Court Opinion

ID: 770339
Source: CourtListenerOpinion
Date Created: 2012-04-18 10:33:19+00
Date Added: 2024-06-11T12:12:40.939616
License: Public Domain

225 F.3d 1208 (11th Cir. 2000)
FLORIDA ASSOCIATION OF REHABILITATION FACILITIES, INC., United Cerebral Palsy Association of Miami, Inc., et al., Plaintiffs-Appellees,v.STATE OF FLORIDA DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES, Gregory Coler, et al., Defendants-Appellants.
No. 99-12507.
United States Court of Appeals,Eleventh Circuit.
September 1, 2000.September 14, 2000.

[Copyrighted Material Omitted]
Appeal from the United States District Court for the Southern District of  Florida.(No. 89-00984-CV-KMM), K. Michael Moore, Judge.
Before TJOFLAT, MARCUS and CUDAHY*, Circuit Judges.
MARCUS, Circuit Judge:

1
This appeal involves difficult questions of mootness as well as the Eleventh  Amendment. Plaintiffs, providers of Medicaid services to  developmentally-disabled persons, sued various State of Florida officials  seeking injunctive and declaratory relief for alleged violations of the Boren  Amendment, which established federal standards governing state plans for  reimbursing Medicaid providers. In September 1991 the district court entered a  preliminary injunction essentially directing the Defendants to comply with the  Boren Amendment. Not until April 1999, however, did the district court enter its  final order concluding that Defendants had violated the Boren Amendment and  directing Defendants to correct their reimbursement plan prospectively as well  as retrospectively to 1991. In the meantime, Congress repealed the Boren  Amendment in 1997, and Defendants contend that before entry of judgment they had  already enacted a new rate plan in accordance with the requirements of the Boren  Amendment's successor.

2
Defendants argue on appeal that these developments render some or all of  Plaintiffs' claims moot, and that in any event the relief ordered by the  district court is barred by the Eleventh Amendment to the extent it effectively  requires the State to pay money to redress pre-judgment violations. Because the  Eleventh Amendment bars retrospective relief affecting the state treasury in  this case, we vacate the district court's judgment to that extent. We remand for  determination of whether Plaintiffs' entitlement to prospective relief had  become moot by the time of judgment.

I.

3
Although the facts of this case are relatively straightforward, its procedural  history is anything but. Plaintiffs include the Florida Association of  Rehabilitation Facilities, Inc. and several operators of intermediate care  facilities for the developmentally disabled ("ICF/DDs"). Plaintiffs provide  essential developmental and health care services to low income persons in  numerous ICF/DDs throughout the State of Florida. A number of Plaintiffs operate  and provide care in ICF/DDs located on land owned by the State-so-called  "cluster" facilities. The care provided in the cluster facilities is the same as  that provided in the private facilities.

4
Plaintiffs began this lawsuit in 1989, asserting that Defendants-various Florida  officials responsible for formulating and administering the State's ICF/DD  Medicaid Program-violated federal law by failing to reimburse Plaintiffs for  reasonable costs incurred as a result of providing care and treatment to  Florida's developmentally disabled citizens residing in ICF/DDs.1 The suit  alleged as well that Defendants violated federal law by reimbursing certain  cluster providers inadequately through fixed-rate contracts.2

5
Plaintiffs' claims arose under the federal Medicaid program, established by  Title IX of the Social Security Act, 42 U.S.C.  1396, et seq. This program is a  cooperative federal-state effort to furnish with public assistance people who  are unable to meet the cost of necessary medical services. Unlike major federal  entitlement programs such as Social Security, Supplemental Security Income, and  Medicare, Medicaid is not a federally-administered program with a uniform set of  statutorily-defined benefits; rather, it is a state-administered program where  the costs of services are allocated between the federal government and the  states. No state is obligated to participate in the Medicaid program. If a state  opts to participate in the Medicaid program, however, it must do so in a manner  that complies with federal statutory and regulatory requirements. See 42 U.S.C.   1396n. Within the general framework of federal law, states that choose to  participate in the Medicaid program (thus qualifying for federal financial aid  covering the medical assistance costs of eligible individuals) are granted broad  latitude in defining the scope of covered services as well as many other key  characteristics of their programs. Florida, like all other states, participates  in the Medicaid program.

6
At the time this suit was filed in 1989, and until October 1, 1997, the Boren  Amendment applied to the reimbursement claims at issue. The Boren Amendment to  the Medicaid Act, formerly codified at 42 U.S.C.  1396(a)(13)(A), authorized a  "state plan to provide ... for payment ... of the hospital services ... through  the use of rates ... which the State finds, and makes assurances satisfactory to  the Secretary, are reasonable and adequate ...." Thus, the Amendment required  that states pay ICF/DD providers under rates "reasonable and adequate to meet  the costs which must be incurred by efficiently and economically operated  facilities in order to provide care and services in conformity with applicable  State and federal laws, regulations and quality and safety standards ." Id. The  purpose of the Boren Amendment was "to give states greater flexibility in  calculating reasonable costs and in containing the continuing escalation of  those costs." Children's Hospital and Health Ctr. v. Belshe, 188 F.3d 1090,  1093-94 (9th Cir.1999) (citation and internal quotation marks omitted), cert.  denied, U.S. , 120 S. Ct. 2197, 147 L. Ed. 2d 233 (2000).

As the Ninth Circuit has summarized:

7
[T]he Boren Amendment authorizes states to develop their own Medicaid   reimbursement standards and methodologies for payment of hospital services,   but subjects those standards and methodologies to three general federal   requirements. First, states must take into account hospitals serving a   disproportionate share of low-income patients. Second, states must make   findings that the rates are reasonable and adequate to meet the necessary   costs of an efficiently operated hospital. And third, states must assure   Medicaid patients reasonable access to inpatient hospital care.

8
Id. (citations and internal quotation marks omitted). Although the Boren  Amendment was intended to grant states greater freedom "in establishing the  methodology for their reimbursement rates, the amendment was 'not intended to  encourage arbitrary reductions in payment that would adversely affect the  quality of care.' " Tallahassee Memorial Regional Med. Ctr. v. Cook, 109 F.3d 693, 704 (11th Cir.1997) (citing S.Rep. No. 139, 97th Cong., 1st Sess., at 478,  reprinted in 1981 U.S.C.C.A.N. 396, 744).

9
On September 13 1991, the district court entered a preliminary injunction in  Plaintiffs' favor, finding specifically that Defendants, in violation of the  Boren Amendment, were not adequately reimbursing Plaintiffs for the costs of  providing ICF/DD care. The district court found that Defendants' use of  fixed-rate contracts for payment of cluster providers (i.e., private providers  of ICF/DD care in state-owned facilities) also violated the Medicaid Act. The  district court enjoined Defendants from reimbursing providers at inadequate  rates, making that ruling retroactive to September 4, 1991 (the date of the  preliminary injunction hearing). The court also enjoined Defendants from  reimbursing cluster providers "in a manner other than as provided in a Rate  Plan" at the "full Medicaid rate." The court further ordered that Defendants  file by October 4, 1991 a rate plan complying with the substantive standards of  the Boren Amendment. Defendants filed a rate plan by the required date and did  not appeal the preliminary injunction.

10
Defendants insist that Plaintiffs never filed any objection to the new rate plan  or the rates paid under it. As best we can tell from the record, Defendants are  correct. Although Plaintiffs filed multiple motions for contempt or sanctions,  only two of those motions implicated the preliminary injunction order, and none  squarely challenged either the lawfulness of the plan or the specific rates.3  Plaintiffs contend that Defendants were always on notice of their objections to  the plan and to the State's post-injunction reimbursement practices.

11
While the case remained pending before the district court (due in part to  repeated continuances sought by Defendants), the Boren Amendment was repealed  effective October 1, 1997. See Balanced Budget Act of 1997, Pub.L. 105-33,   4711(a)(1), 111 Stat. 251, 507-08 (1997). Congress amended the Medicaid Act to  "eliminate the Boren Amendment and establish instead a [public] notice and  comment provision." Belshe, 188 F.3d at 1093 (citation and internal quotation  marks omitted). The new provision repeals the substantive limitations of, and  the methodology set forth in, the Boren Amendment, substituting a "public  process" for determining rates.

12
The successor statute requires that a state plan for medical assistance:

13
(13) provide -

14
(A) for a public process for determination of rates of payment under the plan for hospital services ... under which -

15
(i) proposed rates, the methodologies underlying the establishment of such rates, and justifications for the proposed are published,

16
(ii) providers, beneficiaries and their representatives, and other concerned   State residents are given a reasonable opportunity for review and comment on the proposed rates, methodologies, and justifications,

17
(iii) final rates, the methodologies underlying the establishment of such rates, and justifications for such final rates are published, and

18
(iv) in the case of hospitals, such rates take into account ... the situation of hospitals which serve a disproportionate number of low-income patients with special needs.

19
42 U.S.C.  1396a(a)(13)(A). The legislation explicitly states that the repeal  has only prospective effect and that Boren Amendment rate standards continue to  apply to payment for items and services provided on or before October 1, 1997.  Pub.L. 105-33,  4711(d) ("This section shall take effect on the date of the  enactment of this Act and the amendments made by subsections (a) and (c) shall  apply to payment for items and services furnished on or after October 1,  1997."). Notably, the legislation is silent as to what standards, if any, govern  the period between October 1, 1997 and a state's adoption of a new post-Boren  rate plan under the successor statute's notice-and-comment procedure.

20
Shortly after the Boren Amendment was repealed, in August 1997, Defendants moved  for summary judgment on Plaintiffs' claims and also to vacate the preliminary  injunction. The district court granted the motion in part, and asked the parties  for advice as to which issues remained to be litigated. Both parties agreed that  three issues remained:

21
1. Whether the method of contractual payment of cluster providers met any federal law requirement to pay them according to a rate plan.

22
2. What were the minimum requirements for state plans after repeal of the Boren Amendment.

23
3. Whether cluster providers were currently being paid pursuant to a rate plan that complied with applicable law.

24
In May 1998, the district court conducted a three-day bench trial on these  issues. Defendants moved in limine to bar introduction of evidence of their  prior non-compliance with the Boren Amendment and to limit the scope of the  trial to their present compliance with federal law. The district court denied  the motion but granted Defendants a standing objection to the introduction of  evidence of past non-compliance with Boren standards.

25
On April 11, 1999, the district court entered final judgment in favor of  Plaintiffs, stating its findings of fact and conclusions of law in a separate  order. Florida Ass'n of Rehab., Facilities, Inc. v. State of Florida Agency for  Health Care Admin., 47 F. Supp. 2d 1352 (S.D.Fla.1999). The court ruled "that  Plaintiffs have established that the ICF/DD Rate Plan fails to adequately  compensate Plaintiffs as it is not 'reasonable and adequate to meet the costs  ... of efficiently and economically operated facilities,' in violation of the  Boren Amendment and 42 U.S.C.  1983." Id. at 1360.4 The court noted that "[t]he  Boren Amendment was in effect in 1989 when this lawsuit was filed, and was in  effect through October 1, 1997." Id. at 1357. Significantly, the court also  concluded that even though the Boren Amendment had been repealed effective  October 1, 1997, "[t]he standards governing reimbursement set forth in the Boren  Amendment continue to apply to this case as the State of Florida has not yet  promulgated any rules or regulations, or enacted any legislation, replacing the  Boren Amendment and continues to reimburse ICF/DD providers under the Rate  Plan." Id.

26
The court determined that "[t]he Rate Plan in force in the State of Florida  setting forth the terms, conditions and methodology for reimbursement of the  costs incurred by ICF/DD providers is inadequate and is inherently flawed." Id.  According to the court:

27
[T]he Rate Plan formulated and implemented by Defendants fails to substantively comply with the Boren Amendment. Defendants have failed to convincingly rebut or refute evidence introduced by the Plaintiffs establishing that while they operate efficiently and economically, and indeed are required to establish this by submitting cost reports to the State, they are not reimbursed in a manner that is "reasonable and adequate" to allow them to provide care to Florida's developmentally disabled population in compliance with federal laws and regulations.... Defendants have also violated the Medicaid Act because of their failure and refusal to reimburse cluster providers pursuant to the Rate Plan. The Medicaid Act provides that the federally required State Plan must provide for payment of ICF/MR medical services "through the use of rates" set forth in the Plan.... Neither the regulations nor the Medicaid Act contains any limitation pursuant to a Rate Plan based on ownership of ICF/DD facilities. Thus, cluster facilities are   entitled to sufficient reimbursement. Defendants' continued refusal to pay cluster facilities pursuant to the Rate Plan, therefore, violates the Boren Amendment.

28
Id. at 1358-59.

29
The district court then discussed its preliminary injunction, observing that  "[o]n September 13, 1991, ... this Court entered a Preliminary Injunction ... in  favor of Plaintiffs on Counts I and III of their Complaint seeking,  respectively, adequate and reasonable reimbursement under the Rate Plan in  compliance with the Medicaid Act, and seeking payment pursuant to the same Rate  Plan, on the same basis as ICF/DDs, to cluster providers." Id. at 1355. The  court "adopt[ed] the findings and conclusions ... in the Preliminary  Injunction," id., and found that the factors of irreparable harm, relative  injury to the parties, and the public interest all continued to favor injunctive  relief. Id. at 1359-60.

30
As a remedy, the district court ordered the following specific changes to the  reimbursement plan retroactive to September 4, 1991 (the compliance date  established retroactively in the September 13, 1991 preliminary injunction):

31
a. The prospective inflation index shall be the same as the historical (target) rate which Defendants themselves selected, i.e., DRI times 1.786;

32
b. Three year averaging of cost reports shall be used to calculate rate reductions based on decreases in costs;

33
c. The cap on rates for new facilities of six beds or less shall be deleted;

34
d. Settlement of budgeted rates for new providers shall use an average of the relevant rate periods;

35
e. For providers at small facilities, rates shall be set based on an average (or collectively) for all six bed ICF/DDs operated by that provider;

36
f. The Defendants shall develop a definable standard for an efficiently operated provider;

37
g. Increased costs related to increased needs of a client due to changed medical, behavioral or therapeutic needs shall be a basis for an interim rate request;

38
h. Cost allocations between levels of care shall be revised (except where such a revision would reduce reimbursement already paid to a provider);

39
i. The Defendants shall rebase whenever actual costs exceed actual expenditures for 50% or more of providers in any rate period as shown on KM Schedules of cost reports maintained by Defendants.

40
Id. at 1360-61, Conclusion ¶ 2. The district court also ordered that "Defendants  shall comply with its published Rate Plan including the immediate rebasing for  the 1995 rate setting period where it failed to rebase." Id. at 1361, Conclusion  ¶ 3. Moreover, ordered the Court, "Defendants are enjoined from violation of the  Boren Amendment from September 13, 1991 until the State adopts regulations,  procedures and standards governing the reimbursement of ICF/DD providers in  place of the standards set forth in the Boren Amendment. Defendants shall amend  the Rate Plan accordingly." Id., Conclusion ¶ 4.

41
On April 23, 1999, Defendants moved for reconsideration of the final order.  Defendants pointed out that in 1998, they had amended the state Medicaid rate  plan and taken it through the notice-and-comment process now required by the  Boren Amendment's successor. The amendments had been approved effective October  1, 1998. Defendants argued that this development mooted Plaintiffs' claims.  Attached to the motion was an affidavit from a state official who described the  amendment process in detail and noted that at least one of the Plaintiffs  (Sunrise Community, Inc.) had unsuccessfully challenged the new plan in the  administrative proceeding.

42
On July 9, 1999, the district court denied Defendants' motion, finding that  Defendants had established no good reason for their failure to present the court  evidence of these events prior to its final judgment, and that the new evidence  would not warrant a modification of the final judgment anyway. This appeal  followed.

II.

43
There is no dispute about the proper standard of review. We review a district  court's conclusions of law de novo. See Doe v. Chiles, 136 F.3d 709, 713 (11th  Cir.1998). We review a district court's grant of injunctive relief for abuse of  discretion. See id. (citing Sun America Corp. v. Sun Life Assur. Co. of Canada,  77 F.3d 1325, 1333 (11th Cir.1996)). We also review the disposition of a motion  for reconsideration under an abuse of discretion standard. See Region 8 Forest  Service Timber Purchasers Council v. Alcock, 993 F.2d 800, 806 (11th Cir.1993).

III.

44
This case is made complicated by its unusual procedural posture. The district  court after granting Plaintiffs a preliminary injunction in 1991 did not conduct  a trial on the merits until 1998 and did not issue a final order of declaratory  and injunctive relief until April 1999. As a result of this long lapse, the  substantive federal law underlying Plaintiffs' claims, the Boren Amendment, was  repealed prior to trial.5 Defendants make two primary arguments, both of which  are tied to the delay between preliminary injunction and final judgment. First,  Defendants contend that the Boren Amendment's repeal had mooted Plaintiffs'  claims by the time of final judgment. Second, they assert that the relief  awarded by the district court violates the Eleventh Amendment to the extent that  it requires payment of money from the state treasury for injuries suffered by  Plaintiffs prior to the judgment. Defendants do not appeal the merits of the  district court's factual findings or conclusions of law with respect to their  violation of the Boren Amendment and federal Medicaid law. We take up  Defendants' mootness and Eleventh Amendment objections in that order.

A.

45
Article III of the Constitution limits the jurisdiction of the federal courts to  the consideration of "Cases" and "Controversies ." U.S. Const. art. III,  2.  "The doctrine of mootness is derived from this limitation because an action that  is moot cannot be characterized as an active case or controversy." Adler v.  Duval County Sch. Bd., 112 F.3d 1475, 1477 (11th Cir.1997) (citing Church of  Scientology Flag Serv. Org. v. City of Clearwater, 777 F.2d 598, 604 (11th  Cir.1985)).

46
"[A] case is moot when the issues presented are no longer 'live' or the parties  lack a legally cognizable interest in the outcome." Powell v. McCormack, 395 U.S. 486, 496, 89 S. Ct. 1944, 1951, 23 L. Ed. 2d 491 (1969). Put another way, "[a]  case is moot when it no longer presents a live controversy with respect to which  the court can give meaningful relief." Ethredge v. Hail, 996 F.2d 1173, 1175  (11th Cir.1993) (citing United States v. Certain Real & Personal Property, 943 F.2d 1292, 1296 (11th Cir.1991)). When events subsequent to the commencement of  a lawsuit create a situation in which the court can no longer give the plaintiff  meaningful relief, the case is moot and must be dismissed. See Jews for Jesus,  Inc. v. Hillsborough County Aviation Auth., 162 F.3d 627, 629 (11th Cir.1998)  (citing Pacific Ins. Co. v. General Dev. Corp., 28 F.3d 1093, 1096 (11th  Cir.1994)). Any decision on the merits of a moot case or issue would be an  impermissible advisory opinion. See, e.g., Hall v. Beals, 396 U.S. 45, 48, 90 S. Ct. 200, 201-02, 24 L. Ed. 2d 214 (1969) (per curiam).

47
Plaintiffs filed suit primarily to secure reimbursement at the "reasonable and  adequate" rates required by the Boren Amendment. Defendants argue that the  repeal of the Boren Amendment now renders Plaintiffs' suit moot. They argue that  Congress intended its repeal to prevent just this kind of suit against a state  for alleged inadequate reimbursement procedures. Defendants point to several  portions of legislative history to argue that Congress's repeal of the Amendment  was intended to eliminate the substantive rate-setting requirements of the  Amendment (and the ample litigation attendant to those requirements) and replace  them with a strictly procedural "notice and comment" method for setting  reimbursement rates.6 Defendants therefore assert that the repeal of the  Amendment effectively ended the substantive federal requirement on reimbursement  rate-setting by states-thereby mooting Plaintiffs' case.

48
We disagree as to the period prior to the repeal; indeed, Defendants do not  seriously press this point. Congress's repeal of the Amendment empowered states  to replace their existing Boren-compliant rate plans with new rate plans not  subject to challenge based on the reasonableness and adequacy requirements of  the Boren Amendment. Congress was explicit on how this change was to occur;  states were to promulgate a rate plan and subject it to the "notice and comment"  administrative procedure. Such a new plan, however, would cover only those  services and items provided after October 1, 1997. Pub.L. 105-33,  4711(d).  Congress made clear that the Boren Amendment still applied to payment for items  and services furnished before October 1, 1997. See id. Consequently, Plaintiffs'  request for relief regarding services rendered prior to October 1, 1997 had not  become moot by the time the district court entered judgment in April 1999.

49
To the extent the district court ordered Defendants' compliance with Boren  standards beyond the date of final judgment, the issue is less clear on this  record. The dispositive question is whether Florida has indeed passed a valid  rate plan in accordance with the requirements of the Boren Amendment's  successor. After the district court entered final judgment, Defendants filed a  motion for reconsideration, asserting that as of October 1, 1998 (after trial,  but prior to entry of judgment) the State of Florida passed a new rate plan  under the required "notice and comment" procedures. On this basis, Defendants  argued that the lawsuit had become moot by the time of entry of judgment,  because it would be impossible to grant prospective relief regarding the State's  administration of the Boren-era rate plan when that plan had been superseded and  the Boren Amendment's substantive requirements rendered inapplicable. The  district court denied Defendants' motion, primarily on the ground that  Defendants had produced no good reason for their failure to advise the Court of  the new plan during the over six months that elapsed between the effective date  of the new plan and the entry of final judgment.7

50
Normally we review a ruling on a motion for reconsideration under a deferential  abuse of discretion standard. See Alcock, 993 F.2d at 806. A court abuses its  discretion, however, when it misapplies the law. See, e.g., SunAmerica, 77 F.3d  at 1333 (court necessarily abuses its discretion if it "has applied an incorrect  legal standard"). When a motion for reconsideration raises a fundamental  jurisdictional issue such as mootness, the court is obliged to consider the  merits of the argument regardless of the motion's relative untimeliness. See,  e.g., Tallahassee Memorial Regional Med. Ctr. v. Bowen, 815 F.2d 1435, 1445 n.  16 (11th Cir.1987) ("[q]uestions of jurisdiction" such as mootness "can  appropriately be raised at any time in the litigation"); Carr v. Saucier, 582 F.2d 14, 15-16 (5th Cir.1978) (per curiam) ("If a controversy becomes moot at  any time during the trial or appellate process, the court involved must dismiss  the suit for want of jurisdiction.... Mootness arguments ... can be pressed by  any party at any time[.]"); see also Barilla v. Ervin, 886 F.2d 1514, 1519 (9th  Cir.1989) (because a court "may not decide the merits of a moot case, regardless  of whether it was mooted before or after the entry of judgment," a court "cannot  be divested of its obligation to consider the issue of mootness on the ground  that the timing or manner in which a party has raised the issue is somehow  procedurally improper").

51
If indeed the State had properly enacted a new post-Boren rate plan by the time  of entry of final judgment, then a final order providing prospective relief with  respect to the State's Boren-era plan would serve no purpose and that portion of  the case-if not the entire case-would be moot.8 Accordingly, while we share the  Plaintiffs' and the district court's concern with Defendants' failure to raise  this issue promptly (a situation Defendants concede was "regrettable"), the  district court still was required to address Defendants' mootness argument, and  if that argument had merit, to dismiss any claim for prospective relief on that  ground.

52
That said, we are unwilling on this record to determine whether the new plan  complies with the requirements of the post-Boren statute. Defendants contend  that in conjunction with their motion for reconsideration they submitted  affidavits confirming that the State has taken the new plan through the  notice-and-comment process and that the plan fully complies with Boren's  successor statute. Defendants also assert that Plaintiffs did not submit any  affidavits of their own to dispute these claims. Given that Plaintiffs were  responding to a motion for reconsideration, however, we attach little  significance to their failure to submit counter-affidavits. Moreover, Plaintiffs  suggest (although they do not state clearly) that the new plan may not be in  compliance with the procedural requirements of the post-Boren statute.  Appellees' Brief at 24. In these circumstances, we think, the wisest course is  to remand the case to the district court so that it may determine in the first  instance whether the new plan complied with the requirements of Boren's  successor statute, and if so whether the lawsuit had become moot prior to the  entry of judgment in April 1999. We therefore remand to the district court on  this threshold jurisdictional issue.9

B.

53
We turn next to whether the Eleventh Amendment precluded the district court from  ordering, in essence, that the Defendants rectify improper past payments to  providers such as Plaintiffs. The Eleventh Amendment to the United States  Constitution provides: "The Judicial Power of the United States shall not be  construed to extend to any suit in law or equity, commenced or prosecuted  against one of the United States by Citizens of another State, or by Citizens or  Subjects of any Foreign State." U.S. Const. amend. XI. The Amendment not only  bars suits against a state by citizens of another state, but also bars suits  against a state initiated by that state's own citizens. See Edelman v. Jordan,  415 U.S. 651, 663, 94 S. Ct. 1347, 1355, 39 L. Ed. 2d 662 (1974).

54
Under the doctrine of Ex parte Young, 209 U.S. 123, 28 S. Ct. 441, 52 L. Ed. 714  (1908), there is a long and well-recognized exception to this rule for suits  against state officers seeking prospective equitable relief to end continuing  violations of federal law. See Summit Med. Assocs., P.C. v. Pryor, 180 F.3d 1326, 1336-37 (11th Cir.1999) (citing Idaho v. Coeur d'Alene Tribe, 521 U.S. 261, 269, 117 S. Ct. 2028, 2034, 138 L. Ed. 2d 438 (1997) ("We do not ... question  the continuing validity of the Ex parte Young doctrine.")), cert. denied, U.S. , 120 S. Ct. 1287, 146 L. Ed. 2d 233 (2000). The availability of this  doctrine turns, in the first place, on whether the plaintiff seeks retrospective  or prospective relief.

55
Ex parte Young has been applied in cases where a violation of federal law by a  state official is ongoing as opposed to cases in which federal law has been  violated at one time or over a period of time in the past. Thus, Ex parte Young  applies to cases in which the relief against the state official directly ends  the violation of federal law, as opposed to cases in which that relief is  intended indirectly to encourage compliance with federal law through deterrence  or simply to compensate the victim. " 'Remedies designed to end a continuing  violation of federal law are necessary to vindicate the federal interest in  assuring the supremacy of that law. But compensatory or deterrence interests are  insufficient to overcome the dictates of the Eleventh Amendment.' " Summit Med.  Assocs., 180 F.3d at 1337 (quoting Papasan v. Allain, 478 U.S. 265, 277-78, 106 S. Ct. 2932, 2940, 92 L. Ed. 2d 209 (1986)). Therefore, the Eleventh Amendment does  not generally prohibit suits against state officials in federal court seeking  only prospective injunctive or declaratory relief, but bars suits seeking  retrospective relief such as restitution or damages. See Green v. Mansour, 474 U.S. 64, 68, 106 S. Ct. 423, 426, 88 L. Ed. 2d 371 (1985); Sandoval v. Hagan, 197 F.3d 484, 492 (11th Cir.1999) ("[Individual suits that seek prospective relief  for ongoing violations of federal law ... may be levied against state  officials."]). If the prospective relief sought is "measured in terms of a  monetary loss resulting from a past breach of a legal duty," it is the  functional equivalent of money damages and Ex parte Young does not apply.  Edelman, 415 U.S. at 669, 94 S.Ct. at 1347.

56
Plaintiffs' suit originally fell within the Ex parte Young exception. Their suit  was directed against state officials in their official capacities and asked for  prospective injunctive relief to halt continuing violations of federal law.  Plaintiffs are not barred by the Eleventh Amendment from seeking enforcement, in  a federal court, of a federal statute which state agents have violated.  Defendants, in fact, do not argue that Plaintiffs' suit was barred from the  outset. Instead, they make a more focused argument that much of the relief  ordered by the district court is retrospective rather than prospective. They  assert that, to the extent the district court directed them to make changes to  the State's Boren-era reimbursement plan retroactive to September 4, 1991, it  essentially required them to redress inequities in their past reimbursement  payments from 1991 to the date of final judgment (April 1999), and potentially  to reimburse Plaintiffs for those past deficiencies. We reluctantly agree.

57
To begin with, we note that the judgment clearly does contemplate the payment of  state funds to redress prior inadequate reimbursements. Defendants observe that  the final judgment does not expressly require them to pay any money or arrears  in reimbursements. Technically speaking they are right. It is obvious, however,  that the entire purpose and effect of the judgment is to prescribe a set of  standards upon which Defendants are to provide reimbursement for inadequate past  and future payments, and that failure to provide such reimbursement would  subject them to sanctions by the federal district court, which expressly  "retain[ed] jurisdiction to enforce [its] Order." 47 F. Supp. 2d at 1361.  Plaintiffs view the judgment in those terms. See Appellee's Brief at 39 (arguing  that "the Eleventh Amendment does not preclude the payment of money which  Defendants have withheld improperly"). If the order were read as nothing more  than an idle declaration of Defendants' past obligations, without any intent or  authority on the part of the district court to enforce its ruling, then the  order would be a nullity and plainly invalid on that basis alone. We decline to  adopt such an unrealistic reading of the district court's order.

58
Because some of the relief ordered in the final judgment requires the State in  effect to rectify improper past payments, we see no way to distinguish the  holding of Edelman which prohibits exactly this sort of retroactive award.  Edelman itself illustrates the problem. There, a plaintiff sought declaratory  and injunctive relief against two former directors of the Illinois Department of  Public Aid, alleging that those state officials were administering the  federal-state programs of Aid to the Aged, Blind, or Disabled (AABD) in a manner  inconsistent with various federal regulations and the Fourteenth Amendment to  the Constitution. The plaintiff's complaint charged that the defendants were  improperly authorizing grants to commence only with the month in which an  application was approved and were not including prior eligibility months for  which an applicant was entitled to aid under federal law. The complaint also  alleged that the defendants were not processing the applications within the  applicable time requirements of the federal regulations.

59
The district court granted a permanent injunction requiring compliance with the  federal time limits for processing and paying AABD applicants. It also ordered  the defendants to pay retroactively benefits which would have been awarded if  defendants had complied with federal law. The Seventh Circuit reversed, holding  that this retroactive relief was barred by the Eleventh Amendment, and the  Supreme Court agreed. In this now-famous ruling, the Court articulated the  retrospective/prospective dichotomy for Eleventh Amendment caselaw: prospective  injunctive or declaratory relief can be awarded but retrospective relief cannot.  The Supreme Court explained:

60
[T]hat portion of the District Court's decree which petitioner challenges on   Eleventh Amendment grounds goes much further than any of the cases cited. It   requires payment of state funds, not as a necessary consequence of compliance   in the future with a substantive federal-question determination, but as a form   of compensation to those whose applications were processed on the slower time   schedule at a time when petitioner was under no court-imposed obligation to   conform to a different standard. While the Court of Appeals described this   retroactive award of monetary relief as a form of "equitable restitution," it   is in practical effect indistinguishable in many aspects from an award of   damages against the State. It will to a virtual certainty be paid from state   funds, and not from the pockets of the individual state officials who were the   defendants in the action. It is measured in terms of a monetary loss resulting   from a past breach of a legal duty on the part of the defendant state   officials.

61
415 U.S. at 668, 94 S. Ct. at 1358.

62
The district court judgment in this case effectively requires Defendants to  redress inadequate past reimbursement payments by recalibrating the rates and  paying Plaintiffs the difference out of the state treasury. But the Eleventh  Amendment bars the award of retroactive relief for violations of federal law.  The fact that harm is ongoing in the sense that Plaintiffs are continuing to  suffer the effects of Defendants' prior failure to reimburse them adequately  does not make the relief any less retrospective. Quite simply, the Eleventh  Amendment's immunity is triggered when an declaration or injunction effectively  calls for the payment of state funds as a form of compensation for past breaches  of legal duties by state officials. See id.; Pennhurst State School & Hosp. v.  Halderman, 465 U.S. 89, 102-03, 104 S. Ct. 900, 909, 79 L. Ed. 2d 67 (1984). Such  is the case here.

63
The district court tried to avoid this limitation by describing the relief  decreed in its final order as simply enforcing the 1991 preliminary injunction;  thus, reasoned the court, the relief was not retrospective and did not run afoul  of the Eleventh Amendment.10 We are unpersuaded. To begin with, the district  court's reasoning cannot be squared with the command of the Eleventh Amendment  as it has been interpreted in Edelman as well as other decisions of the Supreme  Court and this Court. Moreover, even assuming that the district court's  reasoning could be squared with binding precedent, the 1991 preliminary  injunction was not enforceable on its own terms and thus could not serve as the  basis for the district court's retroactive relief. Finally, the district court's  judgment imposed reimbursement obligations starkly different from and more  detailed than those contemplated by the preliminary injunction. For each of  these independent reasons, which we address in sequence below, the retrospective  relief ordered by the district court violates the Eleventh Amendment.

64
First, we are aware of no federal court that has upheld against Eleventh  Amendment scrutiny a final judgment requiring a state to pay money for illegal  conduct which pre-dates the judgment on the theory that the conduct violated an  earlier preliminary injunction and therefore the remedy was prospective. The  requirements imposed by the district court in its April 11, 1999 final judgment  with respect to reimbursement for services rendered prior to that date are  undeniably retrospective, and cannot be justified as merely "relating back" to  the date of the preliminary injunction. If Plaintiffs or the district court felt  that Defendants had violated the preliminary injunction, the remedy would have  been to conduct a show cause hearing and, if appropriate, to pursue civil  contempt requiring Defendants to pay rates or provide reimbursement in  accordance with the injunction.11 But the district court could not, at least in  the peculiar circumstances of this case, avoid the constraints of the Eleventh  Amendment by relying on Defendants' past violations of the preliminary  injunction to justify imposing plainly retroactive relief in its final judgment.  See Kostok v. Thomas, 105 F.3d 65, 69 (2d Cir.1997) ("Any claim for retroactive  monetary relief, under any name, is barred .... When state funds are awarded to  compensate for past wrongs by state officials, the Eleventh Amendment bars the  payment as retrospective." (citing Edelman and Green )).

65
Second, even if we assume that such a "relation back" theory could be used to  avoid the constraints of the Eleventh Amendment in some cases, here there are  more fundamental problems with the district court's reasoning. The underlying  preliminary injunction lacked the precision and specificity necessary for it to  be enforceable prospectively from the date of its entry in 1991, let alone to  serve as the linchpin of the district court's "relation back" theory eight years  later. Fed.R.Civ.P. 65(d) requires that a preliminary injunction be "specific in  its terms" and "describe in reasonable detail ... the act or acts sought to be  restrained ." The district court's preliminary injunction did not meet these  criteria; on the contrary, it accomplished little more than enjoining Defendants  from violating the law. It stated that Defendants were enjoined from  "inadequately reimbursing providers of care in the ICF/[DD] program," and from  "paying providers for services at ICF/[DD] cluster facilities in a manner other  than as provided for in a rate plan" that "pay[s] to each provider of ICF/[DD]  services at cluster facilities the full Medicaid rate for that facility" and  affords "each provider at cluster facilities all rights and protections  accompanying a rate plan governing ICF/[DD] facilities." The injunction order  specifically declined to modify the State's existing plan by imposing new rates,  but rather permitted Defendants themselves to file a new plan "which complies  with the substantive requirements of" the Medicaid Act.

66
This Circuit has held repeatedly that "obey the law" injunctions are  unenforceable. See, e.g., Burton v. City of Belle Glade, 178 F.3d 1175, 1200  (11th Cir.1999) (holding that injunction which prohibited municipality from  discriminating on the basis of race in its annexation decisions "would do no  more than instruct the City to 'obey the law,' " and therefore was invalid);  Payne v. Travenol Labs., Inc., 565 F.2d 895, 899 (5th Cir.1978) (invalidating  injunction that prohibited defendant from violating Title VII in its employment  decisions). The specificity requirement of Rule 65(d) is no mere technicality;  "[the] command of specificity is a reflection of the seriousness of the  consequences which may flow from a violation of an injunctive order." Payne, 565 F.2d at 897. An injunction must be framed so that those enjoined know exactly  what conduct the court has prohibited and what steps they must take to conform  their conduct to the law. See Meyer v. Brown & Root Constr. Co., 661 F.2d 369,  373 (5th Cir.1981) (citing International Longshoremen's Assoc. v. Philadelphia  Marine Trade Assoc., 389 U.S. 64, 76, 88 S. Ct. 201, 208, 19 L. Ed. 2d 236 (1967)).  The preliminary injunction in this case differs little from an "obey the law"  order because it fails to identify with adequate detail and precision how  Defendants are to perform such critical obligations as "[ ]adequately  reimbursing providers of care" and "compl[ying] with the substantive  requirements of" the Medicaid Act.

67
Third, even if the preliminary injunction were valid and enforceable, the  injunctive relief awarded by the district court's final order of April 11, 1999  was not the same as that ordered by the preliminary injunction. On the contrary,  the final order imposed more expansive, and far more detailed, obligations on  Defendants for the post-September 1991 period than those imposed prospectively  in the preliminary injunction. The preliminary injunction, as noted above,  essentially enjoined the Defendants from violating the law and directed them to  submit a new rate plan that complied with the law. The final judgment went much  further, ordering ten specific alterations to the rate plan, including  requirements that Defendants use "[t]hree year averaging of cost reports ... to  calculate rate reductions," delete "[t]he cap on rates for new facilities with  six beds or less," set rates for providers at small facilities based on "an  average (or collectively) for all six bed ICF/DDs operated by that provider,"  and "rebase whenever actual costs exceed actual expenditures for 50% or more of  providers in any rate period as shown on KM Schedules of cost reports maintained  by Defendants." Regardless of whether a "relation back" theory comports with  current Eleventh Amendment doctrine, the final judgment plainly cannot relate  back to an altogether different and far less precise injunction.

68
In short, the relief ordered by the district court's final injunction did not  become validly prospective simply because it was intended to redress past  violations of the earlier preliminary injunction.

69
For its conclusion the district court relied primarily on Rye Psychiatric  Hospital Center, Inc. v. Surles, 777 F. Supp. 1142 (S.D.N.Y.1991). The court also  cited Libby v. Marshall, 653 F. Supp. 359 (D.Mass.1986) and Bennett v. White, 865 F.2d 1395 (3d Cir.1989). Plaintiffs likewise rely on these opinions, as well as  an unpublished ruling, Kansas Health Care Association, Inc. v. Kansas Department  of Social and Rehabilitation Services, No. 93-4045-RDR(D.Kan. May 31, 2000).  None of these decisions is binding precedent in this Circuit and none alters our  conclusion.

70
In Rye, the court issued a partial summary judgment ruling finding that the  defendants were providing inadequate reimbursement to the plaintiff Medicaid  provider. The plaintiff later sought a show cause order compelling the  defendants to use the proper formula to reimburse it for services rendered  subsequent to the summary judgment ruling as well as for the four years  preceding that ruling. The court began its analysis of the show cause request by  highlighting the longstanding principles we apply here. 777 F. Supp. at 1146  ("Simply put, the eleventh amendment bars the award of retroactive relief for  violations of federal law which would require the payment of funds from a state  treasury.... [T]he amendment's immunity is triggered when relief amounts to the  payment of state funds as a form of compensation for past breaches of legal  duties by state officials."). The court held that granting relief for the four  years preceding the summary judgment ruling would be prohibited. Id. at 1147-51.  Nevertheless, it concluded, without elaboration, that "[t]he portion of  plaintiff's action relating to inadequate reimbursement payments and improper  rate methodologies occurring since [the ruling] represents injuries arising  after the court issued its decision. Relief for these injuries is clearly  prospective in nature." Id. at 1147.

71
Rye does not help the Plaintiffs in this case. In Rye, the relief granted by the  district court for the post-summary judgment period arguably may be viewed as  prospective because the relief covered a period after a final ruling on the  merits of the plaintiff's claim had been rendered. Moreover, the relief was  granted pursuant to a show cause application. Here, by contrast, the relief  ordered by the district court for the September 1991-April 1999 period cannot be  viewed as enforcing a prior order finally deciding the merits of Plaintiffs'  claim. At best, it enforced a non-final determination of Plaintiffs' claim made  in connection with the preliminary injunction order. Additionally, the district  court was not considering a show cause or contempt application, which would have  been the proper vehicle for Plaintiffs to seek relief for any alleged violation  of the preliminary injunction. The factual differences between Rye and this case  are significant. In any event, to the extent Rye may be read to endorse the  reasoning applied by the district court in this case, it is odds with Eleventh  Amendment doctrine applied by the Supreme Court.12

72
In Libby, the district court found that the Eleventh Amendment did not prohibit  it from entering an injunction requiring state officials to spend state funds to  improve prison conditions in order to comply with a prior preliminary injunction  imposing a cap on the jail's population. The court described the additional  relief as ancillary to a "substantive prospective injunction" and necessary to  ensure future compliance with the prior injunction. 653 F. Supp. at 363. Libby  concerns a well-recognized exception to the Eleventh Amendment for ancillary  monetary relief. That exception is inapposite, however, because the 1991  preliminary injunction, besides being unenforceable, did not simply seek to  regulate Defendants' future conduct without necessarily requiring the  expenditure of funds. On the contrary, this preliminary injunction plainly  contemplated the expenditure of funds by the State in accordance with required  Boren Amendment rates. The relief awarded by this final judgment with respect to  events pre-dating the judgment cannot remotely be described as an "ancillary"  remedy necessary to ensure future compliance with the terms of the preliminary  injunction.

73
The Third Circuit's opinion in Bennett v. White is inapposite as well. Bennett  involved a challenge to a state's administration of a child support benefits  program under the auspices of the Social Security Act. The district court found,  among other things, that the defendants had improperly withheld certain payments  due to the plaintiffs. The district court declined, however, to order defendants  to make those payments. Plaintiffs challenged that ruling on appeal, asserting  that "Edelman v. Jordan should be construed as inapplicable to their suit  because they are not seeking the recovery of entitlements to government benefits  funded by general revenues, but only the recovery of their own property." 865 F.2d at 1407. The Third Circuit rejected the argument, stating that Edelman  "prevents a federal court from requiring state officers to disgorge from the  state treasury even unlawfully converted property, at least so long as the state  pays for the disgorgement." Id. at 1408. The court suggested in dicta an  exception to this principle in instances where payments from the state treasury  would be offset by payments into the treasury by the federal government. Id.

74
Such an exception has not been recognized by this Circuit, and cannot readily be  squared with the Supreme Court's Eleventh Amendment jurisprudence. But even  assuming that it has any validity, it does not help the Plaintiffs here.  Although Plaintiffs speculate that the State of Florida may "financially benefit  from modifications ordered in the Final Judgment through additional federal  funding," Plaintiffs' Supplemental Brief at 2, there is no record evidence for  this proposition, and in any event it is of no legal consequence under the  Supreme Court and this Court's binding precedent, which focus on whether the  "judgment ... would implicate the state treasury," not whether as a bottom line  matter the state treasury would be any worse off. Shands Teaching Hospital and  Clinics Inc. v. Beech Street Corp., 208 F.3d 1308, 1311 (11th Cir.2000)  (emphasis added). And although in Bennett the Third Circuit declined to reverse  the district court's decision to order back payments for improperly withheld  funds in a limited set of cases, the defendants had conceded that issue and thus  no Eleventh Amendment scrutiny was applied. Bennett does not justify the result  here.

75
Simply put, in this case, as in Edelman, the relief would amount to direct state  reimbursement for past unlawful conduct. Although the retrospective relief only  extends back to the preliminary injunction, because the injunction was entered  almost eight years prior to final judgment, it would plainly amount to an award  for past due benefits in contravention of Edelman. The proper recourse for  Plaintiffs would have been to obtain a contempt order after Defendants failed to  comply with the district court's preliminary injunction. The relief awarded in  the final judgment is essentially a surrogate for such a civil contempt award.  Accordingly, we cannot characterize Defendants' reimbursement of past due  payments as anything but impermissibly retroactive. The district court lacked  jurisdiction to order that Defendants recalibrate the rates for the September  1991-April 1999 period and pay Plaintiffs any arrears, because such relief  plainly would require the payment of money from the state treasury to redress  past unlawful conduct toward the Plaintiffs.13

76
To the extent the district court order contemplates the payment of state funds  to remedy unlawful conduct prior to the date of the final judgment, the judgment  is prohibited by the Eleventh Amendment, and we are constrained to vacate it.  This includes all of the changes to the reimbursement plan required "retroactive  to September 4, 1991" by paragraph 2 of the district court's Conclusion. See 47 F. Supp. 2d at 1360. This also includes the requirement in paragraph 3 of the  Conclusion that Defendants conduct an "immediate rebasing for the 1995 rate  setting period where it failed to rebase," and the portion of paragraph 4 which  enjoins the Defendants from violating the Boren Amendment from September 13,  1991 to the date of judgment. Id. at 1361.

77
We do not rule at this time on whether the prospective relief ordered by the  district court also is barred by the Eleventh Amendment. Although a federal  court is prohibited by the Eleventh Amendment from ordering a state to provide  retrospective relief, there are very limited circumstances where a court may  enter an order implicating the state treasury if such payments will be nothing  more than ancillary to compliance with a enforceable prospective injunction  prohibiting future unlawful conduct by state officials. See, e.g., Milliken v.  Bradley, 433 U.S. 267, 289, 97 S. Ct. 2749, 2762, 53 L. Ed. 2d 745 (1977); DeKalb  County Sch. Dist. v. Schrenko, 109 F.3d 680, 690-91 (11th Cir.1997) (per curiam)  (noting Eleventh Amendment exception that "permits federal courts to enjoin  state officials to conform their conduct to the requirements of federal law,  even if there is an ancillary impact on the state treasury," but finding that  injunction at issue was barred by the Eleventh Amendment because the obligation  to make future payments was not merely ancillary). How this exception survives  more recent pronouncements of Eleventh Amendment doctrine, and whether some  portions of the district court's order may conceivably come within this  exception, are potentially difficult questions that need not be answered if on  remand the district court determines that any question of prospective relief had  already become moot by the time it entered final judgment. See supra at 3743.14

78
We do not reach these results without misgivings. The issues raised in this case  by the Plaintiffs are extremely serious and vitally important to the large group  of developmentally-disabled persons who rely on the fair and proper  administration of the State's Medicaid program. As we have noted, Defendants do  not dispute the district court's findings of fact or conclusions of law, which  detail at length Defendants' violations of the Boren Amendment and federal law.  Moreover, we acknowledge Plaintiffs' concern that some of the long lapse between  the commencement of this case and the entry of judgment (as a result of which  the basis for the case-the Boren Amendment-was repealed) may be attributed to  Defendants' repeated requests for continuances. Still, we must observe the  commands of the Eleventh Amendment and binding Supreme Court precedent, which  forbid precisely the kind of retrospective relief awarded by the district court.

79
In light of these circumstances, and given the time and resources that this  litigation has already entailed, we encourage the Defendants to seek a just  resolution of the Plaintiffs' reimbursement claims. We also stress that,  whatever the relief (if any) available in federal court, our decision does not  preclude the Plaintiffs from seeking relief that still may be available to them  in the Florida state courts, where the paramount jurisdictional concerns  addressed in this opinion do not apply.

80
VACATED IN PART AND REMANDED IN PART.

NOTES:

*
  Honorable Richard D. Cudahy, U.S. Circuit Judge for the Seventh Circuit, sitting  by designation.

1
  As originally pled, Plaintiffs' suit also included claims against the Florida  Department of Health and Rehabilitative Services ("HRS"). In an order dated  April 16, 1996, the district court dismissed on Eleventh Amendment grounds all  claims against HRS. Defendants observe that the final judgment nevertheless  extends to HRS's successor, the State of Florida Agency for Health Care  Administration. It is not clear that the district court intended that to be so.  To avoid any confusion, we emphasize the Agency for Health Care  Administration-like its predecessor-is plainly entitled to Eleventh Amendment  immunity. See infra at 3743-44. Plaintiffs' original complaint additionally  included claims against state officials in their individual capacities; those  claims were dismissed pursuant to the parties' stipulation in the district  court's April 16, 1996 order.

2
  Plaintiffs' suit also included an Equal Protection claim which the district  court never reached.

3
  In January 1993 Plaintiffs moved for contempt based on Defendants' alleged  failure to reimburse certain costs of Plaintiff Ann Storck Center. The motion  was based not only on the preliminary injunction, but also on a separate court  order entered in November 1991 as well as on the court's inherent powers. In  opposition to the motion, Defendants asserted that they were complying with the  preliminary injunction and that the relevant costs were excluded because the Ann  Storck Center's status had changed. The motion was withdrawn in March 1993. In  July 1996 Plaintiffs moved for contempt alleging that certain planned enactments  by the Florida Legislature regarding the status of private providers would  violate the preliminary injunction. Defendants countered, among other things,  that the Legislature's action did not offend the preliminary injunction because  it simply changed the status of the providers. The district court denied the  motion without prejudice, permitting Plaintiffs to renew the motion or to raise  the issue at trial. Plaintiffs never renewed the motion, and the matter was not  expressly addressed in the district court's findings and conclusions after  trial.

4
  Because Defendants do not challenge the district court's factual findings, we do  not discuss them at length here. It is useful to highlight several of those  findings, however, not only to provide further background about the case, but  also to underscore the seriousness of the problem created by Defendants'  conduct. Among other things, the district court found that because of inadequate  reimbursement by Defendants, the majority of Plaintiffs and ICF/DDs in Florida  generally operate at a loss. The court concluded that the state's "inadequate  reimbursement detrimentally affects ICF/DDs and the quality of services received  by the residents. ICF/DDs cannot fairly compete in the marketplace in terms of  salaries. Thus, ICF/DDs lose valued and skilled employees who are able to obtain  higher wages and salaries elsewhere. ICF/DD facilities, therefore, are forced to  hire individuals who may be less experienced, but who will work for less than  prevailing wages. This has had a direct and negative impact upon the level and quality of care provided to Medicaid eligible clients treated by ICF/DDs." Id.  at 1354-55. The court also determined that "there is a shortage of new ICF/DD  beds and there have been no applications to develop new ICF/DD beds in the past  five years. There also is a waiting list of individuals requiring ICF/DD  services." Id. at 1355. The court found that "Defendants have not analyzed the  adequacy of ICF/DD rates to meet the reasonable and necessary costs of an  efficiently operated provider ...[and] have failed to adequately investigate or  determine whether the Rate Plan complies with federal requirements." Id. It  found that "Defendants have admitted that the terms of the Rate Plan have caused  providers to not be reimbursed for certain costs, even when the Defendants had  no proof or no reason to believe that the provider was operating inefficiently or had incurred costs for items that were unreasonable or unnecessary." Id. It also found with respect to the cluster providers that "[p]rior to 1991,  Defendants did not pay cluster facilities pursuant to the Rate Plan, but instead  paid these providers on the basis of non-negotiable, fixed rate contracts that  condition reimbursement on appropriations by the State Legislature. Pursuant to  these contracts, Plaintiffs are not reimbursed for a substantial portion of  their actual costs." Id.

5
  Prior to the repeal of the Boren Amendment, it was well-settled that health care  providers under a state Medicaid program could bring actions pursuant to 42  U.S.C.  1983 for declaratory and injunctive relief to redress ongoing  violations of the Amendment. See Tallahassee Memorial, 109 F.3d at 702. Because  Defendants and the State of Florida participate in the Medicaid Program, which  authorizes the payment of federal funds to states to defray expenses incurred in  providing medical assistance to low income individuals, and receive matching  funds from the federal government, they are obligated to comply with the  requirements of the Medicaid Act and corresponding regulations. See id. at 698-  700. Accordingly, in Wilder v. Virginia Hospital Ass'n, 496 U.S. 498, 502, 110 S. Ct. 2510, 110 L. Ed. 2d 455 (1990), the Supreme Court held that the Medicaid Act  and the Boren Amendment created a substantive right, enforceable by health care  providers, to ensure reimbursement at rates that are actually reasonable and  adequate to meet the costs of efficiently and economically operated facilities  providing care to Medicaid patients. Providers were thus permitted to sue in  federal court for injunctive relief to ensure that they were reimbursed  according to "reasonable and adequate" rates.

6
  A review of the legislative history makes clear that Congress was indeed  concerned with the cost of health care provider suits against states and sought  to curb the proliferation of such suits. See, e.g., H.R.Rep. No. 149, 105th  Cong., 1st Sess., at 1175-76.

7
  Although the district court did say that it was "not convinced that the new  evidence offered by Defendants would warrant a modification of the Final  Judgment," there is no indication that the court considered the merits of  Defendants' mootness argument or examined what that argument meant for its  jurisdiction to issue a final judgment.

8
  In light of our ruling regarding Plaintiffs' claims for retroactive relief, see  infra Part III.B, the entire case would have to be dismissed if the court lacked  subject matter jurisdiction to award prospective relief at the time of judgment.

9
  Even assuming Plaintiffs are correct that Florida has not validly adopted a  post-Boren rate plan, there remains a question as to what standards if any  govern the post-Boren era in the absence of such a plan. Defendants, for their  part, assert that no federal standards govern the interim period and thus this  lawsuit is moot (at least with respect to the post October 1, 1997 period)  regardless of whether a valid post-Boren plan was adopted. The district court  appears to have assumed that Boren Amendment standards continue to apply even  after the Amendment's repeal unless and until the state adopts a valid  post-Boren plan to replace its Boren-era plan. See 47 F. Supp. 2d at 1354 ("until  such time as the State amends its Rate Plan in accordance with federal  requirements, the Rate Plan in effect on the effective date of repeal of the  Boren Amendment continues to apply"); 1361 (enjoining Defendants from "violation  of the Boren Amendment ... until the State adopts regulations, procedures and  standards governing the reimbursement of ICF/DD providers in place of the  standards set forth in the Boren Amendment"). But the district court did not  offer any detailed explanation for its assumption, and we note, without deciding  the issue, that courts have suggested different views on the matter. Compare  Belshe, 188 F.3d at 1095 (rejecting argument that repeal of Boren Amendment had  rendered moot a dispute about application of Boren requirements to Boren-era  plan yet to be replaced after the effective date of the repeal) with Hall v.  Sullivan, 129 F.3d 113 (2nd Cir. Oct. 15, 1997) (table case) (dismissing appeal  based on parties' agreement that their dispute about application of Boren  requirements was mooted as of the effective date of the Boren Amendment's  repeal) and HCMF Corp. v. Gilmore, 26 F. Supp. 2d 873, 878-80 (W.D.Va.1998), on  reh.'g, 85 F. Supp. 2d 643 (2000) (ruling that the Boren Amendment's repeal  effectively precluded any claim based on Boren for services rendered after the  repeal date, even though the state had not yet passed a new plan of its own).  Given our ruling that retrospective relief here is barred by the Eleventh  Amendment, see infra Part III.B, resolving what standard applies to the  post-Boren era would be unnecessary if the district court on remand found that  the Defendants had adopted a valid post-Boren plan prior to the entry of  judgment. We therefore need not and do not address now what standards govern in  the post-Boren era in the absence of a validly adopted "notice and comment"  plan.

10
  The district court explained its relief this way:
[B]ecause compliance by the Defendants with the Preliminary Injunction entered  by this Court required expenditure of State funds, such expenditures are  ancillary to preliminary injunctive relief entered. In this case, the Court has,  since September 13, 1991, enjoined Defendants from reimbursement at inadequate  rates and reimbursing cluster providers "in a manner other than as provided in a  Rate Plan" at the "full Medicaid rate." Defendants' conduct, therefore,  constitutes a continuing violation of the Medicaid Act and Plaintiffs' statutory  rights. Further, the portion of Plaintiffs' claim relating to inadequate  reimbursement occurring since the Preliminary Injunction represents injuries  arising after Defendants were ordered to comply with the Medicaid Act and are  therefore prospective in nature.
47 F.Supp.2d at 1359-60.

11
  As discussed above, supra note 4, Plaintiffs' numerous contempt and sanctions  motions never squarely challenged the court-ordered rate plan or the rates paid  under it. We offer no opinion as to how the Eleventh Amendment might have  impacted such a contempt proceeding.

12
  Kansas Health Care Association is unhelpful for many of the same reasons as Rye.  There, the district court issued a preliminary injunction in a Boren Amendment  case enjoining the operation of reimbursement rates in defendants' Medicaid  plan, directing the development of new rates, and directing that an interim rate  be paid pending the adoption of the new rates. The injunction directed that  funds equivalent to the difference between the interim rates and the old rates  be deposited into a court-supervised escrow account (a procedure to which  defendants agreed). Three months after entry of the preliminary injunction, the  defendants adopted new rates, which the plaintiffs did not challenge. Shortly  before trial, Defendants moved to dismiss on Eleventh Amendment grounds, arguing  that any final judgment awarding the escrowed funds to the plaintiffs would  constitute retrospective relief. The district court (relying on the district  court's decision in the case now before us) rejected that argument, explaining  that the funds had already been paid by the defendants and thus the final  judgment would not impose any further drain on the state treasury. The court  also ruled that the payment of funds was simply ancillary to a valid prospective  injunction, and that the funds represented defendants' "continuing obligation"  under the terms of the preliminary injunction.
Kansas Health Care Association is an unpublished opinion and carries little  weight. Its application of the retrospective/prospective distinction required by  cases such as Edelman is open to substantial debate. A court order requiring the  payment of funds from the state treasury to redress prior harm by state actors  is barred by the Eleventh Amendment regardless of whether, as an intermediate  step, the funds were placed at the court's direction into an escrow account for  the specific purpose of preserving them in order to compensate the plaintiffs.  The factual differences between that case and the case at bar also are  significant. Among other things, here Defendants did not pay any funds into  escrow in compliance with the preliminary injunction, and therefore any payment  for prior inadequate reimbursements would undeniably come directly from State  coffers. Moreover, as noted above, in this case the preliminary injunction  itself was insufficient.

13
  During oral argument, we requested the parties to submit supplemental briefing  on two related issues: (1) whether the State of Florida, by accepting federal  Medicaid funds, waived its Eleventh Amendment immunity pursuant to the  congressional power under the Spending Clause to condition a state's receipt of  federal funds on a knowing waiver of state sovereign immunity; and (2) the  effect on this case of the Supreme Court's decision in Wilder v. Virginia  Hospital Ass'n, 496 U.S. 498, 502, 110 S. Ct. 2510, 110 L. Ed. 2d 455 (1990).  Defendants contend that the State has not waived its Eleventh Amendment immunity  by accepting Medicaid funds because the Medicaid statute does not contain an  express and unmistakable statement that Congress intended to condition the  receipt of funds on a waiver of immunity. Defendants also contend that Wilder is  inapposite because it only addressed the question of whether the Boren Amendment  is enforceable in an action by health care providers under section 1983. Plaintiffs do not meaningfully contest either contention.
We agree with Defendants' view on these issues. Under the Spending Clause waiver  theory, a state may waive its sovereign immunity by accepting federal funds. See  Atascadero State Hosp. v. Scanlon, 473 U.S. 234, 238 n. 1, 105 S. Ct. 3142, 3145  n. 1, 87 L. Ed. 2d 171 (1985) ("a State may effectuate a waiver of its  constitutional immunity by ... waiving its immunity to suit in the context of a  particular federal program"); Sandoval, 197 F.3d at 492-93. But a Spending  Clause waiver requires an "unequivocal indication" by Congress that a State  accepting funds thereby waives its claim to immunity-either " 'by the most  express language or by such overwhelming implication from the text as (will)  leave no room for any other reasonable construction.' " Edelman, 415 U.S. at  673, 94 S.Ct. at 1347 (quoting Murray v. Wilson Distilling Co., 213 U.S. 151,  171, 29 S. Ct. 458, 464, 53 L. Ed. 742 (1909)).
The Medicaid Act contains no clear statement of intent to condition receipt of  Medicaid funds on a waiver of state sovereign immunity. Indeed, Congress has  rejected the inclusion of such a statement in the Act. In 1975 Congress amended  the Act to require states to waive any Eleventh Amendment immunity from suit for  violations of the Act. See Pub.L. 94-182,  111, 89 Stat. 1054; H.R.Rep. No. 94-  1122, at 4. The provision generated tremendous opposition from the states,  however, and was repealed during the next session of Congress. Pub.L. 94-522, 90  Stat. 2540. Plaintiffs direct us to no language in the Act that represents an  unequivocal indication by Congress that states accepting federal Medicaid funds  do so on condition that they have knowingly waived their Eleventh Amendment  protection.
The Supreme Court's 1990 decision in Wilder does not affect that analysis. See  Yorktown Medical Laboratory, Inc. v. Perales, 948 F.2d 84, 88 (2d Cir.1991)  (noting that even after Wilder the Boren Amendment "does not authorize  retroactive suits for the recovery of compensation due"). In Wilder, as noted  above, the Supreme Court held that "the Boren Amendment imposes a binding  obligation on States participating in the Medicaid program to adopt reasonable  and adequate rates and that this obligation is enforceable under  1983 by  health care providers." 496 U.S. at 512, 110 S.Ct. at 2518-19. The Court did not  address any Eleventh Amendment issue, and certainly did not hold that by  accepting funds under the Medicaid Act a state waives its immunity. Moreover,  the plaintiffs in Wilder were only seeking prospective injunctive relief against  state officials, see id. at 505, 110 S.Ct. at 2515, and thus no Eleventh  Amendment issue was presented (unlike here, where the district court awarded  plainly retrospective relief). Wilder did not hold that a provider can sue under  section 1983 in federal court to obtain an order imposing retrospective relief  that otherwise would be barred by the Eleventh Amendment. Accordingly, Wilder  does not dictate the outcome here.

14
  Deferring resolution of this potentially unnecessary issue is consistent with  the longstanding rule that constitutional questions should not be resolved  unless necessary to the decision. See, e.g., I.A. Durbin, Inc. v. Jefferson  Nat'l Bank, 793 F.2d 1541, 1553 (11th Cir.1986). Moreover, mootness is a  jurisdictional issue that must be resolved at the threshold. See North Carolina  v. Rice, 404 U.S. 244, 246, 92 S. Ct. 402, 404, 30 L. Ed. 2d 413 (1971) ("The  question of mootness is ... one which a federal court must resolve before it  assumes jurisdiction."). Although this Court has described the issue of Eleventh  Amendment immunity as itself one of subject matter jurisdiction, see Seaborn v.  State of Florida, Department of Corrections, 143 F.3d 1405, 1407 (11th  Cir.1998), cert. denied, 525 U.S. 1144, 119 S. Ct. 1038, 143 L. Ed. 2d 46 (1999),  mootness-like standing and ripeness-raises an even more basic question of  jurisdiction that cannot be waived and goes to the very heart of the "case or  controversy" requirement of Article III. At least in this context, therefore,  questions of mootness ought to be resolved first. See Ainsworth Aristocrat Int'l  Pty. Ltd. v. Tourism Co. of the Commonwealth of Puerto Rico, 693 F. Supp. 1354,  1357 (D.P.R.1988) (refusing to rule upon Eleventh Amendment question after  finding initially that case was moot), aff'd, 899 F.2d 852 (9th Cir.1990) (table  case). Finally, declining to review this issue now permits the district court on  remand (if it concludes the case is not moot) to examine the scope of its  prospective relief in light of the Eleventh Amendment principles set forth in  this opinion.