Opinion ID: 2632913
Heading Depth: 2
Heading Rank: 1

Heading: Administrative Deference

Text: ¶ 41 The majority concludes, almost without discussion, that DSHS should be accorded no deference to its interpretation of the comparability provision. Majority at 392. I disagree. Whether DSHS should be accorded any deference requires a more robust analysis of the comparability provision than the majority puts forth. While I agree that the comparability provision requires comparable services where individuals have comparable needs, majority at 392, the needs of individuals can be compared only after they have been assessed and quantified. Because the comparability provision is silent on that specific question, Chevron deference [2] is warranted to the reasonable interpretation of the provision by the federal agency charged with administering it. That agency has determined that states may consider shared living circumstances in assessing needs and allocating services. Pursuant to state legislative mandate to ensure a uniform system for assessing needs and allocating services, DSHS developed the CARE tool and included a component that considers an individual's shared living circumstances. While not required to consider such circumstances, DSHS in its expertise determined that doing so was appropriate. That determination is entitled to some measure of administrative deference from this court. ¶ 42 The majority suggests that no deference is warranted to DSHS because the Medicaid comparability provision is specific in demonstrating Congress' intent to provide comparable services to similarly situated recipients. Majority at 392 (emphasis added). The comparability provision mandates simply that the medical assistance that a state makes available to an individual under its Medicaid plan shall not be less in amount, duration, or scope than that made available to others who qualify for medical assistance under that plan. [3] 42 U.S.C. § 1396a(a)(10)(B)(i). The comparability provision does not mandate that a state provide all qualifying individuals with identical quantities of services, regardless of their needs for services. Such a requirement would defy logic. Rather, as the majority agrees, the comparability provision requires comparable services [only where] individuals have comparable needs. Majority at 392. However, what the majority fails to note is that the comparability provision is silent as to how states should quantify the relative needs of those to whom it must provide comparable services. ¶ 43 The Centers for Medicare & Medicaid Services (CMS), the federal agency charged with administering the Medicaid program, [4] has promulgated regulations interpreting the comparability provision. When a court reviews a federal statute, if the statute is silent or ambiguous with respect to the specific issue, and the federal agency administering the statute has promulgated a regulation construing it, the court may not substitute its own construction . . . for a reasonable interpretation made by the agency. Chevron U.S.A., Inc. v. Natural Res. Defense Council, Inc., 467 U.S. 837, 842-44, 104 S.Ct. 2778, 81 L.Ed.2d 694 (1984). One CMS regulation interpreting the comparability provision essentially paraphrases it. [5] A second CMS regulation interpreting sufficiency of amount, duration, and scope of services provides that, while [e]ach service must be sufficient in amount, duration, and scope to reasonably achieve its purpose[,] . . . [t]he agency may place appropriate limits on a service based on such criteria as . . . utilization control procedures. 42 C.F.R. § 440.230(a)(2)(b), (d). By clarifying that a state may appropriately limit its provision of a service, CMS indicates that such service limitations do not per se violate the comparability provision. Using the language on such criteria as indicates that utilization control procedures are illustrative, not exhaustive, of the type of criteria by which a state may permissibly limit the provision of services. ¶ 44 CMS has provided further guidance specifically addressing a state's provision of Medicaid state-paid personal care services in shared living situations. When an agency construes its own regulations, [judicial] deference is particularly appropriate, and even more appropriate where, as here, [the court] consider[s] a small corner of a labyrinthine statute. Skandalis v. Rowe, 14 F.3d 173, 178 (2d Cir.1994) (deferring to interpretation of Medicaid statutes and regulations advanced by the secretary of the Department of Health and Human Services). In its guide to the provision of Medicaid home care services, CMS states that, to be Medicaid-reimbursable, services must address the beneficiary's needs. This means that services cannot be furnished if they principally benefit the `family unit.' U.S. Dep't of Health & Human Servs., Understanding Medicaid Home and Community Services: A Primer 131 (Oct.2000) (located in Rule Making File, Gasper v. Dep't of Soc. & Health Servs ., No. 04-2-01400-7, at SHS-0005 to 06). States may take into account the amount of informal care available to an individual. Id. Consideration may also be given to the kinds of household tasks family members typically expect to share . . . when they live in the same household. Id. ¶ 45 Because the comparability provision is silent on the specific question herewhat factors may be considered when assessing the relative needs of individuals seeking Medicaid assistanceI believe that the CMS regulations and guidance interpreting the provision should be accorded this court's deference. Thus, as CMS clarifies, a state does not violate the comparability provision by giving appropriate consideration to individuals' shared living circumstances when allocating state-paid personal care services. ¶ 46 At the state level, this court interprets the meaning of statutes de novo and may substitute its interpretation for that of an agency, but if the statute is ambiguous, `[w]here a statute is within [an] agency's special expertise, the agency's interpretation is accorded great weight.' Port of Seattle v. Pollution Control Hearings Bd., 151 Wash.2d 568, 593, 90 P.3d 659 (2004) (alterations in original) (quoting Postema v. Pollution Control Hearings Bd., 142 Wash.2d 68, 77, 11 P.3d 726 (2000)). ¶ 47 The legislature expressly charged DSHS with developing a uniform system for comprehensively assessing the need of functionally disabled individuals for medical services. See RCW 74.09.520(4); RCW 74.39.005(2). In response, DSHS developed the CARE tool, through which it evaluates eligibility for and allocates state-paid personal care services to functionally disabled individuals. WAC XXX-XXX-XXXX to -0130. [6] DSHS incorporated into the CARE tool a formula for adjusting an individual's allocation of state-paid personal care services to reflect the amount of informal support that individual receives. Built into the informal support formula is consideration of the individual's shared living circumstances. Given that CMS's authoritative interpretation of the comparability provision permits consideration of such circumstances, I believe that DSHS's decision to consider shared living circumstances and its mechanism for such consideration is entitled to some measure of administrative deference. However, administrative deference, while warranted, does not itself resolve whether the shared living rule violates the comparability provision, the question to which I now turn.