0000008002 00000 n PCIP was created by the PPACA for people rejected by private health insurers due to pre-existing conditions, The cost of services charged by the Health Insurance Counseling Advocacy Program (HiCap) is, Any changes in background information that occur after a producer application has been submitted or a license has been issued MUST be reported to the Insurance Commissioner within. Generally speaking, any business or organization that: Yes, if the contracts meet the threshold for coverage. 0000012163 00000 n .manual-search ul.usa-list li {max-width:100%;} 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%;} Secure .gov websites use HTTPSA Question: Are Private Health Insurance Companies Rate Or Return It's time to renew your membership and keep access to free CLE, valuable publications and more. Whether to voluntarily notify state enforcers. 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. 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. 0000024410 00000 n . Currently, the size-of-transaction threshold is $94 million. Region. This policy is based on the decision of DOLs Administrative Review Board (ARB) in OFCCP v. Bridgeport Hospital, ARB Case No. Like the TRICARE Exemption, a health care provider providing services to beneficiaries of a VAHBP that also holds another covered contract outside the scope of VAHBP would still need to comply with all of OFCCPs requirements. .manual-search-block #edit-actions--2 {order:2;} 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. He represents clients in antitrust class action, consumer protection, and breach of contract litigations in federal and state court. In addition to the premerger notification provision, SB 977 also targeted conduct by healthcare systems. 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. Heres how you know. 0000035664 00000 n 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 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. ol{list-style-type: decimal;} 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. 0000025299 00000 n Regardless of how small a deal is, the parties need to understand the competitive implications. History of EBSA and ERISA | U.S. Department of Labor - DOL which entity has jurisdiction over health care coverage providers The following states have notified CMS that they do not have the authority to enforce or are not otherwise enforcing the Affordable Care Act market reform provisions. necessary rule applies to. Have you ever seen a section in a contract that reads something like this? ) 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. 0000011315 00000 n 0000018799 00000 n Each regional MAC. 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. Official websites use .govA If a contractor performs work outside of the United States, is it subject to OFCCPs jurisdiction under the authorities it enforces? 62 0 obj << /Linearized 1 /O 64 /H [ 1401 579 ] /L 114966 /E 50989 /N 8 /T 113608 >> endobj xref 62 48 0000000016 00000 n Before sharing sensitive information, make sure youre on a federal government site. For your additional information, there is an interactive electronic tool called the Federal Contract Compliance Advisor, also referred to as elaws Advisor, to assist federal contractors and subcontractors in understanding basic coverage and the requirements for compliance with the laws administered by OFCCP. Compliance Checkup: Affirmative Action: Is your health care entity 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. Some states lack the authority, the ability to enforce these provisions, or both. 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. website belongs to an official government organization in the United States. According to the California Insurance Code, how is the word "may" interpreted? An official website of the United States government 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. You can decide how often to receive updates. 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. 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. Liberty Mutual Insurance Co. v. Friedman, 639 F. 2d 164 (4th Cir. Which entity has jurisdiction over health care coverage providers? 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. 14-168(c) (2014). My company has contracts with the U.S. Department of Veterans Affairs to provide non-medical services. Notice of Material Change Form. 0000009656 00000 n Is my company covered by the Scheduling Moratorium for Veterans Affairs Health Benefits Program (VAHBP) Providers? 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. Pete is a life agent who has misappropriated fiduciary funds to his own use. 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. An Act Concerning Notice of Acquisitions, Joint Ventures, Affiliations of Group Medical Practices and Hospital Admissions, Medical Foundations, and Certificates of Need, P.A. 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. 0000020745 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 . 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. Recent Changes to the Definition of Sex Discrimination Under Section 1557 of the Patient Protection and Affordable Care Act, Eleventh Circuit Holds that the Government Need Not Prove a Payees Motivation for Accepting a Payment Under the Anti-Kickback Statute, Representations and Warranties Insurance: An Essential Component of Healthcare Mergers and Acquisitions, American Bar Association Chapter 12: test Flashcards | Quizlet 0000014297 00000 n The Affordable Care Act has given Americans new rights and benefits, by helping more children get health coverage, ending lifetime and most annual limits on care, allowing young adults under 26 to stay on their parents' health insurance, and giving patients access to recommended preventive services without cost. -Doctors' services are covered by Medicare Part B. 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. Californias proposed bill recently died in the legislature, but a new or similar version is likely to be introduced next year. The proposed statute defines clinical integration as a reduction in costs to the benefit of consumer care and outcomes or an increase in the quality of care.. The term "nonpersonal services" includes, but is not limited to, the following services: This definition thus explicitly includes agreements for insurance. 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. A representation may be altered or withdrawn, state program that offers health coverage to California residents who are not able to obtain coverage due to pre-existing conditions. CMS will work cooperatively with the state to address any concerns. According to the California Insurance Code, what is the maximum penalty per violation for anyone who unwillfully commits an unfair method of competition? 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. 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. No attorney client relationship is created or implied by this Blog. RCW 19.390.040. Therefore, even small transactions, which might have gone unnoticed by federal enforcers, could be subject to antitrust scrutiny by state enforcement agencies. 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. Megan Morley is a Senior Attorney in the Business Litigation practice group at Troutman Pepper. State Enforcers Expanding Premerger and Antitrust Jurisdiction Over 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. 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? Long-term care is covered by Medicare Part C. Generally speaking, once it has been determined that a business or organization is subject to the equal employment opportunity requirements enforced by OFCCP, all of the businesss or organizations establishments or facilities will be subject to the same regulatory requirements, regardless of where the federal contract is to be performed. When that happens, CMS will work with the state to ensure an effective transition. No. 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. 0000020767 00000 n Moreover, SB 977 not only would have applied to transactions among non-profit healthcare entities but also to acquisitions and affiliations by private equity groups and hedge funds with healthcare investments. However, in 2015, the FAR implemented an inflationary adjustment for VEVRAA, increasing the threshold amount from $100,000 to $150,000. 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. Yes. Those entities involved in healthcare-related deals not only need to understand their obligations and risks under the federal antitrust laws but also how involvement by state enforcers may affect their transactions. 6-4-107(1). Further, except for universities and medical facilities, a state or local government agency, instrumentality, or subdivision that has a government contract is exempt from the requirement to develop and maintain a written affirmative action program. 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. An agency within the U.S. Department of Labor, 200 Constitution Ave NW 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. How long must a policy be in force before an insurer is prohibited from denying claims based on misstatements made on the health policy application? 18. 0000006364 00000 n 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. 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. In addition to identifying the parties, the notice must include the locations where healthcare services are provided by each party, the anticipated effective date, and a brief description of the nature and purpose of the material change.14 Washingtons attorney general can also request additional information (including documents, interrogatory responses, and oral testimony) within 30 days of the notice being submitted.15 Any party that fails to submit the requisite notice faces penalties of up to $200 per day.16, Californias proposed SB 977 would have required healthcare systems, private equity firms, and hedge funds to provide notice to and receive approval from the states attorney general before closing acquisitions or changes of control with other healthcare facilities and providers.17 The proposed bill covered a wide range of healthcare affiliations, including: (1) the direct or indirect purchases through leases, transfers, exchanges, options to acquire assets, or creation of a joint venture by a healthcare system, private equity group, or hedge fund of a material amount of the assets of a healthcare facility or provider; or (2) any agreement, association, partnership, joint venture, or other arrangement that results in a change of governance or control at a provider or facility by a healthcare system.18 The legislation would have expanded the existing notification requirements, which apply only to transactions with nonprofit health providers.19 The California attorney general announced that the legislation was needed to combat anticompetitive behavior in the healthcare sector, which he claimed is a growing concern and responsible for higher rates and decreased quality of care in California.20 Section 2 of the Sherman Act makes it illegal for an entity to monopolize, attempt to monopolize, or conspire to monopolize any market. Reinsurance entities that have subcontracted with the prime contractor to FEGLI are considered to be government subcontractors within the meaning of the regulations implementing Executive Order 11246, as amended, the Vietnam Era Veterans Readjustment Assistance Act of 1974 (VEVRAA), as amended, 38 U.S.C. 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. and Dennie Zastrow, Esq., Troutman Pepper Hamilton Sanders, LLP, Philadelphia, PA Which of the following actions is NOT allowed by Health Insurance Counseling and Advocacy Program (HiCAP) counselors? 1974). Stat. Overseeing the insurance industry and protecting the state's insurance consumers is the responsibility of the California Department of Insurance (CDI). 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. 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.
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