24-2770 Indiana Protection and Advocacy Services Commission v. Indiana Family and Social Services Administration

In the
United States Court of Appeals
For the Seventh Circuit
____________________
Nos. 24-2633, 24-2741, & 24-2770
I NDIANA PROTECTION AND A DVOCACY S ERVICES C OMMISSION ,
et al.,
Plaintiffs-Appellees/
Cross-Appellants,
v.
I NDIANA F AMILY AND S OCIAL S ERVICES A DMINISTRATION , et al.,
Defendants-Appellants/
Cross-Appellees.
____________________
Appeals from the United States District Court for the
Southern District of Indiana, Indianapolis Division.
No. 1:24-cv-00833-TWP-TAB — Tanya Walton Pratt, Judge.
____________________
A RGUED A PRIL 8, 2025 — DECIDED A UGUST 11, 2025
____________________
Before HAMILTON , LEE, and M ALDONADO, Circuit Judges.
HAMILTON , Circuit Judge. These appeals address Indiana’s
obligation to provide medically necessary services to
medically fragile children. Individual Plaintiffs E.R. and G.S.
are two children with severe, complex, and unpredictable
medical conditions. Since birth, both children have required

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2 Nos. 24-2633, 24-2741, & 24-2770
around-the-clock care and supervision by a caregiver trained
to meet their complex medical needs. Many of their medical
needs require actions ordinarily performed by a trained
health care professional. For several years, however, the
families of E.R. and G.S. have been unable to secure nurses to
attend to their needs at home rather than in an institution. In
lieu of other options that would forestall institutional
placement, both children’s needs have been met by their
mothers—their principal caregivers and sole sources of
financial support. Both mothers have been trained by their
children’s medical teams to perform tasks that would
ordinarily be performed by a health care professional. In
addition to addressing E.R.’s and G.S.’s more complex
medical needs, both mothers also provide the 24/7
supervision and assistance with activities of daily living that
both children require.
The Indiana Family and Social Services Administration
(FSSA) has reimbursed both mothers for providing medically
necessary care to their sons through its Medicaid program.
Until recently, FSSA paid them for providing “attendant care
services,” which cover unskilled assistance in performing
basic life activities, such as eating, bathing, dressing, and toi-
leting, that E.R. and G.S. cannot perform by themselves. FSSA
authorized and paid Plaintiffs’ mothers to provide attendant
care services through one of its Medicaid waiver programs.
The programs are intended to enable individuals who would
otherwise require care in an institution to receive services at
homes. For years, Plaintiffs have used waiver services to re-
ceive their medically necessary care at home from their moth-
ers, who care for them full-time.

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Nos. 24-2633, 24-2741, & 24-2770 3
A July 2024 policy change by FSSA would have made both
mothers ineligible to be paid providers of attendant care ser-
vices for their children. If allowed to take effect as applied to
these Plaintiffs, it would eliminate both mothers’ ability to
care for their children full-time. Plaintiffs’ mothers testified
that, if left in place, the July 2024 change would force them to
make the difficult decision to have their children institution-
alized. The Indiana Protection and Advocacy Services Com-
mission and individual Plaintiffs E.R. and G.S. brought this
suit to prevent the July 2024 policy change from going into
effect and to obtain an order requiring FSSA to take concrete
steps toward securing in-home nurses for both children.
Plaintiffs contend that the July 2024 policy change violates the
Americans with Disabilities Act’s requirement that States ad-
minister Medicaid programs “in the most integrated setting
appropriate to the needs of qualified individuals with disabil-
ities.” 28 C.F.R. § 35.130(d). They further allege that the State’s
failure to make in-home skilled nursing available violates the
Medicaid Act.
After briefing and oral argument, the district court entered
a preliminary injunction requiring FSSA to pay Plaintiffs’
mothers for providing attendant care services until in-home
nurses are procured for each child. We affirm and remand for
further proceedings. As the district court concluded, Plaintiffs
have a high likelihood of succeeding on the merits of their
ADA claims. Further, we find no abuse of discretion in the
district court’s balancing of the equities or its assessment that
the public interest is best served by preserving Plaintiffs’ ac-
cess to medically necessary care and enforcing federal anti-
discrimination law.

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4 Nos. 24-2633, 24-2741, & 24-2770
I. Factual Background
A. The Individual Plaintiffs
We begin by summarizing E.R.’s and G.S.’s medical con-
ditions, caregiving arrangements, and financial circum-
stances.
1. E.R. and His Family
E.R. is a six-year-old boy who resides with his mother, Jes-
sica Carter, and his 19-year-old sister. He has a rare genetic
disorder called cri-du-chat syndrome that causes chronic lung
disease, severe respiratory problems, and epilepsy. His epi-
lepsy causes significant seizures that are not fully controlled
by medication. He is also substantially deaf and blind, non-
verbal, and non-ambulatory. Although E.R. is six years old,
his ailments give him the developmental profile of a nine-
month-old. He therefore requires close, 24/7 care and super-
vision and assistance with all his activities of daily living.
Ms. Carter is E.R.’s primary caregiver, in addition to being
solely responsible for supporting E.R. financially. She trained
with E.R.’s medical team for two months to learn how to pro-
vide the care and supervision he requires on a daily basis.
E.R.’s sister has also received some training from E.R.’s med-
ical team. Today, Ms. Carter and E.R.’s sister are the only in-
dividuals who can provide the constant care that E.R. requires
outside of a hospital or nursing facility.
2. G.S. and His Family
G.S. is a ten-year-old boy on palliative care who resides
with his mother, Heather Knight, and his three minor

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Nos. 24-2633, 24-2741, & 24-2770 5
siblings.1 Ms. Knight is G.S.’s primary caregiver, in addition
to being solely responsible for supporting G.S. financially.
G.S. has a severe form of dysautonomia, a disorder that pre-
vents his body from regulating vital processes, including
blood pressure, body temperature, digestion, heart rate,
sweating, and breathing. He also has hypoxic-ischemic en-
cephalopathy, a kind of brain damage that affects the central
nervous system, and progressive white matter brain loss,
which causes developmental and intellectual deficits. In addi-
tion, he has Lennox-Gastaut syndrome, a severe condition
characterized by repeated seizures. G.S. is nonverbal, quadri-
plegic, deaf, and severely immunocompromised. Like E.R., he
requires close, 24/7 care and supervision and assistance with
all his activities of daily living.
B. Services Available through Indiana’s Medicaid Program
Due to their severe medical needs and family incomes,
Plaintiffs E.R. and G.S. are both eligible for services through
Indiana’s Medicaid program, which is administered by de-
fendant Indiana Family and Social Services Administration.
Indiana’s Medicaid program is composed of the “State Plan,”
which covers traditional Medicaid services, and several
home- and community-based waiver programs. “Both the
state’s core Medicaid program and its waiver programs must
be approved by the federal Center for Medicare and Medicaid
Services (CMS), an entity lodged within the Department of
Health and Human Services.” Vaughn v. Walthall, 968 F.3d 814,
822 (7th Cir. 2020)
1 Palliative care is a medical approach intended to optimize qualify of
life and to mitigate the suffering of individuals with serious, complex, and
oftentimes terminal illnesses.

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6 Nos. 24-2633, 24-2741, & 24-2770
Plaintiffs receive services through both the State Plan and
Indiana’s Health and Wellness Waiver (H&W Waiver). In this
suit, they contend that a July 2024 policy change, which
would prohibit their mothers from serving as paid providers
of attendant care services under the H&W Waiver, violates the
integration mandate of the Americans with Disabilities Act
(ADA). See 42 U.S.C. § 12132; 28 C.F.R. § 35.130(d). Plaintiffs
also argue that FSSA’s failure to ensure that they receive home
nursing assistance through the State Plan violates the Medi-
caid Act. We set forth relevant background on those services
below.
1. Traditional Medicaid Services
Due to Plaintiffs’ various medical conditions and func-
tional limitations, they both require what FSSA calls “skilled”
nursing services. Skilled nursing services are health care ser-
vices that are delegated or ordered by a licensed health pro-
fessional, such as administering medication, feeding a patient
through a gastronomy tube, or monitoring seizure activity.
FSSA has approved both Plaintiffs to receive in-home skilled
nursing services through the State Plan. G.S. has been ap-
proved to receive 80 hours per week of in-home skilled nurs-
ing services. E.R. has been approved to receive 40 hours per
week of in-home skilled nursing services.
Despite FSSA’s approval, it has been years since Plaintiffs’
families were able to find nurses to staff their approved
skilled nursing hours in their homes. In early 2020, G.S.’s
nurse moved out of state to accept a higher paying position.
In 2021, E.R.’s nurse did the same. Although Ms. Carter and
Ms. Knight have spoken with their sons’ case managers at
FSSA to explore the possibility of obtaining additional nurs-
ing assistance, FSSA has taken few steps to locate a nurse for

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Nos. 24-2633, 24-2741, & 24-2770 7
either child. In FSSA’s view, its only role is to approve or deny
a request for nursing services once submitted. Ms. Carter has
placed E.R. on waiting lists at numerous nursing agencies but
thus far has had no success. Ms. Knight is unaware of any
skilled providers available to ensure that G.S. receives the care
and supervision that he requires without risking his health.
Nonetheless, both Plaintiffs have skilled nursing needs
that must be met, whether at home or in an institution. In the
absence of any other viable options for caring for E.R. and G.S.
at home, Ms. Carter and Ms. Knight have learned how to meet
their sons’ skilled needs. Both mothers provide Plaintiffs
emergency care for seizures, feed them through gastronomy
tubes attached to their abdomens, and monitor them for res-
piratory distress, among other things. E.R.’s sister also cares
for E.R. to give Ms. Carter a chance to sleep. Because Ms.
Carter and Ms. Knight are not medical professionals, they
cannot be paid for meeting their children’s skilled nursing
needs.
2. Home and Community-based Services
E.R. and G.S. are also eligible to receive services through
the H&W Waiver, one of Indiana’s home- and community-
based waiver programs. Waiver programs allow States to
diverge from the traditional Medicaid structure by providing
community-based services to people who would otherwise
need to be institutionalized. See 42 U.S.C. § 1396n(c)(1);
Steimel v. Wernert, 823 F.3d 902, 906–07 (7th Cir. 2016). Waiver
services are intended to supplement, not to replace, the
services provided through the State Plan such as in-home
skilled nursing. “Participating states have significant
discretion in how they craft their waiver programs.” Steimel,
823 F.3d at 907. They may include any service requested by

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8 Nos. 24-2633, 24-2741, & 24-2770
the State and approved by the federal government “as cost
effective and necessary to avoid institutionalization.” 42
C.F.R. § 440.180(b)(9). Two services that Indiana has chosen to
provide are at issue in this case.
The first, “attendant care services,” is defined as “direct,
hands-on and unskilled care” that assists an individual with
activities of daily living, such as personal hygiene, like bath-
ing and toileting, and mobility. The second, “structured fam-
ily caregiving,” also covers assistance with activities of daily
living. It is designed to facilitate an arrangement in which the
waiver enrollee lives with a principal caregiver who provides
“unskilled” care and support on a daily basis. The services
covered by attendant care and structured family caregiving
substantially overlap. The primary difference between the
two services is the rates of reimbursement that caregivers
earn.
Attendant care is paid currently on an hourly basis at a
rate of $34.36 per hour. Structured family caregiving is paid
on a per diem basis. The rate is between $77.54 and $133.44
per day, depending on the assessed level of need. Individual
caregivers like Ms. Carter and Ms. Knight do not, however,
receive the full Medicaid rate. FSSA estimates that individual
caregivers receive, at most, 60% of the hourly rate for at-
tendant care and between 65% and 70% of the daily rate for
structured family caregiving. Actual compensation may be
less than FSSA’s estimates, and many caregivers are catego-
rized as independent contractors and therefore lack typical
employment benefits

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Nos. 24-2633, 24-2741, & 24-2770 9
a. Attendant Care Services under the Aged and Disa-
bled Waiver
Before the policy changes that led to this lawsuit, E.R. and
G.S. were both approved to receive attendant care services
through the Aged and Disabled Waiver (A&D Waiver). The
A&D Waiver placed an important limit on who was eligible
to serve as a paid provider of both attendant care services and
structured family caregiving. It prohibited a waiver partici-
pant’s “legally responsible individual” or “LRI” from serving
as a paid provider of either service. Federal regulations define
the term “legally responsible individual” to include spouses
of recipients and parents of minor recipients. Personal Care
Services in a Home or Other Location, 62 Fed. Reg. 47896,
47899 (Sep. 11, 1997). Although Indiana could have chosen to
authorize LRIs to serve as paid providers of attendant care
under specified circumstances, it did not elect to do so. As a
result, LRIs like Ms. Carter and Ms. Knight seemed to be inel-
igible to serve as paid providers of attendant care under the
terms of the A&D Waiver.
Despite the prohibition in the A&D Waiver, however,
FSSA for years approved and reimbursed hundreds of LRIs
to provide attendant care. G.S. and E.R. were among the A&D
Waiver participants whom FSSA approved to receive LRI-
provided attendant care. In 2021, FSSA approved Ms. Carter
to be reimbursed for providing E.R. 112 hours of attendant
care each week. In 2022, FSSA approved Ms. Knight, G.S.’s
only attendant care provider, to be reimbursed for providing
84 hours of attendant care each week.
For the last several years, the income that Ms. Carter and
Ms. Knight receive for providing attendant care has been their
only income. Working as paid providers of attendant care

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10 Nos. 24-2633, 24-2741, & 24-2770
enabled Ms. Carter and Ms. Knight to care for their sons in
their homes. Without it, both mothers would have needed to
seek full-time employment outside of their homes. Due to the
unavailability of in-home skilled nursing to provide the care
and supervision Plaintiffs require, returning to full-time em-
ployment outside of the home would have forced both moth-
ers to seek institutional placement for their sons.
b. Attendant Care Services under the Health and Well-
ness Waiver
FSSA’s practice of reimbursing LRIs for providing at-
tendant care lasted until July 2024. The practice came under
fresh review in late 2023 after FSSA discovered a shortfall in
its budget for fiscal years 2023, 2024, and 2025 of more than
$900 million. While much of that variance was the result of
State budget reversions, approximately half stemmed from an
unanticipated increase in projected expenditures for the A&D
Waiver. The forecasted increase in expenditures was the prod-
uct of three factors: (1) increased enrollment in the waiver pro-
gram; (2) a 2023 increase in reimbursement rates; and (3) in-
creased utilization of attendant care services, especially in the
pediatric population. FSSA has not determined what percent-
age of the forecasted expenditure increase is attributable to
increased utilization of attendant care provided by LRIs like
Ms. Carter and Ms. Knight.
FSSA considered different ways of addressing the fore-
casted variance without asking the State legislature for addi-
tional appropriations. It implemented several cost-contain-
ment and sustainability strategies, including some specific to
its home- and community-based waiver programs. For bene-
ficiaries under the age of 60, FSSA replaced the A&D Waiver
with the Health and Wellness Waiver. Through the H&W

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Nos. 24-2633, 24-2741, & 24-2770 11
Waiver, FSSA began enforcing the prohibition on LRIs
providing attendant care. However, it also authorized LRIs to
serve as paid providers of structured family caregiving,
which is reimbursed at a much lower rate than attendant care
services. Like the A&D Waiver, the H&W Waiver prohibits
enrollees from receiving simultaneously both attendant care
services and structured family caregiving. On June 4, 2024, af-
ter a notice and comment period, CMS approved the newly
renamed H&W Waiver. The changes went into effect on July
1, 2024.
II. Procedural History
In May 2024, shortly before the new H&W Waiver went
into effect, the Indiana Protection and Advocacy Services
Commission (IPAS) and E.R. and G.S. through their mothers
filed this suit against FSSA.2 The complaint alleges that the
H&W Waiver’s prohibition on LRI-provided attendant care
violates the ADA and the Rehabilitation Act by placing E.R.,
G.S., and other IPAS constituents at serious risk of institution-
alization. It also alleges that FSSA’s failure to make in-home
nursing services available with reasonable promptness vio-
lates the Medicaid Act. On May 21, Plaintiffs moved for a pre-
liminary injunction to require FSSA to continue reimbursing
Ms. Carter and Ms. Knight for providing attendant care to
their children at the higher rates that apply to those services.
2 The Indiana Protection and Advocacy Services Commission was cre-
ated pursuant to federal law to represent, advocate for, and protect the
rights and interests of individuals with disabilities. See Ind. Code § 12-28-
1-3; 42 U.S.C. § 15001; 42 U.S.C. § 10801; 29 U.S.C. § 794e. While the issues
presented in and the ultimate resolution of this case may affect many IPAS
constituents, the district court’s preliminary injunction and this appeal fo-
cus specifically on E.R. and G.S. We therefore do not discuss IPAS further.

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12 Nos. 24-2633, 24-2741, & 24-2770
To give the district court time to consider Plaintiffs’ request
for a preliminary injunction, FSSA voluntarily extended the
deadline for E.R. and G.S. to transition to the H&W Waiver
until September 1, 2024.
After expedited discovery, briefing, and oral argument on
Plaintiffs’ motion for a preliminary injunction, the district
court granted some of the relief Plaintiffs requested. The court
found that Plaintiffs were likely to succeed on the merits of
their Medicaid Act, ADA, and Rehabilitation Act claims, but
that the balance of harms and public interest precluded the
court from ordering FSSA to pay Plaintiffs’ mothers to pro-
vide attendant care. The court reasoned that Plaintiffs’ re-
quested relief would cause FSSA irreparable harm by forcing
it to violate federal law, putting the State at risk of not receiv-
ing federal reimbursement. Nevertheless, the court ordered
FSSA “to take immediate and affirmative steps to (1) arrange
directly or through referral to appropriate agencies, organiza-
tions, or individuals, corrective treatment of in-home skilled
nursing services to E.R. for a minimum of forty hours and G.S.
for a minimum of eighty hours per week and, (2) reimburse
the mothers for providing [structured family caregiving] in
conjunction.”
Plaintiffs filed an “Emergency Motion to Modify Prelimi-
nary Injunction,” again seeking an order requiring FSSA to
reimburse Ms. Carter and Ms. Knight for providing attendant
care. They argued that the district court’s order was insuffi-
cient to prevent Plaintiffs from being deprived of medically
necessary care at home so that they would have to be institu-
tionalized. The court thought that Plaintiffs may have been
right that the likelihood of FSSA suffering irreparable harm
was low. Nonetheless, it again declined to order Plaintiffs’

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Nos. 24-2633, 24-2741, & 24-2770 13
requested relief, reasoning that such an order would require
FSSA to violate federal law. The court did, however, modify
the preliminary injunction to require FSSA to file biweekly
status reports about its progress toward obtaining in-home
nursing assistance for E.R. and G.S.
Plaintiffs then filed a notice of appeal for the modified pre-
liminary injunction and also sought an injunction pending ap-
peal. For the first time, Plaintiffs argued that 42 C.F.R.
§ 431.250(b)(2) made federal financial participation available
for any payments made to Ms. Carter and Ms. Knight pursu-
ant to a future court order. The district court agreed and, on
September 27, entered a new order requiring FSSA to pay Ms.
Carter and Ms. Knight for providing attendant care services
“in the amount approved by the agency immediately before
the policy changes challenged in this litigation took effect on
September 1.” On October 1, the court entered an amended
preliminary injunction specifying that FSSA is to pay Ms.
Carter and Ms. Knight for providing attendant care “until in-
home skilled nursing services are secured for the Individual
Plaintiffs.” Defendants filed a notice of appeal on September
30 and an amended notice of appeal after the district court
modified its September 27 order. Plaintiffs’ appeal and De-
fendants’ cross-appeal were consolidated before this panel.
We have appellate jurisdiction under 28 U.S.C. § 1292(a)(1).3
3 The parties dispute which of the district court’s orders are properly
before us. We agree with FSSA that we may review all the district court’s
orders, including those filed on September 27 and October 1 after Plaintiffs
filed their notice of appeal. We construe the October 1 preliminary injunc-
tion as a new injunction, which the district court properly entered after
Plaintiffs filed their notice of appeal, and which FSSA timely appealed. A
district court may resolve a new motion for a preliminary injunction after
a previous injunction has been appealed. Adams v. City of Chicago, 135 F.3d

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14 Nos. 24-2633, 24-2741, & 24-2770
Plaintiffs defend the district court’s conclusion that they
are likely to succeed on the merits of their Medicaid Act,
ADA, and Rehabilitation Act claims.4 They also defend the
October 1 injunction as a proper exercise of the court’s equi-
table authority, although they believe it needs to be modified
further to prevent either Plaintiff from experiencing irrepara-
ble harm. FSSA argues that Plaintiffs do not have a private
right of action to pursue any of their Medicaid Act claims. It
further argues that all of Plaintiffs’ claims are disguised chal-
lenges to the State’s Medicaid reimbursement rates and there-
fore barred by Armstrong v. Exceptional Child Center, 575 U.S.
320, 329 (2015). Finally, FSSA argues that Plaintiffs are un-
likely to succeed on the merits of their claims and that the bal-
ance of equities and public interest weigh against the injunc-
tion.
1150, 1153–54 (7th Cir. 1998). That is what the district court did here; it
relied on a new legal authority to grant a new form of relief that it had not
previously ordered. Although a new motion for a preliminary injunction
may be barred for other reasons such as collateral estoppel, see id. at 1153,
FSSA has not made any such argument. As a practical matter, the October
1 injunction superseded the portion of the September 9 order requiring
FSSA to pay Plaintiffs’ mothers for providing structured family caregiving
services. But it did not substantially change the issues on appeal because
the district court’s refusal to order substantially similar relief was the sub-
ject of Plaintiffs’ appeal. We therefore proceed to the merits of the appeal
and cross-appeal.
4 Because the relevant provisions of the Rehabilitation Act and its reg-
ulations are materially identical to their ADA counterparts, courts con-
strue and apply them in a consistent manner. Steimel, 823 F.3d at 909. Go-
ing forward, we will refer only to the ADA, but our analysis applies with
equal force to Plaintiffs’ Rehabilitation Act claims.

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Nos. 24-2633, 24-2741, & 24-2770 15
We affirm the district court’s October 1 injunction and
remand for further proceedings consistent with this opinion.
We first explain that even if the Supreme Court’s recent
decision in Medina v. Planned Parenthood South Atlantic, 606
U.S. —, 145 S. Ct. 2219 (2025), undermines Plaintiffs’ Medicaid
Act claims, they may proceed under the ADA and the
Rehabilitation Act. Then, we explain why the district court
did not abuse its discretion in entering the October 1
injunction ordering FSSA to pay Ms. Carter and Ms. Knight
for providing attendant care until FSSA secures in-home
nurses for E.R. and G.S.
III. Private Right of Action for Medicaid Act Violations
Plaintiffs seek relief under 42 U.S.C. § 1983 for alleged
violations of three provisions of the Medicaid Act, 42 U.S.C.
§ 1396a(a)(8), (a)(10)(A), and (a)(43)(C). Together, these three
provisions require Indiana to provide eligible Medicaid
beneficiaries specified kinds of “medical assistance,”
including skilled in-home nursing care, with “reasonable
promptness.” 42 U.S.C. § 1396a(a)(8); see O.B. v. Norwood, 838
F.3d 837, 839 (7th Cir. 2016). FSSA challenged the use of
section 1983 to enforce only section 1396a(a)(8), even though
sections 1396a(a)(10)(A) and (a)(43)(C) impose overlapping
obligations on the State.
When this appeal was originally briefed, all of Plaintiffs’
Medicaid Act claims were legally viable under Seventh Cir-
cuit precedent. We have long held or assumed that these Med-
icaid Act provisions are privately enforceable through a sec-
tion 1983 action. See Bontrager v. Indiana Family & Soc. Servs.
Admin., 697 F.3d 604, 607 (7th Cir. 2012) (holding that section
1396a(a)(10)(A) is privately enforceable through section 1983);

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16 Nos. 24-2633, 24-2741, & 24-2770
O.B., 838 F.3d 837 (assuming that sections 1396a(a)(8),
(a)(10)(A), and (a)(43)(C) are privately enforceable).
The Supreme Court’s recent decision in Medina v. Planned
Parenthood may well have undermined the availability of sec-
tion 1983 to enforce these portions of the Medicaid Act. In Me-
dina, the Court wrote that Gonzaga University v. Doe, 536 U.S.
273 (2002), sets out the proper method for determining
whether a plaintiff may bring a section 1983 suit to enforce a
provision of spending clause legislation. 606 U.S. at —, 145 S.
Ct. at 2232–34. To enforce such a spending clause provision
through a private plaintiff’s section 1983 action, the statute
must “unambiguously confer individual federal rights” on the
party seeking to sue. Id. at 2233, quoting Health & Hospital
Corp. of Marion County v. Talevski, 599 U.S. 166, 180 (2023). Ap-
plying that standard, Medina held that the Medicaid Act’s
any-qualified-provider provision, 42 U.S.C. § 1396a(a)(23)(A),
is not privately enforceable under section 1983. Id. at 2239. The
Court relied primarily on the lack of “clear and unambiguous
‘rights-creating language’” in section 1396a(a)(23)(A), id. at
2235, quoting Talevski, 599 U.S. at 186, but it also invoked some
features of the Medicaid Act common to all the provisions of
section 1396a, including those relied upon by Plaintiffs. Id. at
2235–36. The Court also expressly repudiated the reasoning
of Wright v. City of Roanoke Redevelopment & Housing Auth., 479
U.S. 418 (1987), and Wilder v. Virginia Hospital Ass’n, 496 U.S.
498 (1990). See Medina, 606 U.S. at —, 145 S. Ct. at 2233–34.
Although the Gonzaga test as applied in Medina and Talev-
ski is a “demanding bar,” id. at 2233, quoting Talevski, 599 U.S.
at 180, some provisions of section 1396a(a) may yet satisfy it.
This is not the right case, though, to decide whether sections
1396a(a)(8), (a)(10)(A), or (a)(43)(C) clear that hurdle. The

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Nos. 24-2633, 24-2741, & 24-2770 17
ADA indisputably gives Plaintiffs a cause of action to chal-
lenge the H&W Waiver’s terms as a violation of the ADA’s
integration mandate. See 42 U.S.C. § 12133 (incorporating by
reference 29 U.S.C. § 794a; authorizing suit against public en-
tities by “any person alleging discrimination on the basis of
disability”); Olmstead v. L.C. ex rel. Zimring, 527 U.S. 581, 590
n.4 (1999). The integration mandate is sufficiently broad to
justify the district court’s October 1 injunction ordering FSSA
to pay Plaintiffs’ mothers for attendant care until in-home
nursing services can be procured. District courts may craft in-
junctions that are “broad enough to be effective.” Republic
Technologies (NA), LLC v. BBK Tobacco & Foods, LLP., 135 F.4th
572, 587 (7th Cir. 2025), quoting Russian Media Group, LLC v.
Cable America, Inc., 598 F.3d 302, 307 (7th Cir. 2010). The com-
bination of the practical lack of available in-home nursing care
and the H&W Waiver’s prohibition on LRI-provided at-
tendant care creates the serious risk of institutionalization
that triggers the integration mandate here. See Steimel, 823
F.3d at 914 (integration mandate applies when State policies
place individuals with disabilities “at serious risk of institu-
tionalization”). The district court could therefore tailor its in-
junction to order relief under the ADA until in-home nursing
care becomes available, even in the absence of a viable Medi-
caid Act claim.
We say no more here about whether sections 1396a(a)(8),
(a)(10)(A), and (a)(43)(C) of the Medicaid Act may be enforced
through a section 1983 action. Those are issues with high
stakes under other circumstances, and they should be decided
in cases in which those issues will be fully litigated and will
affect the outcomes.

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18 Nos. 24-2633, 24-2741, & 24-2770
As a result, we consider only Plaintiffs’ ADA claims below.
On remand, the district court may consider in the first in-
stance whether Plaintiffs’ Medicaid Act claims are still viable
under Medina. If the court decides that these claims are not
viable, it will be best positioned to modify the terms of its in-
junction to the extent equity might require. Regardless of its
decision, both sides will have another opportunity to appeal
an adverse ruling and to brief that issue to this court.5
IV. The October 1 Preliminary Injunction
Although all the district court’s orders are properly before
us, for clarity’s sake, we focus our analysis on the October 1
preliminary injunction. “A preliminary injunction is ‘an exer-
cise of a very far-reaching power, never to be indulged in ex-
cept in a case clearly demanding it.’” Finch v. Treto, 82 F.4th
572, 578 (7th Cir. 2023), quoting Cassell v. Snyders, 990 F.3d
539, 544 (7th Cir. 2021). “To obtain a preliminary injunction, a
plaintiff must show that (1) he has some likelihood of success
on the merits of his claim; (2) traditional legal remedies are
inadequate; and (3) he would suffer irreparable harm without
preliminary injunctive relief.” Id. “If the plaintiff establishes
these threshold requirements, then the court must balance the
equities, weighing the harm to the moving party if the
5 After Medina was decided, IPAS filed a letter pursuant to Federal
Rule of Appellate Procedure 28(j). It raised the possibility that IPAS may
be able to pursue its Medicaid Act claims through statutory vehicles other
than section 1983. Because Plaintiffs’ Medicaid Act claims were clearly vi-
able under pre-Medina circuit precedent, the parties did not initially brief
whether a right of action other than section 1983 authorizes IPAS to pur-
sue Medicaid Act claims on behalf of its constituents. We need not resolve
that question at this time. On remand, the district court will have the op-
portunity to consider this issue in the first instance.

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Nos. 24-2633, 24-2741, & 24-2770 19
requested injunction is denied against the harm to the non-
moving party and the public—including third parties—if it is
granted.” Id. The party seeking a preliminary injunction bears
the burden of showing that it is warranted. Id.
We review the district court’s factual findings for clear er-
ror and its legal conclusions de novo. Life Spine, Inc. v. Aegis
Spine, Inc., 8 F.4th 531, 539 (7th Cir. 2021). The ultimate deci-
sion to grant or deny preliminary injunctive relief is commit-
ted to the sound discretion of the district court. Wesley-Jessen
Div. of Schering Corp. v. Bausch & Lomb Inc., 698 F.2d 862, 864
(7th Cir. 1983). Our review of the October 1 injunction is there-
fore limited. Absent a clear error of fact or law, the district
court’s balancing of equities and assessment of the public in-
terest is entitled to significant deference. Finch, 82 F.4th at 578;
Cassell, 990 F.3d at 545.
Here, the district court determined that Plaintiffs had
shown a high likelihood of success on the merits of their ADA
claims and had shown irreparable harm in the form of the
denial of medically necessary care. It then held that the
balance of equities and public interest weighed in favor of
enjoining FSSA to “allow the Individual Plaintiffs to continue
receiving medically necessary attendant care services from
their mothers in the amount approved by FSSA immediately
before the policy changes challenged in this litigation took
effect on September 1, 2024, until in-home skilled nursing
services are secured for the Individual Plaintiffs.” We agree.
A. Likelihood of Success on ADA Claims
Title II of the ADA prohibits public entities such as FSSA
from excluding or discriminating against qualified disabled
individuals in the provision of public services. 42 U.S.C.

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20 Nos. 24-2633, 24-2741, & 24-2770
§ 12132. Congress further provided that unjustified segrega-
tion of disabled individuals amounts to an actionable form of
discrimination. Olmstead, 527 U.S. at 600, citing 42 U.S.C.
§ 12101(a)(2), (a)(5). That is so for two reasons. “First, institu-
tional placement of persons who can handle and benefit from
community settings perpetuates unwarranted assumptions
that persons so isolated are incapable or unworthy of partici-
pating in community life.” Id. “Second, confinement in an in-
stitution severely diminishes the everyday life activities of in-
dividuals, including family relations, social contacts, work
options, economic independence, educational advancement,
and cultural enrichment.” Id. at 601. Some of the aspirations
enshrined in these policies may seem lofty for the young
Plaintiffs before us. But for them too, Title II serves a vital pur-
pose: enabling them to receive public services without relin-
quishing close contact with their parents and siblings.
Consistent with Congress’s desire to prevent the
unnecessary confinement of disabled individuals in
institutions, the regulations implementing the ADA contain
an integration mandate. The integration mandate provides:
“A public entity shall administer services, programs, and
activities in the most integrated setting appropriate to the
needs of qualified individuals with disabilities.” 28 C.F.R.
§ 35.130(d). The “most integrated setting appropriate” is
defined as “a setting that enables individuals with disabilities
to interact with nondisabled persons to the fullest extent
possible.” 28 C.F.R. pt. 35, app. B, subpt. B. § 35.130. The
integration mandate, however, does not impose an
“unqualified obligation” on public agencies. Radaszewski ex
rel. Radaszewski v. Maram, 383 F.3d 599, 607 (7th Cir. 2004).
“Although an agency must make such modifications as are
‘reasonable’ in order to avoid unduly segregating the

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Nos. 24-2633, 24-2741, & 24-2770 21
disabled, it is relieved of that obligation if it can show ‘that
making the modifications would fundamentally alter the
nature of the service, program, or activity.’” Id., quoting 28
C.F.R. § 35.130(b)(7)(i).
In Olmstead, the Supreme Court applied the integration
mandate to Medicaid services. It held that the integration
mandate requires States to provide community-based treat-
ment for individuals with disabilities if three conditions are
met. 527 U.S. at 607; see Radaszewski, 383 F.3d at 608. First, the
State’s treatment professionals must find that community-
based treatment is appropriate for the affected individual.
Second, the affected individual must not oppose community-
based treatment. Finally, it must be the case that community
placement can be reasonably accommodated, taking into ac-
count the State’s resources and the needs of others with simi-
lar disabilities. Olmstead, 527 U.S. at 607. We have acknowl-
edged that the third element “‘represent[ed] the thinking of
only a plurality of the Court,’ while the first two commanded
a majority.” Vaughn v. Walthall, 968 F.3d 814, 819 (7th Cir.
2020), quoting Steimel, 823 F.3d at 914–15. “Nonetheless, the
concurring opinions made ‘clear that some version of the
“reasonable modifications” provision—and its flip side, the
fundamental-alteration defense—must be taken into account
before deciding that the integration mandate was violated.’”
Id., quoting Steimel, 823 F.3d at 915.
Plaintiffs assert that the State’s refusal to authorize LRIs to
provide attendant care violates the integration mandate be-
cause it denies E.R. and G.S. an existing benefit that would
enable them to continue receiving care at home instead of in
an institution such as a nursing home. FSSA resists that con-
clusion on two grounds. First, it claims that the H&W

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22 Nos. 24-2633, 24-2741, & 24-2770
Waiver’s prohibition on attendant care provided by LRIs does
not trigger the integration mandate at all because it does not
place E.R. or G.S. at serious risk of institutionalization. FSSA
also argues that authorizing LRI-provided attendant care
would “fundamentally alter” the H&W Waiver. On this rec-
ord, given the district court’s well-supported factual findings,
neither of FSSA’s arguments is persuasive.
1. Serious Risk of Institutionalization
In Steimel, we explained that disabled individuals need not
be institutionalized before they can “challenge an allegedly
discriminatory law or policy that threatens to force them into
segregated isolation.” 823 F.3d at 912, quoting Fisher v. Okla-
homa Health Care Auth., 335 F.3d 1175, 1181 (10th Cir. 2003).
The integration mandate can apply whenever a State admin-
isters Medicaid in a manner that places disabled individuals
at “serious risk of institutionalization.” Id. at 914. The district
court made a factual finding that FSSA’s July 2024 policy
change placed both E.R. and G.S. at serious risk of institution-
alization. We review that finding for clear error. See Life Spine,
8 F.4th at 539.
In finding that the prohibition on LRI-provided attendant
care put Plaintiffs at serious risk of institutionalization, the
district court carefully examined the record and made the
following subsidiary findings. First, given Plaintiffs’ medical
needs and functional limitations, they cannot be left with a
caretaker who is unfamiliar with or incapable of meeting their
skilled needs for any period of time. Second, right now, only
Plaintiffs’ family members are trained to handle their full
array of medical needs. Third, if Ms. Carter and Ms. Knight
cannot serve as paid providers of attendant care for their
children, they will have no choice but to seek outside

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Nos. 24-2633, 24-2741, & 24-2770 23
employment to meet the basic needs of their families. Finally,
in that case, they will also be forced to seek institutional
placement for their children because other home-based and
community-based services are insufficient to ensure that their
sons’ complex and unpredictable needs are met.
We find no clear error in any of these subsidiary findings
or the court’s finding that the H&W Waiver’s prohibition on
LRI-provided attendant care would place E.R. and G.S. at se-
rious risk of institutionalization. To the contrary, the court’s
findings are amply supported by the record. FSSA’s argu-
ments fail to come to terms with the inability of other availa-
ble services to meet either Plaintiff’s needs.6
FSSA first argues that E.R. and G.S. do not require what it
characterizes as “direct, hands-on care” for 24 hours each day.
But as the district court found, FSSA’s litigating position is
contradicted by the eligibility screenings the State completed
for E.R. in 2022 and G.S. in 2023. Those screenings note that
Plaintiffs require “24 hours a day supervision and/or direct
assistance … to maintain safety.” The court also did not err by
6 FSSA attacks the affidavits of Ms. Carter and Ms. Knight as “self-
serving.” Most affidavits from parties and their allies, including those sub-
mitted by FSSA in this case, are self-serving in that they try to support the
submitting party’s legal arguments. See Hill v. Tangherlini, 724 F.3d 965,
967 (7th Cir. 2013) (collecting cases). The federal rules do not prohibit or
give lesser weight to self-serving affidavits based on personal knowledge.
We have repeatedly emphasized that the term “self-serving” should not
be used to “denigrate perfectly admissible evidence.” Id. Ms. Carter’s and
Ms. Knight’s affidavits contain key information about their children’s
medical histories and needs, their financial circumstances, and their ongo-
ing attempts to seek Medicaid services. Their testimony is grounded in
their personal knowledge and years of experience caring for their children
under difficult and at times dire conditions.

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24 Nos. 24-2633, 24-2741, & 24-2770
crediting the assessments of Plaintiffs’ mothers and treating
physicians over that of FSSA’s chief medical officer, Dr. S. Ma-
ria Finnell, who has never examined either Plaintiff.
Even if Plaintiffs did not need “direct, hands-on care” at
all times, that would not undermine the district court’s key
finding that E.R. and G.S. simply cannot be left in the care of
someone who is not capable of meeting their skilled nursing
needs. That finding explains why Plaintiffs’ mothers, and not
unskilled home-health aides, must provide Plaintiffs’ at-
tendant care to preserve Plaintiffs’ health and safety. Despite
some handwringing about whether Plaintiffs require skilled
nursing services every moment of every day, Dr. Finnell’s af-
fidavit is fully consistent with that part of the district court’s
findings. As Dr. Finnell acknowledges, both children have se-
vere and unpredictable medical needs that may produce a
medical emergency requiring skilled aid at any moment.
The State next argues that Plaintiffs’ attendant care hours
may be replaced with structured family caregiving hours. The
district court explained why this argument is not persuasive.
Ms. Carter and Ms. Knight are currently the only people ca-
pable of providing the full-time care their children require at
home. The court explained in detail why it would not be fea-
sible for Ms. Carter and Ms. Knight to transition to structured
family caregiving: the reimbursement rate for structured fam-
ily caregiving is too low to be the sole source of income for
either family. If Ms. Carter and Ms. Knight were unable to
serve as paid providers of attendant care, they would need to
seek full-time employment outside the home to meet their
families’ basic needs and their children’s heightened needs.
None of these findings is clearly erroneous. In practice,
then, neither Plaintiff can replace attendant care hours with

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Nos. 24-2633, 24-2741, & 24-2770 25
structured family caregiving hours staffed by their mothers.
The theoretical availability of structured family caregiving
hours does nothing to prevent either Plaintiff from being in-
stitutionalized. See Waskul v. Washtenaw County Community
Mental Health, 979 F.3d 426, 462 (6th Cir. 2020) (reversing dis-
missal when complaint allowed for inference that plaintiff
would be “at serious risk of institutionalization if his guard-
ian is unable to continue caring for him due to her dire finan-
cial situation”).
FSSA’s final argument is that other services—specifically,
in-home skilled nursing and public schools—could fill the
gap left by the inability of Ms. Carter and Ms. Knight to care
for their children while they seek and obtain full-time em-
ployment. But this argument too relies on mere theoretical
possibilities rather than evidence of alternative services that
are currently available to meet Plaintiffs’ medical needs at
home. FSSA begins by faulting Plaintiffs for failing to use their
approved skilled nursing hours—the same hours that Plain-
tiffs seek to staff through their Medicaid Act claims. FSSA re-
lies on the fact that the State has approved skilled nursing
hours for both Plaintiffs and ignores entirely the evidence
showing that Plaintiffs and FSSA have not been able to find
nurses who are actually available and willing to staff those
hours.
The State next contends that Plaintiffs are failing to take
full advantage of resources that are supposed to be available
through the public school system. The State points out that
Plaintiffs are entitled to continuous nursing services under the
Individuals with Disabilities Education Act (IDEA). See 20
U.S.C. §§ 1401(26), 1412; Cedar Rapids Community Sch. Dist. v.
Garret F. ex rel. Charlene F., 526 U.S. 66, 70, 79 (1999) (holding

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26 Nos. 24-2633, 24-2741, & 24-2770
that under IDEA, school district was required to provide
continuous one-on-one nursing services that ventilator-
dependent plaintiff needed to remain in school). The district
court found, however, that the public schools near E.R. and
G.S. are unable or unwilling to provide continuous nursing
services. Unable to contest the evidence supporting the
district court’s finding that continuous nursing services are
not actually available to either child, FSSA simply emphasizes
that public schools have an obligation to provide such
services under the IDEA. It then goes on to suggest that there
is no reason that these children—with their limited mobility,
their impaired vision and hearing, their intellectual and
developmental deficits, and their frequently life-threatening
medical conditions—should not attend school to the same
extent as children without disabilities.
To state FSSA’s argument is to refute it. E.R. and G.S. can-
not attend school in the same manner and at the same fre-
quency as any other child. Even if either child could attend
school more regularly, he would be excluded from doing so
due to the unavailability of nursing services capable of keep-
ing him safe and healthy during school hours. Without pars-
ing the allocation of responsibility under the IDEA as between
the State itself and the local public school system, we will as-
sume for the sake of argument that FSSA might bring the pub-
lic school system into the case, perhaps as a third-party de-
fendant. That possibility does not show that the district court
erred by focusing on the services that might actually be avail-
able to prevent E.R. and G.S. from being institutionalized.
2. Olmstead Analysis
Having found no clear error in the district court’s finding
that Plaintiffs are at serious risk of institutionalization, we

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Nos. 24-2633, 24-2741, & 24-2770 27
move on to the Olmstead analysis. FSSA contests only the third
prong of the Olmstead test—whether LRI-provided attendant
care is a reasonable accommodation or instead would be a
fundamental alteration of the H&W Waiver. It is the State’s
burden to establish its fundamental-alteration defense. See
Steimel, 823 F.3d at 916. To that end, FSSA makes two argu-
ments. It claims (1) that LRI-provided attendant care is a new
service and (2) that the cost of providing it is fiscally unsus-
tainable. At this stage, neither argument is persuasive. Like
the district court, we think that Plaintiffs have shown a high
likelihood of succeeding on their claims that the H&W
Waiver’s prohibition on LRI-provided attendant care violates
the integration mandate.
a. New Service
FSSA’s principal theory is that LRI-provided attendant
care is a “new service” that should count as a “fundamental
alteration” to its Medicaid program. It cites Radaszewski v.
Maram, which recognized that States are “not obligated to cre-
ate new services in order to enable an institutionalized indi-
vidual to live in a more integrated setting.” 383 F.3d at 609.
Closer attention to the facts and holding of Radaszewski, how-
ever, shows that Plaintiffs are not seeking a new service.
In Radaszewski, the 21-year-old plaintiff sought continuous
private-duty nursing that would enable him to remain at
home instead of being institutionalized in a hospital. Id. at
600. At that time, the State generally did not provide private-
duty nursing to people over the age of 20. Id. at 601–02. The
plaintiff could obtain some private-duty nursing through a
cost-limited waiver program for adults, but the applicable
“service cost maximum” would not cover the 24/7 nursing
care that he needed to remain at home. Id. at 602–03.

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28 Nos. 24-2633, 24-2741, & 24-2770
Nonetheless, we rejected the State’s argument that it was
entitled to judgment on the pleadings based on its argument
that private-duty nursing was an entirely new service. The
State conceded that if the plaintiff were placed in an institu-
tion, it would be required to provide him with the level of care
that he needed in order to survive. Id. at 611. The plaintiff al-
leged that if he were institutionalized, he would require a
more care-intensive setting than a nursing home, such as a
hospital, to meet his need for “constant, one-on-one care.” Id.
at 610. We reasoned that private-duty nursing might be a rea-
sonable modification to the form of existing services, rather
than a new service, if the plaintiff could show that a private-
duty nurse would provide the same level of care as a care-
intensive unit in a hospital. Id. at 611. The care would be de-
livered differently in the plaintiff’s home, with a private-duty
nurse replacing a hospital staff. But the substance of the
care—“constant monitoring and continuous skilled assistance
in accomplishing basic bodily functions”—would remain the
same. Id.
Although Radaszewski was about the adaptation of
institutional services to community-based settings, the same
general principles apply where, as here, a plaintiff seeks an
accommodation in the form of a modification to a service
already delivered in a community setting. An unreasonable
limit on a home- or community-based service that places a
disabled individual at serious risk of institutionalization is
just as capable of violating the integration mandate as a
State’s refusal to modify a service ordinarily delivered in an
institutional setting. To determine whether a plaintiff is
requesting a new service or only a modification to the way an
existing service is delivered, Radaszewski instructs us to look
at the substance of the care, not the form, method, or provider.

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Nos. 24-2633, 24-2741, & 24-2770 29
See id. at 611 (“But so long as it is possible for the plaintiff to
show that the services he seeks to receive at home are, in
substance, already provided in the institutional setting, then
the State is not entitled to judgment on the pleadings based
on the argument that the services would take on a different
form or method if provided in a community setting.”). Under
that standard, Plaintiffs are not seeking a new service here.
FSSA already provides the exact service that Plaintiffs seek
in the exact form that Plaintiffs seek it in, and it has already
approved both Plaintiffs to receive it. Removing the prohibi-
tion on LRIs serving as paid providers of attendant care for
these Plaintiffs does not change the substance of the service as
defined by the H&W Waiver. It merely gives Plaintiffs access
to an existing benefit that has been granted to other disabled
individuals, and one that FSSA agrees Plaintiffs need and for
which they qualify. See Steimel, 823 F.3d at 913 (no fundamen-
tal alteration where plaintiffs sought “access to existing bene-
fits available under [the waiver programs]—benefits that
[had] been granted to some persons with disabilities, but not
to them”); Radaszewski, 383 F.3d at 611–12 (“the fact that the
State already provides for some private-duty nursing tends to
belie the notion that providing such care … would require the
State to alter the substance of its Medicaid programs by creat-
ing an entirely ‘new’ service”); cf. Rodriguez v. City of New
York, 197 F.3d 611, 618–19 (2d Cir. 1999) (neither ADA nor Re-
habilitation Act compelled State to offer safety monitoring to
persons with mental disabilities so that such individuals
could remain at home, where safety monitoring was not an

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30 Nos. 24-2633, 24-2741, & 24-2770
existing personal care service that city offered through its
Medicaid program).7
FSSA cites Vaughn v. Walthall as support for its argument
that LRI-provided attendant care is a new service. But in
Vaughn, we evaluated the reasonableness of an accommoda-
tion very similar to the one requested by Plaintiffs and came
to a different conclusion. The Vaughn plaintiff requested the
ability to hire and train non-nurses to perform skilled tasks
that the State allowed only licensed nurses to perform. 968
F.3d at 823. We explained that if the relevant tasks could be
lawfully delegated to a trained caregiver, “but Indiana simply
as a matter of policy prefers that they be performed by
nurses,” then the State’s “exercise of discretion might well be
unreasonable given the integration direction.” Id. Because it
was unclear, though, whether non-nurses could lawfully per-
form skilled care under State and federal law, we remanded
the case to the district court for further fact-finding. Id. at 824
Here, unlike in Vaughn, FSSA explicitly acknowledges that
it could authorize LRIs to perform attendant care consistent
with State law and federal requirements for waiver program
approval and funding. The fact that Indiana could allow LRIs
7 In this court, FSSA renews its argument that Plaintiffs are seeking a
new service because they want to be paid for performing skilled tasks out-
side of the scope of attendant care. This argument is not supported by the
record. At the preliminary injunction hearing, Plaintiffs’ counsel explicitly
denied that Plaintiffs are seeking to be reimbursed for providing skilled
care. Counsel asserted that Plaintiffs are seeking reimbursement only for
attendant care exactly as that service is defined in the State’s waiver doc-
ument. The fact that Plaintiffs have complex medical needs explains why
their mothers, and not untrained caretakers, must provide their attendant
care. It does not transform LRI-provided attendant care into a new service
within the meaning of Radaszewski.

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Nos. 24-2633, 24-2741, & 24-2770 31
to provide attendant care but has simply chosen not to do so
makes Plaintiffs’ case for an accommodation stronger. See id.
at 823. Authorizing a different, unambiguously qualified pro-
vider to perform an existing non-skilled service is just the
kind of minor modification to an existing service that the in-
tegration mandate can require.
At bottom, FSSA’s argument appears to be that LRI-
provided attendant care is a new service merely because it is
not currently permitted under the H&W Waiver. In Steimel v.
Wernert, we rejected the same kind of circular objection to
changing the eligibility criteria of a waiver program: “After
all, the state creates the waiver programs, and therefore those
programs’ eligibility criteria. If the state’s own criteria could
prevent the enforcement of the integration mandate, the man-
date would be meaningless.” 823 F.3d at 916. Likewise, the
integration mandate would be an empty promise if a State’s
policy choices regarding the services it provides were insu-
lated from judicial review under the ADA merely because
they were formalized in the State’s Medicaid documents. LRI-
provided attendant care is not currently authorized by the
H&W Waiver, but if Plaintiffs prevail in this suit, the district
court could enter a permanent injunction requiring FSSA to
amend the H&W Waiver. The fact that Plaintiffs’ requested
relief may eventually require the State to amend its waiver
does not transform an otherwise reasonable accommodation
into a new service. To hold otherwise would enable the State
to “avoid the integration mandate by binding its hands in its
own red tape.” Id. at 916.
b. Fiscal Sustainability
FSSA also argues that amending the H&W Waiver to au-
thorize LRI-provided attendant care would be fiscally

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32 Nos. 24-2633, 24-2741, & 24-2770
unsustainable. It contends that a permanent injunction would
impair its ability to mitigate the effects of its anticipated
budget deficit and would therefore result in interruptions to
Medicaid services.
A State’s resource constraints are relevant to the
fundamental-alteration inquiry. In Olmstead, the plurality
explained that a State may establish its fundamental-
alteration defense by showing that “in the allocation of
available resources, immediate relief for the plaintiffs would
be inequitable, given the responsibility the State has
undertaken for the care and treatment of a large and diverse
population of persons with mental disabilities.” 527 U.S. at
604. However, neither the plurality nor the concurring
Justices suggested that a State’s fiscal problem, by itself,
justifies any restriction on an existing, medically necessary
service. As other courts have recognized after Olmstead, a
State’s reasonable attempt to solve a fiscal problem may still
violate the integration mandate. See, e.g., Pashby v. Delia, 709
F.3d 307, 323–24 (4th Cir. 2013) (collecting cases for the
premise that “although budgetary concerns are relevant to the
fundamental alteration calculus, financial constraints alone
cannot sustain a fundamental alteration defense”); Fisher, 335
F.3d at 1182–83. States are not required, however, to make an
accommodation that would be so costly or would so disrupt
the allocation of available resources that it would compel the
State to alter the substance of the services it provides to other
disabled Medicaid beneficiaries.
On this record, FSSA has not yet shown that amending the
H&W Waiver to authorize LRIs to provide attendant care
would either solve its fiscal problem or be inequitable. Re-
garding its fiscal situation, FSSA has not shown that

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Nos. 24-2633, 24-2741, & 24-2770 33
prohibiting LRI-provided attendant care actually saves the
State any money. As the district court observed, this case is
not about how many services an enrollee may receive. It is only
about whom FSSA is willing to pay to provide those services.
One curious feature of FSSA’s position here is that if E.R. or
G.S. had any other family member or family friend qualified
and willing to provide the full-time care they need to remain
at home, FSSA would have no problem reimbursing those
providers at the higher attendant care rates. If E.R. or G.S. had
less extreme ailments that did not place them in danger if su-
pervised part of the day by a home-health aide incapable of
meeting their skilled needs, FSSA would have no problem re-
imbursing their providers. If Plaintiffs’ families could find
nurses willing to work in their homes, FSSA would not hesi-
tate to pay for home nursing at a cost that is nearly identical
to the cost of attendant care. And, of course, FSSA would also
have no objection to placing both Plaintiffs in institutions that
would be far more expensive than home-based care.
In other words, the State is willing to provide the services
and care that Plaintiffs require, and it is willing to spend as
much—or more—as it would cost to reimburse Ms. Carter
and Ms. Knight to do so in the form of attendant care. Even
though FSSA justifies the prohibition on LRI-provided
attendant care as a cost-containment strategy, it has provided
no evidence that the limitation would actually reduce the
expense of Plaintiffs’ care. Given the unavailability of other
services, it appears the restriction would eventually push
Plaintiffs into nursing homes, which are significantly more
costly than home-based care—even when we factor in the rise
in FSSA’s expenditures for home-based care. If even a
substantial increase in the cost of a plaintiff’s care cannot
defeat a Title II claim, see Radaszewski, 383 F.3d at 614,

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34 Nos. 24-2633, 24-2741, & 24-2770
evidence that a plaintiff’s request would cost the State the
same or less than every other alternative, including
institutionalization, does not establish a fundamental-
alteration defense.
Although our analysis highlights the cost of providing
care to E.R. and G.S., we are cognizant of the need to consider
the cost of authorizing LRI-provided attendant care for all el-
igible waiver enrollees. Looking only at the cost of changing
Plaintiffs’ care “would be unfair to the state and fail to give it
the leeway for which [the concurring Olmstead Justices]
called.” Steimel, 823 F.3d at 915, citing Olmstead, 527 U.S. at 603
(plurality op. of Ginsburg, J.) (“If the expense entailed in plac-
ing one or two people in a community-based treatment pro-
gram is properly measured for reasonableness against the
State’s entire mental health budget, it is unlikely that a State,
relying on the fundamental-alteration defense, could ever
prevail.”). Our analysis applies equally when we look at the
cost of providing care to all individuals with disabilities com-
parable to Plaintiffs. If other waiver recipients need to seek in-
home skilled nursing services or institutionalization as a re-
sult of the prohibition on LRI-provided attendant care, the
cost of their care would rise in the way explained above.
As for the services that the State provides to other
Medicaid beneficiaries, FSSA invokes a parade of horribles to
show that authorizing LRI-provided attendant care would be
inequitable. It hypothesizes that it may have to limit the H&W
Waiver in various ways or even eliminate the waiver program
entirely. It relies on the affidavit of FSSA’s Medicaid Director,
Cora Steinmetz, who listed, without any explanation, several
options of varying gravity that FSSA might take if the district
court enters a permanent injunction. That list includes the

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Nos. 24-2633, 24-2741, & 24-2770 35
possibility of seeking additional budget augmentation or
appropriations from the State Budget Agency and the Indiana
legislature. That indicates to us that, at this time, all options
are on the table. FSSA’s unexplained and unsupported
assertions about the options a permanent injunction might
lead it to consider are too speculative to sustain its
fundamental-alteration defense. They do not show that
authorizing attendant care from LRIs would compel cutbacks
in services to other Medicaid waiver participants or be
otherwise inequitable.
Beyond Steinmetz’s affidavit, FSSA’s experience to date
with the H&W Waiver tends to undermine its suggestion that
it would be either impossible or undesirable for FSSA to au-
thorize LRI-provided attendant care while staying within its
fiscal constraints. As of July 1, 2024, FSSA had received tran-
sition service plan updates for most pediatric waiver enrol-
lees. Of those enrollees, more than 68% have transitioned to
structured family caregiving, and many remaining enrollees
are receiving attendant care from a non-LRI or have pursued
other waiver and State Plan services. It appears, therefore, that
only a small minority of H&W Waiver enrollees with various
combinations of uniquely challenging ailments and family
circumstances are likely to need LRI-provided attendant care
to avoid institutionalization. To satisfy the integration man-
date, the State may design the H&W Waiver to preserve LRI-
provided attendant care as a last resort for that small subset
of cases without prohibiting it entirely. That would be a law-
ful and reasonable alternative to hoping that imaginary or hy-
pothetical providers will provide needed care. The federal
government encourages States to develop waiver policies that
make LRIs providers of last resort, without prohibiting them.
If LRI-provided attendant care is needed in only a small

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36 Nos. 24-2633, 24-2741, & 24-2770
minority of cases, the expense of reimbursing it is unlikely to
compel drastic reductions in services for other disabled indi-
viduals—especially since the alternative, institutionalization,
is more expensive.8
This lawsuit is still in its early stages. Perhaps FSSA can
develop the record and show that authorizing LRI-provided
attendant care would require it to shift resources in an
inequitable manner. But at this time, it has offered only
doomsday predictions about the impact of authorizing LRI-
provided attendant care on Indiana’s Medicaid program.
Those predictions are difficult to reconcile with the State’s
apparent willingness to spend the same amount of money or
more on other home-based services or to institutionalize
Plaintiffs and other waiver enrollees. FSSA has therefore
failed to show that LRI-provided attendant care is so
financially burdensome that it would compel a fundamental
alteration to the substance of the H&W Waiver.
8 FSSA has also raised the concern that authorizing attendant care ser-
vices for a smaller subset of waiver enrollees would result in some families
being without any option for paid care from an LRI. This argument as-
sumes that LRI-provided attendant care cannot be authorized without
taking away the option of LRI-provided structured family caregiving.
FSSA has not pointed to any legal authority, and we have found none, that
would require it to eliminate LRI-provided structured family caregiving
to authorize LRI-provided attendant care. Like the decision to disallow
LRI-provided attendant care, eliminating LRI-provided structured family
caregiving would be the State’s policy choice—a choice that would also be
subject to the integration mandate. If FSSA is permanently enjoined from
enforcing the restriction on LRI-provided attendant care, it could obvi-
ously modify other parts of the H&W Waiver as necessary to comply with
its legal obligations and fiscal constraints. At all times, though, FSSA is
subject to and must comply with the integration mandate.

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Nos. 24-2633, 24-2741, & 24-2770 37
3. Effect of Armstrong v. Exceptional Child Center
Having failed to show that Plaintiffs are not at serious risk
of institutionalization or that authorizing LRI-provided at-
tendant care would fundamentally alter the H&W Waiver,
FSSA offers one last argument. It depends on recharacterizing
Plaintiffs’ position. FSSA contends that Plaintiffs’ ADA claims
seek in substance to raise the State’s reimbursement rates, a
form of relief that FSSA says is barred by the Supreme Court’s
decision in Armstrong v. Exceptional Child Center, Inc., 575 U.S.
320 (2015). In Armstrong, the Court considered whether
health-care providers have a private cause of action to enforce
42 U.S.C. § 1396a(a)(30)(A) of the Medicaid Act, which sets out
requirements that States must follow when setting Medicaid
reimbursement rates. 575 U.S. at 322–24. The Court concluded
that section 1396a(a)(30)(A) is not privately enforceable under
the Supremacy Clause or through a suit in equity. Id. at 326–
28. Although the Armstrong plaintiffs did not assert that sec-
tion 1396a(a)(30)(A) itself contains an implied private right of
action, a plurality of the Court and Justice Breyer agreed that
it does not, albeit for different reasons. Id. at 331 (plurality
opinion of Scalia, J.), 336 (opinion of Breyer, J.).
FSSA reads Armstrong to prohibit Medicaid beneficiaries
from bringing any claim seeking a different Medicaid reim-
bursement rate under section 1396a(a)(30)(A) or through any
other vehicle. It believes that Plaintiffs’ ADA claims are dis-
guised challenges to the State’s Medicaid reimbursement
rates and therefore barred by Armstrong. We disagree on both
points. Neither Armstrong’s holding nor its reasoning sup-
ports FSSA’s attempt to evade the Olmstead framework for
evaluating Plaintiffs’ ADA claims. And regardless, Plaintiffs’

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38 Nos. 24-2633, 24-2741, & 24-2770
ADA claims are not disguised attempts to engage the district
court in ratemaking.
First, Plaintiffs are not proceeding pursuant to section
1396a(a)(30)(A), and Armstrong has no bearing on Plaintiffs’
ADA claims. The question presented in Armstrong was nar-
row: whether section 1396a(a)(30)(A) is privately enforceable.
In saying no, the Court never suggested that the unenforce-
ability of section 1396a(a)(30)(A) somehow nullifies other
causes of action explicitly created by Congress in different
statutes, such as the ADA. Furthermore, Armstrong did not
place a substantive limit on the relief that Medicaid benefi-
ciaries may seek through litigation brought under statutory
provisions other than section 1396a(a)(30)(A). See M.G. ex rel.
Garcia v. Armijo, 117 F.4th 1230, 1252–53 (10th Cir. 2024) (Arm-
strong does not preclude every suit that might require States
to spend funds or to raise health-care rates). None of the var-
ious opinions even broached the unpresented and legally dis-
tinct issue of the kind of relief that a plaintiff may seek under
the ADA.9
9 Our precedent does not hold otherwise. In O.B., we speculated that
“we could not order the agency to eliminate the [nurse] shortage by rais-
ing [its] rates.” 838 F.3d at 842. But the O.B. plaintiff did not seek that relief,
and our statement considering such a hypothetical request is not binding,
as we later recognized in Vaughn. See 968 F.3d at 826 (clarifying that the
“question whether a Medicaid recipient has a private right of action to
challenge Medicaid rates as too low to elicit necessary services may come
up” is still unresolved). Moreover, in O.B., the plaintiffs relied exclusively
on other provisions of section 1396a(a). See O.B., 838 F.3d at 839. If they
had sought an order requiring the State agency to raise its Medicaid rates,
there would have been a genuine possibility that they were attempting to
circumvent Armstrong since their claims relied exclusively on other

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Nos. 24-2633, 24-2741, & 24-2770 39
Even if Armstrong could be read to limit substantively the
relief that disabled individuals may seek through litigation
under the ADA, it would have no bearing on the outcome of
this case. Plaintiffs “are not, directly or surreptitiously, seek-
ing to engage the district court in ratemaking pursuant to
§ 1396a(a)(30)(A)” or any other statute. Id. at 1252. They do not
ask FSSA to raise the rate it pays to any category of providers
or for any category of services. They ask only that FSSA allow
their uniquely qualified and available LRIs to provide at-
tendant care services, as it had for years prior to the July 2024
policy change. In other words, Plaintiffs are challenging who
is allowed to perform a certain service, not the rate at which
FSSA reimburses providers. Their request for a different pro-
vider does not embroil the courts in the kind of direct rate-
setting that Justice Breyer found problematic in Armstrong.
See 575 U.S. at 334–35 (opinion of Breyer, J.).
Because the State continues to raise Armstrong in ADA
cases, we acknowledge that rates have a significant impact on
the availability of Medicaid services. Many Medicaid benefi-
ciaries would likely be better off if States raised their Medicaid
reimbursement rates. But a plaintiff’s ADA suit does not au-
tomatically fail under Armstrong merely because she brings it
to rectify an issue that could be addressed in numerous ways,
one of which is raising rates. The State cannot avoid its legal
obligations under the ADA and its integration mandate by
pointing out that a plaintiff’s dilemma could be solved by a
rate increase that she did not request. Here, the preliminary
injunction record shows that the difference between the rates
for attendant care services and structured family caregiving is
provisions of section 1396a(a). Because the Plaintiffs here are seeking relief
primarily under the ADA, this suit does not present that problem.

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40 Nos. 24-2633, 24-2741, & 24-2770
the difference between E.R. and G.S. remaining at home with
their loved ones and being forced to reside in institutions. The
State could comply with the integration mandate by paying
structured family caregiving providers more, but that is not
what Plaintiffs request, nor what the district court’s injunction
requires. Armstrong therefore does not block the injunctive re-
lief granted in this case.
In sum, then, Plaintiffs have shown a substantial likeli-
hood of prevailing on the merits of their claims under the
ADA’s integration mandate, supporting the injunctive relief
ordered in this case.
B. Irreparable Harm and Balance of the Equities
Because the district court did not err in finding that Plain-
tiffs are likely to succeed on the merits of their ADA claims,
we turn to its finding that Plaintiffs are likely to suffer irrepa-
rable harm without preliminary injunctive relief and its equi-
table balancing of the harms. We agree with the district court
that Plaintiffs will likely suffer irreparable harm—the denial
of medically necessary attendant care services in their
homes—without preliminary injunctive relief. See Bontrager v.
Indiana Family & Soc. Servs. Admin., 697 F.3d 604, 611 (7th Cir.
2012) (collecting cases).
FSSA argues, however, that the October 1 injunction
places it at risk of grave and irreparable harm. It contends that
the injunction impermissibly compels FSSA to violate federal
law, thereby placing the entire H&W Waiver at risk of being
terminated. FSSA further argues that the district court ex-
ceeded its equitable authority in entering the October 1 in-
junction. It asserts that Seventh Circuit precedent prohibits
district courts from issuing injunctions requiring a State to

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Nos. 24-2633, 24-2741, & 24-2770 41
furnish a Medicaid beneficiary’s care “entirely out of its own
funds, unreimbursed and unsupplemented by Medicaid.”
Vaughn, 968 F.3d at 826. In the State’s view, any payments
made to Plaintiffs’ mothers are ineligible for federal reim-
bursement, rendering the October 1 injunction impermissible.
We appreciate FSSA’s concerns—the termination of the
H&W Waiver would undoubtedly cause irreparable harm to
both the State and to other waiver enrollees who would expe-
rience service disruption. The argument has the superficial
appeal of a complete showstopper. But a closer look shows
that the October 1 injunction does not compel FSSA to violate
federal law or to furnish Plaintiffs’ care entirely out of its own
funds. FSSA’s allegations of irreparable harm are too specula-
tive to overcome Plaintiffs’ concrete evidence that they will be
denied medically necessary care without preliminary injunc-
tive relief.
1. Violation of Federal Law?
FSSA asserts that federal regulations expressly prohibit
FSSA from paying Ms. Carter and Ms. Knight for providing
attendant care services. By ordering the State to pay them for
providing attendant care services, the argument goes, the dis-
trict court’s order compels it to violate federal law. Needless
to say, courts are not authorized “to issue injunctions that au-
thorize or direct people to violate valid federal statutes” or
regulations. Schering Corp. v. Illinois Antibiotics Co., 62 F.3d
903, 907 (7th Cir. 1995). But after reviewing the applicable reg-
ulations, we think that FSSA misconstrues the legal con-
straints on its ability to pay Ms. Carter and Ms. Knight for
providing attendant care.

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42 Nos. 24-2633, 24-2741, & 24-2770
FSSA’s argument hinges on 42 U.S.C. § 1396d(a)(24) and
42 C.F.R. § 440.167, both of which define “personal care ser-
vices,” the category of services to which attendant care and
structured family caregiving belong. As relevant here, both
provisions define personal care services as services
“[p]rovided by an individual who is qualified to provide such
services and who is not a member of the individual’s family.”
42 C.F.R. § 440.167(b) specifies: “For purposes of this section,
family member means a legally responsible relative,” which
is defined in turn to include the spouse of a recipient or the
parent of a minor recipient. Personal Care Services in a Home
or Other Location, 62 Fed. Reg. 47896, 47899 (Sep. 11, 1997).
According to FSSA, sections 1396d(a)(24) and 440.167 ex-
pressly prohibit it from paying Plaintiffs’ mothers for provid-
ing attendant care services.
Neither provision relied upon by FSSA expressly prohibits
the State from doing anything. They both define “personal
care services” and therefore inform States which services are
eligible for approval and reimbursement through the Medi-
caid program. But they do not contain any prohibitory lan-
guage directly regulating the conduct of States, which remain
free to authorize and reimburse any service they like—just
without federal financial participation. That understanding of
section 440.167 comports with the federal government’s tech-
nical Medicaid guidance, which explains that “42 CFR 440.167
prohibits [federal financial participation] for payments to le-
gally responsible individuals for the provision of state plan
personal care services.” CMS Technical Guidance at 120. The
technical guidance confirms that section 440.167 sets out
CMS’s policy for when it will approve and pay for personal
care services. It does not prohibit States from paying LRIs for

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Nos. 24-2633, 24-2741, & 24-2770 43
providing personal care services. The October 1 injunction
therefore does not compel FSSA to violate federal law.
2. Federal Financial Participation
Our discussion of 42 U.S.C. § 1396d(a)(24) and 42 C.F.R.
§ 440.167 emphasizes what is really at stake here: the State’s
ability to receive federal financial participation for its provi-
sion of these Medicaid services. The State’s concern about the
prospect of losing federal financial participation is well taken.
In Vaughn, we explained that district courts should not order
injunctive relief that requires a State to furnish Medicaid ser-
vices “entirely out of its own funds, unreimbursed and un-
supplemented by Medicaid.” 968 F.3d at 826. That limitation
makes good sense.
Medicaid is a cooperative federal-state program in which
States agree to provide certain medical care and services in
exchange for receiving federal funding. See Douglas v.
Independent Living Center of Southern California, Inc., 565 U.S.
606, 610–611 (2012). Requiring the State to provide services
that are ineligible for federal reimbursement denies it the
benefit of the bargain that it has struck with the federal
government. The ADA does not require States to go beyond
the constraints imposed by federal Medicaid law to
accomplish its purposes. Although our equitable authority to
enforce federal anti-discrimination laws is broad, we do not
think it stretches as far as compelling the State to provide
Medicaid services that are ineligible for federal
reimbursement and therefore outside the scope of Medicaid.
See Georgia ex rel. Dep’t of Med. Assistance v. Heckler, 768 F.2d
1293, 1298 (11th Cir. 1985) (holding that services for which
federal funds are not available are outside scope of federal
Medicaid program); see also Harris v. McRae, 448 U.S. 297, 310

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44 Nos. 24-2633, 24-2741, & 24-2770
(1980) (unavailability of federal funding for medically
necessary abortions under Hyde Amendment relieved States
of the obligation to cover those abortions in their Medicaid
plans).
At present, however, there is no evidence that the State
will be forced to bear the full cost of Plaintiffs’ care. That dis-
tinguishes this case from Vaughn, where there was conclusive
evidence that the district court’s permanent injunction had
compelled the State to provide Medicaid services without fed-
eral financial participation. In Vaughn, the State certified that
it had complied with the injunction by contracting with a
home-health agency at the market rate for skilled nursing
care, which was higher than the Medicaid cap. 968 F.3d at 818.
Because the contract exceeded the Medicaid cap, the State was
not authorized to use any federal Medicaid funds to pay the
home-health agency. As a result, it allocated only State funds
to cover the cost of the plaintiff’s services. Id.
In this case, there is no similar affirmative evidence that
federal financial participation is unavailable for payments
FSSA makes to Ms. Carter and Ms. Knight pursuant to the Oc-
tober 1 order. CMS’s policy is that it will not pay LRIs “for
supports that they are ordinarily obligated to provide.” CMS
Technical Guidance at 120. It will, however, pay LRIs for
providing “extraordinary care,” which is defined as “care ex-
ceeding the range of activities that a legally responsible indi-
vidual would ordinarily perform in the household on behalf
of a person without a disability or chronic illness of the same
age.” Id. Plaintiffs argue, and the district court agreed, that
“there is no doubt … that what [Ms. Carter and Ms. Knight]
do for their children is extraordinary in every sense of the
word.” We agree. The 24/7 supervision and assistance with

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Nos. 24-2633, 24-2741, & 24-2770 45
activities of daily living that E.R. and G.S. require go far be-
yond what the law expects of parents of children without dis-
abilities. The October 1 injunction is therefore consistent with
CMS’s policy for when it will and will not pay LRIs for
providing attendant care. We will not disturb the injunction
in the absence of affirmative evidence that federal financial
participation is not available.10
Setting aside the lack of affirmative evidence for FSSA’s
position, the agency’s own conduct in this case and experi-
ence in prior ADA cases undermine the force of its stated fear
of losing federal financial participation or of having its waiver
program terminated. FSSA paid LRIs (including Ms. Knight
10 FSSA also cites 42 C.F.R. § 441.360(d) as evidence that federal
financial participation is not available for payments made to Ms. Carter
and Ms. Knight for providing attendant care. This argument is also
unpersuasive. Section 441.360(d) provides that federal funds are not
available for expenditures for “[s]ervices that are not included in the
approved State Plan and not approved as waiver services by CMS.” But
this section only applies to services listed in 42 C.F.R. § 440.181, which
governs home- and community-based services for individuals age 65 or
older. E.R. and G.S. are both children, so the limits in section 441.360(d) do
not apply to them. 42 C.F.R. § 441.310 sets out the limits for federal
financial participation applicable to the services that E.R. and G.S. receive.
See 42 C.F.R. § 440.180(a)(3). Unlike section 441.360(d), section 441.310
does not prohibit federal financial participation for services not approved
by CMS. The absence of that limit in section 441.310 is evidence that no
such limit applies to the services received by Plaintiffs. See Miller v.
F.D.I.C., 738 F.3d 836, 842–43 (7th Cir. 2013) (“the inclusion of limiting
language in one subsection but not another subsection usually yields the
inference that the limitation does not apply to the latter subsection” (citing
Pacific Operators Offshore, LLP v. Valladolid, 565 U.S. 207, 216 (2012))); Bria
Health Servs., LLC v. Eagleson, 950 F.3d 378, 382 (7th Cir. 2020) (“The same
basic rules that apply to statutory interpretation apply to regulatory
interpretation.”).

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46 Nos. 24-2633, 24-2741, & 24-2770
and Ms. Carter) to provide attendant care services for years
even though such payments were not authorized by the terms
of the A&D Waiver. There is no evidence that the federal gov-
ernment ever threatened to terminate the A&D Waiver over
FSSA’s supposed noncompliance.
FSSA has not presented any evidence that CMS intends in
the future to withhold federal funds for payments made to
Plaintiffs’ mothers for providing attendant care pursuant to
the district court’s order. At oral argument, FSSA confirmed
that there is currently no indication that CMS will take such
action. Further, this is not the first or even the second time that
FSSA has been ordered to act contrary to the terms of its fed-
erally approved Medicaid program. E.g., Bontrager, 697 F.3d
604 (affirming injunction preventing State from enforcing cap
on dental services); Order of Judgment, B.N. ex rel. A.N. v.
Murphy, No. 3:09-CV-199 (N.D. Ind. Nov. 30, 2011) (enjoining
enforcement of A&D Waiver provision). FSSA has not pro-
vided any evidence that it lost federal funding in any of the
past cases in which it was enjoined.
Accordingly, the availability of federal funding for partic-
ular expenditures is, at least in this case, a factual question.11
Further factual development might call for a different out-
come. If FSSA produced persuasive evidence that federal
funding for Indiana’s Medicaid plan is actually at risk, the dis-
trict court would have to consider that evidence, rebalance the
11 In other cases, it may be clear from the language of the Medicaid
Act or its implementing regulations that federal funding is unavailable.
See, e.g., 42 C.F.R. § 441.360(d). Because the federal regulations applicable
to the H&W Waiver are ambiguous about the availability of federal finan-
cial participation, we treat the availability of federal funding for payments
to Ms. Carter and Ms. Knight as a factual question.

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Nos. 24-2633, 24-2741, & 24-2770 47
equities, and potentially modify the October 1 injunction.
Still, we have yet to find a single example of a State agency
that has been denied federal funds or had its waiver program
terminated for complying with a court order providing relief
under the ADA. Courts have been adjudicating ADA cases for
decades and on occasion have enjoined States from enforcing
parts of their Medicaid programs that violate the ADA’s inte-
gration mandate. They have also ordered preliminary and in-
terim relief to prevent irreparable harm until States can for-
mally amend their Medicaid programs through the federal
approval process. See, e.g., Chisholm ex rel. CC v. Kliebert, No.
97-3274, 2013 WL 4089981, at *11–12 (E.D. La. Aug. 13, 2013)
(declining to stay a preliminary injunction requiring State to
provide services pursuant to court order that were not yet ap-
proved by CMS). We see no reason to depart from that prac-
tice. On this record, the risk that the H&W Waiver will be ter-
minated or that the State will have to fund E.R.’s and G.S.’s
care entirely out of its own funds appears to be more specula-
tive than real.12
3. Balancing the Equities
Having rejected FSSA’s argument that the preliminary in-
junction improperly compels it to violate federal law or to
12 Because there is no evidence that payments made pursuant to the
preliminary injunction are ineligible for federal financial participation, we
need not opine on whether 42 C.F.R. § 431.250(b) explicitly makes federal
funds available under these circumstances. If it does, that would reinforce
our conclusion that the district court properly ordered FSSA to continue
paying Ms. Carter and Ms. Knight for providing attendant care. If, how-
ever, section 431.250 does not authorize federal financial participation in
these circumstances, it would not render the district court’s injunction an
abuse of discretion for the reasons set forth above.

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48 Nos. 24-2633, 24-2741, & 24-2770
fund Plaintiffs’ care exclusively out of State funds, we further
conclude that the district court did not abuse its discretion by
finding that the balance of equities and public interest
weighed in favor of granting injunctive relief. In making this
determination, the court had to consider whether “the harm
to the defendant would substantially outweigh the benefit to
the plaintiff.” Bontrager, 697 F.3d at 611, quoting Michigan v.
U.S. Army Corps of Eng’rs, 667 F.3d 765, 789 (7th Cir. 2011). Be-
cause the court’s “equitable judgment is entitled to substan-
tial deference on appeal,” FSSA has a “steep hill to climb.”
Finch v. Treto, 82 F.4th 572, 578 (7th Cir. 2023). Its task is espe-
cially difficult because we have already affirmed a prelimi-
nary injunction under very similar circumstances.
In Bontrager, we affirmed the district court’s preliminary
injunction preventing the State from enforcing its $1,000 cap
on medically necessary dental services covered by its Medi-
caid plan. 697 F.3d at 612. As in this case, the State had
adopted the $ 1,000 cap as a cost-cutting measure. Id. at 606.
Regarding the balance of the equities, we explained that the
State’s “potential budgetary concerns” did not outweigh the
potential harm the plaintiff would suffer from the denial of
medically necessary dental services. Id. at 611. Because the
“Medicaid statute was designed to pay for the healthcare
costs of ‘the most needy in the country,’” the public interest
was best served by preserving “Medicaid recipients’ interests
in access to medically necessary health care.” Id. at 611–12,
quoting Schweiker v. Hogan, 457 U.S. 569, 590 (1982).
This case presents essentially the same constellation of in-
terests that we considered in Bontrager. The attendant care
that Plaintiffs seek from their mothers is necessary to prevent
them from being uprooted from their homes, families, and

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Nos. 24-2633, 24-2741, & 24-2770 49
support systems. In the absence of preliminary injunctive re-
lief, Plaintiffs are highly likely to be institutionalized. Before
the court entered the October 1 injunction, both Ms. Carter
and Ms. Knight had already taken concrete steps toward plac-
ing their children in institutions. By contrast, for the reasons
explained above, FSSA is unlikely to experience any irrepara-
ble harm as a result of complying with the injunction. The dis-
trict court therefore did not err in concluding that Plaintiffs’
interest in receiving medically necessary health care on terms
equal to non-disabled persons outweighs the State’s concerns
about its budget variance or the highly speculative possibility
of the loss of federal funding. The court also did not err in
determining that the public interest is best served by enforc-
ing federal anti-discrimination law.
C. Scope of Relief
Finally, Plaintiffs contend that the district court’s October
1 injunction is insufficient to fully prevent Plaintiffs from ex-
periencing irreparable harm in two ways. First, they argue
that Plaintiffs’ mothers must be allowed to serve as paid pro-
viders of attendant care until home nurses are both secured
and properly trained—a process that could take weeks or
months to complete. Second, Plaintiffs argue that the amount
of home nursing ordered by the district court is inadequate,
given Plaintiffs’ medical conditions and the care they have
needed in the past.
The appropriate scope of an injunction is committed to the
district court’s sound discretion. Republic Technologies (NA),
LLC v. BBK Tobacco & Foods, LLP, 135 F.4th 572, 587 (7th Cir.
2025); Eli Lilly Co. v. Arla Foods, Inc., 893 F.3d 375, 384 (7th Cir.
2018). On this record, it is uncertain whether Plaintiffs’ re-
quested modifications are necessary or appropriate.

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50 Nos. 24-2633, 24-2741, & 24-2770
Regarding the amount of home nursing Plaintiffs need, the
court’s most recent order did not order a specific amount of
home nursing, and it is not clear whether the court intended
to retain that element of its previously ordered relief. Further-
more, after Medina, it may no longer be appropriate for the
district court to order a specific amount of home nursing ser-
vices.
It is also not clear that it would be appropriate for Plain-
tiffs’ mothers to serve as paid providers of attendant care until
their hypothetical and not-yet-newly-hired home nurses are
eventually trained to care for these Plaintiffs. As Plaintiffs
themselves explained, they are seeking to be paid for at-
tendant care as that service is defined in the H&W Waiver.
Training home nurses does not appear to be one of the ser-
vices encompassed by that definition. It may be, however, that
a combination of home nursing and attendant care services is
necessary to prevent either child’s institutionalization and
therefore that the injunction should be modified to take that
possibility into account. For example, G.S.’s medical provid-
ers have advised that he needs multiple caretakers at a time
to meet his mobility needs. Ms. Knight might therefore need
to continue providing attendant care, even if she secured a
nurse to meet G.S.’s skilled nursing needs. Because the district
court is closer to the facts and to changing circumstances, it is
best positioned to consider Plaintiffs’ arguments and to tailor
the preliminary injunction to prevent Plaintiffs’ avoidable in-
stitutionalization.
The district court’s October 1 injunction is AFFIRMED,
and we remand this case for further proceedings consistent
with this opinion.

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