## Facts

- Parents’ League for Effective Autism Services (PLEAS) and three Medicaid-eligible children with autism received intensive Applied Behavioral Analysis (ABA) therapy through a nonprofit provider.
- Ohio agencies adopted amended Medicaid mental-health rules that reclassified covered services as “rehabilitative services” and, in practice, excluded or sharply reduced coverage for the intensive ABA program.
- Plaintiffs alleged the amended rules conflicted with federal Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) requirements because ABA, when ordered by qualified professionals, was medically necessary and fell within mandatory EPSDT coverage as “rehabilitative services” under 42 U.S.C. § 1396d(a)(13).
- The district court credited expert evidence that ABA is an effective treatment for autism and found it medically necessary for the plaintiff children and aimed at maximal functional improvement.
- The district court entered a temporary restraining order and then a preliminary injunction barring implementation of the amended rules; state officials appealed.

## Issues

1. Whether the district court abused its discretion in finding plaintiffs likely to succeed on the claim that the amended Ohio rules conflicted with EPSDT by restricting medically necessary ABA that qualifies as “rehabilitative services” under 42 U.S.C. § 1396d(a)(13).
2. Whether the district court abused its discretion in weighing the preliminary-injunction factors (likelihood of success, irreparable harm, harm to others, and public interest).

## Decision

- The Sixth Circuit affirmed the preliminary injunction.
- The court held the district court did not abuse its discretion in applying the four-factor preliminary-injunction test.
- The court upheld, for preliminary-relief purposes, the district court’s conclusion that plaintiffs showed a strong likelihood of success that medically necessary ABA could fall within EPSDT “rehabilitative services.”
- The court found no clear error in the district court’s factual findings supporting medical necessity and irreparable harm from interruption of early intensive therapy.

## Legal Principles

- A preliminary injunction is reviewed for abuse of discretion; legal conclusions are reviewed de novo and factual findings for clear error.
- Under EPSDT, participating states must provide Medicaid-eligible children medically necessary services that fall within covered categories in 42 U.S.C. § 1396d(a).
- For preliminary-relief analysis, a district court may reasonably treat professionally recommended, medically necessary autism therapy as “rehabilitative services” under § 1396d(a)(13), notwithstanding a state’s narrower regulatory classification.
- Interruption or loss of medically necessary early-intervention services for children can constitute irreparable harm not readily remedied by monetary damages.
- Maintaining the status quo to avoid potential violations of federal law and to protect access to medically necessary care may support the balance of equities and public interest factors.

## Conclusion

The Sixth Circuit left in place an injunction preventing Ohio from implementing Medicaid rule changes that would curtail ABA therapy, holding that the district court reasonably found likely EPSDT violations and that the equities and public interest favored continued access to medically necessary services pending final adjudication.


Parents’ League for Effective Autism Servs. v. Jones-Kelley, 339 F. App’x 542 (6th Cir. 2009)