By Christine Sexton, Florida Phoenix
In Summary:
The U.S. Court of Appeals for the 11th Circuit affirmed a permanent injunction requiring Florida to clearly explain financial eligibility decisions in Medicaid termination notices. The case highlighted confusing, contradictory letters and errors involving household income and family size that recipients struggled to identify or challenge. Health care advocates welcomed the decision and said it underscores the importance of clear notices as states prepare for additional Medicaid eligibility changes.
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Florida has lost another round in a long-running legal battle over how the administration of Gov. Ron DeSantis removed people from Medicaid.
A federal appeals court ruled this week that the DeSantis administration did not provide adequate notice to people it claimed were no longer financially eligible before dropping them from the safety-net program after the end of the public health emergency caused by COVID-19.
Related: Florida’s ACA enrollment opens as rising premiums strain household budgets.
The 23-page decision, written by U.S. Court of Appeals for the 11th Circuit Judge Barbara Lagoa, upholds a permanent injunction issued earlier this year by U.S. District Judge Marcia Morales Howard in Jacksonville.
Howard wrote a scathing 273 page opinion ordering Florida to clearly explain in its Medicaid termination letters why the state determined people were no longer financially qualified for the program.
“After a six-day bench trial, the district court found that the notices did not ‘unambiguously communicate the State’s decision to terminate benefits, the reason for that decision, or to whom it applies,’ and that the other available sources did not cure those deficiencies,” Lagoa wrote in the ruling issued Thursday. “We agree.”
The Florida Agency for Healthcare Administration (AHCA), which administers the Florida Medicaid program and one of the defendants in the lawsuit, did not immediately respond to the Florida’ Phoenix’s email request for comment on the ruling.
The Department of Children and Families, the state agency charged with determining Medicaid eligibility, also did not respond to Phoenix’s request for comment.
It’s not clear whether the state plans to seek review by the U.S. Supreme Court — an action that would need to be started before DeSantis leaves office in early January. Also unclear is how Gov.-Elect Byron Donalds views the litigation.
‘Crystal clear’ standard
Florida Health Justice Project Legal Director Lynn Hearn
The National Health Law Program and Florida Health Justice Project filed the legal challenge on behalf of plaintiffs who were erroneously removed from the program. Both groups lauded the ruling.
“It is unfortunate that it took three years and extensive state resources to confirm the non-controversial proposition that Medicaid enrollees must be informed of the grounds upon which the state is ending their health care coverage before the coverage ends,” Florida Health Justice attorney Lynne Hearne said in a written statement Friday to the Florida Phoenix.
“The good news is, going forward it is crystal clear that this is the standard for all Medicaid termination notices.”
National Health Law Program senior attorney Katherine DeBriere said the ruling comes as states prepare to implement eligibility changes under the One Big Beautiful Bill Act, which changes who qualifies for Medicaid and brings even more “urgency” to well-designed notices that explain coverage decisions.
“Florida has already begun issuing notices to immigrant enrollees noting coverage terminations,” DeBriere said in a prepared statement. “As states prepare for a new wave of Medicaid paperwork and notices under OBBBA, they should heed this decision.”
“People need enough information to understand why the state proposes to end their coverage and to challenge mistakes,” she added. “States must build those protections into their systems now. Confusing notices and inaccessible explanations put people’s health care at risk.”
Medicaid is a health care program jointly administered and paid for by the state and federal governments. Financial eligibility for Medicaid hinges on several factors, including the qualifying eligibility category; the size of the family unit and allowable income limits based on that; and the recipient’s reported income.
During the COVID-19 pandemic, the federal government increased its contributions to the Medicaid program by 6.2% to help cover the costs of the growing number of people who qualified because of the financial downturn.
With the additional federal funding came the requirement that states couldn’t disenroll anyone from Medicaid until the public health emergency expired.
That occurred on March 31, 2023. Florida started its Medicaid unwinding the following day. By the following year, DCF redetermined Medicaid eligibility for more than 4 million people.
Howard’s initial ruling focused on termination notices sent to children, parents (and other caretakers of children), pregnant women, and former foster children under age 26. They are all part of the “family related Medicaid” category of beneficiaries, described by Howard as some of the state’s “most vulnerable citizens.”
Howard found that the state did not provide enough case-specific information for recipients to understand how DCF reached its decision that they no longer qualified, making it “difficult, if not impossible, for the recipient to understand the State’s intended action as to each enrollee or the reasons for that action.”
Bad notices
The named plaintiff in the underlying case is identified in court papers as Chianne D, who received an 11-page notice in April 2023 that she and her newborn son were being disenrolled for financial reasons. The notice contained eight pages discussing health-benefit criteria. One section said that neither she nor her newborn son, S.D., was eligible for Medicaid benefits because Chianne D’s household income was too high. Several pages later, another section of the letter said S.D. was eligible.
The notice didn’t include the size of Chianne D’s family or the qualifying income corresponding to the family’s size. Neither did it disclose what Chianne D’s reportable monthly income was or the Medicaid eligibility category assigned her.
Calling the DCF call center didn’t provide clarification. The court record indicates a DCF agent acknowledged to Chianne D that S.D.’s Medicaid “remained open” but the agent also told her that S.D. was being terminated because her income was too high.
Ultimately, the state determined that Chianne D.’s own coverage had been incorrectly terminated and that she remained eligible for Medicaid.
In confirming Howard’s decision on appeal, Lagoa wrote, “When a trained DCF employee could read the notice and come away with the wrong answer about whose coverage was ending, the district court did not err in finding that the notice did not reasonably convey DCF’s decision to its intended recipient.”
It wasn’t the only example of flawed determination letters plaintiffs highlighted during the six-day hearing in Jacksonville.
A.V. received an eight-page termination notice from the Medicaid program because of income limits. But the notice didn’t say what family size the state used for A.V’s family. Ultimately, A.V. , who had been on a Medicaid program called Medically Needy learned the state assigned a family size of six instead of her actual family of eight.
The smaller family size figure lowered the allowable monthly income A.V. could earn to qualify for the Medically Needy program. Moreover, the state incorrectly inflated A.V’s reported monthly income.
‘This is pretty bad’
Attorney Andy Bardos represented the DeSantis administration on appeal. Appearing before Lagoa and U.S. Circuit Court judges Adalberto Jordan and Robin Rosenbaum, he defended the state’s termination notices.
Bardos argued Florida needed to adhere only to minimum due-process requirements such as the information about the state’s intended action, the date when the action would occur, and a statement of the reason why.
“With nothing else?” Jordan asked.
“We think that’s the minimum requirement of due process,” Bardos replied.
Jordan offered that perhaps the state notices could have included additional information steering people to a website where they could input pertinent information like their income and family size to ensure the determination was accurate, but didn’t.
“This is pretty bad,” Jordan told Bardos at the time.
Jordan wasn’t the only judge who appeared skeptical during the arguments.
Lagoa, once a DeSantis appointee to the Florida Supreme Court, told Bardos that “it’s clear” Medicaid notices must provide the recipient with meaningful notice and the opportunity to be heard.
“You cannot be heard if you don’t know what you’re objecting to. Because, by the way, I don’t think you would like a trial judge to issue an order just telling you ‘denied’ and not tell you the basis. Correct? Because you wouldn’t be able to have meaningful appellate review.”
Key Points:
- The federal appeals court upheld an injunction requiring Florida to provide adequate explanations before terminating Medicaid coverage for financial eligibility reasons.
- Judge Barbara Lagoa wrote that the notices failed to clearly communicate whose benefits were ending and why.
- The lawsuit documented contradictory notices and eligibility errors involving household size and income.
- The court found that other available sources of information did not resolve the notices’ deficiencies.
- Advocates said the ruling reinforces recipients’ ability to understand coverage decisions and challenge mistakes before losing benefits.
