitation center for further treatment and for training to control his bowels and bladder. The recommended method for control of his bowels taught to Brownlee included use of a suppository inserted rectally every other night and use of a bedpad, also known as underpads or chucks to catch and absorb excrement from Brownlee's bowels as he sleeps during the night.
The suppositories used in this bowel control method - dulcolax or generic bisacodyl - initially were described by Brownlee's physicians. They may be obtained without a prescription, and later Brownlee began to obtain them without a prescription. But Brownlee's physician, Dr. Frank Davis, has always considered the suppositories to be necessary for Brownlee's use in controlling his bowels.
Dr. Davis also recommends that Brownlee use stool softeners - surfak or generic colace - in connection with the method for bowel control taught to Brownlee under his supervision. Like the suppositories, Dr. Davis thinks stool
softeners are necessary for Brownlee's use in controlling his bowels. Surfak and colace are not prescription drugs but Davis has always prescribed them for Brownlee's use, and Brownlee has used Davis' prescriptions in obtaining them from a pharmacist.
Like the suppositories and stool softeners, Dr. Davis deems the bed underpads or chucks to be necessary for Brownlee's use as part of the overall method of controlling and caring for his bowels. However, there is no requirement of a prescription to obtain them, and Brownlee has never received or used a prescription to obtain them.
As a result of Brownlee's bladder disfunction, Drs. Davis and Webster have put Brownlee on a regular dosage of Mandelamine Unigrams to prevent urinary tract complications. Mandelamine Unigrams must be taken with something acidic, and Brownlee's doctors initially prescribed ascorbic acid tablets (Vitamin C) for use in connection with Mandelamine Unigrams. There is, of course, no prescription required to obtain ascorbic acid or Vitamin C tablets, and Brownlee later obtained them without a prescription. Drs. Davis and Webster deem the ascorbic acid or Vitamin C tablets to be necessary for use in connection with the Mandelamine Unigrams for preventing urinary tract complications.
Continuously since June 1975, Brownlee has been covered under the State Employees' Group Health Insurance Program in effect at the time. Over the years, Brownlee has submitted numerous claims to Respondent, Department of Administration, through its intermediary Blue Cross and Blue Shield of Florida, Inc., for coverage under the State of Florida Employees' Group Health Insurance Program. Several items Brownlee claimed were covered were not paid as being ineligible. Brownlee timely and diligently followed up each preliminary ruling of ineligibility and was led to believe by representatives of Respondent, Department of Administration, including some of its employees and representatives of Blue Cross and Blue Shield of Florida, Inc., that the methods he used to follow up--including telephone calls, correspondence and personal meetings with representatives of respondent--were adequate and sufficient to preserve Brownlee's right to have his claims considered on their merits. Brownlee relied upon and followed what he was led to believe was the proper course of action.
Included among the claims preliminarily ruled ineligible and not paid
are:
Date of
Purchase Item Quan. Amount 12-19-83 wheelchair repairs $17.50
9-7-82 | elastikon surgical tape | 12 | 15.62 |
6-19-81 | sterile exam gloves | 50 | 5.00 |
9-26-81 | skin prep | 1 | 5.90 |
1-2-81 | wheelchair repairs |
| 5.67 |
10-20-81 | " " |
| 15.60 |
10-26-81 | elastikon surgical tape | 1 box | 11.82 |
4-1-80 | elastikon tape | 1 box | 10.42 |
6-13-80 | wheelchair tires | 2 | 21.84 |
4-9-79 | sterilon connectors | 2 | .70 |
4-9-79 | surgical tubing | 3 ft. | 1.05 |
4-9-79 | urinary drainage bags | 2 | 6.00 |
6-11-79 | wheelchair arm rests | 2 | 16.30 |
9-13-79 | urinary drainage bags | 3 | 7.20 |
9-13-79 | skin bond | 2 | 4.70 |
9-13-79 | skin prep | 2 | 9.90 |
11-2-79 | urinary drainage bag | 1 | 4.75 |
6-13-78 | urinary drainage bag | 1 | 4.25 |
6-13-78 | elastikon surgical tape | 1 box | 10.40 |
7-25-78 | Jobst wheelchair cushion | 1 | 57.50 |
7-12-77 | elastikon surgical tape | 1 box | 9.00 |
7-12-77 | skin bond | 1 | 2.35 |
9-14-77 | wheelchair seat guide | 1 | 1.00 |
10-19-77 | wheelchair tires | 2 | 22.05 |
10-19-77 | urinary drainage bag | 1 | 4.05 |
10-19-77 | sterilon connectors | 2 | .70 |
At final | hearing, Respondent conceded that | the above items | are indeed eligible |
for reimbursement at the rate of 80 percent for a total of $217.02 of reimbursement. Of this total, $90.94 has already been paid to Brownlee, leaving a balance of $126.08 due and owing.
In addition, Brownlee's claims for the following items of expenditures preliminarily were ruled not payable as ineligible for payment:
Date of Purchase |
Item |
Quan. |
Amount |
3-31-83 | colace | 100 | $4.00 |
6-16-83 | " | 100 | 4.00 |
11-29-83 | " | 100 | 6.50 |
1-30-82 | colace | 40 | 2.10 |
2-18-82 | " | 90 | 4.50 |
9-7-82 | " | 100 | 5.00 |
9-23-82 | underpads-chucks | 30 | 8.00 |
12-13-82 | colace | 98 | 4.90 |
1-14-81 | underpads-chucks | 40 | 7.00 |
9-4-81 | colace | 30 | 2.10 |
10-9-81 | " | 30 | 2.10 |
11-13-81 | " | 30 | 2.10 |
12-11-81 | " | 60 | 4.00 |
1-23-80 | surfak | 100 | 11.70 |
1-23-80 | suppositories | 12 | 4.50 |
2-4-80 | ferrous sulfate | 100 | 2.75 |
2-4-80 | vitamin C | 100 | 2.00 |
3-7-80 | suppositories | 12 | 4.50 |
4-28-80 | vitamin C | 50 | 1.98 |
9-30-80 | surfak | 10 | 1.00 |
9-30-80 | underpads-chucks | 20 | 3.60 |
1-16-79 | bisacodyl suppositories | 12 | 4.50 |
1-31-79 | ascorbic acid |
| 100 | 2.00 |
1-31-79 | ferrous sulfate |
| 100 | 2.75 |
2-21-79 | bisacodyl suppositories |
| 12 | 4.50 |
4-5-79 | " " |
| 12 | 4.50 |
5-24-79 | " " |
| 12 | 4.50 |
6-14-79 | ferrous sulfate |
| 100 | 2.00 |
7-2-79 | surfak |
| 100 | 11.70 |
7-2-79 | bisacodyl suppositories |
| 12 | 4.50 |
7-10-79 | " " |
| 12 | 4.50 |
7-10-79 | underpads-chucks | 1 | box | 22.00 |
8-16-79 | bisacodyl suppositories |
| 12 | 4.50 |
8-16-79 | ferrous sulfate |
| 100 | 2.75 |
8-16-79 | ascorbic acid |
| 100 | 2.00 |
9-24-79 | bisacodyl suppositories |
| 12 | 4.50 |
10-15-79 | surfak |
| 100 | 11.70 |
10-15-79 | ascorbic acid |
| 100 | 2.00 |
10-30-79 | bisacodyl suppositories |
| 12 | 4.50 |
12-10-79 | ascorbic acid |
| 100 | 2.00 |
12-10-79 | bisacodyl suppositories |
| 12 | 4.50 |
1-21-78 |
ferrous sulfate |
|
100 |
2.75 |
1-24-78 | dulcolax suppositories | 12 | 4.50 |
2-20-78 | ascorbic acid | 100 | 2.00 |
2-20-78 | ferrous sulfate | 100 | 2.75 |
3-2-78 | dulcolax suppositories | 12 | 4.50 |
3-2-78 | surfak | 100 | 11.70 |
3-15-78 | ferrous sulfate | 100 | 2.75 |
4-4-78 | dulcolax suppositories | 12 | 4.50 |
4-13-78 | ascorbic acid | 100 | 2.00 |
4-13-78 | ferrous sulfate | 100 | 2.75 |
5-8-78 | dulcolax suppositories | 12 | 4.50 |
6-3-78 | ascorbic acid | 100 | 2.00 |
6-3-78 | surfak | 100 | 11.70 |
6-3-78 | ferrous sulfate | 100 | 2.75 |
6-7-78 | bisacodyl suppositories | 12 | 4.50 |
7-22-78 | " " | 12 | 4.50 |
7-22-78 | ascorbic acid | 100 | 2.00 |
7-22-78 | ferrous sulfate | 100 | 2.75 |
8-18-78 | bisacodyl suppositories | 12 | 4.50 |
9-11-78 | ascorbic acid | 100 | 2.00 |
9-11-78 | surfak | 100 | 11.70 |
9-11-78 | ferrous sulfate | 100 | 2.75 |
10-3-78 | bisacodyl suppositories | 12 | 4.50 |
10-25-78 | ascorbic acid | 100 | 2.00 |
10-25-78 | ferrous sulfate | 100 | 2.75 |
11-2-78 | bisacodyl suppositories | 12 | 4.50 |
12-11-78 | " " | 12 | 4.50 |
12-14-78 | ferrous sulfate | 100 | 2.75 |
12-23-78 | surfak | 100 | 11.70 |
The ferrous sulfate listed in the immediately preceding paragraph initially was prescribed by Brownlee's physicians while he was in the hospital but is not a drug for which a prescription is required in order for it to be obtained from a pharmacist. Brownlee took the ferrous sulfate for a while and then discontinued it. There was no evidence why the ferrous sulfate was prescribed.
There also was evidence of other items of expenditures during calendar year 1977, but there was insufficient evidence to establish how many of those items were ferrous sulfate as opposed to the other items on the list in paragraph 9. above.
Between January 21, 1978 and May 1, 1978, the State of Florida Employees' Group Health Insurance Program was underwritten and administered by Blue Cross and Blue Shield of Florida, Inc. Under the contract of group health insurance between Brownlee and Blue Cross and Blue Shield of Florida, Inc., it was provided under the major medical benefits portion of the policy:
"COVERED EXPENSES:
Expenses covered by this program include the customary and reasonable charged for all necessary services for the treatment of an injury or illness, in or out of the hospital that are prescribed by a licensed physician. These services are:
6. The following services and supplies deemed necessary by the attending physician:
Drugs and medicines which require written prescription by a physician and which must be dispensed by a licensed pharmacist;
Other medical services and supplies generally recognized as being required for treatment of the subscriber's disability
(as determined by a medical review committee of the Plans), except services or supplies received in a hospital or other institution which does not meet the definition of a "General Hospital".
Covered expenses shall be deemed to be incurred as on the date the service is rendered or the article is supplied."
Effective May 1, 1978, the State of Florida Employees' Group Health Insurance Program became a program of self-insurance underwritten by the State of Florida and administered by Respondent, Department of Administration, through Blue Cross and Blue Shield of Florida, Inc. Under the self-insurance program, the State of Florida contracted with Brownlee to provide the following pertinent benefits for medical and surgical care by a physician:
"20. COVERED MAJOR MEDICAL EXPENSES
(all other covered expenses)
The following services rendered both in and out of the Hospital for treatment of an Accident or Illness will be paid at 80 percent of the reasonable and customary charge,
after satisfaction of the deductible, when such services are deemed necessary by a Physician:
C. Drugs and medicines which require a written prescription by a Physician and which must be dispensed by a pharmacist,
including drugs and medicines for the treatment of mental and nervous conditions.
H. Other medical supplies, including durable medical equipment, for therapeutic treatment generally recognized as being required for treatment of the Insured's disability as determined by the Administrator.
CONCLUSIONS OF LAW
Under Section 110.123, Florida Statutes (1983), group health insurance plans are a part of the State employees group health insurance program administered by Respondent, Department of Administration. Respondent determines the benefits to be provided and the contributions to be required, prepares the specifications necessary to implement the program, and contracts on a competitive proposal basis with an insurance carrier or carriers.
Alternatively, Respondent may self-insure any plan or plans contained in the State employees' group health insurance program subject to actuarial soundness.
On the relevant dates before May 1, 1978, Respondent contracted with Blue Cross & Blue Shield, Inc., as both underwriter and administrator of the State of Florida Employees' Group Health Insurance Program. Effective May 1, 1978, Respondent initiated a program of health self-insurance to meet the obligations of the State of Florida to its employees.
As reflected in the Findings Of Fact, the pertinent coverages under both group health insurance plans were essentially the same. Drugs and medicines are covered only when they require written prescription by a physician. By the plain meaning of the words, "medicines and drugs" are not "medical services and supplies." In addition, by expressly mentioning coverage for "medicines and drugs" that require a prescription, the coverage reflects an intention to exclude from coverage "medicines and drugs" that do not require a prescription. Finally, the same intention is reflected by the express mention of coverage for "medicines and drugs." There would be little reason to expressly mention them if the "medical services and supplies" language were intended to include them.
As prescribed by Brownlee's doctors in this case, the suppositories, stool softeners, and ascorbic acid tablets are considered medicines and are not covered regardless whether the doctors deem them medically necessary. Cf. Bertens v. Stewart, 453 So.2d 92 (Fla. 2nd DCA 1984).
The bed underpads or chucks qualify for coverage as other medical supplies." They are deemed by Brownlee's physicians to be necessary for use in connection with the method they have prescribed for Brownlee to control his bowels. As such, they are used for therapeutic treatment generally recognized as being required for treatment of Brownlee's disability. This is true even though the specific role they play in the treatment is to catch and absorb Brownlee's excrement during sleep. Brownlee's expenditures for bed underpads or chucks total $40.60, and the reimbursable 80 percent totals $32.48.
Based upon the foregoing Findings Of Fact and Conclusions Of Law, it is recommended that Respondent, Department of Administration, enter a Final Order that Petitioner, Marvin Brownlee, is owed a total of $158.56 under the State of Florida Employees' Group Health Insurance Program consisting of $126.08 of expenditures previously conceded to be eligible coverage but not yet paid, plus
$32.48 of expenditures for bed underpads or chucks determined after final hearing to be covered.
RECOMMENDED this 10th day of February, 1986, in Tallahassee, Florida.
J. LAWRENCE JOHNSTON Hearing Officer
Filed with the Clerk of the Division of Administrative Hearings this 10th day of February, 1986.
APPENDIX TO RECOMMENDED ORDER, CASE NO. 84-0806
1-2. Covered by Finding 1.
4-6. To the extent necessary and relevant, covered by Findings
8 through 11.
evidence. See Findings 2 and 5. (The part on prescription drugs is covered by Findings 3 through 6 and 10.)
Augustus D. Aikens, Esquire Department of Administration
