The federal courthouse in downtown Jacksonville. | Florida Trib file photo

A federal appeals court on Wednesday upheld a district court ruling that Florida violated the due process rights of hundreds of thousands of low-income Medicaid enrollees by sending termination notices so confusing that recipients — and at times the state’s own employees — couldn’t tell whose coverage was ending or why.

In August, a three-judge panel of the 11th U.S. Circuit Court of Appeals repeatedly grilled Florida’s lawyers over the termination notices, which they also found were nonsensical and confusing. The Wednesday ruling affirmed U.S. District Judge Marcia Morales Howard’s January decision and her injunction requiring Florida to tell enrollees, before cutting them off over income, the figures it used to decide.

Morales Howard’s ruling also scrutinized the state’s understaffed call center, which she found dropped as many as a third of all calls in one month, and the woefully outdated 1980s technology the system relied on.

It’s unclear if the state will ask the U.S. Supreme Court to take up the case.

“A recipient who is informed only that his ‘income is too high’ cannot tell whether DCF has based its determination on the wrong income, counted the wrong people in the recipient’s [home], evaluated the recipient under the wrong Medicaid category, or applied the wrong income limit,” wrote Judge Barbara Lagoa, a former Gov. Ron DeSantis appointee later nominated to the appeals court by President Donald Trump in 2019. “And without knowing which premise DCF used, the recipient does not know what objection to make.”

In August 2023 legal advocacy groups filed a class-action lawsuit on behalf of people enrolled in “family-related Medicaid” — children, pregnant women, and parents or caretakers of minors who were found ineligible because their income exceeded the state’s limit and then received notices that didn’t explain how the state reached that figure and what steps they could take to appeal. That class included nearly 500,000 people.

Morales Howard, the district judge, agreed and barred the state from terminating anyone else over income until its notices met constitutional standards and that it fix the underlying system that generates the letters. Her injunction also required the state to send corrected notices to people already cut off, explaining why and on what basis; the household size and income used to determine eligibility; a link to a clear explanation of income limits; and a pathway to appeal case by case.

By May 1, DCF and AHCA had sent roughly 1 million corrective notices but still appealed the ruling. In August attorneys for the state argued in front of the appeals panel that Morales Howard demanded more than the Constitution requires and pushed back against her understanding of what information a termination notice is required to include.

“This is truly great news for all Medicaid recipients,” said Lynn Hearn, legal director of the Florida Health Justice Project, which sued the state over the notices. The roughly 2.5 million Floridians enrolled in family-related Medicaid, she said, now receive “a clear, cogent, descriptive explanation of why the state is terminating their coverage. The value of that can’t be overstated.”

Florida’s Agency for Health Care Administration and The Department of Children and Families, which decides eligibility, were not immediately available for comment. 

What the court continues to require

The ruling leaves in place an injunction barring Florida from ending a class member’s Medicaid based on income unless the written notice clearly says coverage will end, names each person losing it and explains why.

For income-based cutoffs, the notice must include, at a minimum, the enrollee’s household size and countable income, identify the eligibility category the person had been covered under and explain any change, and give enough information for the recipient to work out which categories they were tested in and which income limits applied.

Hearn said the state, required to follow the injunction while it appealed, revised its notices and “are now providing notices with the information that the court required.”

“Now that’s not to say that the information on the notices is always correct,” she said. “In fact, that’s why it’s so important that the notices contain the information.”

Clearer notices may be driving more appeals, Hearn said. But the state’s appeals office is badly backlogged. “People are not getting the coverage pending appeal that they’re entitled to. They are not getting their evidence packets timely,” she said. “There are some serious problems in the appeal office.”

In its appeal, Florida said Morales Howard’s order unfairly forced the state to show its math, claiming the demands fell outside the requirements of due process. In other words, the letters include enough information for people to make inquiries of their own and decide if the determinations are correct.

The appellate panel disagreed: “The district court did not impose a rule requiring every agency to reproduce every internal calculation in every notice,” Lagoa wrote. The injunction doesn’t dictate how Florida designs its notices, she added, only that DCF indicates clearly what is happening, to whom and why.

The state’s attorneys also argued that Morales Howard overstepped by faulting the notices’ layout — their contradictory sections and confusing groupings of household members — when the class was certified only to challenge the income information the notices left out. 

The panel pushed back, finding that how a notice communicates is part of whether it gives adequate notice at all. Those layout problems, Lagoa wrote, “do not create a second constitutional claim called ‘structure.’”

Competing information within the agency

Chianne D., a Jacksonville mother named as a plaintiff in the FHJP’s lawsuit, received an 11-page notice with eight separate health-benefit sections. One listed her newborn son as ineligible because the household’s “income is too high”; several pages later, another said he remained eligible. According to the lawsuit, when she called DCF, an agent read the notice and told her, wrongly, that the baby was losing coverage.

“When a trained DCF employee could read the notice and come away with the wrong answer about whose coverage was ending,” Lagoa wrote, the trial court was right to find the notice failed.

Another plaintiff, A.V., lost coverage after DCF counted six people in her household instead of eight — lowering the income limit from $6,110 a month to $4,868 — and credited the family with $6,456.99 in monthly income when it had reported $4,727.10. Her notice disclosed none of those figures. Even a DCF Medicaid policy official couldn’t explain the decision at trial without an internal screen recipients can’t access.

“The information needed to understand what DCF had done was available inside the agency but not to the person whose coverage DCF terminated,” the court wrote.

The panel also dismissed Florida’s argument that its call center filled the gap. 

In April 2024, DCF blocked 744,000 calls before they could reach a live-agent queue — 53.9% of those requests — and nearly a third of calls that did get in line ended before anyone answered. (The court noted that those figures count calls, not individual callers.) And when the state’s system moves someone into its Medically Needy program, it deletes the screen explaining the termination, forcing agents to reconstruct it.

“Faced with competing answers from the agency itself, a recipient has no reliable basis for knowing which one to trust,” Lagoa wrote.

DCF’s fullest explanation — a supervisor’s review of the case — comes only after a recipient has requested a hearing. “Florida’s process runs in the opposite direction,” the court wrote, “with the fuller explanation coming only after the recipient decides to object.”

At oral arguments in August, U.S. Circuit Judge Robin Rosenbaum had asked the state’s lawyer, “What is the whole point of hiding this information?”

What the ruling means for families on public assistance

The court’s decision settles what Florida must communicate to one class of Medicaid recipients before cutting off their benefits.

But faulty notices are also turning up in new places, Hearn said. As Florida enforces new federal limits on Medicaid for immigrants, DCF has sent letters that cite the wrong reasons or outdated rules and don’t say what immigration status the state has on file, leaving some families who still qualify with no clear way to contest the decision.

Those notices, Hearn said, raised “some of the same concerns” that prompted the original lawsuit.

Medicaid termination notices are only the most frontfacing part of larger, systemic issues: DCF, which decides eligibility for Medicaid, food assistance and other benefits, has been stretched thin for years in part because of shifting priorities over the past years away from its eligibility staff. Its caseworkers are largely new and low-paid, and the call center Florida told the courts could fill the gaps in its notices gives agents only minutes per caller.

“I think the problems with caseworker workload, training, processing times are very much still there,” Hearn said, adding that it’s unclear what’s driving the delays in the hearing process. 

“Although in some ways this is very much a significant legal victory, at the same time it wasn’t, or shouldn’t have been, that big of an ask,” Hearn said. “What the plaintiffs and the class members sought in this case was basic information about the reasons they were losing access to health care. It should not have required a three-year lawsuit, expending exorbitant state dollars and judicial resources, to get what should have been obvious from the outset was required.”

Sharmila Venkatasubban is The Trib’s senior editor and health reporter and a Report for America corps member. You can reach her at sharmila.venkatasubban@floridatrib.org.