Iliana Garrido v. Interim Secretary, Florida Agency for Health Care Administration
2013 U.S. App. LEXIS 19409
| 11th Cir. | 2013Background
- Medicaid EPSDT requires states to provide medically necessary services to eligible minors under 21.
- Florida AHCA excludes autism-related ABA services from Medicaid coverage per Handbook Rule 2-1-4.
- Plaintiffs diagnosed with autism/ASD were prescribed ABA and sought coverage under EPSDT.
- AHCA determined ABA was experimental and not medically necessary for ASD, denying coverage.
- District court found ABA within 1396d(a)(13) and not experimental, enjoining AHCA and ordering coverage.
- Court later remanded to modify the injunction and declaratory judgment to reflect limited scope and preserve ability for individual medical-necessity determinations.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Is the injunction's scope overbroad regarding automatic ABA coverage | K.G. argues injunction requires ABA for all under-21 ASD cases | Dudek says injunction improperly limits state medical-necessity determinations | Partially affirmed; vacated and remanded to limit scope for individual determinations. |
| Does declaratory judgment correctly reflect authority on medical-necessity determinations | Plaintiffs seek declaratory scope aligned with EPSDT/CA laws | Defendant argues for narrower, case-specific determinations | Remand to modify declaratory judgment to preserve ability for individual determinations. |
| Did district court improperly treat ABA as uniformly medically necessary | ABA is standard ASD treatment required under EPSDT | Medicaid policy permitted medical-necessity determinations at the state level | District court’s broad finding upheld but requires adjustment in order language on scope. |
| Should the injunction be read to reflect AHCA’s authority over individual medical-necessity determinations | Injunction should ensure ABA coverage as prescribed | AHCA retains authority to determine necessity on a case-by-case basis | Remand to clarify language preserving individual medical-necessity determinations. |
Key Cases Cited
- Angel Flight of Ga., Inc. v. Angel Flight Am., Inc., 522 F.3d 1200 (11th Cir. 2008) (four-factor injunction framework and public interest considerations)
- Alley v. U.S. Dep’t of Health & Human Servs., 590 F.3d 1195 (11th Cir. 2009) (contextual inquiry into injunction scope and Rule 65(d) specifics)
- Keener v. Convergys Corp., 342 F.3d 1264 (11th Cir. 2003) (injunctions must be specific and detailed to avoid ambiguity)
- S.E.C. v. Goble, 682 F.3d 934 (11th Cir. 2012) (contextual assessment of injunctions to avoid contempt)