## Facts

- S.J.H. (S.H.) was born in 1994 and was diagnosed with autism; he received Medicaid benefits.
- S.H.’s physician recommended intensive applied behavioral analysis (ABA) therapy, and the medical necessity of ABA to correct or ameliorate S.H.’s condition was not disputed.
- In 1998, the Colville School District agreed to provide S.H. with in-home ABA therapy.
- The school district did not adequately staff or supervise the ABA program, and S.A.H. (Ms. H.), S.H.’s mother, withdrew S.H. from the district in 2000.
- In 2001, Ms. H. began taking S.H. to Richland, Washington, to receive ABA therapy from providers there.
- At Ms. H.’s request, the Washington Department of Social and Health Services (DSHS) paid transportation-related costs associated with the Richland treatment, including food and lodging, for Ms. H., S.H., and S.H.’s two siblings so the family could stay in Richland during the week and return to Colville on weekends.
- In 2003, DSHS denied Ms. H.’s request to continue the Richland transportation assistance. DSHS informed her that Colville School District officials had committed to make ABA therapy available to S.H. locally and stated the Richland transportation payments would not be terminated before ABA therapy was available in Colville.
- Ms. H. sought administrative review. An administrative-law judge reversed DSHS, reasoning that a nonexistent or only potential Colville ABA program could not be as effective as the available Richland treatment.
- DSHS sought agency review. The DSHS Board of Appeals ruled DSHS was not required to transport the family to Richland once ABA therapy was available in Colville.
- The Stevens County Superior Court affirmed the Board of Appeals, and Ms. H. appealed to the Washington Court of Appeals, Division Three.

## Issues

1. Whether federal Medicaid’s EPSDT provisions required DSHS to continue paying for weekly transportation, meals, and lodging so S.H. could receive ABA therapy in Richland rather than in Colville once local ABA was available.
2. Whether ending the Richland transportation payments violated Medicaid requirements regarding sufficiency (“amount, duration, and scope”) or comparability of services.
3. Whether the agency decision, as affirmed on judicial review, rested on an error of law or was arbitrary and capricious under Washington’s Administrative Procedure Act.

## Decision

- The Washington Court of Appeals, Division Three, affirmed the superior court and the DSHS Board of Appeals.
- The court held that EPSDT’s mandate to cover medically necessary treatment for eligible children did not require DSHS to pay ongoing out-of-town transportation, food, and lodging costs once ABA therapy was available to S.H. in Colville.
- The court concluded DSHS’s decision to discontinue the Richland transportation assistance, tied to local availability of ABA, did not violate Medicaid comparability or sufficiency rules and was not arbitrary or capricious under the state APA.

## Legal Principles

- EPSDT requires a state Medicaid program to cover medically necessary services for eligible children to correct or ameliorate physical or mental conditions, but it does not guarantee a recipient’s preferred provider or preferred location when comparable medically necessary care is available.
- Medicaid rules allow a state to place reasonable limits on the amount, duration, and scope of coverage, so long as the limits do not effectively deny access to a covered medically necessary service.
- Transportation assistance connected to Medicaid services must be sufficient to allow access to covered care, but Medicaid does not require a state to fund ongoing travel, meals, and lodging to reach a more distant provider when adequate services are available closer to home.
- Medicaid comparability is satisfied when the state applies neutral coverage limits to similarly situated recipients and does not single out an individual for unequal treatment.
- On judicial review under Washington’s APA, courts give substantial weight to the administering agency’s interpretation of the statutes and regulations it enforces and will not overturn agency action absent legal error or action that is willful and unreasoning in disregard of the facts and circumstances.

## Conclusion

The court upheld DSHS’s decision to stop paying weekly transportation, food, and lodging for S.H.’s Richland ABA therapy because EPSDT required access to medically necessary ABA, not payment for continued out-of-area travel once comparable ABA services were available in S.H.’s home community, and the agency’s decision was lawful and not arbitrary or capricious.


S.A.H. ex rel. S.J.H v. Department of Social & Health Services, 136 Wn. App. 342 (2006)