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Hasner v. Western Oregon Advanced Health

Court of Appeals of Oregon

December 6, 2017

Lucinda HASNER, Petitioner,
v.
WESTERN OREGON ADVANCED HEALTH and Division Of Medical Assistance Programs, a division of the Oregon Health Authority, Respondents.

          Argued and submitted June 15, 2017.

         Oregon Health Authority 20151447;

          Beth Englander argued the cause for petitioner. With her on the brief were Jonathan P. Strauhull, Legal Aid Services of Oregon, William Niese, Emily Teplin Fox, and Oregon Law Center. With them on the reply brief was Megan Dorton.

          Dustin Buehler, Assistant Attorney General, argued the cause for respondent Division of Medical Assistance Programs. With him on the briefs were Ellen F. Rosenblum, Attorney General, and Benjamin Gutman, Solicitor General.

          No appearance for respondent Western Oregon Advanced Health.

          Before DeVore, Presiding Judge, and Garrett, Judge, and Haselton, Senior Judge.

         Case Summary:

         Petitioner, a member of the Oregon Health Plan, seeks judicial review after the agency that administers the plan, the Division of Medical Assistance Programs of the Oregon Health Authority, denied her physician's request for prior authorization of treatment for her medical condition. On review, the parties dispute whether petitioner can receive coverage for her requested treatment when the condition and treatment appear separately on the Oregon Health Plan's Prioritized List of Health Services and are not paired together above the chosen funding line. Held: Petitioner's entitlement to coverage, if any, depends upon the application of OAR 410-141-0480(10), which provides that, if its prerequisites are satisfied, a “coverage decision” should be made in an individual case.

         Reversed and remanded.

          [289 Or. 208]

          DeVORE, P. J.

         Petitioner receives medical assistance as a member of the Oregon Health Plan (OHP). She seeks judicial review after the agency that administers the plan, the Division of Medical Assistance Programs (DMAP) of the Oregon Health Authority (OHA), denied her physician's request for prior authorization of treatment for her medical condition. The dispute involves a list of conditions and treatments-the Prioritized List of Health Services-that the agency uses to determine what medical services that the plan covers. OHP members are eligible to receive treatments for conditions when the condition and treatment are paired on that list and appear above a chosen funding line. This dispute arises because petitioner's condition and treatment appear separately on the Prioritized List and not paired together above the funded line. On review, we conclude that, in that circumstance, DMAP must apply OAR 410-141-0480(10), which may require DMAP to make an ad hoc coverage decision. Because we cannot determine that DMAP considered or applied that rule, we reverse and remand.

         Before summarizing the facts, we must sketch the regulatory landscape. The OHP is Oregon's Medicaid program, which provides health care assistance to qualifying residents. In the administration of the plan, the Health Evidence Review Commission ("HERC") creates and maintains a list of health conditions paired with treatments for those conditions-the "Prioritized List of Health Services." HERC ranks the condition/treatment pairs on the Prioritized List in order of importance, based on the clinical and cost effectiveness of services. The Oregon legislature then draws a "funded line" on the Prioritized List.

         Generally speaking, OAR 410-141-0480 ties coverage under the OHP to whether conditions and treatments are paired above or below the funded line on the Prioritized List. Specifically, OAR 410-141-0480(1) provides:

"Division members are eligible to receive, subject to section (11) of this rule [regarding services excluded under OAR 410-141-0500], those treatments for the condition/ treatment pairs funded on the Health Evidence Review Commission (HERC) Prioritized List of Health Services [289 Or. 209] adopted under OAR 410-141-0520 when such treatments are medically or dentally appropriate, except that services shall also meet the prudent ...

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