A federal Judge ruled this week that Florida violated the constitutional rights of hundreds of thousands of people it had removed from the Medicaid rolls following the end of the COVID public health emergency, when it sent beneficiaries “vague, confusing and often incorrect and misleading” termination letters.

In a 273-page ruling in the class action, U.S. District Judge Marcia Morales Howard ordered the state in the next two months to send appropriate Medicaid termination notices to roughly 500,000 low-income people whose benefits the state terminated for financial reasons following the pandemic and were not subsequently reenrolled in the safety-net health care program.

The notice must advise the people of the court’s ruling and, at a minimum, must include “an unambiguous statement” explaining the financial reasons behind the terminations and to whom the decision applies.

“Such notice will ensure that all Class Members have the information needed to determine whether the State’s decision to terminate their Medicaid benefits was correct,” she wrote. “Class Members who believe the State made an error may then pursue the available administrative remedies to correct that error.”

Those “remedies” include an opportunity to request an administrative appeal of their termination, which would enable someone to temporarily be reenrolled in Medicaid pending the outcome of the hearing. The notice must include information about administrative procedures permitting the payment of past medical bills if an error is found.

Howard in her ruling also barred the Department of Children and Families (DCF) — the Florida agency that determines whether people qualify for Medicaid — from terminating someone’s benefits for financial eligibility unless it provides proper notice.

At a minimum, that notice must include the enrollee’s household size, the state-determined countable household income, the eligibility category in which the enrollee had been receiving benefits, and, if it changed, the reason for the change.

DCF did not immediately comment on the ruling or whether it plans to appeal the decision.

‘Welcome news’

Center for Children and Families Executive Director Joan Alker said Thursday she still was reading the lengthy ruling but that she wasn’t surprised by the Judge’s conclusions.

Alker, who has spent more than 20 years studying Florida’s Medicaid program, said the state has a “really complicated” Medicaid eligibility system for children, which includes the optional Medicaid expansion called KidCare. The more complicated the system, she said, the more important it is for termination letters to be easily understood.

“I think it’s welcome news for families here, the Judge recognized that this was a very serious problem that families were facing,” she said. “And again, I’ll say I found the notices extremely difficult to understand and, obviously, I’m a health policy professor who’s been working on this stuff for decades.”

Medicaid is a safety net health care program jointly administered and paid for by the state and federal governments. Just under 4 million people were enrolled in Medicaid in Florida as of Nov. 30, 2025, the latest available data.

During the COVID pandemic, the federal government increased by 6.2% its contributions to the Medicaid program. The increased funding came with the caveat that states couldn’t disenroll people during the pandemic.

The policy ballooned Florida’s Medicaid caseload from 3.8 million people in March 2020, before the pandemic, to more than 5.75 million in March 2023.

Congress agreed the continuous eligibility requirement would end March 31, 2023, and that, post-pandemic, states could return their Medicaid programs to their normal operations. That process was known as Medicaid “unwinding.”

Florida started its Medicaid unwinding on April 1, 2023, and by the following year DCF redetermined the Medicaid eligibility of more than 4 million people.

Attorneys for Florida Health Justice Project and the National Health Law Program filed the lawsuit in Jacksonville in 2023 on behalf of people who erroneously lost benefits. Howard agreed to certify it as a class action in 2024.

“This ruling is a victory for the millions of Floridians who rely on Medicaid for essential health care. Medicaid agencies inevitably make mistakes when deciding eligibility. Clear, easy-to-understand notices are essential to catch and correct those mistakes before someone loses health care. The Court’s decision will ensure that Floridians have that critical protection from now on,” Sarah Grusin, senior attorney at the National Health Law Program, said in a prepared statement Thursday.

“It also underscores that states cannot shirk their constitutional obligations. Florida has known about the problems with their notices for years but has not addressed them, citing the cost and complexity of making changes to the computer system that generates notices. But as the Court emphasized, state officials cannot justify violating the constitutional rights of their citizens because they claim the fix is too expensive.”

‘Poorest of the poor’

There are two broad category groups: “SSI-Related Medicaid” for people who are aged, blind or disabled in the community, and “Family-Related Medicaid” for children, parents and other caretakers of children, pregnant women, and former foster children under the age of 26.

The lawsuit focuses on “Family Related Medicaid” beneficiaries, whom Howard described as some of the state’s “most vulnerable citizens.”

“They are primarily pregnant and postpartum women, infants, and children. And as is evident from the applicable income standards, these individuals are the poorest of the poor,” Howard said. “Prior to terminating the Medicaid benefits on which these individuals depend, the Constitution requires the State of Florida to provide them with adequate notice. The State of Florida is violating this constitutional requirement. “

Regardless of the eligibility group, residents also must meet certain income requirements, which vary by, among other things, age and household composition.

The complicated details of how household income is derived are laid out in policy manuals which, Howard noted in her ruling, are “plainly designed for internal use by those who have been taught how to use it.”

Howard’s lengthy ruling also touches on the DCF call center operations and its website.

Using April 2024 as an example, Howard noted, the call center received more than 1.9 million phone calls, of which 593,923 were resolved with an interactive voice response system through which people can self serve.

Another 1.38 million-plus callers asked to speak with an agent for a variety of reasons, including long wait times and abandoned phone calls; only 32% (444,319 callers) who requested to speak with a live agent succeeded. Upon reaching an agent, those interactions lasted for an average of nine minutes and 28 seconds, including the time the agent spent working on the case after the call ended.

Meanwhile, termination letters referred residents to the DCF website to learn more about eligibility requirements, but Howard noted in her ruling that the webpage didn’t provide all the information people needed or the links to get the information. In some instances, information on DCF’s homepage was incorrect or incomplete.

“The length of this Order might suggest that the question before the Court — whether the State’s notices are constitutionally adequate — is overly complex or a razor close call. It is neither. The length of this Order is not reflective of the complexity of the legal issue, it is reflective of the complexity and unreasonably confusing nature of the notices. It is driven by the need to address the complete inadequacy and borderline incomprehensibility of the notices and the inadequacy of the other resources identified as remedying the failure of the NOCAs (notices of case action) at issue,” she wrote.

“As detailed in this Order, the Court’s review of the evidence and the notices — their structure, the confusing, contradictory, and often misleading reasons they provide, and the lack of alternate available sources for the necessary information — inescapably leads to the conclusion that the State’s notices are fundamentally insufficient to satisfy the requirements of due process.”

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Reporting by Christine Sexton. Florida Phoenix is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Florida Phoenix maintains editorial independence. Contact Editor Michael Moline for questions: [email protected].