Federal appeals court finds Florida Medicaid termination letters did not give adequate notice

The 11th U.S. Circuit Court of Appeals decision, written by Judge Barbara Lagoa and issued Thursday, affirms a permanent injunction ordered by U.S. District Judge Marcia Morales Howard in Jacksonville earlier this year. Howard had found that the termination notices sent by the state to certain Medicaid recipients did not unambiguously communicate the state's decision or the grounds for it, making it difficult for recipients to understand the state's intended action and reasons.

“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. “We agree.”

The case was brought by the National Health Law Program and Florida Health Justice Project on behalf of plaintiffs who were erroneously removed from Medicaid, a health care program jointly administered and paid for by state and federal governments. During the pandemic, states were barred from disenrolling anyone after the federal government increased its contributions to Medicaid. That requirement ended on March 31, 2023, and Florida began redetermining eligibility the next day, ultimately redetermining eligibility for more than 4 million people.

The lower court's initial ruling focused on termination notices sent to children, parents and caretakers of children, pregnant women, and former foster children under 26, described by the lower court as some of the state's “most vulnerable citizens.”

One named plaintiff, identified as Chianne D., received an 11-page notice in April 2023 stating that she and her newborn son were being disenrolled because household income was too high. Several pages later, a different section said the son was eligible. A DCF agent acknowledged that the son's Medicaid remained open but also told her he was being terminated because her income was too high. The state later determined her own coverage had been incorrectly terminated and that she remained eligible for Medicaid.

During oral arguments before the appeals panel, attorney Andy Bardos, representing the DeSantis administration, argued that Florida only needed to meet minimum due-process requirements, stating the intended action, the date, and a statement of the reason. Judge Adalberto Jordan questioned that position, suggesting the state notices could have included information steering people to a website where they could input information such as their income and family size to check the determination, but did not. “This is pretty bad,” Jordan said. Lagoa, a DeSantis appointee to the Florida Supreme Court, told Bardos that meaningful notice requires recipients to know what they are objecting to. “You cannot be heard if you don't know what you're objecting to,” she said.

“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 Project attorney Lynne Hearne said in a statement. “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 for eligibility changes under the One Big Beautiful Bill Act, which brings even more urgency to well-designed notices. “Confusing notices and inaccessible explanations put people's health care at risk,” she said.

The Florida Agency for Healthcare Administration and the Department of Children and Families did not respond to requests for comment. It is not clear whether the state will seek review by the U.S. Supreme Court, an action that would need to begin before Gov. Ron DeSantis leaves office in early January.