A three-judge panel of the 11th U.S. Circuit Court of Appeals on Wednesday grilled an attorney representing Florida’s health care agencies over nonsensical and confusing notices the state sent to families informing them that their Medicaid benefits had been terminated, with one judge calling a letter sent to a Jacksonville mother “clearly defective.”

During an hourlong hearing in Atlanta, the judges questioned the state’s attorney for more than 30 minutes — roughly twice as long as they questioned the lawyer for the Medicaid recipients, who sued the Agency for Health Care Administration and Department of Children and Families in 2023 over the constitutionality of the letters. In January, a federal judge ruled in their favor, barring the state from terminating anyone else over income until it fixed the technology that generates the letters.

U.S. District Judge Marcia Morales Howard also required DCF to send corrected notices to people already cut off, explaining why and on what basis, the household size and income used to determine eligibility, and a pathway to appeal case by case. A month later, the state appealed the ruling.

The legal clash pits Florida’s health agencies against low-income families represented by advocacy groups over how clearly the government must communicate when ending essential public benefits. In 2024, the state’s Department of Health reported over 2.4 million residents were uninsured, one of the highest state counts across the U.S.

A due process problem

The appellate judges returned again and again to a single problem: If the state doesn’t tell people why it found them ineligible, they have no way of knowing what to challenge.

Near the end of the state’s argument, U.S. Circuit Judge Adalberto Jordan pointedly asked Andy Bardos, representing the state health agencies, whether he had looked at the formula Florida uses to calculate Medicaid income eligibility.

“Could you run that formula as a lawyer and figure out whether you’re eligible?” Jordan asked.

“Your Honor, I cannot,” Bardos said.

Bardos told the panel the district court went too far when it ordered Florida to include case‑specific dollar amounts and calculations in its notices. Due process, he said, requires a termination notice to contain three things: that benefits will end, the date they end, and a reason for termination — in these cases, that the recipient’s income exceeds the limit.

“With nothing else?” Jordan asked.

“We think that’s the minimum requirement of due process,” Bardos said.

U.S. Circuit Judge Barbara Lagoa pressed him on the notice sent to Chianne D., a named plaintiff, which stated in one section that her newborn son was ineligible for Medicaid benefits and four pages later that he was eligible and his coverage had never been terminated.

“That notice obviously is clearly defective,” Lagoa said. Later, she offered an analogy: “I don’t think you would like a trial judge to issue an order just telling you’re denied and not tell you the basis. Because you wouldn’t be able to have meaningful appellate review.”

U.S. Circuit Judge Robin Rosenbaum was blunter. “It sounds like the most efficient way to provide this information to people is through the notice,” she said. “What is the whole point of hiding this information?”

Bardos said the state was not hiding anything, and pointed to the age of the system that generates the notices — software written in the 1980s that predates the computer mouse. Changing it, he said, requires enormous time and expense. He told the panel the legislature appropriated another $47 million toward a modernization project this year, and that total appropriations for the effort are “now in nine figures.”

“I agree,” Rosenbaum said, “but I think that you have a due process problem here as well. I’m just trying to understand why it seems like you are purposely making it more difficult.”

The state’s fallback throughout the hearing was its call center. Recipients who don’t understand a notice can call, Bardos argued, and agents can supply the income figure the state used.

The panel was unpersuaded. Jordan noted the district court found the call center an “abject failure,” and pressed Bardos on whether Florida had introduced any evidence to the contrary — about training, accuracy, or access.

“We did not present that evidence, Your Honor,” Bardos said.

Rosenbaum brought up the rate of blocked calls. DCF’s own findings show more than half of all calls never reach a queue. “If you can’t get through to the call center,” she said, “then the accuracy of the call center, even if we want to assume it’s 100 percent, doesn’t matter at all.”

Sarah Grusin, arguing for the plaintiffs, told the panel Florida has known since 2018 that its notices were vague and confusing. During the trial, she said, the state’s own witnesses — Medicaid experts — could not determine what action the state was taking in a given case from the notice alone. They needed data the state does not disclose to recipients: the income counted, the eligibility category, the household size, and the income threshold.

The district court, she said, ordered Florida to give enrollees the “same raw data that Florida itself relies on.”

Grusin also disputed the state’s characterization of the district court’s factual findings.

Florida operates a single statewide call center with 313 agents, she said, who can answer income questions — serving roughly 1.7 million Medicaid enrollees facing disenrollment. The state’s own call center leadership witness testified that adding 200 employees would not solve the blocking problem. Fewer than 1 percent of calls are monitored for quality, Grusin said. Agents have six to seven minutes per call and can’t see the income standard on their screens, meaning they must reconstruct the eligibility decision in real time.

Defending the system

In February, AHCA and DCF appealed the district court’s ruling, even as the agencies moved to comply, pausing income-based terminations that same month and sending roughly 1 million corrected notices by the court-ordered May 1 deadline.

The appeal argues Morales Howard demanded more than the Constitution requires. In its brief, the state says a termination notice only needs to be reasonably calculated to inform someone that the state is taking action, not to supply the figures behind the decision. Appellate courts have upheld standardized benefits notices containing less, the state writes, and Morales Howard was bound to follow them.

An appeal that misfires

The Florida Health Justice Project said in court filings Florida is appealing a ruling the judge didn’t write. Morales Howard never required “calculations,” the brief states — she required four data points. And the earlier cases Florida cites support her reasoning rather than undercut it: The notices approved in one of them listed individual payment amounts recipients could check against their own records, which is what Florida’s notices lack.

The plaintiffs also point to what Morales Howard called a “significant risk” of error in the state’s eligibility system, which routinely pulls income figures from outside databases that can be months out of date, and it carries bugs the state has known about and not fixed.

One cuts off postpartum women still entitled to a year of coverage. Another drops people from the household count, lowering the income limit a family has to clear. Both errors hit families who testified at trial.

In a status report filed Aug. 3, the state told the court that of those people who received corrected notices, 2,270 requested fair hearings and 1,860 of those requests had been resolved by July 31. The department held 42 hearings; 18 people had coverage reinstated while they waited.

What “resolved” means for the roughly 1,818 requests that did not go to a hearing is unclear. The filing doesn’t say whether those requests were withdrawn, dismissed, settled, decided without a hearing or still awaiting a date.

Lynn Hearn, legal director of the Florida Health Justice Project, told The Florida Trib in an email that the advocacy group doesn’t comment on pending litigation. AHCA and DCF did not respond to questions by deadline.

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.