which entity has jurisdiction over health care coverage providers

This definition thus explicitly includes agreements for insurance, which would cover FEGLI contracts. 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. Megan Morley is a Senior Attorney in the Business Litigation practice group at Troutman Pepper. He can be reached at daniel.anziska@troutman.com. 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. . A TRICARE provider that holds another covered contract, such as a prime contract or a subcontract apart from the TRICARE provider contract, would still need to comply with OFCCPs requirements. The Health Insurance Enforcement and Consumer Protections Grant program will provide $25.5 million in grant funds to assist States in implementing and/or planning the following provisions of Part A of Title XXVII of the Public Health Service (PHS) Act: The State Flexibility to Stabilize the Market Grant Program, comprised of - (State Flexibility Cycle I and II Grants,) will provide a funding source to enhance the role of States in planning and implementing several of the Federal market reforms and consumer protections. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. 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. The term nonpersonal services includes, but is not limited to, the following services: utilities, construction, transportation, research, insurance, and fund depository. 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. As such, these entities may qualify for these two exceptions to OFCCP coverage for specific types of health care providers. 0000007980 00000 n It is unclear what would constitute a dominant position under the proposed statute. 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. All contractors and subcontractors who hold a federal contract in excess of $10,000 are subject to regulatory requirements under one or more of the laws enforced by OFCCP depending upon the amount of the contract. Some states lack the authority, the ability to enforce these provisions, or both. All rights reserved. Is an insurance company that supplies workers compensation insurance to a federal contractor subject to the requirements of Executive Order 11246? 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. 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. TRICARE OFCCP believes it has jurisdiction over health care providers that participate as TRICARE network providers. CMS will work cooperatively with the state to address any concerns. 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. Daniel Anziksa is a Partner in the Business Litigation practice group at Troutman Pepper. 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. 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. ol{list-style-type: decimal;} 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. 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. Section 2 of the Sherman Act makes it illegal for an entity to monopolize, attempt to monopolize, or conspire to monopolize any market. A. 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. Which of the following is NOT a primary objective of insurance regulation? 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. Generally speaking, any business or organization that: Yes, if the contracts meet the threshold for coverage. or 0000036317 00000 n Is CMS a regulatory agency? 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. 00-234, (January 31, 2003), which involved the question of whether the hospital was covered under the laws enforced by OFCCP by virtue of its agreement with an insurance carrier that had contracted with the U.S. Office of Personnel Management (OPM) to provide federal employees a fee-for-services health benefits insurance policy. Likewise, a teaching hospital doing research for a university that has a contract with the federal government may be a covered federal contractor. 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. The same holds true under Vietnam Era Veterans Readjustment Assistance Act of 1974, as amended, 38 U.S.C. 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. 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 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. 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. The new threshold applies to contracts entered on or after December 1, 2003. 0000008002 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). We use cookies on our website. An Act Concerning Notice of Acquisitions, Joint Ventures, Affiliations of Group Medical Practices and Hospital Admissions, Medical Foundations, and Certificates of Need, P.A. Long-term care is covered by Medicare Part C. @media only screen and (min-width: 0px){.agency-nav-container.nav-is-open {overflow-y: unset!important;}} 18. Compliance Checkup: Affirmative Action: Is your health care entity subject to affirmative action laws. 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. What is reinsurance example? may have jurisdiction over a health care provider receiving Medicare reimbursements if the health care provider also holds a separate covered federal contract or subcontract. 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. 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. How do I know if my health care entity falls under the jurisdiction of OFCCP? 0000002545 00000 n In addition, business associates of covered entities must follow parts of the HIPAA regulations. 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. What is required after a life agent sells an insurance policy to an applicant without being appointed by the insurer? 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? ) Once it has been determined that a contractor or subcontractor is subject to OFCCP jurisdiction, the regulations implementing the civil rights requirements enforced by OFCCP apply to all of the contractors or subcontractors employees who are engaged in onsite construction, including those construction employees who work on a nonfederal or nonfederally assisted construction site. 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. .gov However, in 2015, the FAR implemented an inflationary adjustment for VEVRAA, increasing the threshold amount from $100,000 to $150,000. .paragraph--type--html-table .ts-cell-content {max-width: 100%;} . Specifically, the amendments would add a provision virtually identical to Section 2 of the Sherman Act. Currently, the size-of-transaction threshold is $94 million. 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. An official website of the United States government COVERED CALIFORNIANS How is an agent's first year commission calculated for a replacement long-term policy? While Proposition 209 is enforceable in California, it does not affect the application of Executive Order 11246. Under the federal merger control regime, both the FTC and DOJ Antitrust Division have the authority to investigate and challenge mergers. 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. 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. According to the California Insurance Code, what is the maximum penalty per violation for anyone who unwillfully commits an unfair method of competition? She can be reached at barbara.sicalides@troutman.com. 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. Non-Federal governmental plans are not regulated the same way as insurance companies or private employer health plans. This policy is based on the decision of DOLs Administrative Review Board (ARB) in OFCCP v. Bridgeport Hospital, ARB Case No. 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. 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