ATLANTA — The policies that Georgia uses to approve or deny services for children enrolled in Medicaid fail to satisfy federal requirements for adequate care, according to a new federal court ruling.
A three-judge panel of the U.S. Court of Appeals for the Eleventh Circuit upheld a federal district judge’s order requiring the Georgia Department of Community Health (DCH) to provide nearly five times more in-home nursing care to a child at risk of dying than the state had approved through a contractor.
The 3-year-old boy, referred to by the court as L.W., has a rare metabolic disease that interrupts his body’s ability to store and use glycogen, a kind of fuel.
He must be fed every three hours through a tube inserted into his stomach.
Before moving to Georgia from Virginia, Medicaid was paying for 56 hours of nursing care per week while paying the boy’s mother to provide another 40 hours.
After moving to Georgia in 2023, Alliant Health Solutions, a contractor that manages Medicaid for the state, approved only 21 hours of nursing services with no supplement for the mother, since Georgia lacks such a program.
“Over the months that L.W.’s parents and physician were asking Georgia to increase L.W.’s nursing hours, L.W.’s parents managed to keep L.W. alive,” the judges wrote in their May 18 opinion. “But their success came at a tremendous cost to L.W.’s parents and L.W.’s health.”
The boy’s fatigued mother often slept through the alarms she set to wake herself up so she could feed him in the middle of the night. Several times she awoke to find his glucose readings dangerously low. Once, when his parents could not maintain his glucose levels, L.W. had to be hospitalized for about a week.
In 2024, his mother requested a change in the number of nursing hours. When Alliant denied it, she sued in federal court in the Northern District of Georgia. Federal Judge Thomas W. Thrash Jr. decided 21 hours of weekly nursing care was inadequate and ordered the state to pay for at least 100 hours.
DCH appealed. The agency’s failure to win that appeal produced a ruling that could influence how Medicaid is administered in Georgia and in the rest of the Eleventh Circuit’s jurisdiction, which includes Alabama and Florida.
“This is telling DCH, ‘your responsibility is to ensure that care gets provided’,” said Roland Behm, co-founder of the Georgia Mental Health Policy Partnership.
“As long as it’s medically necessary and it can go to correct or ameliorate, then you have to say yes to that because that’s the obligation that you took on as the state Medicaid agency and that you contracted with these other entities to do,” he said.
Under the federal Early and Periodic Screening, Diagnostic and Treatment standard, states must cover medically necessary services for children that “correct or ameliorate” a physical or mental condition.
A spokeswoman for DCH said Tuesday that the agency was still reviewing the court decision and had no comment.
The agency’s lawyers had contended in court that the decision to limit L.W.’s nursing hours was legal because it followed agency policy. But the three-judge panel ruled that the policy had failed L.W. and his parents and that the state had an obligation to review the facts of each case to provide the minimum level of care required under the federal Medicaid Act.
One of the Eleventh Circuit judges wrote a concurring opinion that criticized DCH’s policy as “poorly drafted and hard to make sense of.” The policy was written with a “repetitive structure and odd phrasing,” Judge Britt C. Grant wrote.
Her critique also noted that DCH had not included the relevant policy in the court record and that she could not find it in the agency’s manual.
“Given these discrepancies,” she wrote, “I am unsure about what the Department’s real policy is. Nor do I have any idea what policy, if any, was applied to L.W.’s change request.”
This story is available through a news partnership with Capitol Beat, an initiative of the Georgia Press Educational Foundation.
