A recent decision by the U.S. Court of Appeals for the Eleventh Circuit carries significant implications for Florida’s Medicaid program, particularly for providers serving medically fragile children through Private Duty Nursing (PDN).

In a long-running case brought by the U.S. Department of Justice, the court largely upheld a lower court’s finding that Florida is failing to provide adequate in-home nursing services to children with complex medical needs — resulting in violations of the Americans with Disabilities Act (ADA).

Background: Access to Care and the ADA

At the center of the case is whether Florida is meeting its obligation under the ADA to provide services in the “most integrated setting” appropriate for individuals with disabilities — a standard established under Olmstead v. L.C..

The federal government argued — and the courts agreed — that gaps in Medicaid-funded PDN services have left families without the care their children are entitled to receive at home. In some cases, these gaps have forced children into institutional settings or placed them at serious risk of institutionalization.

Following a two-week trial in 2023, the district court concluded that Florida’s system was failing medically complex children and issued a sweeping injunction to address those deficiencies.

What the Court Upheld

The Eleventh Circuit affirmed the core findings of the lower court, including that:

• Florida’s failure to provide adequate PDN services constitutes a violation of the ADA
• The problem is systemic and widespread, not isolated to individual cases
• The federal government has the authority to bring enforcement actions on behalf of affected individuals

Critically, the court upheld requirements aimed at improving access to in-home care, including:

• Ensuring children receive at least 90% of their authorized PDN hours — considered the minimum necessary to safely remain in the community
• Expanding data collection and oversight related to service delivery, workforce capacity, and unmet needs
• Maintaining a court-appointed monitor to assess the state’s compliance with these requirements

The court emphasized that inadequate PDN is both a primary driver of institutionalization risk and a barrier preventing children from returning home after being placed in facilities.

Where the Court Drew the Line

While affirming the overall direction of the injunction, the appeals court limited certain provisions, finding that the lower court had overstepped in specific areas.

Notably, the court:

• Rejected requirements imposing strict caseload limits on care coordinators, citing insufficient evidence
• Scaled back the scope of the independent monitor’s authority, particularly regarding unrestricted access to personnel and facilities
• Clarified that families cannot be compelled to transition children out of institutional settings if they choose not to

These modifications reflect the court’s effort to balance federal oversight with state operational authority.

Key Takeaways for Providers

Although the ruling is directed at the state, its implications will be felt across Florida’s home care delivery system:

• Access and Utilization: Authorized services must translate into delivered care. Gaps between approved and delivered PDN hours are now a compliance issue — not solely a workforce challenge.
• Data and Oversight: Expect increased focus on tracking authorized versus delivered services, workforce capacity, and unmet need — particularly within managed care.
• Policy Implications: The decision reinforces the need for policy solutions that support access, including reimbursement adequacy, network sufficiency, and care coordination.
• Care at Home Standard: When clinically appropriate, care in the home setting is not discretionary — it is required under federal law.

Looking Ahead

The ruling places continued pressure on Florida to address structural challenges in PDN, including workforce availability, reimbursement adequacy, and care coordination. It also raises expectations for accountability in how services are authorized, delivered, and monitored.

For providers, the decision underscores the importance of aligning operations with both clinical need and evolving compliance expectations.

HCAF will continue engaging with state agencies, managed care plans, and policymakers to advance solutions that are operationally feasible and support access to care.