Central Or. Independ. Health Serv. v. Omap

156 P.3d 97, 211 Or. App. 520
CourtCourt of Appeals of Oregon
DecidedMarch 28, 2007
Docket02C17943 A127934
StatusPublished
Cited by6 cases

This text of 156 P.3d 97 (Central Or. Independ. Health Serv. v. Omap) is published on Counsel Stack Legal Research, covering Court of Appeals of Oregon primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Central Or. Independ. Health Serv. v. Omap, 156 P.3d 97, 211 Or. App. 520 (Or. Ct. App. 2007).

Opinion

156 P.3d 97 (2007)
211 Or. App. 520

CENTRAL OREGON INDEPENDENT HEALTH SERVICES, INC., an Oregon corporation, Plaintiff-Appellant,
v.
STATE of Oregon, acting by and through the Department of Human Services, Office of Medical Assistance Programs, Defendant-Respondent.

02C17943; A127934.

Court of Appeals of Oregon.

Argued and Submitted August 4, 2006.
Decided March 28, 2007.

*98 William F. Gary, Eugene, argued the cause for appellant. With him on the briefs were Sharon A. Rudnick, Karla Alderman, and Harrang Long Gary Rudnick P.C., and Matthew G. Weber and Holland & Hart, LLP, Denver.

Paul L. Smith, Assistant Attorney General, argued the cause for respondent. With him on the brief were Hardy Myers, Attorney General, and Mary H. Williams, Solicitor General.

Before LANDAU, Presiding Judge, and SCHUMAN, Judge, and LIPSCOMB, Judge pro tempore.

LANDAU, P.J.

This case involves a disagreement about the meaning of a series of complex contracts concerning the rates at which the state is obligated to reimburse health care services providers who provide services under the Oregon Health Plan. Pared to essentials, the disagreement amounts to a straightforward dispute about a potential conflict between two provisions in the contracts. On the one hand, the contracts provide that the specified reimbursement rates are calculated in accordance with a particular formula. On the other hand, the contracts state that those rates constitute the "total" or "maximum" rate of payment. The dispute arises out of the contentions of plaintiff, a health care *99 provider, that the state failed to calculate the reimbursement rates in accordance with the formula and that the rates should be higher than those specified in the contracts. The state responds that whether it complied with the formula is irrelevant, because the contracts establish the "total" or "maximum" reimbursement rates, and it is undisputed that it has reimbursed plaintiff at those rates.

Plaintiff initiated this action for breach of contract, promissory estoppel, and reformation. The trial court dismissed the latter two claims for failure to state a claim. The parties filed cross-motions for summary judgment on the remaining breach of contract claim. The trial court denied plaintiff's motion, granted the state's motion, and entered judgment accordingly.

On appeal, plaintiff assigns error to the trial court's decision to grant the state's summary judgment motion and to deny its own motion. Plaintiff also assigns error to the dismissal of its reformation claim. For the reasons that follow, we conclude that, although the trial court did not err in denying plaintiff's motion for summary judgment, it did err in granting the state's motion. We also conclude that the trial court erred in granting the state's motion to dismiss the reformation claim. We therefore reverse and remand.

I. BACKGROUND

We begin with a brief description of the regulatory backdrop against which the parties negotiated the agreements at issue. We then describe the provisions of the agreements that are in dispute, before turning to the specific events that led to the initiation of this action and the judgment that is the subject of the appeal.

A. The Oregon Medical Assistance Program

Congress created the Medicaid program to provide basic health care services to individuals of limited means. 42 U.S.C. § 1396. The program is jointly administered by federal and state governments; that is, it is funded by both federal and state governments but is managed by the states, subject to the requirements of federal law. Under that federal law, states may serve Medicaid recipients by, among other things, using a network of "fee-for-service" providers that are reimbursed for the actual costs of providing services or by using managed health care organizations (MCOs) that are reimbursed on the basis of a predetermined per capita patient basis, also known as a "capitation" basis.

The basic idea of capitation payments is to allocate risk in a way that creates incentives for health care services providers to provide those services in an efficient manner. The rates are calculated by means of various actuarial assumptions and formulae designed to predict the likely actual cost of providing the services. If the providers can provide the services at a cost less than the projected rates, the providers are entitled to "keep the difference" as a reward for their efficiencies. If the providers cannot do so, however, their reimbursement remains at the predetermined rate. The providers are barred from seeking retroactive payment beyond the predetermined capitation rate.

Oregon's Medicaid program is known as the Oregon Health Plan (OHP), see ORS 414.019 (listing laws comprising the OHP) and is administered by the Oregon Medical Assistance Program (OMAP). By law, OMAP is required to serve Medicaid-eligible individuals "to the greatest extent possible" through MCOs on a prepaid capitation basis. ORS 414.725. OMAP does just that through the use of capitation contracts with health care services providers in particular geographic areas. In those contracts, the providers agree to provide medically appropriate services to OHP participants within a specified geographic area. In exchange, OMAP agrees to reimburse the providers in accordance with a specified capitation payment—a specific monthly per-person rate for different classes of participants.

B. The contracts

Plaintiff is a health care services provider certified by OMAP to provide services to OHP participants. Beginning in 1997, plaintiff and OMAP entered into a series of annual "Fully Capitated Health Plan Agreements" *100 to provide services to OHP participants in central Oregon. Five of those contracts—for the years 1997 to 2001—are at issue in this case. The material provisions of each contract are substantially similar.

Each contract contains a "consideration" section. The contract for fiscal year 1997, for example, provides:

"A. In consideration of all work to be performed by Contractor under this Agreement, OMAP shall pay Contractor:
"(1) A Capitation Payment for each OMAP Member, beginning with the date of enrollment and ending with the date of disenrollment. Contractor shall be paid a capitation only for those OMAP Members who are enrolled with Contractor according to OMAP records. Where the date of enrollment is during mid-month, the Capitation Payments shall be prorated."

There follows at that point a listing of capitation rates for 14 categories of OMAP members. For example, the rates for the Grant County service area are listed as follows:

"$121.35 for Aid to Families with Dependent Children (AFDC)
"$431.76 for General Assistance (GA)
"$544.18 for PLM [Poverty Level Medical] Adults under 100% Federal Poverty Level
"$653.91 for PLM Adults over 100% Federal Poverty Level
"$ 86.90 for PLM Children under 100% Federal Poverty Level

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Cite This Page — Counsel Stack

Bluebook (online)
156 P.3d 97, 211 Or. App. 520, Counsel Stack Legal Research, https://law.counselstack.com/opinion/central-or-independ-health-serv-v-omap-orctapp-2007.