## Facts

- Lisa McHenry participated in an ERISA-governed health plan that was insured and administered by PacificSource Health Plans (PacificSource).
- McHenry’s minor son had autism and received applied-behavioral-analysis (ABA) therapy.
- The ABA therapy was provided by Emily Hoyt, a board-certified behavior analyst (BCBA).
- The Behavior Analyst Certification Board provided standardized certification for BCBAs, but Oregon law did not treat the BCBA credential itself as a state authorization to bill for health-care services.
- Under the plan, a service was excluded from coverage unless it was provided by an “eligible provider.”
- To qualify as an eligible provider under the plan, the provider had to be “authorized for reimbursement under Oregon law.”
- PacificSource denied coverage for the ABA therapy on the ground that Hoyt was not an eligible provider because she was not authorized for reimbursement under Oregon law.
- McHenry sued PacificSource under ERISA to recover benefits and compel coverage for the ABA therapy.
- In support of her position that Hoyt was authorized for reimbursement under Oregon law, McHenry relied on a letter from the Oregon Department of Human Services (ODHS).
- The ODHS letter stated that ODHS did not recognize BCBAs as a specific provider type, but that therapists with a BCBA specialty could be enrolled as approved County Mental Health Program (CMHP) providers who could then bill ODHS.
- McHenry moved for summary judgment, and PacificSource filed a cross-motion for summary judgment.

## Issues

1. Whether, under the plan term requiring services to be provided by an “eligible provider” authorized for reimbursement under Oregon law, PacificSource properly denied ABA-therapy benefits because the BCBA therapist was not shown to be authorized for reimbursement under Oregon law.

## Decision

- The court denied McHenry’s motion for summary judgment.
- The court granted PacificSource’s cross-motion for summary judgment.
- The court held that McHenry did not establish that the ABA provider met the plan’s “eligible provider” requirement because the record did not show the provider was authorized for reimbursement under Oregon law.
- The court treated the ODHS letter as insufficient to prove eligibility: it did not state that BCBAs were recognized as a reimbursable provider type, and it did not show that Hoyt was actually enrolled or otherwise authorized to bill ODHS as a CMHP provider.
- Judgment was entered for PacificSource on McHenry’s ERISA benefits claim based on the plan’s provider-eligibility limitation.

## Legal Principles

- Under ERISA § 502(a)(1)(B), a participant seeking benefits must show entitlement to benefits under the terms of the plan.
- Courts enforce unambiguous plan limits that condition coverage on the use of certain categories of providers, including requirements that a provider be legally authorized to receive reimbursement under applicable state law.
- Evidence that a provider could potentially qualify for reimbursement (for example, by enrolling in a state or county program) does not establish that the provider is currently authorized or enrolled; the claimant must show the provider actually satisfies the plan’s eligibility condition.
- On cross-motions for summary judgment, the court resolves the case as a matter of law when there is no genuine dispute of material fact and the plan terms, applied to the undisputed record, foreclose coverage.

## Conclusion

McHenry sought ERISA benefits for her son’s ABA therapy, but the plan covered services only when provided by an eligible provider authorized for reimbursement under Oregon law. Because McHenry did not present evidence that the BCBA therapist was recognized as a reimbursable provider type or was actually enrolled or otherwise authorized to bill under Oregon law, the court granted summary judgment to PacificSource and upheld the denial of coverage.


McHenry v. PacificSource Health Plans, CV-08-562-ST (2010)