Key Points

  • The Eleventh Circuit affirmed a declaratory judgment and permanent injunction holding that Florida's income-based Medicaid termination notices violated the Due Process Clause.
  • The court held that the notices did not reasonably convey whose coverage was ending or why, because they omitted the household size, countable income, eligibility category and income limit the state used.
  • The court held that Florida's call center, online portal, public materials and Family Resource Centers did not cure the defects, and that supervisory review came too late because it began only after a recipient requested a hearing.
  • The court rejected Florida's argument that the district court decided an uncertified "structural claim," holding that the notices' organization was part of the certified due-process claim and that variation among notices did not defeat classwide resolution.
  • The injunction requires income-based termination notices to state, at a minimum, the enrollee's household size and countable income and the eligibility category, and to let recipients ascertain the categories tested and income limits applied.

The Eleventh Circuit on Nov. 4 upheld a ruling that Florida violated the Constitution's due process guarantee when it cut off Medicaid coverage for residents it found earned too much, sending termination notices that a trial judge found too confusing to tell recipients whose benefits were ending or why.

A three-judge panel affirmed a declaratory judgment and permanent injunction that the U.S. District Court for the Middle District of Florida entered after a six-day bench trial in a class suit against the secretaries of two state agencies that run Medicaid. Circuit Judge Lagoa wrote the published opinion for the panel, which also included Circuit Judges Jordan and Rosenbaum. No judge wrote separately.

The decision leaves in place an order barring Florida from ending a class member's Medicaid for financial ineligibility unless the written notice unambiguously says coverage will end, identifies each person affected and explains why. For income-based terminations, the notice must include, "at a minimum," the enrollee's "household size (SFU) and countable income," the eligibility category under which the person had been covered, and enough information to "ascertain the eligibility categories in which the enrollee was tested and the income limits the State applied." The panel also rejected Florida's argument that the trial court decided a claim it never certified for class treatment.

The case grew out of the Medicaid "unwinding," Florida's return to regular eligibility reviews after Congress ended, on March 31, 2023, a pandemic-era requirement that states receiving enhanced Medicaid funding keep most enrollees covered. Between April 2023 and March 2024, the Department of Children and Families, which decides eligibility, redetermined the eligibility of more than four million people, according to the opinion.

The department's written Notice of Case Action is the only written communication it affirmatively sends to explain a final eligibility decision. The challenged notices said household income was too high, or in some cases gave no income-based reason at all. They did not disclose the household size the agency counted, which it calls the Standard Filing Unit, or SFU, nor the countable income, the income limit or the eligibility category the agency applied.

Named plaintiff Chianne D. received an 11-page notice with eight separate health-benefit sections. One listed her newborn son as ineligible because the household's income was too high; a later section said he remained eligible as a newborn, which was the department's actual decision. A call-center agent who read the notice told her the boy's coverage was ending. "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," Judge Lagoa wrote.

For another named plaintiff, A.V., the department counted a household of six instead of eight, which lowered the monthly income limit from $6,110 to $4,868, and attributed $6,456.99 in monthly income to a family that had reported $4,727.10. William Roberts, who works in the department's Medicaid Policy Unit, testified that he could not tell why A.V. was found ineligible without an internal screen recipients cannot see. The information, Lagoa wrote, "was available inside the agency but not to the person whose coverage DCF terminated."

The panel relied on Goldberg v. Kelly, the Supreme Court's 1970 decision requiring "timely and adequate notice detailing the reasons for a proposed termination" of public benefits. A recipient told only that income is too high, Lagoa wrote, "cannot tell whether DCF has based its determination on the wrong income, counted the wrong people in the recipient's SFU, evaluated the recipient under the wrong Medicaid category, or applied the wrong income limit."

Florida argued that two earlier Eleventh Circuit decisions, Jordan v. Benefits Review Board and Arrington v. Helms, did not require individualized findings or calculations. "True, neither case required an agency to reproduce their arithmetic," Lagoa wrote. But the notices approved in those cases gave recipients "enough concrete information to understand the basis of the decision and to test it against information already available to them," she wrote.

The panel also agreed with the trial court that the state's other information sources did not fill the gap. In April 2024, the department blocked 744,000 calls before they could reach a queue for a live agent, 53.9 percent of calls requesting one, and another 31.3 percent of queued calls ended before an agent answered. The opinion noted that those figures count calls rather than individual recipients. Agents who did answer sometimes gave wrong information. "Faced with competing answers from the agency itself, a recipient has no reliable basis for knowing which one to trust," Lagoa wrote.

The department does give a full explanation through a supervisory review, but only after a recipient requests a hearing. "That is essentially the explanation the recipient needed before deciding whether to challenge the termination," Lagoa wrote, contrasting the sequence approved in Goldberg. "Florida's process runs in the opposite direction with the fuller explanation coming only after the recipient decides to object."

Lagoa wrote that the trial court "did not impose a rule requiring every agency to reproduce every internal calculation in every notice," but applied Supreme Court precedent to the notice system proved at trial.

On class certification, Florida argued that the trial court certified only a challenge to information missing from the notices but then ruled on an uncertified "structural claim" about how the notices were organized. The panel disagreed, holding that confusing sections and conflicting statements in the notices were "directly relevant to the due process claim certified for classwide consideration." The class was limited to income-based terminations, and "that common question does not turn on whether every notice looked the same," Lagoa wrote. She added that the injunction "does not tell Florida how to design its notices."

The panel affirmed in full, concluding that Rule 23 of the Federal Rules of Civil Procedure "permitted the district court to answer that question for the class and to enter an injunction requiring that notice." The injunction's requirements therefore remain binding on Florida for a class defined to cover enrollees who, on or after March 31, 2023, "have been or will be found ineligible" for Medicaid on income grounds through notices that omit the income or the income standard used.