A federal appeals court ruled that Georgia’s policies for approving or denying Medicaid services for children did not meet federal requirements for adequate care.
A three-judge panel of the U.S. Court of Appeals for the 11th Circuit upheld a district court order requiring the Georgia Department of Community Health to provide at least 100 hours a week of in-home nursing care to a 3-year-old boy identified as L.W.
L.W. has a rare metabolic disease that affects his body’s ability to store and use glycogen. He must be fed every three hours through a tube inserted into his stomach.
Before moving from Virginia to Georgia in 2023, Medicaid covered 56 hours of nursing care a week and paid the boy’s mother to provide another 40 hours. After the move, Alliant Health Solutions, a contractor that manages Medicaid for the state, approved 21 hours of nursing care and no payment for his mother because Georgia does not have that program.
In a May 18 opinion, the judges wrote: “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. But their success came at a tremendous cost to L.W.’s parents and L.W.’s health.”
The opinion said the boy’s mother, who was fatigued, sometimes slept through alarms set to wake her to feed him at night. On several occasions, she found his glucose levels dangerously low. He also was hospitalized for about a week when his parents could not maintain those levels.
In 2024, his mother requested more nursing hours. After Alliant denied the request, she sued in federal court in the Northern District of Georgia. U.S. District Judge Thomas W. Thrash Jr. ruled that 21 hours a week was inadequate and ordered the state to cover at least 100 hours.
The Department of Community Health appealed.
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.
Agency lawyers argued that limiting L.W.’s nursing hours was lawful because it followed department policy. The appeals court ruled that the policy did not satisfy the state’s obligation to review each case and provide the minimum care required under the federal Medicaid Act.