which entity has jurisdiction over health care coverage providers

62 0 obj << /Linearized 1 /O 64 /H [ 1401 579 ] /L 114966 /E 50989 /N 8 /T 113608 >> endobj xref 62 48 0000000016 00000 n 0000017659 00000 n For covered insurance contracts, does OFCCP use the insurance premium or the face value of the policy to determine whether a federal contractor is required to develop and maintain an Executive Order 11246 affirmative action plan (AAP)? The amendments proposed to the Donnelly Act, if enacted, would dramatically expand the reach of New Yorks state antitrust laws and the ability of the attorney general to pursue claims under state law that it previously was only able to bring under federal law. 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. In addition to the premerger notification provision, SB 977 also targeted conduct by healthcare systems. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. Is a health care provider covered under laws enforced by OFCCP because of reimbursements for services to federal employees, retirees, or their dependents from an insurance carrier that participates in the federal Employee Health Benefits Program (FEHB)? Generally speaking, once it has been determined that a business or organization is subject to the equal employment opportunity requirements enforced by OFCCP, all of the businesss or organizations establishments or facilities will be subject to the same regulatory requirements, regardless of where the federal contract is to be performed. These three programs enforced by the Office of Federal Contract Compliance Programs (OFCCP) require equal employment opportunity by government contractors. All of these statements concerning Medicare are true EXCEPT. OFCCP will use the insurance premium to determine if the covered insurance contract meets the $50,000 threshold requirement necessary to obligate the federal contractor to develop and maintain an Executive Order 11246 AAP, not the face value of the policy. lock .manual-search-block #edit-actions--2 {order:2;} 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. How the proposed transaction affects competition. States and CMS have worked closely to ensure compliance with the health insurance accountability and consumer protections in federal law. As a reinsurer for the Federal Employees Group Life Insurance (FEGLI) program, are we a federal government subcontractor? Although specifics regarding the content of the notice were not provided in SB 977, the bill did state that the notice should contain information sufficient for the attorney general to assess the nature of the transaction and whether it will lead to clinical integration or an increase or maintenance of access to underserved populations.23 Once the notice was received, the attorney general would have 60 days to consent to the transaction, grant a waiver, or issue a request for additional information from the parties. RCW 19.390.080. Californias proposed bill recently died in the legislature, but a new or similar version is likely to be introduced next year. The purpose of the HSR Act is to allow federal authorities an opportunity to review, in advance of closing, transactions exceeding a certain size in order to determine whether they might adversely affect competition. Barbara Sicalidesis a Partner in the Business Litigation practice group at Troutman Pepper. 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. She can be reached [email protected]. 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. All rights reserved. An official website of the United States government 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. Is CMS a regulatory agency? %PDF-1.4 % P.A. You can decide how often to receive updates. The Scheduling Moratorium for VAHBP Providers only applies to providers of health care and does not extend to contractors that hold a separate, independent non-health-care-related contract. To learn more about how we use cookies and how to change your cookies settings if you do not want cookies on your computer, please see our updated Privacy Statement. You may wish to consult the elaws Advisor if you have additional questions about coverage. .usa-footer .grid-container {padding-left: 30px!important;} .gov 0000002414 00000 n 0000025299 00000 n With respect to Washington, since January 1, 2020, provider transactions that constitute a material change must be reported to the state attorney general no less than 60 days prior to consummation.11 Under the statute, a material change includes an acquisition, merger, or contracting affiliation. 2023 Brouse McDowell. 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. 0000015627 00000 n 0000035742 00000 n Secure .gov websites use HTTPSA Which entity has jurisdiction over health care coverage providers? and Dennie Zastrow, Esq., Troutman Pepper Hamilton Sanders, LLP, Philadelphia, PA Since the effective date of a transaction can have a myriad of implications (financing, tax, contractual, regulatory, etc. The new threshold applies to contracts entered on or after December 1, 2003. .gov 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. Insurer What type of license is required for an individual who charges a fee to review an insured's existing life insurance policy? Sign up to get the latest information about your choice of CMS topics. 1. For example, Connecticut and Washington enacted and California has proposed legislation requiring premerger notification to their respective state attorney general offices of certain healthcare-related deals before consummation. 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. Executive Order 11246, as amended (Executive Order) implementing regulations at 41 CFR 60-1.40(a) and 41 CFR 60-2.1(b) state, in relevant part, that any nonconstruction (Supply and Service) contractor that serves as a depository of government funds in any amount or a financial institution which is an issuing and paying agent for U.S. saving bonds and saving notes in any amount must develop an affirmative action program. 18116. An Act Concerning Notice of Acquisitions, Joint Ventures, Affiliations of Group Medical Practices and Hospital Admissions, Medical Foundations, and Certificates of Need, P.A. Department of Insurance: How is an agent's first year commission calculated for a replacement long-term policy? The ARB determined that the reimbursement agreement did not provide a basis for coverage of the hospital under the laws enforced by OFCCP. Dennie Zastrow is an Associate in the Business Litigation practice group at Troutman Pepper. The Section 503 regulations 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." You can decide how often to receive updates. 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. 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. Potential covered contracts or subcontracts may include contracts related to Medicare Advantage (Part C) or Part D programs. The site is secure. Moreover, if this Blog in any way seems to contradict advice of counsel, counsel's opinion should control over anything written herein. 0000001980 00000 n Are Federal Reserve Banks subject to the affirmative action and equal employment opportunity laws OFCCP enforces? 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). 1-888-4LA-CARE (1-888-452-2273)Provider Information. Notwithstanding any other provision of law to the contrary, and except as provided herein, any person or other entity which provides coverage in this state for medical, surgical, chiropractic, physical therapy, speech pathology, audiology, professional mental health, dental, hospital, or optometric expenses, whether such coverage is by direct The HSR Act thresholds are adjusted annually and transactions and for which no exemptions apply must file a notification with the antitrust agencies and wait 30 days after making this submission before closing. 6-4-107(1). Holds a single federal contract, subcontract, or federally assisted construction contract in excess of $10,000.00; Has federal contract or subcontracts that combined total in excess of $10,000.00 in any 12month period; or. It is not intended as a form of, or as a substitute for legal advice. If a state informs CMS that it does not have authority to enforce one or more of the provisions of the Affordable Care Act, and the state has not entered into a collaborative arrangement, CMS has the responsibility to directly enforce the relevant provisions in the state with respect to health insurance issuers in the group and individual markets. She can be reached at [email protected]. 0000022775 00000 n The Affordable Care Act has given Americans new rights and benefits, by helping more children get health coverage, ending lifetime and most annual limits on care, allowing young adults under 26 to stay on their parents' health insurance, and giving patients access to recommended preventive services without cost. 0000027421 00000 n .dol-alert-status-error .alert-status-container {display:inline;font-size:1.4em;color:#e31c3d;} No attorney client relationship is created or implied by this Blog. 0000006364 00000 n Per SB 977, substantial market power can be shown by either (1) the conduct having a substantial anticompetitive effect, or (2) the health care system having substantial market share in one or more markets (with a system presumed to have substantial market power if it has greater than a 60% share). -Long-term care is covered by Medicare Part C. -Hospice is covered by Medicare Part A. Health care system consolidation: Attorney General approval and enforcement, California Senate Bill 977 (2020). 18. Is my company covered by the Scheduling Moratorium for Veterans Affairs Health Benefits Program (VAHBP) Providers? c^J\o$GP%O4KI/7u51 d .bv Gq KA7P0:Bb:l8!'rY)%n&ecPA\Ma!1Wh%HiQ#dIs|?#Cy@ ,t].mTj 4Z4F tJ 'E4ijO)- qv,x ` ^~S.z7s]X',i,F`+'*ms/(:~G/*)3=@D$v.bLh`CEd-hl2c&QicBIRFj!/lyTTb9%1k+~K@PAnb means youve safely connected to the .gov website. State Flexibility Cycle I and II Grants will provide States with the opportunity to ensure their laws, regulations, and procedures are in line with Federal requirements, and enhance the States ability to effectively regulate their respective health insurance markets through innovative measures that support the pre-selected market reforms and consumer protections under Part A of Title XXVII of the Public Health Service (PHS Act). This definition includes any reinsurance agreement related to FEGLI. This deal analysis should include talking to business personnel, reviewing relevant documents, and potentially, analyzing patient draw data. The same holds true under Vietnam Era Veterans Readjustment Assistance Act of 1974, as amended, 38 U.S.C. Yes. For example, a hospital may be a covered contractor as a result of a contract with the Department of Veterans Affairs or the Department of Defense requiring the provision of medical services to active or retired military personnel. 0000001958 00000 n Based on the difference between the new and original policy annual premiums: Before an insurer is allowed to test an individual for HIV, what must be completed . website belongs to an official government organization in the United States. This election was authorized under section 2721(b)(2) of the PHS Act, which is now designated as section 2722(a)(2) of the PHS Act (42 USC 300gg-21(a)(2)). Healthcare providers are responsible for developing ____ ____ and policies and procedures regarding privacy in their practices. Colo. Rev. Further, a hospital or health care provider may have other contracts that provide a basis for coverage under the laws enforced by OFCCP. Health Care Market Participants, RCW 19.390, et seq.. 0000013829 00000 n Select the appropriate response The proposed statute defines clinical integration as a reduction in costs to the benefit of consumer care and outcomes or an increase in the quality of care.. The information in this section will be of interest to state and local governmental employers that provide self-funded group health plan coverage to their employees, administrators of those group health plans, and employees and dependents who are enrolled, or may enroll, in those plans. As part of its contract with the plan and typically required by state law, the in-network provider agrees not to charge the plan or enrollee more than the negotiated rate. 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. . The term "nonpersonal services" as used in this section includes fund depository. For example, the FTC typically investigates transactions involving healthcare providers, whereas the DOJ reviews insurance-related deals. . LCDs only have jurisdiction . The parties settled prior to trial with CHI Franciscan agreeing to have separate payor contracting for primary care and orthopedic services and to pay $2.5 million to the state. 0000002545 00000 n 0000016504 00000 n An in-network provider is a physician, hospital, or other health care provider with whom a health plan has negotiated a payment rate. Long-term care is covered by Medicare Part C. In the past, the U.S. Department of Labors Office of Federal Contract Compliance Programs (OFCCP) has aggressively argued that health care providers that participate in one of three federal health care programs Medicare, TRICARE, and the Federal Employee Health Benefits Program are federal subcontractors. In addition to identifying the parties, the notice must include the locations where healthcare services are provided by each party, the anticipated effective date, and a brief description of the nature and purpose of the material change.14 Washingtons attorney general can also request additional information (including documents, interrogatory responses, and oral testimony) within 30 days of the notice being submitted.15 Any party that fails to submit the requisite notice faces penalties of up to $200 per day.16, Californias proposed SB 977 would have required healthcare systems, private equity firms, and hedge funds to provide notice to and receive approval from the states attorney general before closing acquisitions or changes of control with other healthcare facilities and providers.17 The proposed bill covered a wide range of healthcare affiliations, including: (1) the direct or indirect purchases through leases, transfers, exchanges, options to acquire assets, or creation of a joint venture by a healthcare system, private equity group, or hedge fund of a material amount of the assets of a healthcare facility or provider; or (2) any agreement, association, partnership, joint venture, or other arrangement that results in a change of governance or control at a provider or facility by a healthcare system.18 The legislation would have expanded the existing notification requirements, which apply only to transactions with nonprofit health providers.19 The California attorney general announced that the legislation was needed to combat anticompetitive behavior in the healthcare sector, which he claimed is a growing concern and responsible for higher rates and decreased quality of care in California.20 For your additional information, there is an interactive electronic tool called the Federal Contract Compliance Advisor, also referred to as elaws Advisor, to assist federal contractors and subcontractors in understanding basic coverage and the requirements for compliance with the laws administered by OFCCP. 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 .

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