Parents as Paid Attendant-Care Providers:
Seventh Circuit Re-Affirms the ADA’s Integration Mandate in Indiana Protection & Advocacy Services Commission v. Indiana FSSA

1. Introduction

The consolidated appeals in Indiana Protection & Advocacy Services Commission v. Indiana Family and Social Services Administration (Nos. 24-2633, 24-2741 & 24-2770, 7th Cir. Aug. 11 2025) confront an urgently practical question: when medically fragile children cannot obtain home nurses, may their parents be excluded from Medicaid payment for providing 24/7 attendant-care that keeps the children out of institutions? The Indiana FSSA adopted a 2024 policy barring “legally responsible individuals” (LRIs)—parents of minors—from being paid attendant-care providers under its Health & Wellness Waiver (H&W Waiver). Two children, E.R. (age 6) and G.S. (age 10), whose mothers have performed such care for years, faced institutionalisation if the rule took effect. The district court issued, and later broadened, a preliminary injunction compelling FSSA to keep paying the mothers until it secures in-home nurses; the State appealed, and the children cross-appealed seeking broader relief.

Judge Hamilton, writing for a unanimous panel (Hamilton, Lee, Maldonado JJ.), affirms the injunction and articulates a robust application of the ADA’s “integration mandate,” holding that:

2. Summary of the Judgment

• Plaintiffs: Indiana Protection & Advocacy Services Commission (IPAS) and minors E.R. & G.S., by their mothers.
• Defendants: Indiana Family and Social Services Administration (FSSA) and officials.
• District-court holding: Preliminary injunction requiring FSSA to (i) continue paying mothers for attendant care at pre-policy rates, and (ii) secure approved home-nursing hours for E.R. (40/wk) and G.S. (80/wk).
• Seventh Circuit: Affirms, finding (a) a high likelihood of success on ADA integration-mandate claims, (b) irreparable harm to the children absent relief, and (c) no comparable harm to the State because federal funds are likely available and the State had already paid LRIs for years.
• Medicaid claims reserved: After Medina v. Planned Parenthood South Atlantic (U.S. 2025) narrowed §1983 enforcement, the court declines to decide whether plaintiffs still have private rights of action under the Medicaid Act, resting the injunction solely on ADA/Rehabilitation-Act grounds.

3. In-Depth Analysis

3.1 Precedents Cited and Their Influence

• Olmstead v. L.C., 527 U.S. 581 (1999) — Foundation for the “integration mandate.” The panel applies Olmstead’s three-part test, emphasising that serious risk of institutionalisation triggers the mandate even before institutional placement occurs.
• Steimel v. Wernert, 823 F.3d 902 (7th Cir. 2016) — Recognised “serious risk” standard in the 7th Circuit; relied on for allowing challenges to waiver-eligibility criteria that endanger integrated living.
• Radaszewski v. Maram, 383 F.3d 599 (7th Cir. 2004) — Clarified distinction between a “new service” (not required) and a reasonable modification of existing services; court analogises LRI attendant care to existing authorised care.
• Vaughn v. Walthall, 968 F.3d 814 (7th Cir. 2020) — 7th Cir. guidance on private-duty nursing and limitation on compelling states to fund services totally out of state dollars; panel distinguishes it.
• Armstrong v. Exceptional Child Center, 575 U.S. 320 (2015) — Limits on private enforcement of Medicaid rate provisions; State invoked it, but panel holds plaintiffs are not seeking rate-setting, so Armstrong is inapplicable.
• Bontrager v. Indiana FSSA, 697 F.3d 604 (7th Cir. 2012) — Confirmed public interest in Medicaid recipients’ access to medically necessary care outweighs state budget concerns; cited in balancing equities.
• Medina v. Planned Parenthood South Atlantic, 145 S.Ct 2219 (2025) — Recent limit on §1983 Medicaid claims; prompted the court to rest decision on ADA while leaving Medicaid questions for remand.

3.2 The Court’s Legal Reasoning

1. ADA Cause of Action Remains Intact.
   Regardless of Medina, Title II of the ADA (42 U.S.C. §12132) and 29 U.S.C. §794a expressly create a private right of action. Thus, the children’s integration-mandate theory stands on solid ground.
2. Serious Risk of Institutionalisation.
   The panel finds no clear error in the district court’s factual findings: parents are the only current, trained caregivers; without payment they must seek outside work, forcing institutional placement. Alternative services (structured family caregiving, school nurses, home-health aides) are unavailable or insufficient.
3. Reasonable Modification vs. Fundamental Alteration.
   • Allowing LRIs to be paid does not create a “new service”; it merely shifts “who may deliver” an already-approved service.
   • Fiscal-impact defense fails: State presented speculative doomsday predictions but no data showing net cost increase. Institutional care would be more expensive.
   • CMS policy permits payment to LRIs for “extraordinary care,” undercutting State’s argument of federal-funding jeopardy.
4. Armstrong Not a Bar.
   Plaintiffs seek access to existing benefit, not a higher rate. Court declines to extend Armstrong to bar ADA relief.
5. Equitable Balance.
   Harm to children (loss of life-sustaining care, institutionalisation) far outweighs speculative fiscal harm. No evidence CMS will terminate funding; State had long reimbursed LRIs without penalty.

3.3 Impact of the Decision

• National Guidance on LRI Policies: States that adopted blanket bans on parent/spouse payment for “unskilled” waiver services must now reckon with ADA exposure where the ban threatens institutionalisation.
• Framework for Budget-Driven Waiver Reforms: Fiscal motives alone cannot sustain policies that segregate disabled persons.
• Interaction with Medina: Even if private Medicaid Act enforcement narrows, the ADA remains a potent tool for integration claims.
• Preliminary-Injunction Standards Clarified: The case reinforces that a speculative loss of federal funds does not outweigh concrete medical harms.
• Legislative & Agency Considerations: CMS may issue clarifying guidance encouraging “parent-of-last-resort” provisions and streamlined waiver amendments where integration is at stake.

4. Complex Concepts Simplified

• Integration Mandate: A rule under the ADA requiring public entities to deliver services “in the most integrated setting” feasible. In plain terms, people with disabilities should, whenever reasonably possible, receive care at home or in the community instead of institutions.
• Legally Responsible Individual (LRI): A person—usually a parent of a minor or a spouse—who has a general legal duty to care for the Medicaid beneficiary. Federal Medicaid policy normally presumes LRIs perform “ordinary” care without payment, but allows payment for extraordinary, medically-necessary tasks.
• Attendant Care vs. Structured Family Caregiving: Both are “personal care services” (help with bathing, toileting, eating, mobility). • Attendant care: hourly, higher rate (~$34/hr).
  • Structured family caregiving: daily rate (~$78–$133/day), significantly lower.
• Fundamental Alteration Defense: A state can refuse an ADA accommodation if proving the change would fundamentally alter its program—i.e., impose unreasonable cost or disrupt services for others. The burden is on the state.
• Federal Financial Participation (FFP): The federal government’s share of Medicaid costs. States fear losing FFP when they deviate from approved plans, but CMS often pays during court-ordered transitional periods, especially for “extraordinary” LRI care.

5. Conclusion

The Seventh Circuit’s decision crystallises a key principle: When a state Medicaid policy pushes people with disabilities toward institutions solely by depriving them of feasible, home-based supports, the ADA obliges the state to modify that policy— even if budget justifications exist.

By upholding the injunction, the court ensures that E.R. and G.S. can remain safely at home while the State explores compliant, sustainable solutions. The ruling will reverberate beyond Indiana, guiding states that restructure waiver programs in the face of budget pressures to leave a narrow—but crucial—safety valve for parent-caregivers whose involvement is the last line preventing unnecessary institutionalisation.

Going forward, litigation is likely to test the outer limits of Medina’s contraction of §1983 Medicaid claims, but the ADA’s integration mandate remains a resilient statutory backbone for protecting the civil rights of Americans with significant disabilities who wish—like everyone else—to live at home with their families.