which entity has jurisdiction over health care coverage providers

CMS will also conduct targeted market conduct examinations, as necessary, and respond to consumer inquiries and complaints to ensure compliance with the health insurance market reform standards. Whether California (or another state) enacts legislation requiring state approval of transactions. Further, the VAHBP Moratorium is not a complete exclusion from OFCCPs authority as it only relieves an entity from being neutrally scheduled for a compliance evaluation. SB 977, at 1190.25(d). The term "health care providers," as used in the TRICARE Exemption and VAHBP Moratorium, is easily interpreted to include providers like blood banks, diagnostic labs, or ambulance services. According to PPACA, what is a health benefits exchange? Liberty Mutual Insurance Co. v. Friedman, 639 F. 2d 164 (4th Cir. Potential covered contracts or subcontracts may include contracts related to Medicare Advantage (Part C) or Part D programs. The ARB determined that the reimbursement agreement did not provide a basis for coverage of the hospital under the laws enforced by OFCCP. website belongs to an official government organization in the United States. Washington alleged that the transactions combined the largest primary care and orthopedic service providers, resulting in reduced choice and higher prices for consumers. .manual-search-block #edit-actions--2 {order:2;} This antitrust safety zone will not apply if that hospital is less than 5 years old. Statements of Antitrust Enforcement Policy in Health Care. However, in 2015, the FAR implemented an inflationary adjustment for VEVRAA, increasing the threshold amount from $100,000 to $150,000. How is an agent's first year commission calculated for a replacement long-term policy? If the transaction also triggers the HSR filing requirements, the parties can satisfy Washingtons premerger notification requirement by submitting a copy of the HSR filing to the Washington attorney general. Given the importance and rising costs of healthcare as well as a concern about whether federal authorities have the same interests and incentives to enforce the antitrust laws, recently states have taken actions to be better informed about, challenge, or prevent healthcare affiliations. ERISA requires plans to provide participants with plan information including important information . The statutory framework for enforcement of non-Federal governmental plans was established in Part A of title XXVII of the PHS Act with the enactment of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Megan Morley is a Senior Attorney in the Business Litigation practice group at Troutman Pepper. 0000048160 00000 n 12 The healthcare material change notice requirement applies when (1) both parties are Washington entities or (2) one party is a Washington entity and the other is an out-of-state entity that generates $10 million or more in revenue from healthcare services for patients residing in Washington.13 Transactions meeting these criteria must be reported regardless of size. Moreover, given the countrys focus on access to and the affordability of healthcare, it would not be surprising if other states attempt to enact antitrust legislation targeting healthcare affiliations. Accordingly, if your business or organization became a fund depository or an issuing and paying agent for savings bonds and notes on or after December 1, 2003, it would also be subject to the written AAP requirement under VEVRAA if the contract is for $150,000 or more. 0000022775 00000 n 7500 Security Boulevard, Baltimore, MD 21244, An official website of the United States government, Coventry Life and Health Insurance Company, East Missouri (PDF), Coventry Life and Health Insurance Company, West Missouri (PDF), UnitedHealthCare Insurance Company, Texas (PDF), In-Person Assistance in the Health Insurance Marketplaces, The Mental Health Parity and Addiction Equity Act (MHPAEA), Self-Funded, Non-Federal Governmental Plans, Federal Market Conduct Examination (Oversight Group) Checklist (PDF), Blue Cross and Blue Shield of Alabama (PDF), Allegiance Life and Health Insurance Company, Inc., Montana (PDF), Health Insurance and Consumer Protections Grant Fact Sheet (PDF), Health Insurance and Consumer Protections Grant Map: State-by-State Summary of Health Insurance and Consumer Protections Grants, State Flexibility to Stabilize the Market Cycle I Grant Map: State-by-State Summary of State Flexibility to Stabilize the Market Grantsfor Cycles I and II, Fact Sheet: The State Flexibility to Stabilize the Market Cycle I Grant Program (PDF), Fact Sheet: The State Flexibility to Stabilize the Market Cycle II Grant Program (PDF), Information Related to COVID19 Individual and Small Group Market Insurance Coverage, FAQs on Essential Health Benefits Coverage and the Coronavirus (COVID-19), FAQs on Catastrophic Plan Coverage and the Coronavirus Disease 2019 (COVID-19), FAQs on Availability and Usage of Telehealth Services through Private Health Insurance Coverage in Response to Coronavirus Disease 2019 (COVID-19), Payment and Grace Period Flexibilities Associated with the COVID-19 National Emergency, FAQs on Prescription Drugs and the Coronavirus Disease 2019 (COVID-19) for Issuers Offering Health Insurance Coverage in the Individual and Small Group Markets, FAQs about Families First Coronavirus Response Act and the Coronavirus Aid, Relief, and Economic Security Act Implementation, Postponement of 2019 Benefit Year HHS-operated Risk Adjustment Data Validation (HHS-RADV), Section 2707 - Non-discrimination under Comprehensive Health Insurance Coverage (Essential Health Benefits Package), Section 2713 - Coverage of Preventive Health Services, Section 2718 - Bringing down the Cost of Health Care Coverage (MLR), Section 2726 - Parity in Mental Health and Substance Use Disorder Benefits, Section 2702 Guaranteed Availability of Coverage, Section 2703 Guaranteed Renewability of Coverage, Section 2707 Non-discrimination under Comprehensive Health Insurance Coverage (Essential Health Benefits Package). How do I know if my health care entity falls under the jurisdiction of OFCCP? 41 CFR 60-741.40(a). See 41 CFR 60-1.5(a)(3), 60-300.4(a)(3), 60-741.4(a)(3). Financial institutions with federal share and deposit insurance are considered to be government contractors within the meaning of the regulations implementing Executive Order 11246, as amended (Executive Order); Section 503 of the Rehabilitation Act of 1973, as amended (Section 503); and the Vietnam Era Veterans Readjustment Assistance Act of 1974, as amended, 38 U.S.C. LCDs only have jurisdiction . Brouse McDowell, A Legal Professional Association. What is an "insurance broker" according to California Insurance Code? .cd-main-content p, blockquote {margin-bottom:1em;} An official website of the United States government. Currently, the size-of-transaction threshold is $94 million. Yes. Issuers required to submit form filings to CMS will need to follow instructions posted under Training Resources below. 0000035052 00000 n Further, except for universities and medical facilities, a state or local government agency, instrumentality, or subdivision that has a government contract is exempt from the requirement to develop and maintain a written affirmative action program. These efforts show that states are taking a more active role in the investigation and enforcement of the antitrust laws, especially in the healthcare sector. An official website of the United States government 42 U.S.C. She advises healthcare clients on the antitrust implications of transactions, defends hospital systems against allegations of antitrust wrongdoing, and prepares pre-merger notification filings for healthcare deals. This strategy must be considered carefully, but can be beneficial depending on the acquiring providers risk tolerance, market concentration, and the extent and number of competitive overlaps between the affiliating providers. You may wish to consult the elaws Advisor if you have additional questions about coverage. {{currentYear}} American Bar Association, all rights reserved. 0000004716 00000 n The Patient Protection and Affordable Care Act, enacted on March 23, 2010, and the Health Care and Education Reconciliation Act of 2010, enacted on March 30, 2010, (collectively known as the Affordable Care Act)(ACA) reorganized, amended, and added to the provisions of Part A of title XXVII of the PHS Act. He counsels clients on antitrust issues with respect to mergers and acquisitions; litigates boycott, monopolization, and patent misuse cases; and advises clients on distribution, joint venture, and licensing strategies. Notably, unlike the federal premerger notification system under the Hart-Scott-Rodino Antitrust Improvements Act (HSR),1 neither the Connecticut nor the Washington statute has a minimum size-of-transaction threshold. What entities are subject to the requirements of Executive Order 11246? 1980). @media (max-width: 992px){.usa-js-mobile-nav--active, .usa-mobile_nav-active {overflow: auto!important;}} As such, these entities may qualify for these two exceptions to OFCCP coverage for specific types of health care providers. Share sensitive information only on official, secure websites. If California (or other states) pass the same or similar legislation, then parties will need to be prepared to explain these outcomes or will risk the deal being denied approval. /*-->*/. Colo. Rev. For providers serving rural areas, the attorney general would have the authority to waive these standards.22 Any person or other entity, including a provider sponsored organization that operates under the Medicare-plus-choice program established under the balanced budget act of 1997 (42 United States Code sections 1395w-21 through 1395w-28 and title XVIII, part C of the social security act . HHS has jurisdiction over public sector group health plans (referred to as "non-Federal governmental plans"), while the Departments of Labor and the Treasury have jurisdiction over private group health plans. The term nonpersonal services includes, but is not limited to, the following services: utilities, construction, transportation, research, insurance, and fund depository. 15 U.S.C. .h1 {font-family:'Merriweather';font-weight:700;} Similarly, consumers will continue to contact the state for inquiries and complaints relating to the health insurance market reform requirements. The implementing regulations for Executive Order 11246 at 41 CFR 60-1.3, for VEVRAA at 41 CFR 60-300.2 and for Section 503 at 41 CFR 60-741.2, consistently define a government contract as any agreement or modification thereof between any contracting agency and any person for the purchase, sale or use of personal property or nonpersonal services. Is CMS a regulatory agency? 0000002523 00000 n 15 U.S.C. website belongs to an official government organization in the United States. Your practice or facility may not be subject to affirmative action laws, so read on to understand whether you should accept this provision in an agreement or not. Washington State Office of the Attorney General Past Cases (last visited Nov. 19, 2020), https://www.atg.wa.gov/past-cases. The provisions of title XXVII of the PHS Act that apply to group health plans that are non-Federal governmental plans are enforced by the Centers for Medicare & Medicaid Services (CMS) under PHS Act section 2723(b)(1)(B) using the procedures described in 150.301 et seq. 0000017052 00000 n 1. Notice of appointment must be submitted to the Commissioner. In order to be eligible for the TRICARE Exemption, the entity must hold a TRICARE subcontract (rather than a prime contract) and hold no other covered agreements. #views-exposed-form-manual-cloud-search-manual-cloud-search-results .form-actions{display:block;flex:1;} #tfa-entry-form .form-actions {justify-content:flex-start;} #node-agency-pages-layout-builder-form .form-actions {display:block;} #tfa-entry-form input {height:55px;} /content/aba-cms-dotorg/en/groups/health_law/publications/aba_health_esource/2020-2021/december-2020/sta-enf, http://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201920200SB977, https://leg.colorado.gov/sites/default/files/2020a_064_signed.pdf, https://www.nysenate.gov/legislation/bills/2019/s8700/amendment/a, https://www.cga.ct.gov/2014/ACT/pa/pdf/2014PA-00168-R00SB-00035-PA.pdf, https://portal.ct.gov/AG/General/Notice-of-Physician-Acquisition, https://app.leg.wa.gov/RCW/default.aspx?cite=19.390&full=true, https://oag.ca.gov/sites/all/files/agweb/pdfs/charities/publications/nonprofithosp/new_statutes.pdf, https://oag.ca.gov/news/press-releases/attorney-general-becerra-and-senator-monning-announce-legislation-reduce, https://www.justice.gov/atr/statements-antitrust-enforcement-policyin-health-care. What is required after a life agent sells an insurance policy to an applicant without being appointed by the insurer? The implementing regulations for VEVRAA and Section 503, found at 41 CFR 60-300.2 and 41 CFR 60-741.2, respectively, also define a government contract as any agreement or agreement modification between any contracting agency and any person for the purchase, sale or use of personal property or nonpersonal services. 0000025299 00000 n Your membership has expired - last chance for uninterrupted access to free CLE and other benefits. 1-888-4LA-CARE (1-888-452-2273)Provider Information. means youve safely connected to the .gov website. Which entity has jurisdiction over health care coverage providers? This blog is intended to provide information generally and to identify general legal requirements. To the extent that CMS and a state agree on a collaborative approach, the state will perform the same regulatory functions with respect to the Affordable Care Act market reform provisions as it does to ensure compliance with state law, and will seek to achieve voluntary compliance from issuers if the state finds a potential violation. 0000014828 00000 n Given the narrow geographic market definition applied to providers and the fact that high market concentration among specialists or service lines (e.g., Level 1 Trauma) often exists, physician groups and hospitals will need to proceed with caution when taking actions that are likely to harm their actual or potential competitors. Accordingly, non-Federal governmental plans are subject to the provisions of Part A of title XXVII of the PHS Act, including any changes made by the ACA. https:// The provider agreements, pursuant to which hospitals and other health care providers receive reimbursement for services covered under Medicare Parts A and B, and the provider agreements that hospitals and other health care facilities have entered into with State Medicaid agencies, are not covered government contracts under the laws enforced by OFCCP. However, these time frames could be extended if the attorney general decided to hold a public meeting about the transaction or if the parties substantially changed the deal.24 Parties could appeal the attorney generals determination to deny approval for a transaction via writ of mandate to a California superior court.25 means youve safely connected to the .gov website. Accordingly, a hospital or other health care provider is not covered under the laws enforced by OFCCP if its only relationship with the federal government is as a participating provider under Medicare Parts A and B and Medicaid. You can decide how often to receive updates. Even if not reportable to federal or state regulators, a deal can be challenged, and the parties should be prepared to advocate for their transaction. 2023 Brouse McDowell. This deal analysis should include talking to business personnel, reviewing relevant documents, and potentially, analyzing patient draw data. Overseeing the insurance industry and protecting the state's insurance consumers is the responsibility of the California Department of Insurance (CDI). Dennie Zastrow is an Associate in the Business Litigation practice group at Troutman Pepper. The decision in Bridgeport Hospital concerned only the contractual obligations assumed by an insurance carrier that has contracted to provide a fee-for-service health benefits plan to federal employees; it does not address the contractual obligations assumed by providers of other types of plans under the FEHB Program, (e.g., a Health Maintenance Organization). Likewise, a teaching hospital doing research for a university that has a contract with the federal government may be covered. 0000001958 00000 n The Colorado attorney general is now authorized to challenge transactions when the effect of such acquisition may be to substantially lessen competition or may tend to create a monopoly regardless of whether the Federal Trade Commission (FTC) or the Department of Justice (DOJ) challenged the transaction within the HSR waiting period.32 Importantly, the legislation merely gives the attorney general the authority to challenge proposed acquisitions it neither imposes any additional filing requirements on parties nor creates a standard that differs from that applied under federal law -- Section 7 of the Clayton Act. 0000007980 00000 n HlW$5|y~8N3|-oOU93-.?G9b?w]vg,TTTu_>z#:HOTH%SO>cavF^OvK>R$l]aSbgu?sVdYpv|C}`,Z#MH#}-^U"} $sF'tq7i!G?>:835^27LX lock 0000009656 00000 n ) He can be reached at dennie.zastrow@troutman.com. In addition to the premerger notification provision, SB 977 also targeted conduct by healthcare systems. If a State or local government has Government contracts, is it subject to the requirements of Executive Order 11246? Compliance also includes, but is not limited to, writing and maintaining an affirmative action program, requiring equal employment opportunity in employment processes, and including an equal opportunity clause in all job advertisements and contracts. Heres how you know. Yes. Federal government work is performed in some other division in another state. 0000011859 00000 n ) Since the effective date of a transaction can have a myriad of implications (financing, tax, contractual, regulatory, etc. Proposed amendments to New York States antitrust statute the Donnelly Act would expand that law to capture unilateral conduct generally treated as competitively neutral or even procompetitive under current federal antitrust laws. Although the proposed amendments to New Yorks Donnelly Act are not limited in application to the healthcare industry, the contemplated abuse of dominance provision could present significant increased enforcement risk for healthcare providers. Regardless of how small a deal is, the parties need to understand the competitive implications. The Affordable Care Act made a number of changes, with the result that sponsors of self-funded, non-Federal governmental plans can no longer opt out of as many requirements of Title XXVII. Federal contracts and subcontracts are exempt from the requirements of the equal opportunity clause with regard to work performed outside the United States by employees who were not recruited within the United States. Overseeing the insurance industry and protecting the state's insurance consumers is the responsibility of the California Department of Insurance (CDI). An Act Concerning Notice of Acquisitions, Joint Ventures, Affiliations of Group Medical Practices and Hospital Admissions, Medical Foundations, and Certificates of Need, P.A. It is unclear what would constitute a dominant position under the proposed statute. Compliance Checkup: Affirmative Action: Is your health care entity subject to affirmative action laws. 0000013829 00000 n Generally speaking, any business or organization that: Yes, if the contracts meet the threshold for coverage. 18(a). What is the purpose of the Pre-Existing Condition Insurance Plan (PCIP)? The .gov means its official. Policy form review is one of the compliance tools used to confirm health insurance issuers' compliance with the provisions of the health insurance market reforms of the Affordable Care Act. No. Holds government bills of lading, serves as a depository of federal funds, or is an issuing and paying agency for U.S. savings bonds and notes in any amount will be subject to requirements under one or more of the laws enforced by OFCCP. Missouri The term "health care providers," as used in the TRICARE Exemption and VAHBP Moratorium, is easily interpreted to include providers like blood banks, diagnostic labs, or ambulance services. Each regional MAC. 0000027421 00000 n lock Evidently not satisfied with the way in which the courts and federal enforcement agencies have applied Section 2 of the Sherman Act and seeking more expansive enforcement power over unilateral conduct, the proposed amendments include an ambiguous prohibition against activities of dominant firms that might be considered abus[ive]. Specifically, the amendments would make it unlawful under state law: for any person or persons with a dominant position in the conduct of any business, trade or commerce or in the furnishing of any service in this state to abuse that dominant position.34. Non-Federal governmental plans are not regulated the same way as insurance companies or private employer health plans. According to the California Insurance Code, how is the word "may" interpreted? Health Care Market Participants, RCW 19.390, et seq.. https:// In such instances, OFCCP uses a "single entity" test to determine whether the businesses or organizations are so closely related that they constitute a single entity for purposes of OFCCP jurisdiction. All of these statements concerning Medicare are true EXCEPT. Which of the following actions is NOT allowed by Health Insurance Counseling and Advocacy Program (HiCAP) counselors? According to the California Insurance Code, what is the maximum penalty per violation for anyone who unwillfully commits an unfair method of competition? 18116. Local Coverage Determinations are administered by whom? Have you ever seen a section in a contract that reads something like this? 7500 Security Boulevard, Baltimore, MD 21244, An official website of the United States government, Self-Funded, Non-Federal Governmental Plans, In-Person Assistance in the Health Insurance Marketplaces, The Mental Health Parity and Addiction Equity Act (MHPAEA), Information Related to COVID19 Individual and Small Group Market Insurance Coverage, FAQs on Essential Health Benefits Coverage and the Coronavirus (COVID-19), FAQs on Catastrophic Plan Coverage and the Coronavirus Disease 2019 (COVID-19), FAQs on Availability and Usage of Telehealth Services through Private Health Insurance Coverage in Response to Coronavirus Disease 2019 (COVID-19), Payment and Grace Period Flexibilities Associated with the COVID-19 National Emergency, FAQs on Prescription Drugs and the Coronavirus Disease 2019 (COVID-19) for Issuers Offering Health Insurance Coverage in the Individual and Small Group Markets, FAQs about Families First Coronavirus Response Act and the Coronavirus Aid, Relief, and Economic Security Act Implementation, Postponement of 2019 Benefit Year HHS-operated Risk Adjustment Data Validation (HHS-RADV). .usa-footer .container {max-width:1440px!important;} Official websites use .govA Understanding these tools and the trend will allow healthcare entities and their counsel to better estimate their deal timelines and better prepare for and predict state intervention. What is Medicaid? -Doctors' services are covered by Medicare Part B. CDI has jurisdiction under the CaliforniaInsurance Code over all other types of health insurance,including plans that offer traditional health insuranceproducts, such as indemnity plans, and some PPOplans.7 Many more Californians with health coveragefall under the jurisdiction of DMHC than CDI, asshown in Table 1. Long-term care is covered by Medicare Part C. The implementing regulations for Executive Order at 41 CFR 60-1.3 have consistently defined a government contract as any agreement or agreement modification between any contracting agency and any person for the purchase, sale or use of personal property or nonpersonal services. 0000015627 00000 n Press Release from the California Office of the Attorney General, SB 977, at 1190.25(a). Under 45 CFR 146.145(a), a group health plan means an employee welfare benefit plan to the extent that the plan provides medical care (including items and services paid for as medical care) to employees (including both current and former employees) or their dependents (as defined under the terms of the plan) directly or through insurance, reimbursement, or otherwise. Non-Federal governmental plans can operate as self-funded plans, purchase a fully insured group insurance product, or consist of a mixture of self-funded and fully insured options. 0000006386 00000 n 0000002187 00000 n #block-googletagmanagerfooter .field { padding-bottom:0 !important; } Nonetheless, OFCCP has not conceded jurisdiction over healthcare providers that participate in TRICARE and FEHBP networks. No, an insurance company that supplies workers compensation insurance to a federal contractor does not need to meet the requirements of Executive Order 11246; however, if such insurance company has a separate covered federal contract or subcontract other than providing worker compensation insurance, they may be subjected to the requirements of Executive Order 11246. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. 6-4-107(1). Which of the following is NOT a primary objective of insurance regulation? Although not discussed in this Article, federal antitrust law also forbids agreements that restrain trade, including, for example, price-fixing conspiracies among competitors, under Sherman Act Section 1. Further, it is unclear what conduct would rise to the level of a prohibited abuse. How long must a policy be in force before an insurer is prohibited from denying claims based on misstatements made on the health policy application? and Dennie Zastrow, Esq., Troutman Pepper Hamilton Sanders, LLP, Philadelphia, PA Part 60-250.5(a) and Part 60-300.5(a), and 41 C.F.R. Some examples of non-Federal governmental plans are plans that are sponsored by states, counties, school districts, and municipalities. In addition to inserting language virtually identical to the Sherman Act Section 2s monopolization, attempt to monopolize and conspiracy to monopolize prohibition,4 the pending proposed legislation seeks to add a vague prohibition of firms with a dominant position abus[ing] that dominant position.5 Generally, whether a deal is reviewed by the FTC or DOJ depends on the industry and the agencys history of investigations in that industry. 0000012163 00000 n While Proposition 209 is enforceable in California, it does not affect the application of Executive Order 11246. Further, a hospital or health care provider may have other contracts that provide a basis for coverage under the laws enforced by OFCCP. We use cookies on our website. ol{list-style-type: decimal;} Official websites use .govA For guidance on this topic, please consult OFCCPs FAQs on the Single Entity Test at https://www.dol.gov/agencies/ofccp/faqs/single-entity-test. She represents clients in the healthcare industry on a full range of antitrust matters, including provider affiliations and acquisitions, contract negotiations between health systems and payors, litigation against competitors, and advocacy before federal and state enforcement agencies.
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