which entity has jurisdiction over health care coverage providers

OFCCP v. Safeco Insurance Co. of America, Secretary of Labors Decision, July 31, 1984. Generally speaking, any business or organization that: Yes, if the contracts meet the threshold for coverage. 0000008002 00000 n 0000009656 00000 n Health care system consolidation: Attorney General approval and enforcement, California Senate Bill 977 (2020). which entity has jurisdiction over health care coverage providers 131E-176 (13) that has an electronic health Covered Entities for purposes of HIPAA include health care providers who submit claims using electronic "standard transactions" as well as health plans and health care clearinghouses. The contents of this document do not have the force and effect of law and are not meant to bind the public in any way. You may wish to consult the elaws Advisor if you have additional questions about coverage. 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. The new threshold applies to contracts entered on or after December 1, 2003. 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). 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. 0000015627 00000 n -Medicare is primarily funded by Federal payroll and self-employment taxes. 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. .gov SB 977, at 1190.25(d). 0000011315 00000 n #block-googletagmanagerheader .field { padding-bottom:0 !important; } 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. Perhaps equally concerning, the proposed amendments appear to permit criminal penalties for violations of the abuse of dominance prohibition.35 This is puzzling given that federal law technically provides for criminal penalties for monopolization claims, but as a matter of policy, the Department of Justice Antitrust Division does not seek criminal penalties for monopolizing conduct. 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). All of these statements concerning Medicare are true EXCEPT. Whether to voluntarily notify state enforcers. The ARB determined that the reimbursement agreement did not provide a basis for coverage of the hospital under the laws enforced by OFCCP. Likewise, a teaching hospital doing research for a university that has a contract with the federal government may be a covered federal contractor. 0000002523 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 . Therefore, if you serve as a depository for federal funds of $50,000 or more, or have an agreement valued at $50,000 or more to be an issuing and paying agent for savings bonds and notes, you would be obligated to develop and maintain a Section 503 AAP. 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. .manual-search-block #edit-actions--2 {order:2;} 15 U.S.C. The term "nonpersonal services" as used in this section includes fund depository. 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. As such, these entities may qualify for these two exceptions to OFCCP coverage for specific types of health care providers. What is required after a life agent sells an insurance policy to an applicant without being appointed by the insurer? OFCCP uses VAHBP providers as an umbrella term to encompass health care providers that contract with the U.S. Department of Veterans Affairs, including those in Veterans Affairs Community Care Networks, as well as Veterans Care Agreements created pursuant to 2018 VA MISSION Act. Non-Federal governmental plans are not regulated the same way as insurance companies or private employer health plans. Covered entities taking reasonable steps to limit use or disclosure of PHI . https:// Which entity has jurisdiction over health care coverage providers? SB 977 required the California attorney general to reject a transaction if the parties failed to show that it will result in a substantial likelihood of clinical integration, a substantial likelihood of increasing or maintaining the availability and access of services to an underserved population, or both.21 Even if the parties demonstrated clinical integration and increased access, the legislation gave the attorney general the discretion to reject a transaction if there was a substantial likelihood that the transaction would lead to anticompetitive effects, such as increased prices, diminished quality or access, and reduced choice, that outweigh any benefits of a substantial likelihood of clinical integration or an increase or maintenance of services to an underserved population. What is reinsurance example? 0000007980 00000 n Instead, the Antitrust Division typically seeks criminal penalties only for agreements between or among competitors to fix prices or allocate customers or markets. Which type of jurisdiction requires an insurer to have its rates accepted by the Insurance Department prior to using them? Likewise, a teaching hospital doing research for a university that has a contract with the federal government may be covered. 0000004716 00000 n Is a hospital or other health care provider covered under the laws enforced by OFCCP as a result of the reimbursements it receives for medical care and services provided to Medicare or Medicaid patients? This article first describes the legislation in Connecticut, Washington, California, Colorado and New York in more detail and then offers guidance for those entities considering entering into healthcare-related deals. Megan Morleyis a Senior Attorney in the Business Litigation practice group at Troutman Pepper. 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. She can be reached atmegan.morley@troutman.com. Healthcare providers are responsible for developing ____ ____ and policies and procedures regarding privacy in their practices. 0000011859 00000 n {{currentYear}} American Bar Association, all rights reserved. Further, a hospital or health care provider may have other contracts that provide a basis for coverage under the laws enforced by OFCCP. Washington, DC 202101-866-4-USA-DOL1-866-487-2365www.dol.gov, Office of Federal Contract Compliance Programs, Office of Administrative Law Judges OFCCP Collection, Significant Guidance Documents (formerly "Guidance Documents"), Functional Affirmative Action Programs (FAAP), Notification of Construction Contract Award Portal, Opening Doors of Opportunity for All Workers Poster. 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. 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. lock 0000017659 00000 n 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. To do so, CMS will notify issuers in the state that they must submit policy forms to CMS for review. 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. Federal government websites often end in .gov or .mil. trailer << /Size 110 /Info 60 0 R /Root 63 0 R /Prev 113598 /ID[<316761acfb838f940b729f6e746b7375><0433f655088ef2546be3616a7ff69e33>] >> startxref 0 %%EOF 63 0 obj << /Type /Catalog /Pages 59 0 R /Metadata 61 0 R /PageLabels 58 0 R >> endobj 108 0 obj << /S 360 /L 533 /Filter /FlateDecode /Length 109 0 R >> stream No. Is an insurance company that supplies workers compensation insurance to a federal contractor subject to the requirements of Executive Order 11246? 0000014297 00000 n RCW 19.390.040. Proposition 209 amended Californias constitution to prohibit the state from discriminating against or granting preferential treatment to any individual or group on the basis of race, sex, color, ethnicity, or national origin in the operation of public employment, public education or public contracting. According to the California Insurance Code, what is the maximum penalty per violation for anyone who unwillfully commits an unfair method of competition? Before sharing sensitive information, make sure youre on a federal government site. 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. Which entity has jurisdiction over health care coverage providers? No, Federal Reserve Banks are not subject to OFCCPs equal employment opportunity and affirmative action laws because they are federal entities and not federal contractors. OFCCPs policy is that the receipt of reimbursements from a health insurance carrier that provides a health benefits plan under the FEHB Program, for the medical services provided to federal employees or their dependents, will not provide a basis for coverage of the hospital or other health care provider under the laws enforced by OFCCP. 0000035664 00000 n 0000002187 00000 n California Senate Bill 977 (SB 977), proposed earlier this year, required written notification to and the consent of the states attorney general before consummation for most healthcare affiliations or change of control transactions.2 Under SB 977, the attorney general would be required to deny consent for transactions that would not lead to (a) clinical integration or (b) the increase or maintenance of access to healthcare in underserved populations. Employment-related group health plans may be either "insured" (purchasing insurance from an issuer in the group market) or "self-funded." For questions and concerns regarding non-Federal governmental plans, please e-mail NonFed@cms.hhs.gov. If your entity is not subject to affirmative action requirements, make sure you dont inadvertently agree to comply in any contract you may have with a federal contractor. In addition, some businesses or organizations that do not independently hold Government contracts/subcontracts may still be covered under the laws enforced by OFCCP if they are considered a "single entity" with a related business or organization that holds such contracts. 0000022775 00000 n Prior to enactment of the Affordable Care Act, sponsors of self-funded, non-Federal governmental plans were permitted to elect to exempt those plans from, or opt out of, certain provisions of the Public Health Service (PHS) Act. 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. Some examples of non-Federal governmental plans are plans that are sponsored by states, counties, school districts, and municipalities. Sign up to get the latest information about your choice of CMS topics. She can be reached at megan.morley@troutman.com 6-4-107(3), which provided that the attorney general shall not challenge any merger or acquisition under the provisions of this section which has been reviewed by any federal department, agency, or commission under section 7A of the federal Clayton Act and for which all applicable waiting periods have expired or have been terminated without a challenge to such merger or acquisition by that department, agency, or commission. The Act took effect on August 5, 2020 (90 days after final adjournment of the general assembly). She can be reached at barbara.sicalides@troutman.com. My company has contracts with the U.S. Department of Veterans Affairs to provide non-medical services. 0000036317 00000 n 2. Some states lack the authority, the ability to enforce these provisions, or both. Overseeing the insurance industry and protecting the state's insurance consumers is the responsibility of the California Department of Insurance (CDI). 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. 0000018799 00000 n How do I know if my health care entity falls under the jurisdiction of OFCCP? The .gov means its official. As a result of the enactment of the Federal Employees' Retirement System Act of 1986 (FERSA), EBSA has fiduciary and auditing oversight of the Thrift Savings Plan that was established by this Act. The State Flexibility Cycle I Grant program will provide $8.6 million in grant funds and the State Flexibility Cycle II Grant program will provide $19.6 million in grant funds to assist States in implementing and/or planning the following provisions of Part A of Title XXVII of the PHS Act: Sign up to get the latest information about your choice of CMS topics. 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. 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. Under Section 503 of the Rehabilitation Act of 1973, as amended (Section 503), a government contractor with 50 or more employees and a Government contract of $50,000 or more must develop a Section 503 AAP. /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. Are we subject to the equal employment laws enforced by OFCCP? Secure .gov websites use HTTPSA or 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. This blog is intended to provide information generally and to identify general legal requirements. 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 atbarbara.sicalides@troutman.com. ) If a contractor performs work outside of the United States, is it subject to OFCCPs jurisdiction under the authorities it enforces? Is CMS a regulatory agency? Pete is a life agent who has misappropriated fiduciary funds to his own use. Californias proposed bill recently died in the legislature, but a new or similar version is likely to be introduced next year. Select the appropriate response The same holds true under Vietnam Era Veterans Readjustment Assistance Act of 1974, as amended, 38 U.S.C. Health Care Market Participants, RCW 19.390, et seq.. 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. There are circumstances where explaining the benefits of and reasons for a transaction before an agency formulates its independent view can streamline and shorten the timeline of a likely inevitable investigation as well as providing greater certainty to the parties. 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. LCDs only have jurisdiction . 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. Brouse McDowell, A Legal Professional Association. 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. Although the extent of the states future role in antitrust and healthcare affiliations, and, whether a change in the federal administration will affect that role, remains unclear, there is no doubt that a number of states have added or are considering adding to their available enforcement tools, giving them more opportunities to intervene. For example, Washingtons reporting statute requires that the notice be submitted 60 days prior to close, which is 30 days longer than the federal HSR waiting period. 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. It is not intended as a form of, or as a substitute for legal advice. This deal analysis should include talking to business personnel, reviewing relevant documents, and potentially, analyzing patient draw data. 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). 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. However, it is reasonable to assume that proof of a dominant position would not require proof of market power because conduct by firms with market power is already addressed by the monopolization section of the amendments. Therefore, federal contractors in the State of California must comply with the Executive Order and its affirmative action requirements. div#block-eoguidanceviewheader .dol-alerts p {padding: 0;margin: 0;} 2023 Brouse McDowell. 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. Regardless of how small a deal is, the parties need to understand the competitive implications. Texas 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)). We use cookies on our website. This definition thus explicitly includes agreements for insurance, which would cover FEGLI contracts. Insurer What type of license is required for an individual who charges a fee to review an insured's existing life insurance policy? 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. 0000012185 00000 n Thus, the agreement to serve as a federal funds depository is a "government contract.". When selling a long term care insurance rider to an applicant, a life agent must take into consideration all of these factors, EXCEPT. For a list of provisions that are applicable to non-Federal governmental plans both grandfathered and non-grandfathered please see the checklists available at the Other Resources link on this page. Department of Insurance: How is an agent's first year commission calculated for a replacement long-term policy? Therefore, even small transactions, which might have gone unnoticed by federal enforcers, could be subject to antitrust scrutiny by state enforcement agencies. 0000001958 00000 n 0000001401 00000 n For additional qualifications and requirements, please visit the U.S. Department of Labor Office of Federal Contract Compliance Programs website, at https://www.dol.gov/ofccp/ and ask your attorney to ensure your health care entity is in compliance. In addition, business associates of covered entities must follow parts of the HIPAA regulations. Oklahoma Daniel Anziksais a Partner in the Business Litigation practice group at Troutman Pepper. 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. He can be reached atdaniel.anziska@troutman.com. 0000048160 00000 n 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. Similarly, consumers will continue to contact the state for inquiries and complaints relating to the health insurance market reform requirements. CMS has responsibility for enforcing these requirements in a state that is not enforcing the health insurance market reforms either through a collaborative arrangement with the state or by direct enforcement to ensure all residents of the state receive the protections of the Affordable Care Act. 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. Federal government work is performed in some other division in another state. CMS will work cooperatively with the state to address any concerns. An entity to which individuals and small businesses can have access to affordable health coverage According to the California Insurance Code, who is responsible for submitting a life agent's appointment? He represents clients in antitrust class action, consumer protection, and breach of contract litigations in federal and state court. Importantly, however, even if a merger is not reportable under the HSR Act, the federal antitrust regulators still can become aware of (via customer complaints, news reports, trade publications, and the like), investigate, and challenge the transaction. 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. Although Washington has not challenged a healthcare transaction since the implementation of the reporting requirement earlier this year, the state has done so in the past. A. Indeed, under Connecticuts statute, a hospital acquiring a group practice of two physicians must be reported. 1. 1-888-4LA-CARE (1-888-452-2273)Provider Information. Accordingly, healthcare providers and counsel to such providers should consider the following: As states are taking a more active role in antitrust investigations and enforcement, it is important for healthcare entities, investors in the healthcare space, and their counsel to keep an eye on this trend and how it impacts their deals and conduct. An official website of the United States government. The Office for Civil Rights (OCR) enforces Section 1557 of the Affordable Care Act (Section 1557), which prohibits discrimination on the basis of race, color, national origin, age, disability, or sex (including pregnancy, sexual orientation, gender identity, and sex characteristics), in covered health programs or activities.

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