Opinion ID: 4215122
Heading Depth: 1
Heading Rank: 4

Heading: medicaid-specific arguments

Text: Subject to defendant’s arguments specific to the Medicaid context, plaintiff is entitled to restitution. We address one of those arguments and remand the case to the Court of Appeals for its determination as to the second of those arguments. Before the Court of Appeals, defendant first asserted that plaintiff’s action is an improper collateral attack on the department’s exclusive right under ORS 410.070(1) to make Medicaid eligibility decisions.9 Based solely on the citation to ORS 410.070, she contends on review that the department’s original decision to qualify Prichard for Medicaid is legally binding on plaintiff in this action, unless and until the department itself overturns it or plaintiff successfully challenges it in an unspecified administrative proceeding brought against the department. In essence, defendant contends that, in light of the department’s charge to administer Medicaid in Oregon, plaintiff cannot invoke the assistance of an Oregon court of equity. We reject that contention and agree with plaintiff’s arguments in the Court of Appeals. First, ORS 410.070 does not contain a provision barring equitable actions by Medicaid service providers. Furthermore, given 9 In part, ORS 410.070(1) provides: “(1) The Department of Human Services shall: “(a) Serve as the central state agency with primary responsibility for the planning, coordination, development and evaluation of policy, programs and services for elderly persons and persons with disabilities in Oregon. “     “(e) Receive and disburse all federal and state funds allocated to the department and    enter into contracts with private entities for the purpose of providing or contracting for case management services for long term care insurance for the benefit of elderly persons and persons with disabilities in this state. “     “(k) Conduct regulatory functions with regard to program operation, by adopting rules for providing social services, including protective services, to elderly persons and persons with disabilities who need services that the department or area agencies are authorized to provide and rules for standard rate setting and quality assurance.” Cite as 362 Or 115 (2017) 141 ORS 411.630,10 which establishes that it is unlawful for recipients of public assistance to use fraud to obtain benefits, there is no reason to infer from ORS 410.070 that, when a recipient commits fraud against a Medicaid service provider, the provider is barred from recovering from the fraud feasor in equity. Defendant’s second Medicaid-specific argument in the Court of Appeals was that plaintiff is barred from recovering because of plaintiff’s contract with the department and Medicaid law concerning acceptance of payment for services. Specifically, defendant cited ORS 443.739(16) (adult foster care resident has a right to be “free from financial exploitation” and provider “may not solicit, accept or receive money or property from a resident other than the amount agreed to for services”) and OAR 411-050-0435(1)(d) (“The rate of compensation established by the [department] is considered 10 ORS 411.630 provides: “(1) A person may not knowingly obtain or attempt to obtain, for the benefit of the person or of another person, any public assistance or medical assistance to which the person or other person is not entitled under state law by means of: “(a) Any false representation or fraudulent device, or “(b) Failure to immediately notify the Department of Human Services or the Oregon Health Authority, if required, of the receipt or possession of property or income, or of any other change of circumstances, which directly affects the eligibility for, or the amount of, the assistance. “(2) A person may not transfer, conceal or dispose of any money or property with the intent: “(a) To enable the person to meet or appear to meet any requirement of eligibility prescribed by state law or by rule of the department or the authority for any type of public assistance or medical assistance; or “(b) Except as to a conveyance by the person to create a tenancy by the entirety, to hinder or prevent the department or the authority from recovering any part of any claim it may have against the person or the estate of the person. “(3) A person may not knowingly aid or abet any person to violate any provision of this section. “(4) A person may not receive, possess or conceal any money or property of an applicant for or recipient of any type of public assistance or medical assistance with the intent to enable the applicant or recipient to meet or appear to meet any requirement of eligibility referred to in subsection (2)(a) of this section or, except as to a conveyance by the applicant or recipient to create a tenancy by the entirety, with the intent to hinder or prevent the department or the authority from recovering any part of any claim it may have against the applicant or recipient or the estate of the applicant or recipient.” 142 Larisa’s Home Care, LLC v. Nichols-Shields payment in full and licensees must not accept additional funds or in-kind payment[.]”). Defendant also noted that the contract between plaintiff and the department provided that plaintiff agreed to accept the “rate authorized by [the department] plus the established room and board payment as payment in full, and will not charge the client any additional amounts for these services.” Defendant contended that plaintiff both agreed to and was required to accept payment at the Medicaid rates as “payment in full.” The Court of Appeals did not reach that conten- tion in its opinion. Although defendant briefly reasserts her argument in this court, she does not flesh out why her reading of the statute and the rule is correct in the context of a recipient’s fraudulent receipt of the Medicaid rate, and plaintiff did not address it in its briefing in this court. That Medicaid-specific issue may well involve consideration of federal law, and it has not been briefed on elementary matters of statutory and rule construction. Under those circumstances, we decline to decide the issue as a matter of initial impression. We remand to the Court of Appeals so that it may consider that Medicaid-specific argument in the first instance. The decision of the Court of Appeals is reversed, and the case is remanded to the Court of Appeals for further proceedings.