Which of the following is NOT a primary objective of insurance regulation? 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 . Official websites use .govA div#block-eoguidanceviewheader .dol-alerts p {padding: 0;margin: 0;} CMS will form a collaborative arrangement with any state that is willing and able to perform regulatory functions but lacks enforcement authority. Washington State Office of the Attorney General Past Cases (last visited Nov. 19, 2020), https://www.atg.wa.gov/past-cases. State Enforcers Expanding Premerger and Antitrust Jurisdiction Over Department of Insurance HiCap MRMIP California life and health guarantee association Department of Insurance Insurance agents and brokers must make their insurance records available to the commissioner Only during the first month of the year only during the last month of the year Notice of Material Change Form. 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. Wyoming. Nonetheless, OFCCP has not conceded jurisdiction over healthcare providers that participate in TRICARE and FEHBP networks. 0000018480 00000 n .dol-alert-status-error .alert-status-container {display:inline;font-size:1.4em;color:#e31c3d;} 1980). https://www.dol.gov/agencies/ofccp/faqs/single-entity-test, Scheduling Moratorium for VAHBP Providers. 0000024410 00000 n Therefore, federal contractors in the State of California must comply with the Executive Order and its affirmative action requirements. Stat. 15 U.S.C. and Dennie Zastrow, Esq., Troutman Pepper Hamilton Sanders, LLP, Philadelphia, PA 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. Final Exam Flashcards | Chegg.com 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. 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. Which entity has jurisdiction over health care coverage providers? 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. 0000002414 00000 n She can be reached at barbara.sicalides@troutman.com. 0000015627 00000 n Is a financial institution covered by the federal Deposit Insurance Corporation (FDIC) or the National Credit Union Association (NCUA) with deposit insurance subject required to comply with Affirmative Action Program (AAP) obligations under Executive Order 11246, VEVRAA, and Section 503? Hospital, physician, and private equity industry groups, however, opposed the legislation. These three programs enforced by the Office of Federal Contract Compliance Programs (OFCCP) require equal employment opportunity by government contractors. Our business operates as a fund depository, and an issuing and paying agent for U.S. It would make it unlawful under state law: for any person or persons to monopolize, or attempt to monopolize, or combine or conspire with any other person or persons to monopolize any business, trade or commerce or the furnishing of any service in this state.33. 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. 0000001980 00000 n lock 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. The legislation only applies to mergers commenced on or after the applicable effective date of this act.31 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 . .paragraph--type--html-table .ts-cell-content {max-width: 100%;} Generally speaking, any business or organization that: Yes, if the contracts meet the threshold for coverage. 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. 0000035742 00000 n [Your company] shall abide by the equal employment opportunity and affirmative action requirements set forth in 41 C.F.R. 0000027421 00000 n Some examples of non-Federal governmental plans are plans that are sponsored by states, counties, school districts, and municipalities. 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. 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. Dennie Zastrowis an Associate in the Business Litigation practice group at Troutman Pepper. He represents clients in antitrust class action, consumer protection, and breach of contract litigations in federal and state court. He also counsels clients on the HSR Act. He can be reached atdennie.zastrow@troutman.com. In addition to the premerger notification provision, SB 977 also targeted conduct by healthcare systems. This was the subject of ongoing litigation against a Florida hospital, but in 2014, OFCCP dismissed this case and announced a five-year moratorium for affirmative action enforcement. Are Federal Reserve Banks subject to the affirmative action and equal employment opportunity laws OFCCP enforces? However, in 2015, the FAR implemented an inflationary adjustment for VEVRAA, increasing the threshold amount from $100,000 to $150,000. This definition includes any reinsurance agreement related to FEGLI. 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. 0000002545 00000 n 4212 (VEVRAA). SB 977, at 1190.25(d). The South Carolina Lifeand Accident and Health Insurance Guaranty Association(SCLAHIGA) may cover certain direct life insurance policies, accident and health insurance policies, annuity contracts, and contracts supplemental to life, accident, and health insurance policiesand contracts under South Carolina law. 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 2719 - Appeals Process Section 2726 - Parity in Mental Health and Substance Use Disorder Benefits .agency-blurb-container .agency_blurb.background--light { padding: 0; } 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. How is an agent's first year commission calculated for a replacement long-term policy? Balance Billing by Health Care Providers: Assessing Consumer CMS will work cooperatively with the state to address any concerns. Share sensitive information only on official, secure websites. TRICARE OFCCP believes it has jurisdiction over health care providers that participate as TRICARE network providers. .manual-search ul.usa-list li {max-width:100%;} Californias proposed bill put the onus on the parties to show the attorney general how the transaction would lead to clinical integration and increased or maintained access for underserved populations. Covered entities taking reasonable steps to limit use or disclosure of PHI . 0000017052 00000 n 0000017602 00000 n Pursuant to this authority, CMS may investigate and implement corrective action or impose civil monetary penalties for any non-Federal governmental plan that fails to comply with applicable PHS Act requirements. Yes. 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. ERISA requires plans to provide participants with plan information including important information . Pete is a life agent who has misappropriated fiduciary funds to his own use. 0000035664 00000 n 0000045440 00000 n OFCCP Issues Final Rule on TRICARE Participation and Covered Health 20-115 - Department jurisdiction over certain health care providers 1-888-4LA-CARE (1-888-452-2273)Provider Information. An official website of the United States government. 1. 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. https:// 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). The site is secure. ( or 0000014297 00000 n However, the requirements of Executive Order 11246 apply only to the agency, instrumentality or subdivision of the State or local government that participates in work on or under the Government contract or subcontract. An agency within the U.S. Department of Labor, 200 Constitution Ave NW 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 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 41 CFR 60-741.2(i). Watch out for this language! Federal government work is performed in some other division in another state. 15 U.S.C. 0000012185 00000 n He can be reached at daniel.anziska@troutman.com. ( A. Long-term care is covered by Medicare Part C. Theres little concrete guidance on this complex issue, but heres what we do know about common areas of concern: 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. 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. .h1 {font-family:'Merriweather';font-weight:700;} 42 U.S.C. 0000011859 00000 n 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. Federal Reserve Bank of Boston v. Commissioner of Corporations and Taxation of the Commonwealth of Massachusetts, 499 F.2d 60 (1st Cir. 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. {{currentYear}} American Bar Association, all rights reserved. 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. .cd-main-content p, blockquote {margin-bottom:1em;} .gov Free Flashcards about Financial Test - StudyStack 0000002523 00000 n What is the purpose of the Pre-Existing Condition Insurance Plan (PCIP)? The term "nonpersonal services" includes, but is not limited to, the following services: This definition thus explicitly includes agreements for insurance. The Employee Retirement Income Security Act of 1974 (ERISA) is a federal law that sets minimum standards for most voluntarily established retirement and health plans in private industry to provide protection for individuals in these plans. Texas Before sharing sensitive information, make sure youre on a federal government site. Pre-ERISA Legislation Initially, the IRS was the primary regulator of private pension plans. On July 2, 2020, the Office of Federal Contract Compliance Programs (OFCCP) issued a final rule1 amending its regulations to confirm the agency lacks jurisdiction over health care providers whose sole government contract is based on the providers' participation in TRICARE, ending 13 years of controversy and uncertainty over this issue.BackgroundOFCCP is the agency within the U.S. What entities are subject to the requirements of Executive Order 11246? necessary rule applies to. Although only a few states currently require certain transactions be notified, this list will likely continue to grow. @media (max-width: 992px){.usa-js-mobile-nav--active, .usa-mobile_nav-active {overflow: auto!important;}} As a reinsurer for the Federal Employees Group Life Insurance (FEGLI) program, are we a federal government subcontractor? 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. Brouse McDowell, A Legal Professional Association. Which of the following actions is NOT allowed by Health Insurance Counseling and Advocacy Program (HiCAP) counselors? Even if states do not have premerger notification requirements, they still can challenge transactions. Liberty Mutual Insurance Co. v. Friedman, 639 F. 2d 164 (4th Cir. 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. Therefore, even small transactions, which might have gone unnoticed by federal enforcers, could be subject to antitrust scrutiny by state enforcement agencies. Likewise, a teaching hospital doing research for a university that has a contract with the federal government may be a covered federal contractor. At any time, a state that is willing and able may assume enforcement authority of the Affordable Care Act market reform standards. If a request for additional information was issued, then the attorney general had 45 days from substantial compliance with the request to grant or deny approval of the transaction. 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. 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. All of these statements concerning Medicare are true EXCEPT. 41 CFR 60-741.2(i)(4). /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. He can be reached at dennie.zastrow@troutman.com. 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. 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). Despite Congressional Action OFCCP Signals Intent to Continue 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. 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 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. 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. 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. 0000001308 00000 n What is Medi? Such advice should always come from in-house or retained counsel. Which entity has jurisdiction over health care coverage providers? Heres how you know. 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? 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. RCW 19.390.040. This definition thus explicitly includes agreements for insurance, which would cover FEGLI contracts. You may wish to consult the elaws Advisor if you have additional questions about coverage. An entity to which individuals and small businesses can have access to affordable health coverage. This antitrust safety zone will not apply if that hospital is less than 5 years old. Statements of Antitrust Enforcement Policy in Health Care. What is Pete guilty of? 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. Colo. Rev. Select the appropriate response Department of Insurance: How is an agent's first year commission calculated for a replacement long-term policy? 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. Currently, the Donnelly Act prohibits only anticompetitive activities from agreements or conspiracies, like federal laws Section 1 of the Sherman Act. ol{list-style-type: decimal;} According to PPACA, what is a health benefits exchange? Further, it is unclear what conduct would rise to the level of a prohibited abuse. Megan Morley is a Senior Attorney in the Business Litigation practice group at Troutman Pepper. 0000011315 00000 n 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 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. 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 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. He also counsels clients on the HSR Act. According to the California Insurance Code, how is the word "may" interpreted? 14-168(d). 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
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