McHenry v. PacificSource Health Plans

Lisa McHenry (plaintiff) had a minor son who had autism and received applied-behavioral-analysis (ABA) therapy from Emily Hoyt, a board-certified behavior analyst (BCBA). A nationally accredited certification agency, the Behavior Analyst Certification Board, provided standardized certification of BCBAs. McHenry participated in a health plan insured and administered by PacificSource Health Plans (PacificSource) (defendant). Under the plan, a service was excluded from coverage unless the service was provided by an eligible provider. To be an eligible provider, a service provider was required to be authorized for reimbursement under Oregon law. PacificSource denied coverage for the ABA therapy on the grounds that Hoyt was not an eligible provider under the plan. McHenry filed suit against PacificSource under the Employment Retirement Income Security Act (ERISA) to compel coverage. McHenry’s only evidence regarding Hoyt’s authorization for reimbursement under Oregon law was a letter from the Oregon Department of Human Services (ODHS) responding to McHenry’s attorney’s inquiry about whether BCBAs were approved as providers by ODHS. The 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 filed a motion for summary judgment, and PacificSource filed a cross motion for summary judgment.