Pediatric Associates, Florida\u2019s largest pediatric provider, is sounding the alarm about a change by the state that could make it difficult for doctors to treat children who are insured through Medicaid in the future.<\/p>\n
And it\u2019s suing to stop that from happening.<\/p>\n
The group, which has over 95 locations across the state, claims in a lawsuit filed Tuesday that the problem stems from a 2025 change the state made to the funding formula that establishes how much providers will be reimbursed for Medicaid services.<\/p>\n
The administrative petition says the \u201cflawed\u201d methodology created by the Florida Agency of Health Care Administration has led to doctors being paid less than they had been before for treating kids insured through Medicaid.<\/p>\n
The move, which has led to severe reimbursement reductions in pediatric care, has forced some pediatricians to reduce or discontinue Medicaid services, making it harder for kids to get the care they need, the lawsuit alleges. Others, like those with Pediatric Associates, are taking some financial loss, at least for now, every time medical care is provided to a child who\u2019s insured through the government-funded health insurance.<\/p>\n
But Pediatric Associates in its lawsuit warns that unless a fix is made soon, it may be forced to stop providing some or all services to kids with Medicaid, a decision it described as having \u201cdevastating consequences to its Medicaid patients.\u201d<\/p>\n
The provider says it currently serves over 300,000 children, or about 15% of Florida\u2019s pediatric Medicaid population, more than any other healthcare provider in the state. But the reimbursement changes, the pediatric provider claims, make it \u201ceconomically infeasible\u201d to continue treating pediatric Medicaid patients.<\/p>\n
\u201cIf the children I care for every day lose access to pediatric care, it would be absolutely devastating,\u201d Dr. Rasciel Socarras, a North Miami-based physician with Pediatric Associates, said in a news release. \u201cI know from experience that if action is not taken, more families will end up relying on emergency rooms for everyday care \u2014 or worse, skipping care entirely. The funding miscalculation we are asking the state to correct is fixable, and fixing it matters for every Medicaid-insured child in Florida, not just the ones in my practice.\u201d<\/p>\n
Florida\u2019s Agency for Health Care Administration, which administers the state\u2019s Medicaid program, told the Miami Herald it \u201cdoes not comment on pending litigation.\u201d<\/p>\n
Medicaid, a joint state and federal health insurance program, provides coverage to millions of kids, pregnant women, seniors and people with disabilities in Florida, including in Miami-Dade and Broward, home of the highest enrollments in the state.<\/p>\n
What\u2019s the problem?<\/p>\n
Michael Manocchio, market president for Pediatric Associates East Region, told the Herald on Tuesday afternoon that the problem comes from changes that were made to the reimbursement formula.<\/p>\n
Under the new formula, millions of dollars that were initially meant to pay doctors for providing primary, specialty and acute primary care to pediatric Medicaid patients are now instead being set aside to pay for behavioral health services, particularly for those with autism spectrum disorder, according to Manocchio.<\/p>\n
The prevalence of autism continues to rise in the country, with one in 31 kids estimated to have autism<\/a>, according to the U.S. Centers for Disease Control and Prevention. In Florida, which has some of the highest autism prevalence in the nation among adults and kids, about 41,000 children are estimated<\/a> to receive applied behavioral analysis therapy through Medicaid, according to Tampa Bay 28. Medicaid covers autism therapy for eligible patients until age 21.<\/p>\n Manocchio told the Herald that Pediatric Associates supports evidence-based autism therapy and has its own efforts to help kids get the needed care. But the company takes issue with how Florida has allocated the funding. He said the allocation doesn\u2019t account for factors that can impact how often services are used in a given area and how much the provided services cost.<\/p>\n South Florida, for example, has \u201cfar higher\u201d autism therapy utilization rates compared to other parts of the state but was underfunded for both autism and non-autism pediatric care, according to Pediatric Associates\u2019 lawsuit.<\/p>\n Miami-Dade pediatricians have also seen a nearly 30% reduction in funding for \u201ccore\u201d pediatric services, which more children need compared to autism therapy, according to the lawsuit. \u201cCore\u201d pediatric services encompass all types of care, including primary services such as checkups and vaccinations, specialty care for diabetes and other conditions, and acute care for severe illnesses.<\/p>\n Autism therapy is the second-highest funded line item in the state\u2019s Medicaid budget, at approximately $2 billion annually, even though most children do not have the disorder, according to Pediatric Associates.<\/p>\n The state previously allocated $198 per child ages 1 to 13 per month for \u201ccore\u201d pediatric services and $91 per child per month for autism therapy. After the November 2025 \u201cfix,\u201d it now allocates $141 per child per month for non-autism therapy pediatric care and $147 per child per month for autism therapy services, according to the court document.<\/p>\n For families, that means there\u2019s a risk their pediatricians will reduce the number of core services he or she is willing to offer Medicaid patients \u2014 or that they will stop treating Medicaid patients altogether, according to Manocchio.<\/p>\n \u201cIt becomes that much harder to get an appointment. It becomes that much harder to get to develop a trusted relationship with a doctor. Maybe it means going to the emergency room more,\u201d Manocchio said, describing it as a problem that could impact the access and quality of care patients can receive, similar to how patients with commercial health plans sometimes need to find new doctors if their existing provider goes out-of-network.<\/p>\n Florida\u2019s Agency for Health Care Administration is responsible for creating the \u201crate calculations\u201d that determine how much providers are paid for providing care to children with Medicaid.<\/p>\n The federal Centers for Medicare and Medicaid Services (CMS) has to give the green light before states can adjust rates, but Pediatric Associates believes the federal agency did not have enough details to detect the reimbursement issues. The Herald has contacted CMS for comment.<\/p>\n Pediatric Associates said it met with the state agency at least five times between January and May 2026 but that \u201cwhile AHCA has acknowledged the importance of the problem, it has taken no action to mitigate, let alone solve, this problem.\u201d The lawsuit points to a letter from the state agency that appears to indicate it was aware the change would have \u201cthe potential to result in access issues for children in Florida Medicaid to the extent a provider experiences significant financial loss and is unable to continue to provide services.\u201d<\/p>\n The state agency, in the letter, said it expects managed care organizations \u2014 health companies or health plans that are paid by the state to contract providers to provide services to Medicaid patients \u2014 to independently negotiate \u201cmutually agreeable terms\u201d with providers to help doctors navigate any potential financial fallout with the inclusion of autism therapy services in their contract.<\/p>\n Manocchio said the problem is that those groups often declined to negotiate, telling pediatricians that they were following the rates set up by the state, while also being paid more under the new reimbursement rates for any adults undergoing autism therapy.<\/p>\n What happens now?<\/p>\n Manocchio said Pediatric Associates is dedicated to caring for its patients and that he\u2019s confident the state will \u201cultimately do the right thing.\u201d<\/p>\n But, if it doesn\u2019t get fixed, \u201cthen certainly there are hard decisions we would have to make,\u201d he said.<\/p>\n For now, Pediatric Associates is asking the judge to restore funding for pediatric care. It wants the state agency to revise or revert the existing rate calculation to \u201caccurately reflect\u201d when autism therapy services \u201care actually used.\u201d It also wants the state agency to \u201capply correct rates to 2026-2027,\u201d part of a budgetary process that is now being finalized.<\/p>\n","protected":false},"excerpt":{"rendered":"Pediatric Associates, Florida\u2019s largest pediatric provider, is sounding the alarm about a change by the state that could…\n","protected":false},"author":2,"featured_media":323317,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[6],"tags":[133872,28,30,29,13120,133871,84819],"class_list":["post-323316","post","type-post","status-publish","format-standard","has-post-thumbnail","category-florida","tag-autism-therapy","tag-florida","tag-florida-headlines","tag-florida-news","tag-medicaid","tag-pediatric-associates","tag-pediatric-care"],"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/us-fl\/wp-json\/wp\/v2\/posts\/323316","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/us-fl\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/us-fl\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us-fl\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us-fl\/wp-json\/wp\/v2\/comments?post=323316"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/us-fl\/wp-json\/wp\/v2\/posts\/323316\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us-fl\/wp-json\/wp\/v2\/media\/323317"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/us-fl\/wp-json\/wp\/v2\/media?parent=323316"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/us-fl\/wp-json\/wp\/v2\/categories?post=323316"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/us-fl\/wp-json\/wp\/v2\/tags?post=323316"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}