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. This document is intended only to provide clarity to the public regarding existing requirements under the law or agency policies. 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. -Doctors' services are covered by Medicare Part B. Your Rights Under HIPAA | HHS.gov According to the California Insurance Code, how is the word "may" interpreted? All contractors and subcontractors who hold a federal or federally-assisted construction contract in excess of $10,000 will be subject to regulatory requirements under one or more of the laws enforced by OFCCP depending upon the amount of the contract. 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. div#block-eoguidanceviewheader .dol-alerts p {padding: 0;margin: 0;} In addition, pursuant to Section 7 of the Clayton Act, the federal antitrust laws prohibit acquisitions that may substantially lessen competition or tend to create a monopoly. ) 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. 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. 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. ERISA. As such, these entities may qualify for these two exceptions to OFCCP coverage for specific types of health care providers. Which entity has jurisdiction over health care coverage providers? 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. A Member of TAGLaw a Worldwide Alliance of Independent Law Firms. .usa-footer .container {max-width:1440px!important;} 0000001308 00000 n 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. Even if the parties carry their burden of demonstrating such benefits, the attorney general would still have the discretion to deny his or her consent if he or she finds there is a substantial likelihood of anticompetitive effects that outweigh the benefits of anticipated clinical integration and/or increased services to an underserved population. What is an "insurance broker" according to California Insurance Code? 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. Which of the following is NOT a primary objective of insurance regulation? 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. In Colorado, legislators recently expanded the states ability to challenge all mergers, not only healthcare transactions, by repealing a statutory provision that curbed its enforcement power.3 Although Colorado did not create a system for premerger notification, it did give the Colorado attorney general the ability to challenge transactions regardless of whether the federal antitrust authorities object to those deals. Health care system consolidation: Attorney General approval and enforcement, California Senate Bill 977 (2020). 1-888-4LA-CARE (1-888-452-2273)Provider Information. . 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? 0000001980 00000 n 4212 (VEVRAA). Similarly, consumers will continue to contact the state for inquiries and complaints relating to the health insurance market reform requirements. which entity has jurisdiction over health care coverage providers HHS Argues Covered Entities Cannot Intervene in 340B Drug Pricing Case. 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. RCW 19.390.040. Many of the market reforms and consumer protections in Part A of title XXVII of the PHS Act are new provisions that became effective for plan years beginning in 2014. This deal analysis should include talking to business personnel, reviewing relevant documents, and potentially, analyzing patient draw data. RCW 19.390.080. 0000016173 00000 n He represents clients in antitrust class action, consumer protection, and breach of contract litigations in federal and state court. 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. When selling a long term care insurance rider to an applicant, a life agent must take into consideration all of these factors, EXCEPT. Insurer What type of license is required for an individual who charges a fee to review an insured's existing life insurance policy? Despite Congressional Action OFCCP Signals Intent to Continue 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. Connecticuts legislation, enacted in 2014, requires that certain transactions between physician group practices and hospitals, captive professional entities, medical foundations, or other group practices be reported to the states attorney general.6 Under the law, a group practice can be as small as two physicians operating through the same entity, and transactions that cause a material change to the structure or business of a group practice need to be reported no less than 30 days prior to consummation.7 Transactions constituting a material change are broadly defined and include: (1) merger, consolidation, or other affiliation of a group practice with a hospital, hospital system, or another group practice that results in a practice with eight or more physicians; (2) acquisition of all or substantially all of the assets, stock, or equity interests of a group practice by a hospital, hospital system, or another group practice that results in a practice with eight or more physicians; and (3) employment of all or substantially all of the physicians in a group practice by a hospital, hospital system, or another group practice that results in a practice with eight or more physicians.8 Under the statute, the parties must provide to the attorney general a description of the nature of the proposed relationship and information regarding the physicians, entities, and service locations involved.9 In addition, the statute requires any hospital system or other healthcare provider conducting business in Connecticut that files a premerger notification under the HSR Act to provide written notice of that filing to the Connecticut attorney general.10 Yes. The term nonpersonal services includes, but is not limited to, the following services: utilities, construction, transportation, research, insurance, and fund depository. Megan Morley is a Senior Attorney in the Business Litigation practice group at Troutman Pepper. Based on the difference between the new and original policy annual premiums, The California Insurance Code defines "policy" as a(n). To do so, CMS will notify issuers in the state that they must submit policy forms to CMS for review. December 15, 2020 State Enforcers Expanding Premerger and Antitrust Jurisdiction Over Healthcare Transactions: Guidance for This Growing Trend By Barbara Sicalides, Esq., Daniel Anziska, Esq., Megan Morley, Esq. 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. 0000006386 00000 n P.A. Issuers required to submit form filings to CMS will need to follow instructions posted under Training Resources below. which entity has jurisdiction over health care coverage providers Balance Billing by Health Care Providers: Assessing Consumer 0000025299 00000 n 0000035052 00000 n Title XXVII of the Public Health Service Act (PHS Act) contemplates that states will exercise primary enforcement authority over health insurance issuers in the group and individual markets to ensure compliance with health insurance market reforms. These states can then use the information gathered from these notifications for their investigative and enforcement functions possibly challenging the transactions. What type of license is required for an individual who charges a fee to review an insured's existing life insurance policy? 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. . Therefore, even small transactions, which might have gone unnoticed by federal enforcers, could be subject to antitrust scrutiny by state enforcement agencies. When that happens, CMS will work with the state to ensure an effective transition. 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. History of EBSA and ERISA | U.S. Department of Labor - DOL @media (max-width: 992px){.usa-js-mobile-nav--active, .usa-mobile_nav-active {overflow: auto!important;}} 2023 Brouse McDowell. Which entity has jurisdiction over health care coverage providers? Indeed, under Connecticuts statute, a hospital acquiring a group practice of two physicians must be reported. 0000017052 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). An Act Concerning Notice of Acquisitions, Joint Ventures, Affiliations of Group Medical Practices and Hospital Admissions, Medical Foundations, and Certificates of Need, P.A. 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. For example, the FTC typically investigates transactions involving healthcare providers, whereas the DOJ reviews insurance-related deals. For providers serving rural areas, the attorney general would have the authority to waive these standards.22 By continuing to use this site you consent to our use of cookies in accordance with our, Business Restructuring, Bankruptcy & Commercial Law, Business Reorganization and Restructuring, Commercial Contract Preparation and Disputes, Business Transactions & Corporate Counseling, Commercial Transactions and Property Acquisition, Compliance Counseling and Risk Management, Site Remediation and Brownfield Development, Nurse Practitioners and Registered Nurses, Corporate Governance & Compliance Investigations, Real Estate and Title Insurance Litigation, Tax Controversy, Criminal, White Collar Crimes. 1. 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 site is secure. 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 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. Likewise, a teaching hospital doing research for a university that has a contract with the Federal government may be covered.. If you have any doubts about your entitys status, be sure to ask your Brouse attorney for assistance in evaluating whether you need to comply with affirmative action requirements. The same regulations generally define a government subcontract as any agreement or arrangement between a contractor and any person (in which the parties do not stand in the relationship of an employer and an employee) for the purchase, sale or use of personal property or nonpersonal services which, in whole or in part, is necessary to the performance of any one or more contracts; or under which any portion of the contractors obligation under any one or more contracts is performed, undertaken or assumed. See 41 CFR 60-1.5(a)(3), 60-300.4(a)(3), 60-741.4(a)(3). 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. In 2017, Washington sued CHI Franciscan over two consummated deals with orthopedic providers in Kitsap county. 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. {{currentYear}} American Bar Association, all rights reserved. 0000013829 00000 n 20-115.Department jurisdiction over certain health care providers; exception; examination; disclosure. 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. 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. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. 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. Similarly, under federal antitrust policy, rural hospital transactions would often, if applied, fall within the FTC and DOJ Antitrust Divisions small hospital safety zone criteria: The Agencies will not challenge any merger between two general acute-care hospitals where one of the hospitals (1) has an average of fewer than 100 licensed beds over the three most recent years, and (2) has an average daily inpatient census of fewer than 40 patients over the three most recent years, absent extraordinary circumstances. The new Department of Managed Health Care (DMHC) primarily regulates health maintenance organizations (HMOs), while the California Department of Insurance (CDI) has jurisdiction over traditional health insurance. 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. 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. Chapter 1 - The Business of Medicine Flashcards | Quizlet Share sensitive information only on official, secure websites. -Long-term care is covered by Medicare Part C. -Hospice is covered by Medicare Part A. 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. Health Care Market Participants, RCW 19.390, et seq.. Currently, the Donnelly Act prohibits only anticompetitive activities from agreements or conspiracies, like federal laws Section 1 of the Sherman Act. 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.. 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. This antitrust safety zone will not apply if that hospital is less than 5 years old. Statements of Antitrust Enforcement Policy in Health Care. #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;} .dol-alert-status-error .alert-status-container {display:inline;font-size:1.4em;color:#e31c3d;} 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 Health Insurance Enforcement and Consumer Protections Grants will provide States with the opportunity to ensure their laws, regulations, and procedures are in line with Federal requirements and that States are able to effectively oversee and enforce these provisions. Daniel Anziksa is a Partner in the Business Litigation practice group at Troutman Pepper. https:// 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. Whether California (or another state) enacts legislation requiring state approval of transactions. 15 U.S.C. Is an insurance company that supplies workers compensation insurance to a federal contractor subject to the requirements of Executive Order 11246? 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.
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